CASE STUDY REPORT FOR 60 YEARS OLD MAN WITH SCHIZOPHRENIA
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Introduction
The case study report is about Mr. Abu, a 60-year-old Arab male patient who was admitted with a schizophrenia relapse. The patient presented with several symptoms including auditory distortion, complete disorientation to place, time, and person, hallucination, inappropriate responses, and talking to self. Dr. F ordered a full health assessment for the patient and an analysis of his psychiatric history including past medication, possible substance abuse, and stressors. the purpose of this report is to provide the health assessment of the patient, describe the pathophysiology of the main medical diagnosis (schizophrenia), and describe patient interventions including care plans that address nursing interventions and safety plans.
Assessment: Objective Data and Subjective Data
The interview
Chief complaint: “There are police chasing me all over wanting to arrest me”.
The patient is a 60-year-old patient who was brought to the hospital by his son after exhibiting numerous delusions including the belief that he was being tracked by the police for taking alcohol a few years back. The patient could not sleep at night because he told his son that he saw the police in his bedroom and if he sleeps they would arrest him. The patient also talked to himself and was unable to effectively communicate what he was feeling to the physician in charge.
Complete medical history: the patient was diagnosed with schizophrenia at age 40 and has been on medication ever since. He has been hospitalized once in a mental facility after he attacked his neighbors claiming that they wanted to kill him and were following him. He has no other remarkable mental or physical history and has never undergone any surgical procedures. The patient has a history of non-compliance to schizophrenia medication and his son often has to force him to take them. The patient has no need for isolation since he is fully vaccinated against COVID-19 and had a negative test one week ago.
Allergies: No known allergies.
Current medication: Chlorpromazine administered orally 200mg per day.
Social history: the patient’s wife died 10 years ago and he lives with his son and daughter-in-law. The patient denies taking any alcohol or drugs although his son reports that he smokes once in a while. The patient does not work and relies on his son for financial support.
Assessment techniques, the clinical setting, general survey, measurement and vital signs
The main assessment techniques for the patient include a physical and mental exam which will be conducted in the psychiatric wing of the hospital.
Vital signs: BP- 139/86, P 82, RR 18, T 37.3, Ht. 6 ft. 0, Wt. 123 kg, BMI- 36.8.
Thorax and lungs
Normal breathing sounds, denies dyspnea, cough, and difficulty breathing. Patient has no history of any respiratory issues although he had a positive COVID test one year ago but was asymptomatic.
Heart and Neck Vessels
No chest pains, heart murmurs, arrhythmias, or shortness of breath. Patient does not have a history of hypertension.
Peripheral Vascular System and Lymphatic
No leg cramps, vein clots, edema, and intermittent claudication. No rashes or varicose veins. No bleeding disorders, no evidence of lymph node swelling, no history of anemia or hemophilia.
Abdomen: no abdominal pain, no changes in appetite, normal bowel sounds, no nausea or vomiting. The patient has no history of urinary incontinence, urinary infections, or kidney stones. Patient did not agree to assessment of the prostate, rectum, and anus. Wide girth (45 inches), patient is obese.
Neurologic System
No dizziness, falls, fainting, or seizures. The patient has no history of paralysis. The patient is not oriented to place, time, or person. He does not demonstrate good judgment or insight.
Mental Status
Attitude and orientation: The patient could not answer most of the questions asked during the interview including his name or where he was although he recognized his son.
Speech and thought process: His speech was incoherent most of the time and his thought process was scattered in that he could not focus on the topic at hand.
Psychomotor: No evidence of psychomotor agitation.
Mood and affect: the patient could not describe his mood and his affect seemed fairly detached.
Thought content: The patient agreed to experiencing visual and auditory hallucinations and his son estimates that they began two days ago and increased in intensity yesterday. The patient appears to be delusional and out of touch with reality.
Head, Face, Neck, Regional Lymphatics, Eyes, Ears, Nose, Mouth, and Throat
Head, face, and neck: Normocephalic head, symmetrical face, no evidence of lesions, tenderness, or lumps on the scalp. Neck is supple, no evidence of enlarged lymph nodes or thyroid tenderness.
Eyes: Normal vision in both eyes, equal and round pupils, white sclera.
Ears: no bulging and dullness in the tympanic membrane, no signs of lesions or edema of external ears, external auditory canal is clear.
Nose: no tenderness, intact septum, clear rhinorrhea, no edema in the turbinates.
Mouth and Throat: all teeth are intact, no swelling on gums, no lesions, no odor, no bleeding or swelling, uvula located midline, no exudates in the larynx, uvula midline.
Lab Result Interpretation
No lab tests were conducted for the patient. However, his vital signs are normal implying that the main concern is his mental health status.
Patient Risk for Complication
The patient cannot communicate effectively hence it is difficult to assess suicide risk. However, the patient is at risk of self-harm since the hallucinations make him agitated and restless. He is also scared that he will be arrested and taken to jail and that he will be killed in jail.
Medical Diagnosis
The patient was diagnosed with relapsed schizophrenia based on the exhibited symptoms including delusions, hallucinations, and disorganized speech. According to Luptak et al. (2021), the pathophysiology of schizophrenia, including its onset and symptom progression, has not been fully understood although there are hypotheses that provide a description of the neuropathology of the illness. These hypotheses focus on the neurodevelopmental effects, neurochemical effects, genetic, and environmental factors.
Schizophrenia development is linked to genetic factors including gene expression changes and small nucleotide polymorphisms. Pathogenic mechanisms such as changes in histone code, mis-splicing, and poor regulation of the long noncoding RNA are linked to schizophrenia development. Approximately 80 percent of schizophrenia cases are attributed to genetic factors including interactions between DNA, proteins, and RNA that influence the transcription processes. The development and severity of schizophrenia symptoms are mediated by the interaction between environmental and genetic factor such as serum folate levels, exposure to traumatic events during childhood or adulthood, cannabis use, and patients with obstetric complication history. Maternal psychosis , stress, and infections such as herpes simplex are also significant risk factors for schizophrenia (Luptak et al., 2021).
The neurochemical hypothesis posits that the psychiatric manifestations present among schizophrenia patients arises from imbalances in serotonin, glutamate, dopamine, and GABA. The psychotic symptoms are effects of increased dopaminergic activity which is attributed to higher density and sensitivity of dopamine receptors. Positive schizophrenia symptoms are attributed to dopamine hyperactivity within the mesolimbic pathway while negative symptoms such as low motivation, social withdrawal, alogia, and blunted affect are attributed to extremely low dopamine activity within the prefrontal cortex. Low and high dopamine activity occur simultaneously in different brain circuits and this explains why schizophrenia patients can experience negative and positive symptoms at the same time. Multiple genetic and environmental factors work together with other risk factors including substance abuse, obstetric and pregnancy complications, or stress to influence dopamine dysregulation. Environmental and genetic factors are associated with increased sensitization within the dopamine system which makes the system more sensitive to stress resulting in progressive dysregulation and the beginning of psychosis symptoms. To summarize, genetic factors impair dopamine regulation which increases dopamine release in the striatum resulting in aberrant salience and the onset of psychotic symptoms (Luptak et al., 2021).
Schizophrenia is also hypothesized to be a result of glutamate abnormalities caused by changes in glutamate synapse formation in various sites, especially at the GABA interneurons located within the cerebral cortex. High glutamate levels lead to the excess activation of the ventral tegmental area pathway resulting in excess release of dopamine through the mesolimbic pathway to the ventral striatum. Cognitive symptoms exhibited by schizophrenia patients can be explained by the glutamate transmission and GABA impairment in the prefrontal cortex (Stepnicki et al., 2018). Schizophrenia is also attributed to hypofunctioning of the NMDA receptor which induces disturbances in several pathways including calcium entry, neuronal activity, epigenetic machinery resulting in abnormalities in dopamine and GABA. The changes in neuronal activity and neurotransmission lead to social and cognitive deficits. The main pathways linked to delusions and hallucinations among schizophrenic patients include serotonin hyperactivity, dopamine hyperactivity, and hypoactivity of the NMDA receptors. Serotonergic hyperfunction is mainly induced by high stress within the cerebral cortex which results in increased functioning of the 5-HT2A receptors. The pathogenesis of schizophrenia is also attributed to high activation of the endocannabinoid system which results in reduced glutamate levels and high dopamine levels that lead to schizophrenia. Research evidence has indicated that cannabis use among young people, especially adolescents, is a significant risk factor for the development of schizophrenia (Luptak et al., 2021).
Neurodevelopmental deficits are also regarded as significant factors influencing schizophrenia development. Abnormalities in the neurodevelopment of the brain are linked to environmental and genetic factors. Schizophrenia is linked to brain neuroplasticity caused by abnormalities in synaptic connections leading to impaired synaptic efficiency especially in the parts of the brain that are responsible for emotion, memory, and learning. After the onset of schizophrenia, changes in neurochemical levels result in further neurodegeneration (Luptak et al., 2021).
Schizophrenic patients also exhibit prefrontal cortex disconnection which is linked to abnormalities in myelin, white matter, and oligodendrocytes. Genetic and environmental factors work together causing oxidative stress which further increases abnormalities in the myelin and the oligodendrocytes. Oxidative stress induces cognitive symptoms and immune system dysregulation (Murray et al., 2021). Neuroimaging studies have also indicated that schizophrenia is associated with impaired blood brain barrier functioning and neuroinflammation within the central nervous system. Microgial activation and neuroinflammation cause changes in neurochemical levels, especially dopamine, glutamate, and serotonin. High stress levels lead to increased levels of proinflammatory cytokines which leads to neuroinflammation (Luptak et al., 2021).
Relapsed schizophrenia is when a patient experiences an acute exacerbation of psychotic symptoms that puts the patient at risk of harming other people or themselves. Relapse is possible even among patients that adhere to their antipsychotic regimen. Relapses are often triggered by stressful events and in some cases, comorbid mental disorders. Exposure to stress leads to increased proinflammatory cytokines which influence dopaminergic hyperactivity, activation of the astrocytes, and NMDA receptor hypofunctioning which further influences exacerbation of cognitive, negative, and positive symptoms among schizophrenia patients (Moges et al., 2021).
Nursing care plan
The main care plan for Mr. Abu, based on his needs, focuses on minimizing disturbances in auditory and sensory perceptions which are evidenced by the presence of auditory distortions, disorientation to time, place, and person, and difficulties in verbal communication. The desired outcomes include helping the patient learn how to cope with hallucinations, identification of factors that trigger hallucinations, reducing the frequency and intensity of hallucinations, and enhancing patient safety. The patient should also be able to effectively use techniques that reduce stress and distract him from the voices he is hearing such as deep breathing and other relaxation techniques.
The selected nursing interventions include working with Mr. Abu to determine when the hallucinations are most frightening and how the patient experiences them. According to Maki et al., (2021), it is also important to be alert for signs that may indicate increased agitation and anxiety which indicate the onset of hallucinations. Additionally, nursing interventions should include documenting any changes in the patient’s orientation, increased anxiety, and what the patient says especially if he threatens to harm other people. The nurse should stay with the patient when they begin to hallucinate and repeat words that will help the patient focus on other things instead of the voices. The patient should be taken to a place with little environmental stimuli that may further trigger hallucinations. All conversations with the patient should focus on simple topics based on reality. If the voices tell patient to harm other people or themselves, precautions such as notifying the patient’s physician and removing any items that the patient can use to harm themselves should be taken away. Furthermore, the patient should be placed on suicide watch. It may also be important to notify the police in case the patient may harm other people.
Discharge planning for schizophrenia patients should focus on ensuring that the patient has access to medication and has been provided with medication education including the dosage and frequency. Patients who are at high risk of relapses may need residential support and constant follow-up appointments with psychiatrists and physician (Smithnaraseth et al., 2020). Education needs for Mr. Abu include safety instructions, information on the importance of adhering to medication including the right dosage and how to recognize symptoms of schizophrenia exacerbation early.
Mr. Abu may need help with activities of daily living, constant mental and physical check-ups hence discharge planning should include referral to psychiatrists. Furthermore, it would be important to assess if the patient requires financial assistance. The follow-up care team for schizophrenic patients should include social workers, a community support group, and a visiting nurse. Family involvement is also necessary to ensure that the patient has both mental and physical support. Family members should also be educated on how to care for a schizophrenic patient including which symptoms to look out for to facilitate early identification of relapses.
Intervention/Implementation
Pharmacological interventions for schizophrenia patients mostly include antipsychotic medication as first-line treatment. These medications work by blocking dopamine receptors which in turn reduces positive symptoms such as delusions, hallucinations, and disorganized speech (Lloyd et al., 2017). Antipsychotics also help to improve cognitive functioning and reduce disorientation and confusion in daily life. Clozapine is specifically recommended for patients who do not respond positively to other medication although there is a high risk of severe side effects that may range from endocrine and sedative side effects that may make it difficult for patients to comply to the medication. Clozapine is also linked to reduced suicide ideation among patients with chronic schizophrenia. Other medication such as metformin may be required alongside clozapine to help with metabolism and weight management (Ganguly et al., 2018).
Apart from pharmacological interventions, it is important to provide dietary interventions. Schizophrenia patients should have access to foods rich in fiber and vitamins. Supplements such as folic acid and vitamin supplements may help improve schizophrenia symptoms. Apart from medication therapy, therapeutic interventions such as cognitive behavioral therapy (CBT) help to alleviate positive symptoms. CBT, when implemented alongside pharmacological interventions, promotes better management of positive symptoms and enhances cognitive functioning. CBT techniques such as cognitive restructuring are important since they help patients realize the difference between reality and delusions which make it easier to identify triggers and modify behavior (Ganguly et al., 2018). It is important for the Mr. Abu to engage in therapy and also to be provided with proper nutrition to reduce the risk of future relapses. Therefore, the nursing interventions should include providing healthy food regularly and seeking the help of a dietitian who will determine the patient’s nutritional needs. A mental health professional should be part of the medical team and the main role will be to provide psychosocial therapy that will likely go on after the patient is discharged.
Schizophrenia patients should also be encouraged to engage in physical activity which according to Ganguly et al. (2018), improves physical and mental health and also improves metabolism. Many schizophrenia patients are administered with oxytocin as part of their treatment and various forms of exercises, including yoga, increases the levels of oxytocin in the body. Goh et al. (2021) explains that oxytocin improves both positive and negative symptoms by improving social cognition.
The main safety considerations when treating schizophrenia patients include assessing patients for suicide ideation and any talk about harming others. When implementing interventions, nurses should always listen to patients, focus on minimizing stress, and continuously watch those who demonstrate high suicide risk. Additionally, follow-up care should be organized and patients should be provided with a call line which will enable them access help when they experience any issues (Cates et al., 2021).
Evaluation
For the patient in the case study, the nursing interventions will be evaluated by considering the effectiveness of the nursing interventions in improving both negative and positive symptoms. the evaluation plan will include assessing if there are any positive changes in the patient’s orientation, hallucinations, delusions, and affect. The patient should be assessed every four hours and any changes should be documented and the evaluation process will include observing any changes in patient behavior and physical status and asking the patient to describe any changes in the frequency of hallucinations and stress levels.
Conclusion
The case study is about a 60-yearl old man who experienced a relapse in schizophrenia symptoms. The patient’s main complaint was that he was being chased by the police who wanted to arrest him. He demonstrated positive symptoms such as delusions and hallucinations and negative symptoms such as reduced mood and affect. Apart from one psychiatric hospitalization, the patient’s medical history is otherwise unremarkable since he has no surgical history or known allergies. The objective and subjective data illustrate that he is in a poor mental state. The main focus of nursing interventions is to minimize delusions and hallucinations, improve the patient’s orientation, promote better communication, and enhance the patient’s safety. The main interventions include pharmacological treatment especially antipsychotics, psychotherapy, better eating habits, and improved physical activity. Before discharge, Mr. Abu should be educated on the importance of adhering to medication. He may also need help with activities of daily living and his son should be involved in his treatment. The evaluation plan for the patient includes assessing for positive changes in affect, communication abilities, delusions and hallucinations after the implementation of the nursing interventions. The patient should be also constantly monitored to reduce the risk of harm to himself and other people.
References
Cates, A., Catone, G., Marwaha, S., Bebbington, P., Humpston, C. and Broome, M. (2021). Self-harm, suicidal ideation, and the positive symptoms of psychosis: Cross-sectional and prospective data from a national household survey. Schizophrenia Research, 233, pp.80-88.
Ganguly, P., Soliman, A. and Moustafa, A. (2018). Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment. Frontiers in Public Health, 6.
Goh, K., Chen, C. and Lane, H. (2021). Oxytocin in Schizophrenia: Pathophysiology and Implications for Future Treatment. International Journal of Molecular Sciences, 22(4), p.2146.
Lloyd, J., Lloyd, H., Fitzpatrick, R. and Peters, M. (2017). Treatment outcomes in schizophrenia: qualitative study of the views of family carers. BMC Psychiatry, 17(1).
Luptak, M., Michalickova, D., Fisar, Z., Kitzlerova, E. and Hroudová, J. (2021). Novel approaches in schizophrenia-from risk factors and hypotheses to novel drug targets. World Journal of Psychiatry, 11(7), pp.277-296.
Maki, S., Nagai, K., Ando, S. and Tamakoshi, K. (2021). Structure and predictors of in-hospital nursing care leading to reduction in early readmission among patients with schizophrenia in Japan: A cross-sectional study. PLOS ONE, 16(4), p.e0250771.
Moges, S., Belete, T., Mekonen, T. and Menberu, M. (2021). Lifetime relapse and its associated factors among people with schizophrenia spectrum disorders who are on follow up at Comprehensive Specialized Hospitals in Amhara region, Ethiopia: a cross-sectional study. International Journal of Mental Health Systems, 15(1).
Murray, A., Rogers, J., Katshu, M., Liddle, P. and Upthegrove, R. (2021). Oxidative Stress and the Pathophysiology and Symptom Profile of Schizophrenia Spectrum Disorders. Frontiers in Psychiatry, 12.
Smithnaraseth, A., Seeherunwong, A., Panitrat, R. and Tipayamongkholgul, M. (2020). Hospital and patient factors influencing the health status among patients with schizophrenia, thirty days after hospital discharge: multi-level analysis. BMC Psychiatry, 20(1).
Stepnicki, P., Kondej, M. and Kaczor, A. (2018). Current Concepts and Treatments of Schizophrenia. Molecules, 23(8), p.2087.