Case Study 1

Case Study
Jared Tacey
Youngstown State University
Case Study 2

Abstract
This case study will be talking about a client of a 37-year-old female that was admitted at

Trumbull Memorial Hospital on the Adult Psychiatric Unit. Her diagnoses include

schizophrenia, PTSD, psychosis, and Cluster B personality disorder. For this paper,

schizophrenia will be the main focal diagnosis. Information obtained for this includes from the

client’s chart and one on one conversation. Also, this case study will focus on typical behaviors

of schizophrenics, stressors and behaviors that lead to hospitalization, family mental health and

client’s history. Also included in this will be nursing care and interventions, the ethnic, spiritual,

and cultural influences on the client. This case study will also focus on the outcomes related to

the client’s care, plans for discharge, and actual and potential nursing diagnoses.
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Objective Data

The client is a 37-year-old white female admitted involuntary on March 13th, 2018 at

Trumbull Memorial Hospital. She was diagnosed with schizophrenia. Other diagnoses include

PTSD, psychosis, cluster B personality disorder, ADHD, autism, conversion disorder,

fibromyalgia, and rheumatoid arthritis. The client is also 17 weeks pregnant at the time. Date of

care was on March 20th, 2018. The client was wearing two different floral prints for top and

bottom and had purple streaks in her hair. She was cooperative, but however, was restless. When

the client was sitting at the table during the interview, the client was fidgeting, kept changing

body languages, maintained poor eye contact, and being labile. Client was also constantly

playing with her hair and stacking the papers that were presented on the table.

Information gathered from the client’s chart on the reasoning for admission versus from

the client’s statement were mismatched. She was brought into the ED found soaking wet from

being out from the woods nearby and dehydrated. The client was paranoid because she believed

that the police were after her because the doctor wanted to take her baby and lock her up where

no one will ever find her. However, per the client, she was arrested because of a federal warrant

for her arrest due to violating a restraining ordered from her previous husband. Client stated that

she was simply trying to find her son’s birth certificate and was told that she was allowed to.

The client believes in the spiritual world. It was gathered during the interview that she is

able to see other clients’ on the unit dead loved ones. The client denied any visual or auditory

hallucinations. Client took offended by the word “hallucinations” and was calmed when asked if

it was more of a picture that she was able to see. To this she agreed. The client wanted to use this
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experience during a court hearing arguing what she experiences is real and prove that everyone is

wrong about her.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,

(DSM-5), to meet the criteria for diagnosis of schizophrenia, the patient must have experienced at

least 2 of the following symptoms:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Disorganized or catatonic behavior

5. Negative symptoms

At least 1 of the symptoms must be the presence of delusions, hallucinations, or disorganized

speech. The client present with delusions, hallucinations and disorganized speech.

Non-psychiatric medications for the client includes Tylenol 650mg PO every 4 hours as

needed for pain and prenatal vitamin once a day PO. The Tylenol is prescribed for the client’s

rheumatoid arthritis, while the prenatal vitamin is for her pregnancy. Psychiatric medication

patient is prescribed are Risperdal 0.5mg daily PO, Risperdal 1mg PO at night, Haldol 5mg PO

or IM every 6 hours as needed, and Benadryl 50 mg PO every 6 hours. These medications are

labeled as a category C for pregnancy, which means that animal reproduction studies have shown

an adverse effect on the fetus and there are no adequate and well-controlled studies in humans.

Risperdal is ordered for schizophrenia and as a sleep agent. Haldol is ordered as needed for

agitation. Benadryl is ordered as needed for agitation or for a sleep aide. The client refuses to
Case Study 5

take the psychiatric medications but is taking her non-psychiatric medications. Client has a court

hearing scheduled on March 14th, 2018 on medication compliance.

Schizophrenia

Schizophrenia is a mental disorder that affects the person’s emotions, thought process, and

their behavior. People with schizophrenia may seem like they have lost touch with reality.

Symptoms usually first present between ages 16-30. Risk factors include genes, environmental,

and different brain chemistry and structure. Some people may experience hallucinations,

delusions, thought disorders, and movement disorders. According to Melrose, (2004), different

types of delusions includes persecutory delusion, which one believes that they are being tracked,

deceived, or even being watched. There is grandiose delusion which one believes they have powers

of some sort. Reference delusion are ones that believes something is made directly for them with

it being a movie, song, or TV show. Delusions of thought is where they believe others can read

their minds or others are influencing their thoughts onto them (Melrose, 2004, p. 3). There are two

categories of symptoms which are positive and negative symptoms. Positive symptoms include

hallucinations, delusions, racing thoughts, and uncoherent speech. Negative symptoms are

basically the body is slow. The person lack motivation, flat, slow movement, isolated from

socialization, and poor responsiveness. Treatment for schizophrenia is trying to maintain the

person baseline with this chronic illness. Medication compliance and therapy are two huge factors

to help this.
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Stressors

Maintaining stress is vital in preventing relapse with people with schizophrenia as well

with medication compliance. According to Howes, McCutcheon, Owen, & Murray (2016),

