Running Head: CASE STUDY 1
Running Head: CASE STUDY 1
Running Head: CASE STUDY 1
Case Study
Summer Neely
Abstract
J.S. is a 48-year-old Caucasian male who I met and interviewed on November 14th, 2019.
He was admitted to Trumbull Regional Medical Center on October 21st after calling EMS and
disorder bipolar type. Medically, he is diagnosed with obesity, hypertension, chronic kidney
disease, and gout. He does not respond to monotherapy and is on several psychiatric medications
for his schizophrenia. He is a Jehovah Witness and is completely submerged in his faith. He has
both auditory and visual hallucinations, as well as delusions, almost entirely all of which are
religious in nature. He is an only child who was raised solely by his mother. There was no family
history of psychiatric illness noted in either the interview with the client or in the client’s chart.
J.S. is neither homicidal nor suicidal at this time. He spends much of his time praying and
Objective Data
On October 21st, 2019, J.S. called EMS stating he was hearing spirits and that Satan was
in his head. EMS brought him to the emergency department at Trumbull Regional Medical
Center and he was soon admitted to 3 South. J.S. has had hallucinations for the last roughly ten
years, but over a few days just prior to his most recent hospitalization, they had been getting
worse. Ultimately, upon admission, J.S. believed that Satan was in his head and was making him
say and do things. This patient is a 48-year-old male who lives with chronic schizophrenia, and
follows:
Two (or more) of the following, each present for a significant portion of time during a 1-
month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
But that’s not all – diagnostic criteria for schizophrenia also includes markedly low levels of
functioning, compared to the level of functioning prior to the psyche disturbance, in at least one
or more major areas such as self-care, personal relationships, work, etc. Also, signs and
symptoms of the disturbance must persist for at least 6 months, other disorders such as
schizoaffective and bipolar or depression must have been ruled out, and a substance or other
medical condition cannot be found to be the cause of the disturbance (Townsend & Morgan,
2017, p. 342-343). Throughout the following discussion, it will be made evident with a plethora
Now, J.S. not only has a psychiatric diagnosis of schizophrenia, but schizoaffective disorder as
well, bipolar type. As stated by Townsend and Morgan (2017), “This disorder [schizoaffective] is
symptomatology associated with the mood disorders (depression or mania)” (p. 349). When it
comes to medical diagnoses, J.S. is diagnosed with obesity, hypertension, stage 3 chronic kidney
disease, and gout. The patient is on quite a few medications, a few of which are for the
hypertension and gout diagnoses, but most of them being for his psychiatric diagnoses of
schizophrenia and schizoaffective disorder bipolar type. At home, J.S. was taking Symmetrel,
Depakote, and fluphenazine decanoate. During this admission, his medication regimen got some
adjustments. His current medication list and the reasoning for each prescription is discussed next.
For starters, J.S. is still taking Symmetrel, which is an antiparkinson’s medication he was
taking prior to this admission for his EPS symptoms, 100 mg. PO BID. I saw first-hand J.S.’s
EPS- he moves his legs and shakes his foot nonstop. EPS can result from taking antipsychotics.
Next, J.S. takes Norvasc 10 mg. PO daily for his hypertension. He is prescribed Klonopin which
disorder. J.S. has three different orders for fluphenazine HCl (Prolixin). The first is 5 mg. IM
q6H PRN for severe psychotic behavior, next is 5 mg. PO q6H PRN for psychotic behavior, and
last is 5 mg. PO BID for his psychotic behavior/schizophrenia. Prolixin is a typical antipsychotic
and with this class of medications we really need to keep an eye out for EPS which can be
treated with an antiparkinson medication such as Cogentin or Symmetrel, one of which J.S. is
already taking. J.S. is also prescribed Atarax, which is an antihistamine, at 50 mg. PO q6H PRN
for anxiety. He takes Vistaril 50 mg. IM q6H PRN, another antihistamine, for severe agitation,
Trileptal, an anticonvulsant, 600 mg. PO BID as a mood stabilizer, and lastly J.S. has three
CASE STUDY 5
different orders for Invega which is an antipsychotic for his schizophrenia diagnosis. One is 9
mg. PO qHS, another is 3 mg. PO daily, and last is 156 mg. IM q30D. When a patient is on
several antipsychotics, we need to watch for EPS and neuroleptic malignant syndrome.
As with any patient, it is crucial to look over and interpret J.S.’s lab reports. Surprisingly,
for as long as he had been admitted, and for as many medications as he had been on, the patient
did not have too many lab results. First off, the patient’s valproic acid was 99.9 which is indeed
in therapeutic range. It is crucial we look at this lab value since J.S. was previously taking
Depakote not that long ago and we do not want him outside of a therapeutic level. I also checked
his TSH and free T4 which were both within normal limits, as well as his BUN and electrolytes.
