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A Beautiful Mind

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by

Valerie Kirk

on 3 March 2015

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Transcript of A Beautiful Mind

A Beautiful Mind
Assessment Data Continued...
Mental Status Exam
Schizophrenia
Current severity:

4.
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each symptom may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).
Nursing Diagnosis and Goals
Nursing Diagnosis:
Disturbed auditory and visual sensory perception related to Schizophrenia as evidenced by talking to self, inappropriate gestures, obsessive, fixed delusions regarding conspiracy theory, and related hallucinations.
Medication #2
Risperdal (Risperidone)
By Kate Brew, Valerie Kirk, Auna Lawler & LeAnn Quinlan

Objective
Introduction
A Beautiful Mind (2001)
John Nash, Nobel Prize winner of 1994 in Economic Sciences
Princeton University, 1947
Based upon a true story, the movie traces his diagnosis, treatment and recovery
Portrays life as a student, mathematician, husband, father and schizophrenic
Assessment
Medical Diagnosis using DSM V Criteria
Nursing Diagnosis
Long/Short-term Goals and Outcomes
Medications
Consistencies/Inconsistencies
Long-term Goal:
Client will verbalize understanding that the delusions and hallucinations are a result of his illness and demonstrate ways to interrupt these positive symptoms.
A Comparison
Consistencies
Inconsistencies
Onset
Continuous manifestation of disease for at least 6 months
Positive symptoms like fixed delusions
Social isolation
Dysfunctional interpersonal relationships
Difficulty with medication adherence
Safety concerns
Clarity of hallucinations
Received medication intervention only, including thorazine and insulin shock therapy (5x per week)
No psychodynamic therapy
Lack of co-existing diagnosis (i.e. no substance abuse, depression, etc.)
High-functioning, even prior to diagnosis
Conclusion
References
American Psychiatric Association. (2013). Schizophrenia spectrum and other psychotic disorders.
In Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
(pp. 99-105). Arlington, VA: American Psychiatric Association.

Grazer, B. (Producer), & Howard, R. (Director). (2001).
A beautiful mind
[Motion picture]. United States: Universal Studios.

Stuart, G. W. (2013).
Priciples and practice of psychiatric nursing
(10th ed.). St. Louis, MO: Elsevier Mosby.

Townsend, M.C. (2011).
Nursing diagnoses in psychiatric nursing: Care plans and psychotropic medications
(8th ed.). Philadelphia, PA: F.A. Davis Company.

Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2013).
Davis’s drug guide for nurses
(13th ed.). Philadelphia, PA: F.A. Davis Company.

Assessment Data
Subjective
No report of personal or family health history provided
Married with one son
John Nash reports:
"I have two helpings of brains, but only half a helping of heart."
"I don't much like people. And they don't much like me."
"I can't fail."
"They may be listening. There may be microphones."
Claims to be distinguished by his math, obsessed with finding a "new, original idea," described as a "lone wolf," knows he is abrupt and direct in social interactions, and self-identifies as a "genius"
Medication #1
Clozaril (Clozapine)
Class
: Atypical Antipsychotic

Action
: may act by antagonizing dopamine and serotonin in the CNS

Dosage
: PO (Adults): 1 mg twice daily, increase by 1 – 2 mg/day no more frequently than every 24 hr to 4–8 mg daily. IM (Adults): 25 mg every 2 wk; some patients may benefit from a higher dose of 37.5 or 50 mg every 2 wk.

Route
: PO, IM

Adverse Reactions/Side Effects
: Neuroleptic malignant syndrome, suicidal thoughts, aggressive behavior, dizziness, extrapyramidal symptoms, headache, increased dreams, insomnia, fatigue, tardive dyskinesia, visual disturbances, constipation, agranulocytosis

Labs
: May cause increased serum prolactin levels. May cause increased AST and ALT. May also cause anemia, thrombocytopenia, leukocytosis, and leukopenia. Obtain fasting blood glucose and cholesterol levels initially and periodically during therapy. Monitor CBC frequently during initial months of therapy in patients with pre-existing or history of low WBC. May cause leukopenia, neutropenia, or agranulocytosis. Discontinue therapy if this occurs. Creatinine at baseline.

