Running Head: CASE STUDY 1

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Running Head: CASE STUDY 1

Case Study

Summer Neely

Youngstown State University


CASE STUDY 2

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

going to the emergency department. He is diagnosed with schizophrenia and schizoaffective

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

reading his bible.


CASE STUDY 3

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

currently, was experiencing an acute exacerbation.

According to Townsend and Morgan (2017), schizophrenia diagnosis criteria are as

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):

1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or

incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (i.e.,

diminished emotional expression or avolition). (p.342)

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

of examples how J.S. meets the diagnostic criteria for schizophrenia.


CASE STUDY 4

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

manifested by signs and symptoms of schizophrenia, along with a strong element of

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

is a benzodiazepine he takes 1 mg. of PO qHS as a mood stabilizer for his schizoaffective

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

the nurses’ station.

Summarize the Psychiatric Diagnoses and Expected/Common Behaviors

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:

Depression, social withdrawal, hostility or suspiciousness, extreme reaction to criticism,

deterioration of personal hygiene, flat, expressionless gaze, inability to cry or express joy or

inappropriate laughter or crying, oversleeping or insomnia; forgetful, unable to concentrate, odd

or irrational statements; strange use of words or way of speaking. (p. 7)

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

manifested through their speech. Some types of disorganized speech include:

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 –

Meaningless use of rhyming words. (Smith et al., 2019, p. 17)


CASE STUDY 7

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

ambition or drive, and so on.

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

he was getting very little sleep at night.

Identify the Stressors and Behaviors that Precipitated Current Hospitalization

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

was after a meeting with his church that he called EMS.


CASE STUDY 8

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

and to represent his kingdom.

Discuss Patient and Family History of Mental Illness

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

and he has also previously been admitted to Trumbull in 2014.

Describe the Psychiatric Evidence-Based Nursing Care Provided and Milieu Activities

Attended

As stated by Mahone, Maphis and Snow (2016), “Psychiatric nurses use a

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

asked us numerous times to pray for him.

Bernaciak, Farbicka, Jaworska-Czerwinska, and Szotkiewicz conducted a study regarding

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)

Evaluate the Patient Outcomes Related to Care

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

increase his attendance to and participation in therapeutic group sessions.

Summarize the Plans for Discharge


CASE STUDY 12

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.

Prioritized List of all Actual Diagnoses

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

beard, body malodorous, having not showered in several days

3.Self-neglect r/t psychosis AEB not showering, wearing dirty clothes, not sleeping to sleeping

very little at all each night, isolating self from others.

4.Social isolation r/t delusional thinking AEB pt. remaining in room reading his bible and

praying, not attending groups, not wanting to talk to others.

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

List of Potential Nursing Diagnoses

1.Risk for compromised human dignity r/t stigmatizing label.

2.Risk for loneliness r/t inability to interact socially.

3.Risk for powerlessness r/t intrusive, distorted thinking.

4.Risk for suicide r/t psychiatric illness.

5.Risk for self-directed violence r/t hallucinations and delusional thinking.

6.Risk for other-directed violence r/t psychotic disorder.

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

me extremely. It is not as common as some of the other types of hallucinations, is extremely

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

Competencies in Health Care – Jehovah’s Witnesses. Journal of Education, Health and

Sport, 9(3), 301-320. doi:http://dx.doi.org/zenodo.2597466

Bourque, J. et al. (June 2018). Frequent cannabis use may increase psychosis risk among teens.

Healio Psychiatry. doi:10.1001/jamapsychiatry.2018.1330

Mahone, I. H., Maphis, C. F., & Snow, D. E. (April 2016). Effective Strategies for Nurses

Empowering Clients With Schizophrenia: Medication Use as a Tool in Recovery. Issues

in Mental Health Nursing, 37(5), 372-379. doi:10.3109/01612840.2016.1157228

Smith, M., Robinson, L., & Segal, J. (November 2019). Schizophrenia Symptoms and Coping

Tips. Retrieved from https://www.helpguide.org/articles/mental-disorders/schizophrenia-

signs-and-symptoms.htm

Townsend, M.C., & Morgan, K. I. (2017). Essentials of Psychiatric Mental Health Nursing:

Concepts of Care in Evidence-Based Practice. Philadelphia, PA: F. A. Davis Company.


CASE STUDY 15

Case Study Comment Sheet 4842

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format

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