On the day of his admission to the hospital his glucose was 136, likely from the stress of his
disorder’s exacerbation and his trip to the hospital. As the days went on, his glucose came down.
With every patient on the psychiatric inpatient unit, extreme precautions are taken to keep
every patient, as well as all the staff, safe. Every patient is automatically placed on unit
restrictions and patient self-harm precautions. A patient may also be placed on specific protocols
on an individual basis, J.S., however, was not on any specific protocols. In each patient’s room,
they do not have actual bathroom doors; the bathroom “doors” are like soft mats that just Velcro
to the wall, so that if any weight is applied to them, they simply break off from the wall. The
mirrors in the bathrooms are polished steel so that they cannot be shattered and broken like glass
and used as a weapon to cause harm to one’s self or others. The patients cannot access the
windows and they cannot be opened. The beds are bolted to the floor so they cannot be picked up
and/or moved. There are no long cords or wires; the call lights are very short in length. Patients
are not allowed pens or pencils; they must use colored markers to write with. There is limited
furniture and what furniture there is, is all very heavy making it harder to pick up or move.
CASE STUDY 6
Finally, all the doors leaving the unit remain locked at all times as well as the doors leading into
For as an extensive and intense history that J.S. has, it is surprising to me he only has two
psychiatric diagnoses: schizophrenia and schizoaffective disorder bipolar type. According to Smith,
Robinson, and Segal (2019), some common early warning signs of schizophrenia include:
deterioration of personal hygiene, flat, expressionless gaze, inability to cry or express joy or
While the above-mentioned symptoms can be present with numerous other disease processes, they are the
key warning signs of schizophrenia and the individual needs to be further evaluated. There are five
symptoms of schizophrenia and they are delusions, hallucinations, disorganized speech, disorganized
behavior, and negative symptoms which will be discussed later on. “A delusion is a firmly-held idea that a
person has despite clear and obvious evidence that it isn’t true” (Smith et al., 2019, p. 9). There are many
different types of delusions and they are erotomanic, grandiose, jealous, persecutory, somatic, and mixed
(Townsend & Morgan, 2017, p. 347-348). As stated by Townsend and Morgan (2017), hallucinations are
“false sensory perceptions not associated with real external stimuli. Hallucinations may involve any of the
five senses” (p. 813). The most common type of hallucination is auditory followed by visual
hallucinations. People who are diagnosed with schizophrenia have a hard time concentrating and this is
Loose associations – Rapidly shifting from topic to topic, with no connection between one
thought and the next, neologisms – Made-up words or phrases that only have meaning to you.
Perseveration – Repetition of words and statements; saying the same thing over and over, clang –
Schizophrenics also have disorganized behavior meaning their ability to function in daily life declines,
their emotional responses are inappropriate or unexpected, they lack impulse control, and exhibit
behaviors that are bizarre or purposeless (Smith et al., 2019, p. 18). To conclude discussing the expected
behaviors of schizophrenia, schizophrenics also have what are called negative symptoms. Negative
symptoms are “the absence of normal behaviors found in healthy individuals” (Smith et al., 2019, p. 19),
and these include behaviors such as no emotional expression, lack of interest and enthusiasm, little
Now, J.S. also has a second psychiatric diagnosis of schizoaffective disorder which is like
schizophrenia, only with the presence of a mood disorder, as well. In the case of J.S., his schizoaffective
disorder is the bipolar type, meaning while he is schizophrenic, he also exhibits symptoms of mania.
When a person is manic, there mood is elevated, they may be irritable, physical activity is excessive, they
may sleep very little or not at all, and they may or may not experience psychotic features such as
delusions and hallucinations. J.S. was exhibiting symptoms of mania as well as schizophrenia. For
example, his physical activity was indeed excessive, it was although he could never sit still at times, and
According to J.S., the reason for this resurgence of his schizophrenia and why Satan was
in his head telling him to say and do things is because he recently has been making progress with
his spirituality. J.S. stated, “[I am] doing better with my spirituality so now Satan is after me”
and he says he also hears hallucinations in church. He has no homicidal or suicidal ideations. J.S.
