Case Study 1

Case Study

Trey Walden

Youngstown State University

Case Study 2

Abstract

This case study will be talking about a 37-year-old female patient who was admitted at

Trumbull Memorial Hospital on the Adult Psychiatric Unit. Her diagnoses include schizophrenia,

PTSD, psychosis, mild bipolar disorder, and Cluster B personality disorder. For this case study,

schizophrenia will be the main diagnosis being focused on. The information that was obtained for

this is from the patient’s chart and a one on one conversation. This case study will discuss typical

behaviors of schizophrenia, stressors and behaviors that lead to hospitalization, and the familial

mental health history. Also included in this case study will be the nursing care and interventions

the patient received, as well as the ethnic, spiritual and cultural influences on the patient. Finally,

this case study will focus on the outcomes related to the patient’s care, plans for discharge, and

actual and potential nursing diagnoses.

Case Study 3

Objective Data

The patient is a 37-year old Caucasian female admitted involuntarily onto the adult

psychiatric unit on March 13th, 2018 at Trumbull Memorial Hospital. Patient was diagnosed with

schizophrenia. Other diagnoses include PTSD, psychosis, cluster B personality disorder, autism,

ADHD, fibromyalgia, conversion disorder, hallucinations, rheumatoid arthritis, and anxiety. The

patient is currently 18 weeks pregnant at the time as well. Date of care was on March 27th, 2018.

The patient was wearing blue scrubs that are provided by the unit and had purple streaks in her

hair. During the one on one conversation the patient was very cooperative but seemed to be

restless. When sitting at the table during the one on one conversation the patient was fidgeting,

kept changing positions, maintained poor eye contact and switched topics quickly.

The information gathered during the one on one conversation mismatched a lot of things

in the patient’s chart. In the chart it stated that the patient was found running through the woods

in soaking wet clothes and was dehydrated. When talking to the patient she very paranoid and

stated that she believed that the police were after her because the doctor wanted to take her baby

and lock it up in another country where no one will ever find it. Also, according to the patient,

she was arrested because of a federal warrant for her arrest due to violating a restraining order

from her previous husband. Patient stated she was just trying to find her son’s birth certificate

and was told she was allowed to.

The patient is very spiritual and believes in the practice of astrology. She says she can

read palms and tell peoples future and that she can also communicate to peoples dead loved ones.

When asked if the patient could hear any voices or see any people that other people say are not

there, she said that she does not. However, she told me that she does have conversion disorder
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which causes her to sometimes see a yellow room with a lily pad and a princess, but she denies

having any hallucinations.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,

(DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at

least 2 of the following symptoms:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Disorganized or catatonic behavior

5. Negative symptoms

At least one of the symptoms must include hallucinations, delusions, or disorganized speech, the

patient has presented with delusions, hallucinations and disorganized speech so she fits the

criteria.

Psychiatric medications the patient is prescribed are Risperdal 0.5mg daily PO and 1mg

PO at night, and Haldol 0.5mg PO prn. Risperdal is an antipsychotic medication and is ordered

for the schizophrenia diagnosis and it can also help with sleep. Haldol is also an antipsychotic

medication that is prescribed for schizophrenia and it can help by calming patient’s down. Both

of these drugs are labeled as a category C for pregnancy, which means that animal reproduction

studies have shown an adverse effect on the fetus and there are no adequate or well-controlled

studies in humans. Therefore, they may be prescribed if the benefits outweigh the potential risks.

The non-psychiatric medications are Tylenol 650mg PO every 4 hours as need for pain and

prenatal vitamins once a day PO. The Tylenol is prescribed for the patient’s rheumatoid arthritis
Case Study 5

and fibromyalgia. The prenatal vitamins are prescribed for the pregnancy and they contain iron

and folic acid. The folic acid will help prevent any neural tube defects on the baby. The client

was refusing to take the psychiatric medications last week because she wants to have a “perfect

baby” and they will affect the baby. Today she has taken her both her psychiatric and non-

psychiatric medications.

