Schizophrenia

1. Schizophrenia Unfolding Case Study By Amanda Eymard, DNS, RN and Linda Manfrin-Ledet, DNS, APRN

2. 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.

3. 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!!”

4. 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?

5. Theory Burst • police power- state must protect the community • parenspatriae powers- state must provide care for those who cannot care for themselves (Stuart, 2009)

6. Reflect on the patient What is the patient possibly experiencing right now? Reflect on how this patient possibly feels at this time.

7. 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?

8. Police • Report • Patient information • Contact information • Responsible party information

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

10. Patient • Safety • Information • Assess immediate needs • Vital signs • Triage • One-on-one • Insurance

11. 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.

12. Based on the police’s input, what additional information does the nurse need?

13. Answer • Labs • Toxicity screen • Contact parents • Psych history

14. Labs/diagnostics ordered • CBC • CMP • U/A • EKG • RPR • HIV • Toxicity screen • Chest x-ray

15. Additional information • Physician also orders: one on one observation • Vital signs: 128/86, P94, R24, T99.0

16. 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.

17. What is the probable Axis I diagnosis for this patient based on information presented thus far?

18. Answer • Psychosis NOS

19. 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.

20. Answer • Psych history • Medication/medical history • Allergies • Last admission • History of violence • Suicide attempts • Currents meds • Physician

21. 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.

22. 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.

23. 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??

24. Answers • Previous psychiatric admission information • Medications prescribed previously? • Any suicide attempts? • Any substance abuse? • Any history of violence? • Any previous arrests?

25. 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)

26. Positive 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 Theory Burst

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

28. Lab results • Negative tox screen • Reactive RPR • CBC wnl • Blood glucose 385 • HIV negative

29. 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?

30. 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.

31. 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.

32. Administering the med • Calculation • Med available Haldol 2mg/ml • How many mls will the nurse administer?? • Where will the nurse administer the injection??

33. Answer • 2mg:1ml= 10mg:x • Answer= 5ml • Gluteal muscle

34. 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.

35. Situation • Background • Assessment • Recommendation

36. Discussion • What is the worst thing that could happen to this patient??

37. Patient is transported via ambulance to the local mental health hospital.

38. 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.

39. 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.

40. Pause to think • What should the nurse be worried about? • What action will the nurse take? • What could have been done differently?

41. 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?

42. 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.

43. 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

44. Safety huddle • Review the event • How could team have worked better together? • What did team members do well?

45. 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?

46. Read back to lab and verify lab values • Notify physician

47. Notify the physician (SBAR) • Situation • Background • Assessment • Recommendation

48. 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)

49. 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

50. 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.