is no stranger to the hospital; he has been hospitalized numerous times prior to this admission the
most recent being in February of last year, 2018. In an interview with J.S., he claims he was
really starting to get scared and worried with all of the thoughts Satan was trying to put in his
head, he talked to his elders at church about it, and they encouraged him to seek help and so it
J.S. told a story from 2008 of how his mother fell ill. He stated she was suffering from
congestive heart failure and was in the hospital for some time. During this time, being he had the
house to himself, J.S. decided to get some marijuana and smoke it. He also admits he has a
history of using LSD, but it has been several years since the last time he has experimented with
either marijuana or LSD. While he was high on marijuana while his mother was in the hospital,
he said he got a vivid image of his mother in his head who looked as though she was dying (and
she was, in fact, dying in the hospital.) J.S. told of how he has hurt women in the past before
whom he loved more than his mother, and it was in that instant, that he killed his mother with his
mind, he said. J.S. says that was such a significant sin it created a hole in his head, and he
believes that hole is how Satan gets into his mind. In short, on October 22nd, J.S. stated, “I did
something in 2008 that overtook my mind and now it wont stop taking over my mind.” He
claims when he hears Satan’s voice in his head that it sounds like silence and that Satan is trying
to sound like God. He also claims that he sees “wicked spirits zipping around him.”
Researchers studied the relationship between cannabis use and psychosis symptoms.
According to Bourque, (2018) the research showed, “significant links between cannabis use and
symptoms of psychosis” (p. 5). Numerous amounts of research have been done to explore the
relationship between cannabis use and psychiatric symptoms and disorders. It seems to go both
ways – having a psychiatric disorder can lead to cannabis use and cannabis use can lead to
inducing psychiatric symptoms and problems. Regardless, the research shows that drug use in
the vulnerable (and all) populations needs to be monitored and education needs to be provided to
the public about the effects’ drugs can have not only physically but mentally and emotionally as
well. Upon admission, J.S.’s urine drug screen and his blood alcohol both came back negative.
I believe it is now time to recognize that J.S. is a Jehovah Witness. Randomly, during
CASE STUDY 9
assessments, interviews, and whenever, J.S. will throw his head back and say “Jehovah.” He
claims he does this to maintain his focus and not allow Satan to take over his thoughts. He
dresses in a suit every single day and when asked why he does this he says he dresses for his God
The patient does not really have much family to gather history from. He is an only child,
was raised solely by his mother, and she is now deceased. The only information gathered on his
mother was that she suffered from congestive heart failure. I could find no information on his
grandparents in his chart and neither did he bring his grandparents up in conversation. J.S.’s
hallucinations have been present for ten years and have gotten worse over the last couple of days,
as of October 21st, 2019. His last hospitalization prior to this admission was in February of 2018
Describe the Psychiatric Evidence-Based Nursing Care Provided and Milieu Activities
Attended
biopsychosocial model of holistic care, which involves client education and encourages self-
management and spiritual support for clients with schizophrenia; in which the importance of the
client's perspective in treatment decisions is emphasized” (p. 6). On the inpatient psychiatric unit
at Trumbull, the staff implement a variety of practices to provide for their patients a safe and
therapeutic environment. Nurses check on their patients every 15 minutes to make sure their
safety is maintained. Patients are not allowed to have shoelaces, belts, or ties as they pose as a
potential mechanism to cause self-harm. All patients are encouraged to spend time out in the
common area, and everyone is heavily encouraged to attend the therapeutic group sessions. At
CASE STUDY 10
first, J.S. would attend groups, but he was in and out of them throughout the session. The first
time I saw him at group, he walked into the room and stayed for maybe not even a minute, got up
and said he had to go. Just a short while later, he walked back in and said he would be able to
attend group. This back and forth repeated itself several times and so he was quite disruptive
during group and was definitely manic at this time. The previous information was from October
24th, as of October 26th in his charts it stated he was attending some groups. Then, on October
27th, in his chart it stated he was seclusive to his room that day due to voices he was hearing in
his head, and he was hopeful “the shot” (his Invega Sustenna injection) he received the previous
day would help make them go away. As the days went by and his adjusted medications began to
improve his symptoms, J.S. slowly attended more and more groups.
