Running

head: Tillis Case Study

Case Study

Tramaine Tillis

Youngstown State University

Abstract

The patient suffers from Schizoaffective and has been having increase in depression. She

also has been having suicidal thoughts. While caring for this patient she was pleasant,

cooperative but sometime distracted during the conversation. My time there the patient behaves

in a pleasant manner but kept bringing up that everyone in her family suffered from suicidal

thoughts. She was involuntary admitted to the floor due to she planned to jump out the window

and admits she missed several doses of medication. Patient has had increase in depression due to

her daughter committed suicide. Her plans for discharge are to be sent back to her home where

she lives alone in Youngstown. She seemed interested hearing about her diagnoses and sat

through the whole conversation about education and gave her input.
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Objective data

The patient is forty-nine year old, normal weight, white female with dark brown hair and

blue eyes. She was admitted to Mercy health in Youngstown on October 6th, 2017. She was

admitted to the locked psychiatric floor involuntary through emergency room after planning to

jump out the window and admitted to missing dosage of medication. The patient has been

previously diagnosed with schizoaffective disorder. As a diagnosis in DSM-5 she would be in

the Schizophrenia spectrum which she will have uninterrupted period of illness during which

there is a major mood episode. She will also have delusions or hallucinations for 2 or more

weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration

of the illness. As for her physical health the patient is currently suffering from diabetes. Her

Glucose levels were on the higher side which her levels were 153. As with the other lab values

were all in normal ranges along with her vital signs were all in normal limits. For her

Schizoaffective disorder patient is currently taking 200mg bid Clozaril. Some other medication

she takes are Benztropine 1mg bid, Neurotic 100mg3times a day, Haldol 5mgs every 4 hours,

Ativan 0.5mg PRN, Paxil 10mg daily and Desyrel 50mg.

On day of care the patient was wearing a black long sleeve sweater and blue jeans with

socks; it was clean and well fitting. She drank a cup of coffee and even offered me a cup. While

talking with her, she was very cooperative and pleasant. She was very talkative and told me a lot

about her life experience. There were times when she would get easily distracted by the other

patients and I would have to get her to start talking to me again. Her face expressions stayed the

same during the whole interaction. She never smiled or laughed. The expression I observed was

a sad and depressed expression. Her body language was open most part of our interaction. She

stared me straight in my eyes while we were talking. Her speech was slow and monotone and a
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little repetitive. She kept repeating to me how her daughter and brother committed suicide and

she has thoughts about suicide too. She also noted that she hears voices telling her to harm self.

The thoughts also tell her that her family is out to get her. She explained everything about her

life and illness well. She remembers a lot about her past and how she acted when she first got

sick. She seemed a little agitated when I ask questions about her family especially her ex-

husband. She was very cooperative through the interview and answers the question in a well

manner. To ensure the patient in this studies safety as well as the rest of the floors safety suicide

precaution and unit restriction were in place.

Summarize

The patient was diagnosed with schizoaffective disorder and would fall in the

Schizophrenia spectrum using DSM IV axis. The DSM IV criteria for Schizoaffective is

uninterrupted period of illness during which there is a major mood episode (major depressive or

manic) concurrent with Criterion A of schizophrenia (Obad). The patient will experience

delusions or hallucinations for 2 or more weeks in the absence of a major mood episode

(depressive or manic) during the lifetime duration of the illness. Some other criteria for

schizoaffective is Disorganized speech, grossly disorganized or canonic behavior and negative

symptoms such as affective flattening, alogia and avolition (DSM-5). The patient exhibited

several of the symptoms created to schizoaffective disorder including delusion, hallucination,

major depressive episode and cationic behavior in her past. During our interaction she explained

to me that she hears voices. She told me they tell her to harm herself or others and that her family

is out to get her. I told her the voices may sound real but they are not. She explained to me that

when she was about 14 is when she started having symptoms but her parents did not think it was
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something. When she was in her 20’s and had both of her children, her illness was diagnosed.

The behaviors started to appear. She started to have behaviors that made her family worry such

as screaming at husband and children for no reason. There was time when she stops feeding the

kids and would beat them. She also stops feeding herself and doing anything. She just sat there

like she was paralyzed. She was later diagnosed as with Catatonic Shock.

The patient was diagnosed with Catatonic shock at one point in her past . In order for a

person to be given the diagnosis of catatonic schizophrenia, at least one of the following criteria

must be prominent in terms of the overall clinical presentation which includes appears an stupor

state , engages in excessive movement which has no purpose, and is not in reaction to something

external, resists any type of instruction or attempt to be moved, or refuses or is unable to speak

(“mutism”), takes on a bizarre or inappropriate stance or posture, or engages in peculiar

movements, pronounced grimacing or mannerisms and the person senselessly repeats the words

spoken to him/her (echolalia) or involuntarily imitates the movements of another person( Lane,

2017). After talking with the patient she had several of these symptoms such as appearing stupor,

and resisting any intrustions or movement, unable to speak and move.

Identify Stressors

She was brought to the emergency room by family on November 6. The patient describes

the incidents as follows “I was having thoughts of suicide so I told someone I was going to jump

out the window. I’ve been under a lot of stress and been feeling depressed since my daughter

committed suicide in July”. The patient also stated that she doesn't think she was going to

actually jump out the window and never had a plan to commit suicide. She also admits that she

missed several doses of her medication. She felt that the medication of Clozapine was not
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working and ever since she stop taking paranoid has been a factor. Medication compliance is

significant factor regarding admission and readmission into a psych floor. Studies have shown

that when in individual stop taking medication of clozapine they start to have symptoms include

insomnia, hallucinations, or delusions. According to a recent study done by Rosen et. al “Patients

with low and intermediate adherence (combined) had readmission rates of 20.0% compared to a

readmission rate of 9.3% for patients with high adherence (P=0.005). By adding MMAS-4 data

to previously published variables that have been shown to predict 30-day readmissions, we found

that patients with low and intermediate medication adherence had an adjusted 2.54-fold higher

odds of readmission compared to those in patients with high adherence” (Rosen, 2017). When

questioned about the kind of coping strategies she used or plans to prevent readmission she

responded with “ I plan on taking my medication every day, talking with therapist every week

and making crafts/ activities to take mind off of stuff”. She also stated when she hear the voices

she will tell herself that the voices aren't real. The combination of stress from her daughter

committing suicide and not taking her medication as prescribed combined with a history of

schizoaffective disorder led to this admission to psychiatric floor.

Discuss Patient/ Family History

The patient had very little family history in chart. The only thing that was in the chart was

that the daughter committed suicide by shooting herself. The chart also said that the family is

very supportive about patient. During the interview the patient did discuss with me about her

family. She told me that both of her parents are dead. She also told me that on her father side

mental illness runs in the family. She said her father suffered from a mental illness but is unsure

from what. She said she had a bother who suffered from depression his whole life who

committed suicide 11 years ago. She also said suicide behavior runs in her family as well. The
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patient discuss with me that back in 1980s she was admitted to psych ward for about 3 months

for cationic shock. She said after getting better her husband left her and took custody of the kids.

Since her husband divorced her and took the kids, being alone is something that has made her

mental illness worst she discuss. She lives alone in Youngstown in private housing which her

family comes to visit her often. She has a son that’s homosexual which she's accept.

The patient has family that is very supportive of her. The patient highest education is high

school degree. She said she was once a state tested nurse. She does not currently have a job.

She's on disability and receives welfare. She rides WRTA if needed to go places or family and

friends take her places.

