Author: Amanda Eymard, Co-Author: Linda Manfrin-Ledet,
Title: Associate Professor
Institution: Nicholls State University College of Nursing and Allied Health
Evidence-Based Practice, Informatics, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration
<p class="MsoNormal" style="margin-bottom: .0001pt; line-height:
normal; mso-layout-grid-align: none; text-autospace: none;”>This unfolding case study was designed to provide opportunities for nursing students to make decisions regarding a patient diagnosed with schizophrenia. There are KSA safety questions, teamwork questions (especially involving the use of SBAR), medication questions (including safety), a math problem, a video to illustrate schizophrenia, quality improvement questions, and also theory bursts are included.
The strategy is an unfolding case study involving a man diagnosed with schizophrenia. It begins with him encountering the police and evolves as he is transported to the emergency department and then to a psychiatric facility, and ends with his discharge. His family is involved in the patient-centered care scenario. Restraints, medication use, delegation, teamwork, communication, reflection, assessment, and laboratory/diagnostics are all included. It is designed to be an interactive, engaging exercise with students enrolled in a mental health nursing course. Questions and scenarios are posed, and then the next slide provides the answers. Theory bursts are also included.
<p class="MsoNormal" style="margin-bottom: .0001pt; line-height:
normal; mso-layout-grid-align: none; text-autospace: none;”>This unfolding case study is presented in the classroom to senior level nursing students enrolled in a mental health nursing course. The students are encouraged to participate by answering questions and collaborating regarding their answers. The students responded this semester with much enthusiasm; they were very engaged. They initially struggled with the SBAR activities when asked to notify a physician or other team member. This activity has been identified as a weakness in many new grads and was included in the case study for this very reason. As the case study progressed, the students became more confident with making the phone calls.
Sally is a young girl suffering from schizophrenia. Schizophrenia is a psychotic disorder, or a group of disorders represented by a severe impairment of individual thought process, and behavior (TheFreeDictionary, 2012). According to Meyer, Chapman, and Weaver (2009) “it may be more accurate to refer to schizophrenia as a family of disorders rather than a singular disorder.” (p. 90). Untreated patients suffering from schizophrenia are normally unable to filter various sensory stimuli, and exhibit enhanced perception of color, sound, and other environmental factors. In most cases, a patient suffering from schizophrenia will gradually withdraw from personal interactions, and loose the ability to care for his or her individual basic needs (TheFreeDictionary, 2012). Schizophrenia is considered to be one of the top ten illnesses resulting in long-term disability, and accounts estimate that approximately 1% of the world population is affected by the illness (TheFreeDictionary, 2012).
The following analysis is designed to provide and analysis of the patient’s history, and events that resulted in her hospitalization. The analysis will provide the specifics of the patient’s biological, behavioral, cognitive, and emotional components that factor into her illness.
Schizophrenia includes three different subtype, and two over subtypes. The main subtypes include the classifications of paranoid, disorganized, and catatonic, and each of these subtypes displays unique characteristics or symptoms (Hansell, & Damour, 2008). Patients suffering from paranoid schizophrenia will usually display symptoms of hallucinations or delusions. Patients suffering from disorganized schizophrenia are subject to an inappropriate effect, and disorganized speech patterns. Patients suffering from catatonic schizophrenia display symptoms of strange or bizarre sensory motor function (Hansell, & Damour, 2008). Individuals who display symptoms of schizophrenia but lack any symptoms of the three primary classifications are likely to be diagnosed into one of two alternate classifications: residual or undifferentiated schizophrenia (Hansell, & Damour, 2008). Symptoms of schizophrenia are classified into two primary categories. These two categories relate to positive and negative symptoms. Patients displaying positive symptoms exhibit pathological excesses including hallucinations, irrational thinking, and irrational behaviors, whereas patients displaying negative symptoms will exhibit pathological deficits including withdrawal and isolation from social interactions, and poverty of speech capabilities ((Hansell, & Damour, 2008).
Schizophrenia is a complex illness that affects both men and women on an equal level. The illness usually starts around the age of ten, or in young adulthood. However, cases of childhood-onset schizophrenia indicates that the illness can start as young as five years of age. This is a more rare case of schizophrenia that can difficult to diagnose in relation to other childhood developmental problems (PubMedHealth, 2012). While researchers have yet to discover the cause of schizophrenia, many suspect genetics to be a major contributor (PubMedHealth, 20120).