Class
: Atypical Antipsychotic

Action
: binds to dopamine and serotonin receptors in the CNS. Also has anticholinergic and alpha-adrenergic blocking activity

Dosage
: 25 mg 1 – 2 times daily initially; increase by 25 – 50 mg/day over a period of 2 wk up to target dose of 300–450 mg/day. May increase by up to 100 mg/ day once or twice further (not to exceed 900 mg/ day). Treatment should be continued for at least 2 yr in patients with suicidal behavior.

Route
: PO

Adverse Reactions/Side Effects
: Neuroleptic malignant syndrome, seizures, dizziness, sedation, visual disturbances, myocarditis, ventricular arrhythmias, tachycardia, constipation, dry mouth, nausea, vomiting, weight gain, granulocytosis, extrapyramidal reactions

Labs:
Monitor WBC, absolute neutrophil count (ANC), and differential count before initiation of therapy and WBC and ANC weekly for the first 6 mo, then biweekly during therapy and weekly for 4 wk after discontinuation of clozapine or until WBC > 3500/mm3 and ANC > 2000/mm3. Because of the risk of agranulocytosis, clozapine is available only in a 1-wk supply through the Clozaril Patient Management System, which combines WBC testing, patient monitoring, and controlled distribution. If WBC is < 3000 mm3 or granulocyte count is < 1500 mm3, withhold clozapine, increase frequency of WBC monitoring according to management system guidelines, and monitor patient for signs and symptoms of infection. If acceptable WBC and ANC levels were maintained during first 6 mo of continuous therapy, monitoring may decrease to every 2 wk. If levels are maintained for second 6 mo, WBC and ANC may be monitored every 4 wk thereafter. Assess fasting blood glucose and cholesterol levels initially and throughout therapy. Electrolyte and lipid panel at baseline, then periodically.
LOC
Alert and oriented to person/place/time
Concentration is intact, although very focused to misperceptions
Memory
recent, short-term and long-term memory intact
Judgment
Impaired
Insight
Impaired, but shows improvement with recovery
Emotional State
Hyperexpression of emotions
Typically anxious, on-guard and easily distracted, flustered and/or agitated
Affect is blunted
Facial expression is consistently tense, with nervous gestures
Thought Content
Experiences various paranoid delusions(i.e. conspiracy about the Russian bomb movement across the U.S. and his role with the Department of Defense)
Obsessive about mathematics
No evidence of suicidal thoughts, ideation or self-harming
Thought Process
Obsessive
Circumstantial
Calculation ability is intact
Intellect categorized as "genius" with respect to logical-mathematical subcategory
Perception
Experiences auditory and visual hallucinations (i.e. Charles, Marcee and William Parcher)
General Description

Middle-aged, Caucasian male
Appears stated age, is dressed appropriately and groomed, and overall is fairly well-kept
Speech is often loud and occasionally pressured
Appropriate use of humor and sarcasm
Eye contact is inconsistent
Posture is stooped, with gaze maintained downward
Gait is uneven, with limp
Interpersonal behavior ranges from resistant to withdrawn to more cooperative during recovery
"Everyone is haunted by their past."
-John Forbes Nash Jr.
Short-term Goals:

1. Client will adhere to prescribed medication regimen daily to improve positive symptoms.
2. Client will discuss daily content of hallucinations and delusions with wife, health care provider, and colleagues.
3. Client will demonstrate appropriate social boundaries and interactions while engaging with colleagues and community at large, as evidenced by lack of paranoid outbursts.
ALL GOALS WERE MET!
Assessment data
DSM V Criteria for Schizophrenia
Nursing diagnosis, goals and outcomes
Medications (Clozaril, Risperdal)
Consistencies and Inconsistencies
In general, we feel the video depicted schizophrenia in fairly accurate, realistic manner.
QUESTIONS???
Schizophrenia (continued...)
A.
Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), (3):
1.
Delusions
2.
Hallucinations
3. Disorganized speech
4.Grossly disorganized or catatonic behavior
5. Negative symptoms
B.
Level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to onset of disturbance.
C.
Continuous signs of disturbance persist for at least 6 mo. During 6 mo period must include at least 1 mo of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms. During these periods the signs of the disturbance may only include negative symptoms or two or more symptoms listed in Criterion A.
D.
Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occured concurrently with the active phase symptoms, or 2) if mood episode have occurred during active phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
DSM V Criteria:
E.
The disturbance is not attributable to the psychological effects of a substance (a drug abuse or medication) or another medical condition.
F.
If there is a history of autism spectrum or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least one month.
Specified:
Multiple episodes, currently in acute episode. Without catatonia
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