Described Psychic Evidence

Psychiatric care on the floor includes doctors, nurse practitioners, a milieu therapist,

nurses, health care associates, activities directors, and a dietician if needed since many

psychiatric medications can cause weight gain of sixty pounds or more. The milieu therapy on

the floor includes plastic silverware that does not include a butter knife and it gets counted after

each patient’s meal. The rooms all have beds that are low to the ground and bolted down so the

patients cannot lift them or hurt themselves by falling out of them. The mirrors in the room are

not made of glass so they cannot shatter them to cut themselves or other patients with it. The

bathroom doors are made half short for safety issues and lights automatic. There is also rounding

every fifteen minutes by either a health care associate (HCA) or a nurse to ensure that the

patients are all safe if they are not in the common area nurses will check in room to see if patient

is safe. In the common area there are tables where the patient can sit, a TV to watch and they also

play music for the patients. There are also coloring pages, Uno, puzzles, cards used to help calm
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the patients and occupy their minds while on the floor. There is also a coffee machine so patients

can get coffee anytime. Windows so they can look out. Patient’s family can come in visit them in

this location during visiting hours. The floor also consists of a library so patients can read books

but a nurse or Health Care Associate has to be present. On the unit they also have group

discussion/ activities ran by a nurse. The groups may be going over coping strategies, talking

about their thoughts and stress management. In the patient chart it noted that the patient I

interviewed refused to do group therapy when offered.

Analyze influences on Patient

The patient is white female lady who is 49 years old. She identifies herself as

heterosexual. The patient suffers from schizoaffective disorder which would make having

relationship with another person challenging. She said she does not have religion but believe in

god. She said she reads the daily bread every day to get the word of god. She said when she was

a kid all the way till she was 18 she went to church with parents. Recent studies done by

Verghese strongly suggest that “to many patients, religion and spirituality are resources that help

them to cope with the stresses in life, including those of their illness. Many psychiatrists now

believe that religion and spirituality are important in the life of their patients. The importance of

spirituality in mental health is now widely accepted” (Verghese, 2010). The patient family has

been helping with her mental illness and is accepting and is familiar with mental health hospital

stay. The patient stated she never felt judge by anyone after receiving help from her illness.
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Evaluate Patient Outcomes

If the patient follows medication routines, receives therapy and has a support system

than she would be able to go through life. It’s going to be challenging but with the help of many

people it can be done. The main issues are the patient is having thoughts about daughter

committing suicide, compliance with medication and delusion and hallucination. I believe if the

patient lives with someone rather alone than the outcome will be better. Schedules of some kind

need to be in place. Due to the patient has family that loves her and are very supportive, getting

the help she needs such as meeting with a therapist should not be a problem.

Summarize Discharge Plan

The patient will be discharge back to her home where she lives alone. The building she

lives in is for disable people and the elderly. She will be under the care of a psychiatrist who will

continue to prescribe clozapine and other medication. The patient will continue to go to Compass

every week for her mental illness. If medication compliance is still an issue, the medication may

have to be switch to injection type. The patient plan for discharge includes continue to make

crafts, apply for a volunteer job at the park, apply for school for gardening and being around her

family for the holiday. She said she will continue to take medication and get the treatment she

needs.

List of Actual Diagnoses Prioritized

Knowledge deficit related to beliefs about health

Impairment of social interaction related to social interaction skills

Interrupted family process related to no adherence to medication

List Of Potential Nursing Diagnoses

Risk for injury related to delusional thoughts

Disturbed though process

Dressing or grooming self-care deficit

Disturbed personal identity

Imbalanced nutrition: Less than body requirements

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References

Obad. (2012).Schizoaffective disorder http://www.obad.ca/information_schizoaffective

England, M. (2012).Catatonia in Psychotic Patients: Clinical Features and Treatment Response.

Lane, C. (2012).Cationic Shock. Retrieved from

Verghese, A. (2014).Spirituality and Mental Health. Retrieved from

Townsend, M.(2015). Psychiatric Mental Health Nursing. Philadelphia: F.A. Davis.

Rosen.(2017).Medication adherence as a predictor of 30-day hospital readmissions. Retrieved