Schizophrenia

Schizophrenia is a long term mental disorder that involves the breakdown in relation

between thought process, emotion, and behavior, which leads to faulty perception, inappropriate

actions and feelings, withdrawal from reality and personal relationships into fantasy and

delusion. Symptoms of schizophrenia usually start to show between the ages 16 to 30 and men

tend to start having symptoms sooner than women. In order to be diagnosed with schizophrenia

one must present with at least two of the following symptoms discussed earlier from the DSM-5

for at least a month and there has to be some form of mental disturbance over 6 months. The two

main symptoms that are typically seen with schizophrenia are hallucinations, being auditory or

visual, and delusions. There are multiple types of delusions that can be seen in schizophrenia.

Some of these delusions include persecutory, grandiose, jealousy, religious. In the article, The

Effect of Delusion and Hallucination Types on Treatment Response in Schizophrenia and

Schizoaffective Disorder, it states that “Of the 116 patients in the study, 109 (94.0%) showed

persecutory delusions (Table 1). Beyond these, the most common delusions in order of frequency

were religious delusions in 29 patients (25.0%), grandiose delusions in 23 patients (19.8%) and

delusions of poisoning in 18 patients (15.5%)” ( Kilicaslan, Acar, Eksioglu, Kesebir, & Tezcan,

2016). So, among this study they found that the most common delusion was persecutory

delusions, which is when a person believes that they being mistreated or someone is spying on
Case Study 6

them or planning to harm them. My patient did present with persecutory delusions when she

stated that the doctor wanted to take her baby and hide it away from her so that she could never

find it.

In the same article they go on to say that, “In our study, the analysis of the correlation

between delusion types and response to therapy showed that in patients with religious and

grandiose delusions, the duration of hospitalization was statically significantly longer than in

other patients” (Kilicaslan et al., 2016). What this study found was that persecutory delusions

were the most commonly seen delusions in people with schizophrenia, however, when it came to

treatment response they found that people who experience grandiose or religious delusions, tend

to have a longer stay in hospital settings for treatment. This fits my patient because she did also

present with delusions of grandiose. She believes that she can read peoples futures and their past

from their palms, and that she can also communicate with peoples dead loved ones. Grandiose

delusions are when someone believes they have certain powers and that they are special and

unique.

Stressors

Stress can play a big role in people with schizophrenia. People with schizophrenia can

have a hard time handling stress and it can cause them to relapse and end up in a hospital or

treatment facility. I believe this is what caused my patient to be admitted to the adult psychiatric

unit at Trumbull Memorial Hospital. When looking at her chart I read that her fiancé stated that

she had been getting worse within the past couple weeks and really seemed to be having a lot of

paranoia. He believes it is from the pregnancy and other life stressors. There were some legal

issues that I read about in the chart including a court hearing about medication compliance as

well as a restraining order that was violated. When I asked her about the medication compliance
Case Study 7

issues she said the reason she stopped taking her medications is because she wanted to get

pregnant and she also wants to have a perfect baby and they will mess with her baby so she

decided to stop taking them. Some of the medications she was taking include Xanax, Risperdal,

and Adderall. Once she stopped taking her medications she decided to start self-medicating by

smoking weed, which she tested positive for when she was admitted. One reasoning she gave to

me for stopping her Risperdal was because the medication makes her grind her teeth and it

makes them sore.

Along with the stressors that brought the patient into the hospital, I wanted to talk about

how childhood stress can play a role in the development of schizophrenia. The patient has

previous history of childhood abuse which has caused her to develop PTSD. There was a study

done to see if there were any differences in the cognitive function of patients with schizophrenia

that have history of traumatization and those that do not. According to Peleikis, Varga, Sundet,

Lorentzen, Agartz, & Andreassen, there was no difference in cognitive function between the

schizophrenic patients that had no history of traumatization versus those who did (2013).

However, they did find that the schizophrenic patients that had history of traumatization did

present with depression during their childhood (Peleikis et al., 2013). This could mean that a

combination of childhood PTSD and depression can have an influence on the probability of

developing schizophrenia.

Patient and Family History

When talking with the patient about her childhood and family history she was very open

about it. The patient stated that she used to live with her grandparents around the age of 4. She

said that when she lived with her grandparents they would keep her locked up in the attic with no

bed or furniture and that there were bee nests all over the attic. The only time she saw her
Case Study 8

grandparents was when they brought her food and water. She says around the age of 7 or 8 is

when her step father rescued her and took her to live with him and her mother. When talking

about her mother, she said that her mother was a drug addict and would sell her to other men for

money to go buy the drugs.

The patient stated that she has always been a very sexual person and that she even dresses

provocatively. She claims that she is a phone entertainer as well. When talking about her

previous children she said that her first two children were conceived from rape and that this

caused her to develop PTSD. When talking about her family history she indicated that her father

had a history of alcohol abuse and died from cirrhosis of the liver from drinking too much. She

says her mother was diagnosed with schizophrenia and that she died of a brain tumor. This put

the patient at a higher risk of developing schizophrenia because it has been shown that there is a

strong link between schizophrenia and heredity.

In the article Sexual and physical abuse during childhood and adulthood as predictors of

hallucinations, delusions and thought disorder, Read, Agar, Argyle, and Aderhold state; “a

combination of child abuse and adult abuse predicted hallucinations, delusions, and thought

disorder. However, child abuse was a significant predictor of auditory and tactile hallucinations,

even in the absence of adult abuse” (2003). This study found that people with schizophrenia who

had a history of physical or sexual abuse as a child and adulthood tend to show more of the

positive signs of schizophrenia such as hallucinations and delusions versus the negative signs,

compared to the people diagnosed with schizophrenia who did not have any history of abuse. As

mentioned in the quote, they also found that especially if the person had a history of childhood

abuse, they usually presented with either auditory and tactile hallucinations. This correlates with

my patient because she experienced both childhood and adulthood sexual abuse and she
Case Study 9

definitely has visual hallucinations. Like I said earlier in this case study, the patient claims that

she will often see a yellow room with a lily pad and a princess, which is a hallucination even

though she denies that she has them.

Nursing Care

Before interviewing the patient, she was approached by the teacher and asked if it was

okay if a couple Youngstown state university nursing students could talk to her and ask some

questions after breakfast. The patient stated that it was fine with her and she would be happy to

talk after she finished breakfast. Once the patient was done with the breakfast we sat with the

patient at a table and started by asking her what brought her into the facility. She stated that she

was apparently running through the woods all wet and they brought her to the hospital. I then

asked how she was feeling today and if she feels better or worse than usual emotionally. She said

that she was ready to leave because she has a meeting with her psychiatrist on April 4th and

would like to make the appointment. Also, she stated that she wants to talk about switching

medications because the Risperdal makes her clench her teeth together and her teeth hurt. When

asked if she ever has any hallucinations, she denied that she does but stated that she has

conversion disorder and that causes her to sometimes see a yellow room with a lily pad and a

princess in it.

After our one-to-one conversation was over it was group therapy session time. The first

group session we did not make because we were at the computer looking at the patient’s chart.

The second therapy group session was led by nursing students and it was an activity that focused

on positive traits. The paper consisted of questions such as list five things that make you unique,

five times that you made someone else happy, five things that make you happy, and more. My
Case Study 10

patient decided not to participate in either of the group therapy sessions so I could not see how

she would have done in them.

Ethical, Spiritual, and Cultural Influences

The patient claims to be very spiritual and is a strong believer in astrology. She did state

that she is a clairvoyant and she makes money by reading peoples palms. During our

conversation she mentioned that previously in the week she went outside of the hospital and was

in the parking lot reading peoples palms and talking to their dead loved ones as well as reading

their futures. This was never mentioned in the patient’s chart so I believe this is false. It was hard

to talk about the patients ethical and cultural influences because when asked about her spiritual

beliefs, she was very into talking about astrology and her abilities. The patient kept switching

form story to story about her palm reading abilities and her being a clairvoyant. By time I was

able to refocus her on the ethical and cultural influences, it was time to start group therapy

session so I did not get any information on them.

Outcomes Related to Care

Outcomes related to the patient’s care are safety, medication adherence, and coping

strategies. The patient can pose a risk to herself and other people due to her impulsivity and her

mental illness. When the patient encounters stress she tends not to handle it the best, especially

when she decides not to adhere to her medication regimen. The patient stated that she has anxiety

and that when she has any stress it affects her ability to sleep and that she will only get a couple

hours of sleep, if that. The patient already exhibits the positive signs of schizophrenia such as

hallucinations, and delusions, therefore the lack of sleep would not help with these symptoms.

