Schizophrenia

1
Schizophrenia

• Unfolding Case Study
• By Amanda Eymard, DNS, RN
• and Linda Manfrin-Ledet, DNS, APRN

2
Assigned Reading to be completed prior to case
study

• Prior to conducting this unfolding case study,
  students should read the following
• Riordan, H., Antonini, P., Murphy, M. (2011).
  American Health Drug Benefits, 4(5), 292-302.
• Stuart, G. (2009). Principles and Practice of
  Psychiatric Nursing. (9th ed.) Chapter 20, pages
  334-368.

3
Introduction

• A patient is being transported to the local
  emergency department (ED) by the police. The
  nurse receives in report that the mans neighbors
  reported he was standing in the middle of the
  street, yelling out, waving his hands, and acting
  crazy. When the police arrived, he would not
  speak to them and attempted to hit them with a
  baseball bat. He was yelling, Where is Jesus? I
  need to see Jesus!! All of you devil worshippers
  need to leave me alone!!

4
Continued

• The police handcuffed the patient and transported
  him to your local ED. What law allows the police
  to transport the patient to the hospital against
  his will?

5
Theory Burst

• police power- state must protect the community
• parens patriae powers- state must provide care
  for those who cannot care for themselves
• (Stuart, 2009)

6
Reflect on the patient

• What is the patient possibly experiencing right
  now?
• Reflect on how this patient possibly feels at
  this time.

7

• The patient arrives at the ED at 1pm where you
  are working as an RN. The police bring the
  patient in and assist him to a stretcher. What
  are the nurses next actions involving the police?

8
Police

• Report
• Patient information
• Contact information
• Responsible party information

9
Patient

• What are the nurses next actions involving the
  patient?

10
Patient

• Safety
• Information
• Assess immediate needs
• Vital signs
• Triage
• One-on-one
• Insurance

11

• The police tell the nurse they suspect the man
  has been drinking or possibly high on
  something. They tell the nurse the patient lives
  with his elderly parents. His parents reported
  they are scared of him and dont want him to
  return to their house. He is indigent and they
  cant afford to support him anymore.

12

• Based on the polices input, what additional
  information does the nurse need?

13
Answer

• Labs
• Toxicity screen
• Contact parents
• Psych history

14
Labs/diagnostics ordered

• CBC
• CMP
• U/A
• EKG
• RPR
• HIV
• Toxicity screen
• Chest x-ray

15
Additional information

• Physician also orders one on one observation
• Vital signs 128/86, P94, R24, T99.0

16

• Patient continues with religious comments,
  disoriented, paranoid, isolative, appears to be
  talking to the wall, grabs out as if petting an
  animal. His appearance is disheveled, apparent
  body odor noted, soiled clothing, wearing
  multiple shirts and large coat despite it being
  98 degrees outside. He is unable to tell the
  nurse when he last bathed, doesnt know his
  address, or medical history. He only knows his
  name. States he is a messenger from God sent to
  rid the world of evil people with his magic
  baseball bat.

17

• What is the probable Axis I diagnosis for this
  patient based on information presented thus far?

18
Answer

• Psychosis NOS

19
Family contact

• The patients parents return the nurses phone
  call and the nurse is eager to gather additional
  information. What are the nurses most pertinent
  questions for the patients parents?
• Pick up your phone and role model your
  conversation with the parents.

20
Answer

• Psych history
• Medication/medical history
• Allergies
• Last admission
• History of violence
• Suicide attempts
• Currents meds
• Physician

21
Patient information from parents

• His parents tell the nurse he was first diagnosed
  with schizophrenia when he was 27 years old. His
  first psychotic break was while he was in
  college. He didnt complete college due to his
  illness. He has lived with them since leaving
  college. He is not employed. He tried to get a
  job several times, but never kept one.

22
Continued

• He goes to the local mental health unit (MHU) for
  Haldol D depot injections q8weeks. He is allergic
  to peanuts and seafood. He has attempted to kill
  himself on three separate occasions and has been
  violent toward his parents multiple times. This
  is why they dont want him back in their home.
  They are both in their 70s. They state he sees no
  physician regularly and often misses his
  appointments at MHU.

23
Other medications and additional history

• Cogentin (benztropine) 1mg PO QHS
• Seroquel (quetiapine) 200mg PO BID
• Desyrel (trazadone) 100mg PO QHS
• History of HTN, uncontrolled DM with high blood
  glucose levels, and elevated cholesterol, all
  untreated.
• Any additional information needed??

24
Answers

• Previous psychiatric admission information
• Medications prescribed previously?
• Any suicide attempts?
• Any substance abuse?
• Any history of violence?
• Any previous arrests?

25
Theory Burst

• Schizophrenia
• 1 of population has schizophrenia
• Most common psychotic disorder
• Often results in chronic illness
• Increased risk of suicide
• Increased risk factor with positive family
  history of schizophrenia
• First break- adolescence or young adulthood
• Neurotransmitter involved- Dopamine
• MRI, CT changes- very large ventricles atrophy
  of brain tissue (Stuart, 2009)

26
Theory Burst

• Positive signs
• Hallucinations
• Psychosis
• Illusions
• Agitation
• Hostility
• Bizarre behaviors
• Association disturbances

• Negative signs
• Restricted emotion
• Social withdrawal
• Dependency
• Lack of ego boundaries
• Concrete thought processes
• Lack of self care
• Sleep disturbance

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Video clip
http//www.youtube.com/watch?vrCbf-pKtkhU
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Lab results

• Negative tox screen
• Reactive RPR
• CBC wnl
• Blood glucose 385
• HIV negative

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PEC (Physicians emergency certificate)

• At 4pm, the physician decides patient will be
  PECd and transferred to a local mental health
  hospital.
• What is the maximum time the PEC can hold the
  patient against his will?
• What reasons can a patient be held with a PEC?
• What reason(s) can this patient be held?

30
Answers

• He can be held a maximum of 72 hours with the
  PEC.
• If necessary to hold longer, a CEC or FVA must be
  instituted.
• Homicidal, suicidal, or gravely disabled are all
  reasons to legally PEC someone.
• This particular patient is both homicidal and
  gravely disabled.

31

• The patient becomes very angry and agitated when
  he is told that he is being transferred to the
  psych hospital. He becomes very loud and begins
  threatening the ED staff.
• The physician orders Haldol 10mg IM at 430pm.

32
Administering the med

• Calculation
• Med available Haldol 2mg/ml
• How many mls will the nurse administer??
• Where will the nurse administer the injection??

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Answer

• 2mg1ml 10mgx
• Answer 5ml
• Gluteal muscle

34
Calling report (SBAR)

• The nurse is calling report to the psychiatric
  unit. Using the SBAR technique, please pick up
  the phone and call report to the receiving nurse.

35

• Situation
• Background
• Assessment
• Recommendation

36
Discussion

• What is the worst thing that could happen to this
  patient??

37

• Patient is transported via ambulance to the local
  mental health hospital.

38
Mental Health Hospital

• The nurse is now the RN receiving the patient
  from the local ED. The patient is thrashing about
  on the stretcher. The unit is short-staffed, so
  the nurse decides to receive the patient with the
  assistance of one other staff member. Upon
  transferring him to the bed on the unit, he grabs
  the nurses neck and attempts to choke the nurse.

39

• A staff member grabs the restraints and calls a
  code over the intercom.
• Physician is notified.
• Physician orders four point restraints.
• Patient is restrained.
• Physician orders Haldol 10mg IM stat.

40
Pause to think

• What should the nurse be worried about?
• What action will the nurse take?
• What could have been done differently?

41

• Patient becomes calm after being in four point
  restraints for two hours.
• Restraints are released by the nurse.
• What is the proper technique for doing this?
• What safety concerns should the nurse have?

42
Proper Technique for releasing restraints

• Restraints should be released one extremity at a
  time.
• The nurse releasing the restraints should
  alternate between lower and upper extremities.
• For example, release the left lower extremity,
  followed by the right upper extremity.

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Safety Concerns

• Potential retaliation by the patient
• Continued violence after release of restraints
• Safety of patient
• Fall risk due to Haldol
• Potential harm to self
• Safety of other patients on unit
• Safety of staff

44
Safety huddle

• Review the event
• How could team have worked better together?
• What did team members do well?

45
Lab report

• Lab calls with lab values of
• Blood glucose 412
• Total cholesterol 200
• HDL/HDL-C35
• LDL 130
• Triglycerides 150
• Total cholesterol/HDL ratio 4.2
• What should the nurse do?

46

• Read back to lab and verify lab values
• Notify physician

47
Notify the physician (SBAR)

• Situation
• Background
• Assessment
• Recommendation

48
Theory Burst

• The patient has borderline high total
  cholesterol, LDL, triglycerides, a total
  cholesterol/HDL ratio, and a normal HDL. These
  levels need to be monitored. This patient is at
  risk of developing metabolic syndrome due to side
  effects of psychotropic medications
• Metabolic Syndrome
• a group of risk factors that occur together and
  increase the risk for coronary artery disease,
  stroke, and type 2 diabetes
• (Jakopac and
  Patel, 2009)

49
Notify the social worker (SBAR)

• The physician orders a social worker consult for
  placement options for the patient. The nurse
  notifies the social worker using SBAR format.
  Pick up the phone and notify the social worker.
• Situation
• Background
• Assessment
• Recommendation

50

• The patient is on the unit and appears very
  agitated hitting on the walls, yelling out.
• The Medication Administration Record (MAR) has
  Haldol 5mg IM ordered q2h PRN agitation.
• The nurse delegates the LPN to administer the
  injection.

51

• One hour later, the patient continues to be
  agitated.
• What is the nurses next action??

52
Nurses next action

• Take vital signs/assess the patient
• Notify the physician

Vital signs B/P 188/96 P 110 R 28 T 101
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• What do you suspect??

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Answer/Theory burst

• Neuroleptic malignant syndrome
• a potentially fatal adverse reaction of
  antipsychotic medications with symptoms of fever,
  tachycardia, muscle rigidity, sweating,
  catatonia, and a change in mental status.
• especially seen with high potency medication
  doses
• RX support, cool, hydrate
• (Stuart, 2009)

55
Notify physician

• Pick up the phone and notify the physician of
  assessment and findings. Remember, its ok to
  CUS!!
• Situation
• Background
• Assessment
• Recommendation

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What is the recommendation?

• Suspect NMS
• Request CPK level

57

• Patient is treated with cooling blankets, IV
  fluids, and acetaminophen.
• What else did we miss?

58

• NO MORE HALDOL (haloperidol)!!!!!
• NO MORE ANTIPSYCHOTICS!!!

59

• Patients vital signs are stable. He is alert,
  and oriented to person only.
• Physician now orders Clozaril (clozapine) 12.5 mg
  PO 2xdaily and Geodon (ziprasidone) 10mg IM PRN
  q2h not to exceed 40mg/day.

60

• A few days have passed.
• Lab notifies you of patients
• WBC value of 3.2
• What is the nurses next action?

61
Nurses next action

• Read back and verify.
• Notify physician.

62
Call physician (SBAR)

• Situation
• Background
• Assessment
• Recommendation

63
Theory burst

• Normal WBC 5-10
• Clozaril potential side effect/reaction
• agranulocytosis (1-2 of patients!)
• Therefore, patient needs weekly CBCs first 6
  months, then every two weeks for 2 months. Also,
  for 4 weeks after Clozaril is discontinued.
• 7 day only prescription
• increased risk of seizures
• Warn clients to notify the prescriber about a
  sore throat, bleeding gums, or any other signs of
  infection.
• (Stuart, 2009)

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New physicians orders

• Clozaril discontinued
• Risperdal (risperidone) 1mg 2xdaily ordered

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Moment to pause- patient centered care

• How can the nurse include the patient in decision
  making processes?
• How can the nurse empower the patient?

66

• Include the patient in his plan of care
• Include the patient in decision making

67

• Due to history of poor medication compliance, the
  halfway house that is considering accepting the
  patient is requesting assurance of patients
  ability to maintain med compliance.
• What can the nurse recommend to physician?

68
Answer/Theory burst

• Risperdal consta
• Long acting depot injections
• Benefits
• Cautions

69

• The nurse is concerned about the high cost of
  Risperdal consta
• What can the nurse do?
• What is the nurses next action?

70
Answer

• Contact social worker
• Assistance with medications
• Indigent patient programs with pharmaceutical
  companies
• Contact MHU
• Apply for Medicare/ Medicaid

71

• The nurse is assigned another admission and has 4
  patients left to chart on, and has 4 left to
  administer medications. The nurse is the only RN
  on the unit and has 2 LPNs working with the team.
  Delegate tasks to each LPN accordingly.

72

• Patient is oriented to self and place, speaking
  more coherently.
• Patient reports his mouth feels as if he is
  chewing something. The nurse assesses his mouth
  for food or gum. Nothing is observed. What
  further assessment can the nurse do?

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Answer/Theory burst

• Abnormal Involuntary Movement (AIMs) Scale
• Any score above zero should be further
  investigated
• EPS- Extrapyramidal Symptoms
• Medications used to treat EPS
• Possible side effects of meds used to treat EPS
  (anticholinergic)

74
Family

• The patients parents arrive on the unit to
  visit.
• What are the nurses concerns?
• What safety concerns should the nurse have?
• What can the nurse do next?

75
Nursing diagnoses

• What are possible nursing diagnoses that would be
  applicable to this patient throughout his
  hospitalization?

76
Possible Answers

• Impaired thought processes related to possible
  hereditary factors, delusional thinking,
  hallucinations or inaccurate interpretation of
  the environment
• Anxiety related to inaccurate interpretation of
  the environment, unfamiliar environment,
  repressed fear, or panic level of stress
• Individual ineffective coping related to
  inability to trust, low self-esteem, or
  inadequate support systems
• Social isolation related to lack of trust,
  regression to earlier level of function,
  delusional thinking, or past experiences of
  difficulty in interactions with others
• Risk for violence, self-directed or directed
  toward others related to lack of trust, panic
  level anxiety, command hallucinations, delusional
  thinking, or perception of the environment as
  threatening
• (Stuart, 2009)

77
Continued possible answers

• Impaired sensory-perceptual auditory/visual
  related to hallucinations, delusional thinking,
  withdrawal into self or perception of the
  environment as threatening
• Impaired verbal communication related to
  inability to trust, regression to earlier level
  of development, or disordered and unrealistic
  thinking
• Self-care deficit (specify) related to withdrawal
  into self, regression to earlier level of
  development, perceptual or cognitive impairment
• Sleep pattern disturbance related to repressed
  fears, hallucinations, or delusional thinking
• Chronic low self-esteem related to withdrawal
  into self, lack of trust, poor socialization
  skills, or chronic illness
• (Stuart, 2009)

78

• The social worker notifies the nurse that she has
  secured halfway house placement for the patient.
• Appointment has been made with MHU for next
  Risperdal consta injection.
• Transportation will be provided by the halfway
  house to the MHU.
• Patients brother calls the unit and states he
  forgot his brothers ID and wants to know when
  his brother will be discharged. He wants to bring
  him his clothes and other belongings.
• Pick up the phone and respond to the brothers
  call.

79
Theory burst

• HIPPA
• Health Information Privacy Security Rule
• Protects the privacy of individually identifiable
  health information
• Sets national standards for the security of
  electronic protected health information
• http//www.hhs.gov/ocr/privacy/

80

• What should the nurse be worried about for this
  patient?
• What are the nurses concerns?

81
Discharging the patient

• The patient is discharged.
• He is appropriate, friendly, sleeping 8 hours
  each night, oriented x4.
• The nurse calls report to the halfway house using
  SBAR.
• Situation
• Background
• Assessment
• Recommendation

82
Reflection- patient centered care

• What is the patient possibly thinking at
  discharge?
• How is the patient possibly feeling?
• How are the patients parents possibly feeling
  right now?