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Running Head: COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Valerie Kinsey

Youngstown State University

Abstract

This study will explore the life of a patient at Trumbull Memorial Hospital on the

Psychiatric Unit. The patient was diagnosed with Paranoid Schizophrenia. The study will focus

on objective data of the patient’s admission, give a brief summarization of what Paranoid

Schizophrenia entails, and identify the patient’s stressors/behaviors. It will continue on to

discussing the patient and family history of mental illness. The study will describe the

psychiatric evidence-based nursing care provided including the milieu activities the patient has

attended, a prioritized list of all actual diagnoses using individualized NANDA format, and list

all potential nursing diagnoses that could affect the patient. It will also analyze ethnic, spiritual,

and cultural influences that have an impact on the patient. Last, it will evaluate the patient

outcomes related to care and summarize the plans for discharge.

Objective Patient Data

K.F. is a 52-year-old male patient on 3 South, the Psychiatric Unit, located at Trumbull

Memorial Hospital. He was admitted on September 27, 2019. This study examines his date of

care on October 1, 2019. He was diagnosed with Paranoid Schizophrenia with depression and

delusional disorder. He also has a tobacco dependency. He has a known allergy to penicillin.

During his care at the hospital, he is under unit restrictions and patient self-harm precautions. He

was brought in under police hold and is now under outpatient commitment with forced

medications determined by a court hearing.

The hospital had received labs at time of admission which came back normal. Labs that

were focused on that have been connected to mental illness include WBC, RBC, Hemoglobin,

Hematocrit, AST, ALT, Glucose, TSH, T4 which were all within normal limits. His toxicity

screen was negative.

Summarize the Psychiatric Diagnoses/ Identify the Stressors and Behaviors

The patient was diagnosed with Paranoid Schizophrenia. According to the textbook

Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice,

“The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The word

was derived from the Greek ‘skhizo’ (split) and ‘phren’ (mind),” (Townsend & Morgan, 2017. p

341). The author goes on to explain that schizophrenia has been described by various definitions

that have evolved. Multiple treatment strategies have been attempted, but none of them have

been proved to completely eliminate the schizophrenic symptoms or cure the disorder.

Schizophrenic disorders could be caused by genetics, biochemical dysfunctions, physiological

factors, and psychological stress. The patient may present positive and/or negative symptoms.
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Positive symptoms include: delusions, religiosity, paranoia, magical thinking, associative

looseness, neologisms, concrete thinking, clang associations, word slang, tangentiality,

circumstantiality, mutism, preservation, hallucinations, illusions, echolalia, echopraxia,

depersonalization, identification and imitation. Negative symptoms include: inappropriate affect,

bland or flat affect, apathy, inability to initiate goal-directed activity, emotional ambivalence,

emotional ambivalence, deteriorated appearance, impaired social interaction, social isolation,

anosognosia, anergia, waxy flexibility, posturing, pacing/rocking, anhedonia, and regression,

(Townsend & Morgan. 2017).

The patient was also diagnosed with delusional disorder which is, “characterized by the

presence of delusions that have been experienced by the individual for at least 1 month.”

(Townsend & Morgan. 2017. p 347). Delusional disorder can be broken into subtypes such as

erotomanic, grandiose, jealous, persecutory, somatic, and mixed. This patient mostly follows

under the persecutory and somatic type.

Persecutory type is when individuals believe they are being persecuted or malevolently

treated in some way (Townsend & Morgan. 2017. p 348). For example, an individual may

believe that they are being plotted against by a group of people. Marco M. Picchioni and Robin

M. Murray, who are clinical professors of psychiatry, wrote an article that states, “People with

schizophrenia typically hear voices (auditory hallucinations), which often criticize or abuse

them. The voices may speak directly to the patient, comment on the patient's actions, or discuss

the patient among themselves. Not surprisingly, people who hear voices often try to make some

sense of these hallucinations, and this can lead to the development of strange beliefs or

delusions” (Picchioni & Murray. 2007). They go on to explain that these patients have negative
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symptoms which causes a lot of stress on the patients and on the family members. This is very

true in this case.

In this case, the patient (K.F.) believes that the hospital is out to get him by stating, “This

place is committing fraud and we need to call the FBI because I do not believe that I have a

mental illness and do not need to be injected with medications. They are holding me against my

will and this is kidnapping.” The patient believes that he also is, “On active duty but sometimes

I am inactive,” from the military. He states that he has secret intel in code for the cure of cancer

that needs to be given to the military as soon as possible. The patient was found by the police at

the Vienna Airforce Base trying to give the military secret intel for the cure for cancer. The

police then took him to the hospital to get psychiatric treatment.

Somatic type is when individuals believe they have some type of general medical

condition. In this case, the patient believes that he has “New Life Light Bulb Cancer” which he

describes as a type of cancer that an individual that you get from not doing stuff with yourself.

You must either create a new life for themselves or reconnect with their family to treat the

cancer. He diagnosed himself with this cancer in 2013. However, when he went to the hospital

no doctors would listen to him and diagnose him with the cancer. He decided to move to

Colorado to reconnect with his son to help cure his cancer. He states that the Colorado air

helped cure his cancer and he went into remission in 2014.

Discuss Patient and Family History of Mental Illness

The patient has a history of psychiatric hospitalizations. He was admitted three times at

Trumbull Memorial Hospital, two times at Trumbull Medical, and one admission at Northside

Hospital. Those are the only hospitalizations on record during the time he has lived in Ohio. He
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also has a history of being treated at Valley Counseling 13 years ago. The record does not state

any hospitalizations during the time of living in Colorado.

The record does not share much information about family history of mental illness. It

states he is divorced and has two children. His daughter lives in Akron and is not part of his life.

His son lives in Colorado and has filed a restraining order against him for unknown reasons as

stated by the patient. His parents are both deceased. He has one brother who lives in North

Carolina.

He was born in Austintown and lived there until the age of 5. He moved to Pennsylvania

until the age of 14, then resided in Boardman until moving to Colorado to reconnect with his son.

Recently, he was staying at Warren Family Mission when he came back to Ohio. Warren Family

Mission can no longer allow him to reside in their care, so currently he is without a home. He

has received his GED from high school and has some college education in electrical engineering.

He is unemployed and homeless currently. The patient has a history of cocaine and marijuana

use but he states he has not used since 2007. He is tobacco dependent currently. He has a

domestic violence charge in 2000 that was marijuana related which he served three and a half

years in a jail in Ohio. His second domestic violence charge was in 2013 against his son in

Colorado, who filed a restraining order at this time, which led to him serving four months in a

jail in Colorado.

Describe the Psychiatric Evidence-Based Nursing Care Provided

Psychiatric evidence-based nursing care has been provided to the patient since his

admission. The assessment data collected on date of care is as follows: the patient appears to

have an angry facial expression while expressing his feelings towards his admission. He holds a

very tense posture, especially while in the presence of others. He dresses carelessly with unkept
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hair and an unkept beard. He seems restless during conversation and when alone he has an

urgent need to move. He paces while he is thinking about concerns in his head. He is friendly

toward the staff while just speaking to them. However, he is very suspicious of the work of the

staff. He begins to worry while sharing if a staff member is writing assessments down because

he believes that he is on active duty in the military and his information is confidential. He also

has stated about how he cannot share during group therapy because of the confidentiality to his

active duty in the military. He seems very suspicious of others. His speech was clear but

tangential. The cadence of his speech got faster, and his tone got louder if he was talking about

something that frustrated him. Speech was normal when he was calm. He seemed anxious and

agitated with the treatment he was receiving because he believes that he does not have paranoid

schizophrenia. He believes that his doctors diagnosed him after having a bad reaction to laced

marijuana. His cognition shows circumstantiality, tangentiality, flight of ideas, perseveration,

delusions (persecution and somatic), and loose association of thoughts.

The patient is being pharmacologically treated with several medications. The

psychological-related medications given include:

 benztropine mesylate (Cogentin)

o Dosage: 0.5 mg IM BID PRN or 0.5 mg PO q12h

 haloperidol (Haldol)

o Dosage: 5 mg IM q12h PRN or 5 mg PO q6h PRN

 hydroxyzine HCl (Atarax)

o Dosage: 50 mg PO q6h PRN

 hydroxyzine pamoate (Vistaril)

o Dosage: 50 mg IM q6h PRN

 paliperidone (Invega)

o Dosage: 3 mg PO daily and/or 6 mg PO qHS

 trazodone HCl (Trazodone)

o Dosage: 50 mg PO qHS PRN

Cogentin is an anticholinergic medication usually given to patients who have Parkinson’s

Disease. Psychiatric patients are usually given this medication to prevent or treat Extrapyramidal

symptoms (EPS) which are involuntary movements. EPS is a side effect to many antipsychotic

medications. According to authors of an article called Extrapyramidal Symptoms (EPS),

“Centrally-acting, dopamine-receptor blocking agents, namely the first-generation

antipsychotics haloperidol and phenothiazine neuroleptics, are the most common

medications associated with EPS. While EPS occurs less frequently with atypical

antipsychotics, the risk of EPS increases with dose escalation. Other agents that

block central dopaminergic receptors have also been identified as causative of

EPS, including anti-emetics (metoclopramide, droperidol, and

prochlorperazine), lithium, serotonin reuptake inhibitors (SSRIs), stimulants, and

tricyclic antidepressants (TCAs)” (D’Souza and Hooten, 2019).

Haldol is given for acute psychotic behaviors. Atarax and Vistaril is to treat anxiety and

agitation. Invega is an antipsychotic medication. Lastly, Trazodone is an antidepressant given

usually for insomnia.

Medications given in a psychiatric unit are usually ordered two different ways: by mouth

(PO) and intramuscular (IM) due to patients refusing to take their medications. When psychiatric

patients refuse to take their medications, they can become dangerous to themselves and others
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around them. This patient is ordered IM medications because when he first arrived he refused

pharmacological treatment. He did not believe that he had a mental illness and did not want the

medications. The hospital ordered a court hearing to be allowed to force medications. This often

happens to patients on psychiatric floors. This is called an outpatient commitment with forced

medications (OPC) which can hold a patient for 90 days. The steps taken to obtain a court

ordered forced medication order was described in an article called Psychiatry: Force of Law

written by James B. Gottstein,

“First, a court must find that important governmental interests are at stake.

Second, the court must conclude that involuntary medication will significantly

further those concomitant state interests. Third, the court must conclude that

involuntary medication is necessary to further those interests. The court must

find that any alternative, less intrusive treatments are unlikely to achieve

substantially the same results. Fourth, as we have said, the court must conclude

that administration of the drugs is medically appropriate, i.e., in the patient's best

medical interest in light of his medical condition. The specific kinds of drugs at

issue may matter here as elsewhere. Different kinds of antipsychotic drugs may

produce different side effects and enjoy different levels of success.” (Gottstein,

2002. Section 3).

Other treatments for this patient include milieu activities and group therapy. Essentials

of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice defines

milieu therapy as, “The word milieu is French for “middle”. The English translation of the word
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is “surroundings, or environment.” In psychiatry, therapy involving the milieu, or environment,

may be called milieu therapy, therapeutic community, or the therapeutic environment”

(Townsend & Morgan. 2017. p 172). Milieu therapy is used for this patient to create a safe,

comforting environment for the patient to encourage therapeutic healing during the time of

hospitalization. However, the patient did not want to interact with others in a group setting. He

would go to the group therapy sessions, but he would not want to participate. He would pass on

opportunities to share his feelings with the group. He stated that his life was confidential and

that he could not share the secret information because he is on active duty in the military.

Outside of group settings, he will share his experiences with a person in a one-on-one setting.

Analyze Ethnic, Spiritual and Cultural Influences

The patient did not share any ethnic, spiritual, or cultural influences during the time of

care. He was very suspicious of the staff. It was best to not ask very many questions and hope

he would answer most of the questions needed to be asked during the assessment. He was very

invested in his story and how he came to be in this situation that he did not express his feelings

towards ethnic, spiritual, or cultural influences.

Evaluate the Patient Outcomes

While evaluating the patient’s outcomes related to his care, it is noticeable that the patient

still does not believe that he has any form of mental illness. He struggles to understand why he

is at the health care facility and why staff is forcing him to take medications. The patient refuses

to participate in any group activities. However, he will share in a one-on-one setting. Paranoid

Schizophrenia is very hard to treat due to the loss of reality this patient faces. The staff has been

able to obtain the forced medication order, which has been effective. The patient does not want

to take the medications. However, he is taking them as of now. The patient believes that he is
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going to be discharged to Riverbend to be treated afterwards in a group home. However, the

facility is still discussing possible discharge options. They may be keeping the patient for a

while to observe the changes in his mental illness before discharging him. Depending on the

court order, it is believed that the hospital can keep him involuntary hold for 90 days.

Prioritized List of All Actual Diagnoses/ List of Potential Nursing Diagnoses

Actual Diagnoses Include:

 Paranoid Schizophrenia

 Delusional Disorder

 Depression

 Tobacco Dependency

Potential nursing diagnoses include:

 Disturbed sensory perception r/t panic anxiety

 Disturbed thought processes r/t delusional thinking

 Social isolation r/t delusional thinking

 Risk for violence: self-directed or other-directed r/t extreme suspiciousness

 Impaired verbal communication r/t unrealistic thinking

 Self-care deficit r/t perceptual or cognitive impairment

Conclusion

Paranoid Schizophrenia has impacted this patient’s life in drastic ways. This study has

been formed to evaluate the life of a patient with Paranoid Schizophrenia. It has focused on how

this disorder can affect the patient’s physical and psychological life. It shows how the patient’s

family is also affected by a psychiatric disorder. Lastly, the study has described and evaluated
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the evidence-based nursing care given to the patient and potential nursing diagnoses during the

date of care.

References

D’Souza. R. S., & Hooten W. M. (2019, January 9). Extrapyramidal Symptoms (EPS).

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534115/

Gottstein. J. B. (2002, November). Psychiatry: Force of Law. Retrieved from

http://psychrights.org/force_of_law.htm

Picchioni. M. M., Murray. R. M. (2007, July 14). Schizophrenia. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1914490/

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.