The patient’s case study indicates that she has a history of eccentricity. Medical notations indicate that the patent's mother was an avid smoker, consuming approximately two packs of cigarets daily before and during pregnancy. Further notations include that the patient’s mother suffered from a very severe case of the flue during her fifth month of pregnancy. As a child, the patient showed signs of slower developmental skills, and was diagnosed as suffering from hyperactivity in early childhood. Records indicate that the patient experienced a turbulent home life because of ongoing conflicts between her parents that resulted in separation, and reconciliation. Because of her apparent developmental disabilities, her parents devoted time to the patient however, the patient did receive criticism from her father for her behavioral dysfunctions.
As the patient matured, she displayed signs of being socially awkward and isolated from her peers, and in early adulthood started to display worsening symptoms like talking to herself, and displaying unusual behavior like stating at the floor for long periods. Her first documented schizophrenia episode requiring hospitalization occurred shortly after the additional symptoms started to be displayed. During her examination, the patient displayed signs of unresponsiveness, and waxy flexibility that allowed her limbs to be easily positioned (Meyer, Chapman, & Weaver, 2009). After the initial hospitalization, the patient was returned home to facilitate a quicker recovery. that was short lived because the patient failed to follow the prescribed treatment regimen which, resulted in a secondary episode shortly after her return to college. Further home-based treatments proved unsuccessful as the patient slowly declined, resulting in unresponsiveness, and displaying hebephrenic symptoms like unprovoked giggling, and rocking movements (Meyer, Chapman, & Weaver, 2009).
The patient’s second hospitalization and treatments started to show positive results, and she was taken back to her home environment. She was able to obtain a part-time position at work, and maintain daily household chores. However, the patient failed to follow the prescribed treatment regimen. Following the death of her father, and additional stressors resulting from her mother’s added dependency, the patient suffered from a third regression of the illness. Her third hospitalization resulted from local law officials discovering her walking in a local pond while incoherently mumbling to herself.
Components of the Schizophrenic Episodes
The primary component of the patient’s episodes appear to be related to stress as the primary factor. However, biological factors resulting from her mother’s illness and smoking during pregnancy, and a genetic predisposition related to her grandfather's eccentricity are viable underlying factors resulting in the patient’s illness. In addition to the primary stressor, and the underlying genetic and biological factors, it is possible that the emotions of the patient also contributed to her condition. Further documentation indicates that interfamilial expressed emotion, and communication deviance are probably contributors that appear to be operative in the patient’s case (Meyer, Chapman, & Weaver, 2009). The first of these factors, expressed emotion would be explained by the turbulent relationship, combined with her mother’s over protective nature conflicting with her father’s over critical reactions to the patient’s behavioral issues (Meyer, Chapman, & Weaver, 2009). The second of these factors, communication deviance resulted from the patient’s inability to focus and maintain normal dialog with others (Meyer, Chapman, & Weaver, 2009).
Cognitive factors are a viable consideration for this patient’s case. Meyer, Chapman, and Weaver (2009) suggest that prodomal pruning theory may be one example of a cognitive factor. Prodomal pruning theory suggests that the human brain deletes unnecessary synapses to allow the brain to function properly during the change from adolescence to adulthood (Meyer, Chapman, & Weaver, 2009). Behavior is another factor relating to the patient’s repeated hospitalization. The patient displayed behavior deficiencies in regard to compliance to prescribed treatment regimens, and involvement in situations that could produce high level stressors in her life.
Because illnesses like schizophrenia relate to various and different factors, each person effected by the illness will show differences in ability to function in a normal environment. The various classifications of schizophrenia, ability to receive treatments, and the consideration of various influences and base-line factors help researchers determine what classification a patient falls into. In this particular case, the patient displays symptoms of catatonic schizophrenia. She is able to function in environments that do not produce high levels of demand or stress on the individual. However, the underlying assumptions would indicate that the combination of outlined biological, emotional, cognitive, and behavioral were in-place, and waiting for the appropriate stressor to trigger her symptoms.
b.Emotional Factors - Interfamilial Expressed, Emotion, Communication Deviance
d.Behavioral Factors - Lack of Treatment, High Stress Activities