Schizophrenia
Unfolding Case Study
By Amanda Eymard, DNS, RN
and Linda Manfrin-Ledet, DNS, APRN
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.
Introduction
 A patient is being transported to the local
emergency department (ED) by the police. The
nurse receives in report that the man’s
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!!”
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?
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)
Reflect on the patient
 What is the patient possibly experiencing
right now?
 Reflect on how this patient possibly feels
at this time.
 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 nurse’s next
actions involving the police?
Police
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Report
Patient information
Contact information
Responsible party information
Patient
 What are the nurse’s next actions
involving the patient?
Patient
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Safety
Information
Assess immediate needs
Vital signs
Triage
One-on-one
Insurance
 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 don’t want him to return to their
house. He is indigent and they can’t
afford to support him anymore.
 Based on the police’s input, what
additional information does the nurse
need?
Answer

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Labs
Toxicity screen
Contact parents
Psych history
Labs/diagnostics ordered
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CBC
CMP
U/A
EKG
RPR
HIV
Toxicity screen
Chest x-ray
Additional information
 Physician also orders: one on one
observation
 Vital signs: 128/86, P94, R24, T99.0
 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, doesn’t 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.
 What is the probable Axis I diagnosis for
this patient based on information
presented thus far?
Answer
 Psychosis NOS
Family contact
 The patient’s parents return the nurse’s
phone call and the nurse is eager to
gather additional information. What are
the nurse’s most pertinent questions for
the patient’s parents?
 Pick up your phone and role model your
conversation with the parents.
Answer
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Psych history
Medication/medical history
Allergies
Last admission
History of violence
Suicide attempts
Currents meds
Physician
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
didn’t 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.
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 don’t
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.
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??
Answers
 Previous psychiatric admission
information
 Medications prescribed previously?
 Any suicide attempts?
 Any substance abuse?
 Any history of violence?
 Any previous arrests?
Theory Burst
 Schizophrenia
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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)
Theory Burst
 Positive signs
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Hallucinations
Psychosis
Illusions
Agitation
Hostility
Bizarre behaviors
Association
disturbances
 Negative signs
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Restricted emotion
Social withdrawal
Dependency
Lack of ego
boundaries
 Concrete thought
processes
 Lack of self care
 Sleep disturbance
Video clip
www.youtube.com/w
atch?v=rCbf-pKtkhU
http://
Lab results
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Negative tox screen
Reactive RPR
CBC wnl
Blood glucose 385
HIV negative
PEC (Physicians’
emergency certificate)
 At 4pm, the physician decides patient will
be PEC’d 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?
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.
 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
4:30pm.
Administering the med
 Calculation
 Med available Haldol 2mg/ml
 How many mls will the nurse administer??
 Where will the nurse administer the
injection??
Answer
 2mg:1ml= 10mg:x
 Answer= 5ml
 Gluteal muscle
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.
 Situation
 Background
 Assessment
 Recommendation
Discussion
 What is the worst thing that could happen
to this patient??
 Patient is transported via ambulance to
the local mental health hospital.
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 nurse’s neck and attempts to
choke the nurse.
 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.
Pause to think
 What should the nurse be worried about?
 What action will the nurse take?
 What could have been done differently?
 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?
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.
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
Safety huddle
 Review the event
 How could team have worked better
together?
 What did team members do well?
Lab report
 Lab calls with lab values of:
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Blood glucose 412
Total cholesterol 200
HDL/HDL-C=35
LDL= 130
Triglycerides= 150
Total cholesterol/HDL ratio= 4.2
 What should the nurse do?
 Read back to lab and verify lab values
 Notify physician
Notify the physician
(SBAR)
 Situation
 Background
 Assessment
 Recommendation
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)
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
 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.
 One hour later, the patient continues to
be agitated.
 What is the nurse’s next action??
Nurse’s next action
 Take vital signs/assess the patient
Vital signs
B/P 188/96
P 110
R 28
T 101
 Notify the physician
What do you suspect??
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)
Notify physician
 Pick up the phone and notify the physician of
assessment and findings. Remember, it’s ok to
CUS!!
 Situation
 Background
 Assessment
 Recommendation
What is the
recommendation?
 Suspect NMS
 Request CPK level
 Patient is treated with cooling blankets,
IV fluids, and acetaminophen.
 What else did we miss?
 NO MORE HALDOL (haloperidol)!!!!!
 NO MORE ANTIPSYCHOTICS!!!
 Patient’s 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.
 A few days have passed.
 Lab notifies you of patient’s
 WBC value of 3.2
 What is the nurse’s next action?
Nurse’s next action
 Read back and verify.
 Notify physician.
Call physician (SBAR)
 Situation
 Background
 Assessment
 Recommendation
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)
New physician’s orders
 Clozaril discontinued
 Risperdal (risperidone) 1mg 2xdaily
ordered
Moment to pause- patient
centered care
 How can the nurse include the patient in
decision making processes?
 How can the nurse empower the patient?
 Include the patient in his plan of care
 Include the patient in decision making
 Due to history of poor medication
compliance, the halfway house that is
considering accepting the patient is
requesting assurance of patient’s ability
to maintain med compliance.
 What can the nurse recommend to
physician?
Answer/Theory burst
 Risperdal consta
 Long acting depot injections
 Benefits
 Cautions
 The nurse is concerned about the high
cost of Risperdal consta
 What can the nurse do?
 What is the nurse’s next action?
Answer
 Contact social worker
 Assistance with medications
 Indigent patient programs with
pharmaceutical companies
 Contact MHU
 Apply for Medicare/ Medicaid
 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.
 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?
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)
Family
 The patient’s parents arrive on the unit to
visit.
 What are the nurse’s concerns?
 What safety concerns should the nurse
have?
 What can the nurse do next?
Nursing diagnoses
What are possible nursing diagnoses that
would be applicable to this patient
throughout his hospitalization?
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 selfesteem, 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)
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)
 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.
 Patient’s brother calls the unit and states he
forgot his brother’s 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 brother’s
call.
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/
 What should the nurse be worried about
for this patient?
 What are the nurse’s concerns?
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
Reflection- patient centered
care
 What is the patient possibly thinking at
discharge?
 How is the patient possibly feeling?
 How are the patient’s parents possibly
feeling right now?