“acute stress plays a role in triggering psychotic symptoms” (p. 11). The client admitted that she

has been more stress lately and thus resulted in her hospitalization. According to her fiancé in the

client’s chart, she has been getting worse with her symptoms for the past week or so with stress

and paranoia. She has been stressed about being pregnant, legal issues, change, and commitment

issues. Her stress about being pregnant are typically the same as any other pregnant woman such

as will the baby be okay. Her legal issue includes the court hearing on medication compliance

and her restraining order that she supposedly violated. Change is another stressor she identified

relating to her every day life. She likes the way she lives and wants it to stay the same, however,

she stated that everyone is trying to change her with this diagnose she has and does not believe

that she has it.

The client wanted to become pregnant with her fiancé and stopped taking her prescribed

medication as of July 2017. Her medication included Xanax, Adderall, and Risperdal. Instead of

taking her prescribed medication, the client turned to self-medication. For stress and anxiety, she

was self-mediating with marijuana which she tested positive for. On this topic, it was overheard

that the client had planned to grow poppies to sell and smoke them because she believed that

they have medical benefits.

With the patient not being compliant with her medication and her stressors, this all led

her to being hospitalized. She was found paranoid in the woods, soaking wet, with no shoes on.

She was trying to run away from the police and her doctor. She believed that the police were
Case Study 7

raiding her place and that her doctor was trying to lock her up someplace far way and take her

child away from her. While she was in the ED, she was talking to unseen others in the room. She

was not able to identify who she was talking to and when asked about it during the interview, she

could not recall the event.

Patient and Family History

According to the client’s chart, she has had multiple previous psychiatric hospitalizations

since she was a teenager. Asked about her family and childhood, there were plentiful. She

claimed when she was about 4 years old until about 7 years old, she lived with her grandparents.

However, she claimed that she was locked up in the attic without any furniture and claimed that

there were bee nests in the attic as well. The only time she seen her grandparents is when they

gave her a little food and water. She claimed that she was rescued from her step-father and took

her home to live with him and her mother. With her mother, she claimed that her mother would

sell her to gentlemen for money for to be able to get drugs. The client has two children and stated

that they were both conceived from rape. The rapes during this time has led her to have PTSD as

the patient stated. According to Bailey et al. (2018) “There is now considerable evidence that

childhood trauma, including exposures such as sexual, physical, and emotional abuse, and

neglect is a risk factor for psychotic disorder” (p. 1). The main theme seems to be abandonment

issues with the possibly of rape.

Family history of the client includes that her father had a history of alcohol abused and

died from liver cirrhosis due to drinking. Her mother had a diagnosis of schizophrenia had died
Case Study 8

of a brain tumor. With her mother having the same diagnose, that put her at a risk for

schizophrenia since there are strong correlations with schizophrenia and genetically.

Nursing Care and Milieu Activities

Prior to the interview on the date of care, the client was at a table talking to an attorney

that would be with her for her court hearing. Was not able to overhear their conversation due to

noise in the area. After they were finished, she was introduced to two student nurses that wanted

to interview her. She politely agreed. During the interview, she took a question about the

hallucinations offensively and was able to calm down after some rewording and more

amplification of the question. Other than that dispute, the interview process went well. It lasted

until it was time for the clients on the unit to attend to group therapy with the milieu therapist.

The topic of the group therapy was to help unstressed yourself. A worksheet was

provided with positive coping skills and options to write in their own. The group then was able to

share their own and opinions on some if they wished to do so. The client of this case study talked

about some of her stress relievers where meditating and gardening. To help her with her

gardening, the client stated that she was going to purchase $5,000.00 of bulbs to help get her

garden started. Another topic that was discussed was songs that helped calm them. The client

talked about different instrumental and poetic musical helping her.

The next group was the nursing group. It was run by students that presented a game of

bingo. They provided a blank bingo card and asked about different coping skills they used. With

this info, each client filled out their own bingo cards at random. The client of this case study

provided some such as mediating, gardening, and poetry. She also mentioned about sexual
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intercourse as one, however it can be deemed as a negative coping skill. A student was able to

direct that into intimacy. There were prizes provided for people during the game that had bingo

and those that participated. At the end of the session, they were asked of different coping skills

that they learned and wanted to try. The client of this case study talked about how she wanted to

take up on pottery. She then made a statement after this that she has a river of clay in her

backyard that she could use.

