Client Description
National Alliance on Mental Illness (NAMI)
Schizoaffective Disorder
- R.R. is a 47 year old, Caucasian male diagnosed with schizoaffective d/o with acute exacerbation.
- He was brought to Butler Hospital by his mother and admitted due to psychotic symptoms.
- His mother complained that he was "preoccupied with his sins."
- Reported not taking medication for 6 months because he "doesn't need them."
- This national organization describes the symptoms as characteristic of schizophrenia and significant disturbances in mood.
- NAMI also agrees that 2nd generation antipsychotics such as Zyprexa are more effective at treating both positive and negative symptoms of schizophrenia. Zyprexa also has lower risk of adverse side effects such as EPS.
- Patients can also be treated with antidepressants such as SSRI's in conjunction with antipsychotics.
Discharge Planning
Comparison With DSM
Mental Status Exam
Chief Complaint
National Institute of Health
DSM V Criteria for Schizoaffective Disorder:
How does this relate to how R.R. is presenting?
- Presented with non-command auditory hallucinations at admission.
- Delusions of persecution related to preoccupation with his sins.
- During interview, R.R. showed signs of depressed mood, motivation, anhedonia as well as self directed harm (scar on arm).
- "Occupational functioning is often impaired..." (DSM V, pg 107) R.R. is unemployed.
Upon discharge, R.R. should report decreased auditory hallucinations and deny SI or thoughts of harming self or others. R.R will be referred to the Partial Hospital at Butler Hospital. This will encourage adherence to medication regiment and provide group and cognitive behavior therapy. He will return to living with his mother and demonstrate a therapeutic relationship with her.
- An uninterrupted period of illness during which there are concurrent symptoms of a major mood episode (MDD or manic) and criteria for schizophrenia.
- Criteria for schizophrenia: at least 1 symptom of delusions, hallucinations or disorganized speech for at least a 1 month period.
- Symptoms and disturbances must not be related to substance abuse or other medical condition. (DSM V, pg 105)
- Criteria for major mood episode:
- MDD: depressed mood, most all days, most all of the day, complaints of depressed mood or observed by others. (DSM V, pg 160)
- Manic: period of persistent elevated, expansive or irritable mood. Persistent goal oriented behavior. All must last for at least a week, for a majority of every day. (DSM V, pg 124)
Upon admission to Butler Hospital, R.R. had a chief complaint of "Are you a Christian?"
Symptoms of Schizoaffective disorder include but are not limited to;
- Change in appetite and energy
- Lack of concern for grooming
- Delusions
- Sleep disturbances (Insomnia)
- Hallucinations
- Social isolation
R.R. presents with all of these symptoms. This information helps validate his diagnosis.
Indication for Admission
Psychosocial Assessment
Departments of Psychiatry at
Duke and Yale University
- Non-command auditory hallucinations
- