Schizophrenia disorder, substance abuse, and suicidal behavior in a female patient

Mental Health Case Study Connect

Key issues in this Case Study

A review of patient information reveals the following major issues;

Schizophrenia Disorder: This seems to be in relation to her daughter (aged one) being placed in a foster care facility by the Department of Family Services.

Substance/drug abuse: Patient overdosed on prescribed medicines -- Quetiapine and Sodium Valproate (nearly two weeks' dosage). She smoked an average of ten cigarettes a day, consumed marijuana, used intravenous (IV) amphetamine, and overindulged in drink for several years previously.

Suicidal tendency/attempts: Patient admits to consuming nearly two weeks' dosage of Quetiapine and Sodium Valproate (prescribed drugs) with suicidal intent; she also resorted to cutting her left wrist using a sharp knife. Old scars on her wrists are proof of earlier suicide attempts, as are overdosing on medicines, running at moving cars, and an attempt to swim at night in the sea.

Unipolar disorder with self-harming behaviors and psychotic characteristics

5. Mood swings also pointing to the disorder

Step 2 - question

Needed additional information

None

Step 3 - investigate

The disorder presented in this scenario

This case displays a primary schizophrenic disorder, which is an acute, chronic, disabling disorder of the brain, suffered by individuals throughout history. Roughly 1% of U.S. citizens have been inflicted by it. Affected persons may keep hearing voices that nobody else hears, and may feel that others can rule and dominate their thoughts, read what's in their minds, or even contrive to hurt them, thereby terrifying affected individuals and making them overly restless and distressed, or introverted. Schizophrenics may not talk sensibly and may remain without talking or moving for hours together. Schizophrenics, at times, appear to be perfectly alright, until they begin voicing their real thoughts (National Institute of Mental Health, 2009).

Clinical manifestations associated with this disorder?

The key characteristics of schizophrenia comprise distinctive symptoms and indications which have been occurring for an appreciable span of time within a month (or shorter if treated successfully); some schizophrenia signs persist for a minimum of half a year. There is no sole indicative symptom for the ailment. Rather, there may be numerous psychological realms of symptoms, like ideation, perception (hallucinations), reality testing (misapprehensions), feeling (inappropriate affect, flatness), thinking (loose associations), concentration, attention, judgment, behavior (disorganization, catatonia), and motivation (impaired intention, planning, and a volition) (Lehman, et al., 2010).

Schizophrenia's symptoms can be divided broadly into 3 categories, namely, positive, negative and cognitive.

Negative symptoms

These symptoms are linked to troubles with ordinary behaviors and emotions. Identifying them as symptoms of schizophrenia is difficult; they may be taken for conditions like depression. Negative symptoms include:

"Flat affect" (wherein an individual's face doesn't move or the individual speaks in a monotone or a dull voice)

Not taking pleasure in the small things of everyday life

Inability to initiate and carry on planned activities

Little talk, even if forced to mingle.

Those suffering from negative schizophrenia symptoms require assistance with routine activities. Often, they disregard simple personal hygiene; while others may perceive them to be indolent or reluctant to take care of themselves, these are actually symptoms of schizophrenia.

Cognitive symptoms

These are subtle symptoms, and it may be hard to identify them as schizophrenia symptoms. They are normally discovered only upon performance of other tests. They include:

Inadequate "executive functioning" (i.e. the ability to understand information and employ it in decision-making)

Problems with concentration / taking notice

Working-memory-related issues (or inability to instantaneously apply information learned).

These symptoms usually bring difficulties in jobs and leading normal lives. They may trigger intense emotional anxiety or pain (National Institute of Mental Health, 2009).

Common treatment options for this disorder

Schizophrenia treatment components that have proven successful include: antipsychotic medications, community treatment units, family education, psychosocial remedial treatment (clubhouses, planned peer support), case management, and supported housing and employment (Rosenberg, 2009).

Antipsychotic medicine, which is capable of facilitating a swift decline in symptoms' severity, is the foremost means to treating schizophrenic hallucinations. No more than 8% first-episode schizophrenics continue experiencing hallucinations of mild-moderate severity following continued treatment for a year. Drugs like amisulpride, olanzapine, quetiapine, and ziprasidone show equal effectiveness against the problem of hallucinations; haloperidol, however, can be a little less effective (Sommer, et al., 2012).

The ailment, schizophrenia comes under the category of brain diseases, rather than psychological complaints, and therefore, the fundamental course of treatment followed here is use of medication. However, research reveals that a treatment plan combining psychosocial therapy with medicines is more effective with respect to prevention of relapse, as compared to routine care (medicine, observation, and rehab access). An integrated treatment approach for facilitating assuagement of psychotic symptoms can include:

Administering antipsychotic drugs with monitoring

Motivational interviewing to encourage the patient towards committing to change

Social skills development and community-based rehabilitation

Cognitive-behavioral therapy (CBT) for lessening hallucinations and delusions

Family psychotherapy

Schizophrenia therapy has typically dealt with reducing negative symptoms of patients. Physicians now seek to expand treatment and concentrate on patients' independent-functioning ability in everyday tasks like eating, cleaning, cooking, working, shopping, and doing laundry. Detection of the problem at early stages and timely treatment result in better outcomes. Strong proof exists with regards to benefits of treatment in early stages. First-episode patients who are administered antipsychotic medication and other therapy are less likely to be admitted to hospitals in the five years that follow, and may need less time to control their symptoms compared to patients who come in for help at a later stage of the disorder (Simon, 2013).

Step 4 - construct

Nursing interventions and clinical skills required for this Case Study

Goal:

A workable goal must be established with schizophrenic patients, along with required outcomes. Desired standards for families having schizophrenic members must also be established.

Client safety concerns with regard to the given Case Study:

Nursing Interventions for Ruth;

Withdrawal and isolation

1. Adopt a self-therapeutic.

2. Plan an interaction to be carried out with the patient; it must be frequent, short and undemanding.

3. Organize basic one-on-one activities.

4. Ensure reliability and sincerity in interactions.

5. Gradually encourage the patient to mingle with peers in non-threatening settings

6. Offer training in social skills development/improvement.

7. Conduct numerous activities to improve self-esteem.

No clear pattern of communication

1. Ensure one's communication is easy to understand.

2. Be consistent in verbal as well as nonverbal communication.

3. Clarify any aspect in nurse-client interaction that is vague or hazily connected with client communication

Suspicious

1. Forge a professional bond; over-friendliness may be perceived as a threat.

2. Take care with touch, as this may also be perceived as a threat.

3. Allow the client as much independence and control as possible within therapeutic bounds.

4. Gain client trust via short interactions which convey respect and concern.

5. Explain medications, therapies, and lab examinations prior to beginning.

6. Take care not to concentrate on, or reinforce, delusional beliefs or suspicions.

7. Detect and respond to the fundamental emotional requirements of delusional or suspicious patients

8. Step in if the patient displays indications of mounting anxiety and possibly expresses unintentional behaviors.

9. Take care not to behave in such a manner that the patient may develop a misunderstanding.

Hallucinations or delusions

1. Refrain from concentrating on delusions or hallucinations. Intervene to initiate communication about patient hallucination on basis of reality.

2. Inform patients of one's disagreement with their views, but also bear in mind to let them know that one believes them to be real for the patient.

3. Refrain from getting into an argument with patients regarding their delusions or hallucinations.

4. Be reactive to feelings communicated to them during the delusionary or hallucinatory episode.

5. Divert the patient's attention towards a task-focused reality or a structured task.

6. Relocate the patient to a less-stimulating and more tranquil environment.

7. Begin counseling only after the patient ceases having delusions or hallucinations.

8. Explain to them that their delusions or hallucinations form symptoms of mental ailments.

9. Explain how increased environmental stimulus or anxiety triggers the commencement of hallucinations.

10. Aid them with controlling hallucinations through a focus on reality; encourage them to take the prescribed drugs.

11. In case hallucinations persist, patients must be told to take no notice of them and continue taking proper medication.

12. Teach them different cognitive strategies, as well as using self-talk (voices making no sense) and mental cessation (not dwelling on it) (Nanda Nursing, 2012).

Appropriate ANMC RN Competency Standards that would be applicable to an RN in supporting the patient

Fulfills the duty of care:

Conducts nursing interventions according to recognized practice standards

Clears up responsibility for care-related issues with partners in the health unit

Understands the responsibility of preventing harm, and Follows accurate and thorough assessments while performing nursing interventions (ANMC, 2006).

Conducts practice in a manner acknowledging individuals'/groups' rights, values, culture, dignity, and beliefs:

Displays respect for legal and common rights of groups/individuals in the context of health care

Recognizes and abides by strategies for promoting and protecting rights of individuals/groups

Takes into consideration group/individual preferences while delivering care

Outline of how to support the patient

1. Self-education. Acquire knowledge on the schizophrenia disorder and how it is treated to make informed decisions regarding the best way to tackle the ailment, ensure recovery, and cope with setbacks.

2. Stress reduction. Stress may trigger schizophrenia symptoms; therefore, creation of a supportive, structured setting for schizophrenics is crucial.

3. Establishment of realistic expectations. Being realistic regarding the disorder's limitations and problems is vital.

4. Patient empowerment. Take care not to dominate and perform tasks for family members that they can do. Attempt at supporting them while also encouraging them to be independent (Smith & Segal, 2015).

Safety concerns for the patient in this Case Study

Patient's likelihood to carry out another suicide attempt is the key safety concern in this case.

Justification for your chosen interventions

The interventions have been selected as they deal with the major problems the client is experiencing. The chosen intervention strategies have proven to effectively help schizophrenics in prior cases.

Step 5 - Express

Thoughts about these comments made by the night duty RN

The night duty RN remarks that she doesn't understand why they waste their time caring for those wanting to commit suicide when there are numerous sick people in dire need of hospital beds. This comment made me angry, though I could understand her sentiment. My anger stems from the fact that the night RN sounded as though she thought Ruth wasn't really sick and her condition was brought on by herself -- because of slashing her wrist. This reveals that the night nurse's personal views overshadowed her duty as an RN. I also understood her sentiments, as general concern lies with those suffering from physical injuries and accidents rather than the psychologically-ill. However, one question to be considered is whether it is my duty to report the night nurse's lack of understanding of schizophrenia and appropriate attitudes/treatment of patients to our supervisor. Perhaps it is appropriate to consider that nursing staff have a remedial and or reminder 'course' on schizophrenia and appropriate treatment of patients.

Step 6 - Reflect

Justification for your thoughts

As per the ANMC (2006), a registered nurse must fulfill care duties, including ensuring the patient comes to no harm. Through such a statement, the night RN fails in conforming to nursing's codes of conduct and ethics that entail;

Acceptance of individuals/groups irrespective of culture, race, religion, gender, age, sexual inclination, mental or physical state

Ensuring that personal beliefs and values aren't forced upon others (ANMC, 2006).