Ethical, Spiritual, and Cultural Influences

Client describes that she is an extremely spiritual person. She describes herself as one

with nature. She believes that she is a clairvoyant and makes a living off of it. She stated that she

has crystals around her house that helps heal her and it healed her kidney stones. She does not

like to take modern medicine because she wants to be all natural. She also stated that she reads

palms and able to tell ones’ future. She believes to be able to see dead people and are able to help

communicate the living with the dead. When this topic was asked, she could not stop talking

about this and talked about other things that was not related to the original topic. Ethical

influences were not discussed due to patient preference because she wanted to be more private

with that subject. When asked about cultural influences, the client correlated that with spiritual.

Outcomes Related to Care

Outcomes for care safety, recognizing that the client has a mental illness, and compliance

to medication. For safety, she is at risk for harming herself and others. Client denies that she has
Case Study 10

schizophrenia and therefore does not comply with the treatment regimen. Client is eccentric,

restlessness, flat, fidgeting around, labile, euphoric, has delusions of grandeur and persecution

delusion. During the interview she has a flight of ideas and is tangentiality. Client also

experiences visual and auditory hallucinations as well. With all this, she still denies that she has a

problem and refuses to take her medication. The client does have a court hearing on medication

compliance to help her return to her baseline. Client only admits to having ADHD because she is

constantly focusing on one thing after another and PTSD due to her traumatic childhood.

Plans for Discharge

At this time, there is no time or date set for discharge. Doctors’ orders include adhering to

the treatment plan which includes medication compliance and returning the client to baseline.

Client will return home with fiancé and continue to do prenatal care until delivery. Client stated

that there is a fair coming up in April to do her clairvoyant work to help support herself.

Actual Nursing Diagnoses

1. Ineffective health maintenance related to cognitive impairment and ineffective coping as

evidence by medication noncompliance and psychiatric facility

2. Impaired verbal communication related to psychosis, hallucinations, and delusions as

evidence by talking to nonobjects in room, talking to the dead, and doctor wanting to lock

client up

3. Disturbed personal identity related to psychiatric disorder as evidenced by poor memory

4. Ineffective coping related to unrealistic perceptions as evidenced by flight of ideas

5. Ineffective activity planning related to compromised ability to process information as

evidenced by denying diagnoses.

6. Anxiety related to unconscious conflict with reality as evidenced by paranoid delusions

and grandiose

Potential Nursing Diagnoses

1. Insomnia related to sensory alterations contributing to fear and anxiety as evidenced by

nightmares and paranoid delusions

2. Interrupted family process related to impaired cognition as evidenced by stay at

psychiatric facility and limited visitation

3. Risk for loneliness related to limited visitation

4. Impaired memory related to psychosocial conditions as evidenced by different stories on

same event.

5. Risk for compromised human dignity related to stigmatized label as evidenced by

schizophrenia diagnosis

6. Ineffective family therapeutic regimen management related to chronicity and

unpredictability of condition

Conclusion

The client diagnosed with schizophrenia presented classic signs and symptoms that led to

her hospitalization. Those are loss of reality, restlessness, flat, fidgeting, experiencing delusions

and hallucinations, has flight of ideas, tangentiality, and labile. Client has experienced increasing
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paranoia and anxiety and finally lost touch of reality. The client stopped taking her medications

because she wanted to become pregnant with her fiancé and since then has become noncompliant

with her medications and wants to be all natural and heal herself with crystals. The client also

denies that she has no issues regarding with her mental health status. With this client’s situation,

she needs to understand and accept that she has an illness and needs help. It would be wise for

her to do so, not only for herself, but for her unborn child.
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References

Ackley, B. J., & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide

to Planning Care (10th ed.). St. Louis: Elsevier.

Bailey, T., Alvarez-Jimenez, M., Garcia-Sanchez, A. M., Hulbert, C., Barlow, E., & Bendall, S.

(2018). Childhood Trauma Is Associated With Severity of Hallucinations and Delusions

in Psychotic Disorders: A Systematic Review and Meta-Analysis. Schizophrenia Bulletin,

1-12. doi:10.1093/schbul/sbx161

Howes, O. D., McCutcheon, R., Owen, M. J., & Murray, R. M. (2016). The Role of Genes,

Stress, and Dopamine in the Development of Schizophrenia. Society of Biological

Psychiatry, 81(9), 20th ser., 9-20. Retrieved March 31, 2018, from

http://www.biologicalpsychiatryjournal.com/article/S0006-3223(16)32663-4/pdf

Melrose, S. (2009). Schizophrenia: A Brief Review of What Nurses Can Do and Say to Help.

Journal of Practical Nursing, 3-4. Retrieved March 31, 2018, from

https://core.ac.uk/download/pdf/58775967.pdf.

Townsend, M. (2015). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based

Practice (8th ed.). Philadelphia: F.A. Davis Company