Mental Health Capstone Project:

Schizoaffective Disorder
Kristen Nii-Jensen
NURS 360
Kapiolani Community College

STUDENT NURSE REPORTING FORM

SN: Kristen Nii-Jensen
Pt.: Sex: F

Date: _September 24 2014

Age: 52___ Date of Admission: __September 7, 2014____

Transferred? ___No _X_Yes: (Reason/Date) _Admit Queens West 9/07, transferred for Queens
Kakela Makai per physician
Income source: ___Current Ward of state on Medicare Pt C, Ohana Well Care A_______
Legal Status: _MH-4 (an order filled by a physician after admission to the hospital. 48 hour emergency
hold, renewable) upon admit, Currently MH-5 (Voluntary admission based on patients need for inpatient
treatment with all rights retained) (AMHD, 2008).
Expiration: MH-4 expired 9/12 as date has passed no exact time of expiry, Pt readmitted as MH-5 on
9/12
DSM Diagnosis:
DSM V Diagnosis: Schizoaffective disorder
DSM- IV Currently not in use at Queens Kakela, per my assessment
Axis 1: Schizoaffective disorder
Axis II: Null
Axis III: Water intoxication upon admission,
Axis IV: Lives in group home with regular contact with brother, mother and father (parents are divorced,
mother lives on Molokai)
Axis V: I assessed my patient with a GAF of 18. Patient acute mania state requires frequent reminders to
eat, drink, and a toileting schedule to prevent incontinent issues. This presents a risk of harm to patient,
and an occasional lack of hygiene. Patient will go to toilet, change clothes, eat, and drink upon prompting.
Patient denies any homicidal or suicidal ideation, has shown no inclination to violence nor has a history
of assault. However, is communicable but frequently incomprehensible due to flight of thoughts,
tangentially, pressured speech. Frequently influences by delusion and hallucinations and inability to
functions in all areas in addition to risk of self-harm from manic state.

What brought patient to the hospital?

The patient was throwing things in group home and causing a general disturbance. Was exhibiting
both visual and audio hallucinations w/ grandiose and religious delusions. Picked up (ambulance)
from group home on September 7, 2014 and sent to Queens West ER, and found to have water
intoxication. Transferred to Kakela Makai on the same day. She stated she needed to save god by
destroying the world. Per her brother symptoms escalated after Labor Day (September 1), where

patient stated concerns about upcoming thyroid lobectomy with subsequent phone calls becoming
increasingly nonsensical. Patient initially admitted with psychosis NOS, later schizoaffective
disorder, specifically acute mania with psychosis.
Patients description of problems:
Per patient during discussion on September 10, 2014, she came to the hospital because she saved her
sisters life. Her sister had a fall and she saved her, and they all came to the hospital. Patient was
unable to elaborate further on her diagnosis but denies mental disorder at that time. Patient was able
to articulate that she is currently in the hospital on September 24, 2014, but unable to state why.
When asked what she thought her diagnosis was she stated I am losing my mind. However, unable
to continue this line of questioning before patient began to have visual hallucinations.

Spirituality: Patient is catholic, and frequently makes references to God, needing to save or serve
God, and other religious fixations

Considerations r/t ethnicity or religion: Patient is Filipino and Catholic, but requires no special
considerations per patient who stated she needed to pray.
Patients Strengths: Patient has been medication compliant per herself, history and physical, and family,
presents with no history of alcohol or drug abuse per family and negative screenings upon multiple
admissions into Kakela, HSH, and Castle hospital, has a stable home environment to return to, and family
support that checks in with her. Her last episode was six years ago per her brother. The patient has
some college education, and a prior work history as a school cleaner.
Patients Limitations: Patient continues to decompensate despite several changes in medication, and
ability to care for self without frequent interventions is impaired, as seen in the increased mania states
from September 10 to September 24. Though in a stable home, she does not currently live with family,
and mother lives on Molokai. Father and brother contact patient mainly through phone. The patient is
unmarried but fixated on her dead husband, has not worked in many years, and will have difficulty
transitioning back into work force at her current age.
Medications:
Order: risperidone M 2mg translingual BID
Drug class: atypical antipsychotic Pts target sx: psychosis
Total 24h dose: 4mg
Recommended range: 1-2 mg/day max: 8mg : L M H Max
Current Side effects: disinhibition, EPS symptoms prior night per staff