The patient also does not believe that she has schizophrenia and does not believe that she ever
Case Study 11

has any hallucinations. Among the hallucinations, the patient is very animated, fidgety, restless,

euphoric and labile. She also shows delusions of grandiose and persecution. The patient has a

meeting with her psychiatrist on April 4th so she would like to be discharged by then.

Plans for Discharge

Right now, there are no plans for discharge that I know of or can find in the chart. The

doctor would like the patient to adhere to the treatment plan and to be compliant with her

medication regiment. When the patient does get discharged she will return home with her current

fiancé and hopefully will remain compliant with her medications as well as her prenatal care.

The patient is very eager to be discharged.

Actual Nursing Diagnoses

1. Ineffective health maintenance related to cognitive impairment and ineffective coping as

evidenced by medication noncompliance and psychiatric facility

2. Ineffective coping related to unrealistic perceptions as evidenced by flight of ideas

3. Disturbed personal identity related to psychiatric disorder as evidenced by poor memory

4. Ineffective activity planning related to compromised ability to process information as

evidenced by denying diagnoses

5. Impaired verbal communication related to psychosis, hallucinations, and delusions as

evidenced by talking to non-objects in room, talking to the dead, and doctor wanting to lock

client up

6. Anxiety related to unconscious conflict with reality as evidenced by paranoid delusions and

grandiose
Case Study 12

Potential Nursing Diagnoses

1. Impaired memory related to psychosocial conditions as evidenced by different stories on

same event

2. Insomnia related to sensory alterations contributing to fear and anxiety as evidenced by

nightmares and paranoid delusions

3. Risk for compromised human dignity related to stigmatized label as evidenced by

schizophrenia diagnosis

4. Interrupted family process related to impaired cognition as evidenced by stay at psychiatric

facility and limited visitation

5. Ineffective family therapeutic regiment management related to chronicity and unpredictability

of condition

Conclusion

The patient is diagnosed with schizophrenia and has other secondary diagnoses including mild

bipolar disorder, cluster B personality disorder, ADHD, PTSD, psychosis, hallucinations, and

anxiety. Patient presented to the hospital with signs and symptoms of hallucinations and

delusions. There is a strong probability that this admission was due to medication non-

compliance as well as not being able to cope with some new stressors, one of the main ones

being pregnancy. Like stated earlier, the patient was animated, tense, restless, well kempt,

fidgety, labile, and had flight of ideas. The fiancé reported increased paranoia within the past

couple of weeks and an increase in anxiety. The medication non-compliance is due to the fact

that she wanted to get pregnant and she believes the medications will affect her natural birth and

will mess with her perfect baby. She also denies any hallucinations or delusions and claims that

she only has PTSD and conversion disorder. The goal for the patient is to establish medication

compliance and to return her to her baseline functions.

Case Study 13

References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide

to Planning Care (10th ed.). St. Louis: Elsevier.

Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. (2016). The Effect of

Delusion and Hallucination Types on Treatment Response in Schizophrenia and

Schizoaffective Disorder. Dusunen Adam: Journal Of Psychiatry & Neurological

Sciences, 29(1), 29-35. doi:10.5350/DAJPN2016290103

Peleikis, D. E., Varga, M., Sundet, K., Lorentzen, S., Agartz, I., & Andreassen, O. A. (2013).

Schizophrenia patients with and without Post-traumatic Stress Disorder ( PTSD) have

different mood symptom levels but same cognitive functioning. Acta Psychiatrica

Scandinavica, 127(6), 455-463. doi:10.1111/acps.12041

Read, J., Agar, K., Argyle, N., & Aderhold, V. (2003). Sexual and physical abuse during

childhood and adulthood as predictors of hallucinations, delusions and thought

disorder. Psychology & Psychotherapy: Theory, Research & Practice, 76(1), 1.

Townsend, M. (2015). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based

Practice (8th ed.). Philadelphia: F.A. Davis Company