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Case StudyCase Study

Kevin T. is a 33-year-old Caucasian male who is unemployed and resides with his mother. Kevin has two young children and shares custody with the children’s mother. He does not own a car. Has not had a job in over 10 years and aside from receiving social security benefits relies completely on his mother. He is an only child and has not had contact with his father in over 5 years.

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Kevin was diagnosed as a paranoid schizophrenic approximately 7 years ago. He is 25 lbs overweight and states that rigorous exercise makes him anxious. He tends to sleep a lot throughout the day and during periods of sleep he has outbursts and yells obscenities. During the past several years Kevin has lost contact with friends and shows little interest in socializing.

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He also lacks energy and motivation. Kevin often forgets what he is saying and is easily distracted. He smokes a pack of cigarettes per day and smokes marijuana daily. Family history includes prenatal complications. Kevin’s father was an avid heroin user and was physically violent towards his mother during pregnancy. Kevin’s father is also a diagnosed schizophrenic.

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Kevin has previously been admitted for crises that have occurred during periods of noncompliance with medications.

This time, Kevin was brought into the Emergency Department by his mother soon after a crisis occurred. Kevin’s mother, reported that he had become increasingly anxious and agitated soon after returning from a trip to visit family.

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Upon returning from his trip, his mother had noticed that there was an excess of pills in his container of Thorazine. She proceeded to ask him about his medication. Kevin admitted to having stopped his medications while on the trip. His mother also reported that upon arriving home, Kevin changed all the locks in their home and stated, "I’m sure someone followed me home".

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Upon admission, Kevin stated that he was visiting family and didn’t want to “sleep all day” and that the medications make him gain weight. He also admitted to being in fear of his life. Kevin also admits to use of marijuana and stated “it calms me down". He denies any suicidal ideation. He also stated, "I am not crazy. I don’t hear voices". He continued to express fear that someone was "out to get him".

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Kevin was placed on a 72-hour observation hold. After a psychiatric consult was conducted, he was voluntarily admitted into the behavioral health unit. A plan to treat with atypical antipsychotic medication was put forth – Risperdal 1mg P.O. BID.

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Kevin was discharged home after being a week in the behavioral health unit. Discharge planning included patient and family teaching regarding diagnosis, adherence to treatment, developing a relapse prevention plan, new medication teaching, avoidance of alcohol/drugs and referral to community support groups for schizophrenia.

Contributing FactorsContributing Factors

Biological Factors:

Genetics – First-degree relative has schizophrenia

Psychological Factors: Prenatal Stressors – Prenatal complications

and

psychological trauma during pregnancy.

Psychological Stressors – Cannabis use. Social

defeat.

Nurse’s Subjective Nurse’s Subjective ResponseResponse

The nurse caring for Kevin is a student and is apprehensive about speaking to “crazy people”. She is afraid that “these people” may hurt her. She doesn’t know much about schizophrenia and is unsure about how to begin her assessment.

She consults with an experienced RN who then helps her during the assessment.

Universal SCR’sUniversal SCR’s

AIR:• Smokes 1 pack of cigarettes daily• Smokes marijuana daily• Resp. rate 18/min, RRR, O2 sat 98%

on RA• Productive cough in the morning

WATER:• BP 133/85, HR 100, skim warm, pink

and intact• Thorazine. S/E: dry eyes, hypotension,

dry mouth.

Universal SCR’s Universal SCR’s Continued...Continued...

FOOD/ELIMINATION• 6 ft. tall, 210 lbs (says his optimal

weight would be 185)• BMI = 28.5 (high side of “overweight”)• States that he “eats when bored” • Does not like vegetables, eats 1 or 2

pieces of fruit a week – diet consists mainly of fast food

• Thorazine S/E: weight gain

Universal SCR’s Universal SCR’s Continued…Continued…

ACTIVITY/REST• Does not exercise due to exercise

making “him anxious”• Reports staying in bed and

sleeping a lot throughout the day• Family has noted that while he

sleeps he can have outbursts of yelling obscenities

• His personal hygiene has recently began to decline

• Thorazine S/E: sedation

Universal SCRs Universal SCRs Continued…Continued…

SOLITUDE & SOCIAL INTERACTION• Unemployed (last employment was 10 yrs

ago) • He is an only child who lives with his

mother; no contact with father in past 5 yrs• Does not own a car• Has lost contact with friends over the past

few years & verbalizes that he has “little interest in socializing”

• Stated that he used to like to mountain bike and go camping but has done neither in the past few years

Developmental SCR’sDevelopmental SCR’s

Kevin lives with his mother, has no car/transportation, besides his social security check he relies totally on his mother’s support

Erikson’s psychosocial developmental stage: Intimacy vs. Isolation• Patient is currently incapable or willing to

develop intimate, reciprocal relationships• Has lost contact with previous friends

and can’t trust enough to form a new romantic relationship

Developmental SCR’s Developmental SCR’s Continued…Continued…

Patient shares custody of his 2 young children with the mother but does not have a good relationship with her; they tend to end up arguing when they do communicate.