Order: clonazepam (klonopin) 1mg oral TID

Drug class: benzodiazepine
Pts target sx: anxiety
Total 24h dose: 3mg
Recommended range: 1-2mg/day divided maxL 4mg : L M H Max
Current Side effects: glassy eyed appearance, slurred speech, hallucinations
note: use of this this drug can increase risperidone levels
Order: divalproex dr (Depakote) 500 mg BID oral 750mg at bedtime
Drug class: Pts target sx:
Total 24h dose: 1250 mg Recommended range: 750mg/day in divided doses or 25mg/kg/day
(pt 53.9*25=1,347.5 mg): L M H Max
Current Side effects: hallucinations is a side effect, but may be symptomatic with schizoaffective
disorder
Order: lorazepam 1 mg Q6h PRN NTE: 6mg/day
Drug class: benzodiazepine
Pts target sx: agitation, anxiety
Total 24h dose: 2mg
Recommended range: 2-6mg/day divided doses : L M H Max
Current Side effects: Hallucinations, unsteadiness, weakness, restlessness, hallucinations,
confusion, sleep disturbances
Order: haloperidol 5mg PO Q4h PRN NTE 20mg/day
Drug class: typical antipsychotic Pts target sx: Severe psychosis
Total 24h dose: 15mg
Recommended range:3-5mg BID or TID, may need up to
100mg/day : L M H Max
Current Side effects: EPS prior night per staff, insomnia, restlessness, agitation, confusion,
acerbation of psychotic symptoms,
Order: diphenhydramine cap 25mg oral Q 3hour PRN
Drug class: antihistamine Pts target sx: EPS
Total 24h dose: 25mg Recommended range: 25-50mg TID or QID (max 300mg/day) : L M H
Max
Current Side effects: confusion and excitement
Medical Conditions: List all conditions even if they are not listed in the diagnoses or on
chart. (Particularly note any unstable conditions & all non-medication interventions.)
1. High fall risk stand-by assist for transfers and for ambulation
2. Bowel and bladder incontinence related to mania state, requires toileting every hour.
3. Hx of water intoxication observe intake and output
4. Thyroid nodule, scheduled lumpectomy to r/o cancer (canceled d/t manic state)
BMI: 22.46 Category: Heathy weight

(Height: 154.9cm

Weight: 53.9kg

Food & fluid intake: Ate 75% of breakfast, drank 840 ml fluids
Bladder & bowel status: Occasionally bowel and bladder incontinent, requiring toileting schedule q
hour

Sleep pattern: Sleeps upon exhaustion, or after PRN benzodiazepine antipsychotic administration for 3-4
hours at a time

Total sleep/24 hrs: 9 hours per staff

(circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning awakening

Number of hours of disruption: 2 hours

Naps: When? 9/23 eve shift & 9/24 mid-

morning Total nap time: 3 hours

Lab & studies
Date/Panels in which all values were normal:
9/7
WBC: 9.06
RBC: 3.65 10^6/ml
HCT: 12.3 g/dl
HGB: 36.4%
Platelets: 228, 000
Creatinine: 1.2 mg/dl
NA+:145 meq/l
K+: 3.6 meq/l
Cl-:107 meq/l
9/16
AST: 18 iu/l
ALT:18 iu/l
Alk Phos: 56 iu/l
Total bilirubin: 0.4 mg/dl
Albumin 4.3 mg/dl
Valproic acid: 120 mcg/ml
TSH 2.19 mciu/ml
9/23
Valproic Acid: 107 mcg/ml
Date/Any abnormal labs:
9/7
BUN: 25 elevated
GFR: 50 low
These labs may indicate renal dysfunction. GFR should be between 90-120, and BUN 7-20 mg/dl. This
may also be related to patients water intoxication upon admission.
9/18

Valproic Acid: 141 mcg/ml elevated Therapeutic range is 50-120 mcg/ml, toxicity begins at 150 mcg/ml.
Though current patient Valproic acid levels are not toxic, this is above the therapeutic range.

Labs you would expect but were not ordered:

CBC with differential to asses for agranulocytosis. However, most recent assessment by resident stated
CBC within normal limits, but not seen under labs. There was nothing concerning PT, PTT< or INR as
Depakote can result in prolonged bleeding.
Glucose readings x 24h for all diabetic pts.: NA
All drug screen findings: Obtained 9/7
Alcohol, amphetamines, barbiturates, benzodiazepines, cocaine, methadone, opiates, PCP, THC :
NEGATIVE

MENTAL STATUS ASSESSMENT: On September 24, 2014

Appearance:
Patient presented as disheveled in hospital gown and shorts. Her hair was uncombed, and her teeth
appeared to be unbrushed as there were food fragments between her teeth. She had a stooped posture,
glazed eyes, and appeared to be nodding off slightly.

Behavior:
The patient was very manic, alternating between non-stop pressured incoherent speech directed partially
at me, and partially at no one. She frequently attempted to grab the snake and at one time caught it, and
asked what do I do with the snake? Her speech was loud, slurred, pressured. Though initially sleepy,
patient was often impulsive and silly.

Affect:
Though initially presented with a flat restricted affect after medication, she later presented as labile
and expressive smiling frequently in euphoria, or expressing fear when she stated the devil is on my
back.
Mood:
The patients mood was euphoric throughout the day, except for a short period where she appeared tired
and anxious about half an hour after taking her medications where she also stated the devil is on my
back. However, after asking her to elaborate her train of thought shifted and her mood elevated.

Form of Thought:
The conversation with my patient initially veered off course with her looseness of thought. We would
start on topic for a few words, then veer off into things only loosely associated with a word spoken. As
we continued on in the conversation, she began going into a flight of ideas quickly changing from topic to
topic using very pressured speech. The patient also presented with the use of clanging, using rhyming
words and eventually utilizing them to veer off topic.
Content of Thought:
The content of our conversation was difficult to follow at times due to the flight of ideas. However, the
patient did present with no suicidal thought of homicidal ideation. She also denied seeing anything that
was not real, or hearing voices or sounds. However, during this conversation she attempted to get the
devil off her back, catch a snake off the ground, and told me the devil whispers to her. She had thoughts
of grandeur, and informed that she was The greatest marital artist in the world, Janet Jackson, Wonder
Woman, and Ms. America. She also states that people were going to get her, but was not suspicious of
me or the staff. When I asked if it felt as if someone was in her mind, she stated Yes, close the curtains.
They cant look inside my mind. In addition to thoughts of being controlled, she has magical thinking,
She complained of not sleeping a wink, and seemed excessively religious, frequently speaking about
god, the devil, and at one point went to her knees to pray in a prone position.

Orientation/Sensorium:
Though the content of our conversation was marked with many abnormalities, the patient did understand
who she was, and she did understand that she was in the hospital. She initially was certain she was there
due to losing her mind. However, she believed the year to be 1983. However, due to her mania, and
hallucinations I would still asses her as severely orientation impaired.

Perceptions:
Patient presented with active visual hallucinations stating the devil is on my back, auditory
hallucinations with the devil speaking to her, and illusions with the patient picking up a napkin and
stating I have the snake.

Cognition:
The patients short-term memory is impaired and unable to recall anything said minutes prior when
speaking to her. The patient is unable to recall things spoken moments prior as she is unable to articulate
or expand on topic presented. While attempting to interpret proverb patient began to utilize clanging,
Stone, bone, moan and began moaning when asked to interpret the phrase a rolling stone collects no

moss. However, the patient was able to identify 3 presidents, Bush, Kennedy, and Lincoln, but was
unable to perform simple math without going off on flight of ideas. The patient was severely cognitively
impaired on this day.

Interpersonal relationships: Patient is nonaggressive, easily engages in conversation but quickly

changes topics and shifts into a flight of ideas. She maintains contact with her mother, father, and brother,
and is pleasant through manic and difficult to converse with.

Suicidality/Homicidally:
The patient denies any suicidal or homicidal ideation, though she did state without prompting in my
dreams they are killed. But when asked if she thought of hurting herself or others she stated, No,
never. The patient also has no prior history of suicide attempts, and staff stated she is distractible not
violent.

Developmental level: (Assets & barriers)

Drugs: Substance abuse or dependence: (Include nicotine & any alcohol & drugs. List by
drug: Last date of use/Current acute intoxication or withdrawal sxs when SN caring for pt./Used
how long/Route/Usual amount/Negative consequences)
Length of
Usual
Route
Negative Consequences
Time
Use
amt.
Used
Pt has no history of alcohol or drug use. Has PRN Nicotine gum order, but this PRN never been used by
Drug class

Last

Acute intox or
withdrawal sx?

patient and patient denies history of tobacco use.

Issues Identified In Treatment Plan: Per resident plans and approved by assigned psychiatrist
1. Follow-up on orthostatic BP orders 9/23
2. Continue with Klonopin 1mg TID and Ativan 1mg PRN q6h
3. Start Depakote 9/23 2100 monitor for therapeutic effect for acute psychosis
4. Continue to monitor for signs and symptoms of EPS
5. Discharge to group home once patient can go 48 hours without any PRN medication for psychosis &
agitation
Current Discharge Plan:
Patient is to be discharged to group home in Ewa Beach once she has stabilized. The owner of the group
home is amenable to her return. Patient must be instructed on dangers of water toxicity. Should articulate

understanding of adequate amounts of water, and taught alternative technique to satiate thirst associated
with anticholinergic effect of medications such as chewing sugar-free gum.
Though patient reports medication compliance, group home owner may be instructed to keep eye
on patient if it is with in her scope of responsibilities. Family can also monitor patient for signs of
increasing mania or psychosis, and to encourage patient to check with physician when this first happens.
Group home owner and family can also be taught to monitor for signs of EPS and NMS to prevent life
threatening complications or severe disabilities.

Nursing interventions you performed this shift (Include safety and teaching!):
-

1:1 focused mental status exam with patient

Reminders to eat her breakfast and drink fluids

Q15 minute safety checks

Frequent refocusing and redirections for manic state

Frequent reminders to stay off the floor for safety reasons

Standby assist for patient sit-to-stand and ambulation

Assess for signs and symptoms of EPS and NMS

inform RN about possible pseudo parkinsonism AEB shuffling gait, slowed movements, and
unsteady posture

Inform RN about patient reports of disturbed sleeping pattern

Patient-centered Care Analysis

PRIORITIZED PATIENT NEEDS using PES format (problem, etiology, signs/symptoms)
What are the patients 4 highest needs/problems?
(Use your best nursing judgment! It may be different from the treatment plan.)
Priority #1
1. P: Risk for injury
E: Patients presenting with acute mania and psychosis can be agitated, have poor judgment, and
experience hallucinations and delusions that increase their risk for injury (Schultz & Videbeck, 2009, p. 203).
S: Patient rolling on floor, history of throwing objects, patient falling to ground to pray, kicking at
door frame, crawling under desks and scratching wood with finger nails.
Short Term Goal: Patient will be free from injury during this shift.
Long Term Goal: Patient will be free of agitation, restlessness, and hyperactivity before discharge.

Intervention & Frequency

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including page number)

Evaluation

Decrease environmental stimuli whenever

possible. Remove stimuli and isolate
patient, providing a private room may be
beneficial.

The clients ability to deal with stimuli is impaired

(Schultz & Videbeck, 2009, p. 205).

Patient was directed away from milieu and

was able to sleep one hour in room before
returning to milieu in a manic state. After
being led to quiet room, was able to stay for
45 minutes, before agitation increased.

Give simple direct explanations. Do not

argue with the client.

The client is limited in the ability to deal with

complex stimuli. Stating a limit tells the client what is
expected. Arguing interjects doubt and undermines
limits (Schultz & Videbeck, 2009, p. 205).
Consistency and structure can reassure the client. The
client must know what is expected before her or she
can work towards meeting those expectations (Schultz
& Videbeck, 2009, p. 205).

Patient able to understand simple and

comply direct statements such as be quiet,
speak softer, lets go to the quiet room.

Medication can help the client regain self-control but

should not be used to control the clients behaviors for
the staffs convenience or as a substitute for working
with clients problems (Schultz & Videbeck, 2009, p.
204).
Berk et al. (2010) finds early interventions in bipolar
symptoms decreases the risk for persistent unremitting
illness.

Patient was administered PRN medication

early in the AM hours, and was able to
sleep for 4 hours uninterrupted. Though
patient presented as manic, was redirectable
and compliant with instructions. PRN
administration of medication was not
necessary at this time.

Provide consistent, structured environment.

Let the client know what is expected of him
or her. Set goals with the client as soon as
possible.

Administer PRN medication judiciously,

preferably before the clients behavior
becomes destructive.

Informed patient the need to speak softer

and to stand up if she wanted to stay in the
milieu. Patient attempted to speak softer
and was able to comply with instructions to
go to quiet room when she began to act our
and shout without agitation or aggression.

Priority #2
2. P: Self-care deficit: feeding, hygiene, toileting (Schultz & Videbeck, 2009, p. 208)
E: Patients experiences acute manias rapid through processes and disorganized behaviors can affect
their ability to intake sufficient fluids and food, maintain self-care and hygiene, or need for toileting.
(Fortinash & Holoday Worret, 2012, p.231)
S: Patient needs constant reminder to continue eating food, multiple occasions of incontinence this
hospitalization, deficient grooming AEB foul breath, food in teeth, disheveled clothing, and
uncombed hair.

Short Term Goal: Patient will consume 75-100% of meals and 800mls of fluid during my shift and be
directed to use toilet Q hour, and reminded to engage in self-care activities.
Long Term Goal: Patient will able to consume at least 75% of all meals and imbibe a minimum of 1,500
ml of fluids, and participate in self-care activities such as bathing, brushing teeth, and toileting without
supervision or reminder before discharge

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Priority #3
3. P: Disturbed sensory perception: Visual and auditory (Schultz & Videbeck, 2009, p. 170)
E: Schizophrenia and acute mania includes hallucinations, delusions, and disordered thought
processes. These hallucinations may involve any of the sense. Client may act out on these
perceptions. The current theory is that hallucinations may be a metabolic response to stress,
neurochemical imbalance of symbolic expressions of disassociated thoughts. (Schultz & Videbeck, 2009,
p. 169)

S: Patient talking, laughing, moaning and screaming in quiet room to self. Reports of devil on my
back whispering to me, and attempts to grab at snake on the ground.
Short Term Goal: Client will interact with staff and converse for 5 minutes this shift.
Long Term Goal: Client will verbalize plans to deal with hallucinations if they reoccur before discharge.

Priority #4
4. P: Disturbed sleeping pattern
E: Biochemical imbalances related bipolar disorder affect normal sleep patterns secondary to mania
and hyperactivity resulting in disturbed sleeping pattern (Fortinash & Holoday Worret, 2012, p.231).
S: Patient report of not sleeping a wink Frequent awakenings at night, early awakening in morning,
visibly fatigued and report of being tired.
Short Term Goal: Patient will be provided time to rest and decreased stimuli before this time this shift.
Long Term Goal: The patient will establish a balance of sleep, rest, and activity before discharge.

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Works Cited:

Berk, M., Hallam, K., Malhi, G. S., Henry, L., Hasty, M., Macneil, C., & ... McGorry, P. D. (2010).
Evidence and implications for early intervention in bipolar disorder. Journal Of Mental
Health, 19(2), 113-126.
Fortinash, K. M., & Holoday Worret, P. A., (2012). Psychiatric mental health nursing (5th ed).St.
Louis, MO: Elsevier
Schultz, J. M., & Videbeck, S. L., (2009) Lipincotts manual of psychiatric nursing (8th ed.). China:
Lippincott, Williams & Willkins.
Wilson, B., Shannon, M. T., & Shields, K. M. (2013). Pearson nurses drug guide 2013. Upper
Saddle River, NJ: Pearson

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