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Townsend, Essentials, 6e – Schizophrenia Case Study

Case Study: Schizophrenia

Caroline, age 22, was diagnosed with schizophrenia at age 19. She led a relatively normal life during school-age and high school years. She left her parents at age 17 to attend a college somewhat distant to her home. She apparently had no problems during her first year, but when she returned for Thanksgiving break during her second year, her parents noticed a distancing about her. She spent a lot of time alone, was irritable, and had begun chain smoking and drinking alcohol. She failed two courses that fall and was placed on probation. When she went back to school in the spring, her former roommate refused to stay with her, saying, “She acts so crazy sometimes. She talks out of her head, and I’m afraid of her.” In late February, Caroline’s parents got a call from the dean of students who related that the campus police had to be called to Caroline’s room to quiet her. She had been “yelling and screaming” and no one could understand what it had all been about. She had apparently really frightened the other students in the dormitory. These bizarre behaviors continued, and during spring break in March, Caroline’s parents moved her home and made an appointment with a psychiatrist for an evaluation. During the assessment, Caroline’s thought processes were loose, vague, and often circumstantial. She exhibited behaviors that suggested auditory hallucinations (stopping mid-sentence and “cocking” her head to the side as if listening), although when questioned about whether or not she heard voices, she denied it. Paranoid delusional thinking was evident. She made statements such as, “There is no one I can trust at that college. Every student in that dorm has been told to keep an eye on me. They all know I am too smart to be there, so they will do what they can to make me fail. If I pass, then everyone else fails.” She also expressed somatic delusions: “I’m pregnant, you know. It will be a virgin birth.

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Townsend, Essentials, 6e – Schizophrenia Case Study

That’s another reason the college kids are out to get me. They are so jealous! I am the chosen one.” Since that time, she has been on several antipsychotic medications (chlorpromazine, clozapine, and risperidone), each with only minimal success, and which she would eventually quit taking altogether. She currently lives at home with her parents, who are beside themselves with concern and frustration. The psychiatrist has admitted Caroline to the hospital at this time to evaluate her behavior and to begin her on a trial of fluphenazine decanoate, which will eventually be administered only every 3 weeks by IM injection, in an effort to encourage increased medication compliance on Caroline’s part. 1. What symptoms do you see? Complete the nursing mental status component of assessment form. -

Caroline is exhibiting symptoms of attitude and behavioral changes as well as altered perception and thought processes Caroline’s behavior was first noticed by her parents as distant, irritable and spending a lot of time alone. Its later progress to Caroline yelling and screaming for no apparent reason as stated by her roommate. Caroline’s thoughts became loose vague and often circumstantial. Although she denied auditory hallucinations, she exhibited behavior that would suggest otherwise. She also expressed paranoid and somatic delusions thinking that she was pregnant although she was a virgin and that people were out to get her.

2. Based on this initial phase of the intake interview alone, what symptoms are already suggested in her behavior that would be significant in terms of potential psychosis or schizophrenia? -

Based on the initial interview some of Caroline’s symptoms that suggested potential psychosis and schizophrenia were that her thoughts became loose vague and often circumstantial. Although she denied auditory hallucinations, she exhibited behavior that would suggest otherwise like “cocking” her head to the side as if she was listening. Other symptoms she exhibited were paranoid delusional thinking, stating “There is no one I can trust at that college. Every student in that dorm has been told to keep an eye on me. They all know I am too smart to be there, so they will do what they can to make me fail. If I pass, then everyone else fails.” And lastly Caroline expressed somatic delusions thinking she was pregnant although she was a virgin.

3. List negative and positive symptoms of schizophrenia. - Negative: Withdrawal from social situations, flat affect, lack of speech, difficulty with activities of daily living - Positive: Trouble concentrating, Delusion, movement disorder, hallucinations, confused thoughts. 4. What are command hallucinations?

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Townsend, Essentials, 6e – Schizophrenia Case Study -

Command hallucinations are usually auditory but can also be visual hallucinations that tells the patient to act in specific ways. These commands can range from mild to potential life threatening.

5. Develop 3 Nursing care plans with 3 interventions for each and one short term outcome and prioritize them for this case.

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Impaired social interaction related to feeling threatened in social situations as evidence by verbalized observed discomfort in social situations. Interventions:  Identify with client symptoms she experiences when she begins to feel anxious around others.  Keep client in an environment as free of stimuli as possible  Structure activities that work at the client’s pace and activity. Short term goal:  Patient will use appropriate social skills and interactions within 1 week of therapy.

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Disturbed sensory perception related to psychological barriers as evidenced by difficulty communicating thoughts verbally. Interventions: 

Keep environment calm, quiet, and as free of stimuli as possible.

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Use clear or simple words and keep directions simple as well.

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Focus on and direct client’s attention to concrete things in the environment.

Short term goal: 

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Patient will demonstrate reality-based thought process in verbal communication within the first week of therapy.

Disturbed though process related to mental disorder as evidence by inappropriate social behavior. Interventions:  Schedule structured activity and rest period  Maintain a pleasant and quiet environment and approach patient in a slow and calm manner.  Be consistent in setting expectations, enforcing rules, and so forth. Short term goal:

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Townsend, Essentials, 6e – Schizophrenia Case Study 

Patient uses coping strategies to deal with effectively with hallucinations/delusions within 1 week of therapy.

6. Identify 3 typical antipsychotics, the use and side effect. Identify 3 atypical antipsychotics, the use and side effects. 7. Develop a Medication teaching plan on the medication that’s prescribed (fluphenazine decanoate). 8. What are some recovery Goals? a. Teach her family about Schizophrenia

General Description (Appearance) Motor Activity (Describe) Speech Patterns (Describe) General Disposition (Describe) Emotions (Mood and Affect) Thought Process (Form and content of thought) Perceptual Disturbances (Describe) Sensorium and Cognitive Ability (Orientation) Impulse Control (Agitation) Judgment and Insight (Awareness)

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