His mother is essentially his only support system

Patient recently had a crisis after stopping his medications while on a short vacation which led to paranoid feelings that people were following/watching him

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Has a high school education and becomes concerned when he thinks about searching for employment

Besides tobacco and marijuana addiction, Kevin is overall in good health

Health Deviation SCR’sHealth Deviation SCR’s

Kevin understands his diagnosis of paranoid schizophrenia and that this is the cause of his unwanted symptoms

Kevin is familiar with the medications he is currently taking but does not like the side effects – this has led to him stopping his meds suddenly in the past which have led to crisis and hospitalization (would benefit from medication education and possible change in meds)

Health Deviation SCR’s Health Deviation SCR’s Continued…Continued…

He has had trouble in the past adhering to his treatment/medication regimen

Uses marijuana daily to help “calm him down”

Kevin has accepted his mental illness but states that thinking about his illness makes him more anxious

Would benefit from a more extensive support system via groups/social support

Nursing Diagnosis #1Nursing Diagnosis #1

Noncompliance r/t altered thought process aeb abruptly stopping his medications, excess number of pills in bottle of Thorazine

ST Goal: Pt. will verbalize knowledge of condition and understanding of treatment regimen

LT Goal: Pt. will verbalize commitment to agreed-upon goals and treatment plan

Nursing Diagnosis #1Nursing Diagnosis #1InterventionsInterventions

Determine clients understanding of his illness and effects of the medication regimen (W/C)

Provide information/education and inform client of where to find information on his own (S/E)

Consult with MD about prescribing medications that have more manageable side effects (W/C)

Contract with client for participation in care (P/C)

Have client repeat and paraphrase information learned about his meds and condition (P/C & S/E)

Nursing Diagnosis #2Nursing Diagnosis #2

Disturbed thought process r/t biochemical/neurological imbalances aeb thoughts of being followed and verbalizing “someone is out to get me”, changing all locks at home

ST Goal: Pt. will state that the paranoid thoughts are less intense and less frequent by the end of this week

Pt. will demonstrate two effective coping skills that can help reduce delusional thoughts by time of discharge

Nursing Diagnosis #2 Nursing Diagnosis #2 InterventionsInterventions

Be aware that the patient’s delusions represent the way that he experiences reality (W/C)

Implement safety measures to protect patients and/or others (W/C)

Teach patient coping skills that would help reduce paranoid/delusional thought processes (Ex: talking to his mother, calling a help line, exercising, etc.) (P/C & S/E)

Encourage incorporation of healthy and positive habits into life (ex: get regular sleep, exercise, decrease/stop marijuana smoking, hygiene) (S/E & P/C)

Never argue with patients thoughts or beliefs (W/C)

Nursing Diagnosis #3Nursing Diagnosis #3

Social isolation r/t altered state of wellness aeb lost contact with friends; lack of interest in socializing

ST Goal: Client will verbalize willingness to be involved with others within 3 days

LT Goal: Client will participate in activities or programs at level of ability/desire by the end of the week

Nursing Diagnosis #3Nursing Diagnosis #3InterventionsInterventions

Assess client’s feelings about himself, sense of hope, and coping skills. (W/C)

Identify support systems available to client (W/C)

Promote participation in activities in a setting that Kevin views as safe (P/C)

Note drug use (S/E)

Discuss use of medications w/client and MD (W/C & S/E)

EvaluationEvaluation

It has been one month since Kevin has returned home from the hospital. Since returning home he has been participating in daily group therapy sessions, as well as one-on-one counseling, and has even made a few new friends. His mother continues to be supportive of his recovery and has gone with Kevin to all of the family sessions. He says that while he still sometimes feels the urge to smoke pot he relies on his new CBT skills to combat those thought patterns.

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He has not any recurrence of paranoid thoughts and states that he “hasn’t felt this relaxed in a long time.” He has been sleeping better at night and has enough energy during the day that he doesn’t feel like taking naps. He has also lost 5 lbs and said that he went for his first bike ride in years.

Evaluation ContinuedEvaluation Continued

In addition to his newly learned coping skills Kevin’s medication regimen has been changed so that the side effects are now something he feels confident he can manage. He has been engaged in learning more about his condition, medications, and strategies that will help him improve his life. He understands that his condition is something he will be struggling with for the rest of his life but he now feels like he is beginning to learn how to manage it best and has a hopeful outlook on his future.

Thank You!Thank You!