Analyze Ethnic, Spiritual and Cultural Influences that Impact the Patient
J.S. is a Caucasian male who lives in Ohio and has no significant ethnic or cultural
influences that were made known to me. However, practically his entire life is based on and
revolved around his spirituality. J.S. is a Jehovah Witness and it seems he has devoted his life to
his church. He has no family or friends really, just the elders of his church. He spends his time
praying and reading the bible. When he does hang out with people, it is church-related and with
his elders most of the time. If you walked into J.S.’s room at Trumbull, often, he had open bibles
and religious items all about him and his bed. As mentioned earlier, he wore his suit to dress for
his God every single day. When asked about if he listens to music and what kind, he said he
listens to songs about God’s kingdom. Upon leaving his room at the end of our interview, he
intercultural competencies in healthcare and Jehovah Witnesses. Interestingly, “In the United
CASE STUDY 11
States, schizophrenia is 4-6 times more common in Jehovah's Witnesses than in the rest of the
population” (Bernaciak et al., 2019, p. 8). These researchers further discussed the prevalence of
schizophrenia in Jehovah Witnesses. Members of the religion are encouraged not to seek help of
specialists, and with that, the researchers Bernaciak et al. (2019) stated:
Lack of help, in the initial stage of the disease, leads to its further development. All
activity in the social sphere, which is extremely important for the human psyche, is
inhibited. The exception is the activity in the organization's ranks, which can lead to full
identification with this doctrine. This identification is the reason that the follower of this
doctrine sees everything through the "glasses" of faith. The reality with which he meets is
not always consistent with the truth and the authentic feelings of the observer. (p. 8)
The patient outcome of highest priority is to keep the patient safe. This is done through
all the unit restrictions and patient self-harm precautions that are put in place for every patient on
the floor, as discussed earlier. Another patient outcome for J.S. would be to increase the amount
of sleep he is getting. It is dangerous to keep going and going, and we need J.S. to be functioning
at his highest level and in a healthy manner. The next patient outcome would be to see a decrease
in the amount of hallucinations J.S. is experiencing. With that, adjusting the patient’s
medications and getting him adjusted, well-regulated and in therapeutic range would be another
patient outcome. We also want J.S. to increase his performance with his self-care. He needs to
care about his personal hygiene and realize the importance of it and take showers and change and
wash his clothes. Last but not least, another valuable patient outcome for J.S. would be to
On November 14th, J.S. said that he was hoping to be discharged within a week. He
planned to be compliant with his medication regimen, which he had done well with previously
both prior to this hospitalization and during his stay. Prior to this admission, the Compass Care
Team followed him and helped him to buy his groceries and plan his meals and so forth and he
planned to continue to have their help after he was discharged. A few people from Compass even
came to visit him during his stay he told us. He lives in an apartment and planned to go back
there. He told his landlord he would be out for a few weeks so that they knew no one was in his
apartment and where he would be. He plans to continue with his spiritual practices.
1.Sleep deprivation r/t mania AEB getting little to no sleep on several different nights, sleeping
for only 30 minutes one night, sleeping only two and a half hours another night, and the like on
several occasions, pt. stating “I do my best thinking when I do not sleep” and “I do not think you
understand, I do not want to sleep,” up singing till 0430, staying up all night to read his bible.
2.Self-care deficit r/t impairment of perception AEB visibly soiled clothes, unkept hair and
3.Self-neglect r/t psychosis AEB not showering, wearing dirty clothes, not sleeping to sleeping
4.Social isolation r/t delusional thinking AEB pt. remaining in room reading his bible and
5.Impaired social interaction r/t disturbed thought processes AEB pt. remaining in room reading
his bible and praying, not attending groups, not wanting to talk to staff or be assessed, talking on
the phone to no one, having few visitors, having no one outside of church that he really talks to
or socializes with.
CASE STUDY 13
Conclusion
J.S. is one of the most interesting patients I have come across so far in my experience as a
student nurse. Something about the religious aspect of his delusions and hallucinations intrigues
thought-provoking and just raises so many questions for me. J.S. is a patient who will continue to
be in and out of the hospital the rest of his life with his schizophrenia. He is extremely
medication resistant and does not respond to monotherapy. That being said, he is on several
medications and some that we do not see a whole lot of. He is and, I think always will be,
extremely religiously preoccupied. Through this admission he has not reported any suicidal or
homicidal ideations. He also has a psychiatric diagnosis of schizoaffective disorder bipolar type
and he manifested as manic during this hospital stay. He spends the majority of his time reading
his bible, praying, and taking part in religious activities with his elders. With help from the
Compass Care Team, this individual is able to live on his own within the community.
CASE STUDY 14
References
Bernaciak, E., Farbicka, P., Jaworska-Czerwinska, A., & Szotkiewicz, R. (2019). Intercultural
Bourque, J. et al. (June 2018). Frequent cannabis use may increase psychosis risk among teens.
Mahone, I. H., Maphis, C. F., & Snow, D. E. (April 2016). Effective Strategies for Nurses
Smith, M., Robinson, L., & Segal, J. (November 2019). Schizophrenia Symptoms and Coping
signs-and-symptoms.htm
Townsend, M.C., & Morgan, K. I. (2017). Essentials of Psychiatric Mental Health Nursing:
Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________
___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient