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 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 Report Patient information Contact information Responsible party information

Patient What are the nurse’s next actions involving the patient?

Patient 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 Labs Toxicity screen Contact parents Psych history

Labs/diagnostics ordered 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 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 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 Negative 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

Video clip http://www.youtube.com/watch?v=rCbf-pKtkhU

Lab results 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: 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 Metabolic Syndrome 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 Notify the physician Vital signs B/P 188/96 P 110 R 28 T 101

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 Situation Background Assessment Recommendation 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 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.

Lab notifies you of patient’s What is the nurse’s next action? 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 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)

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?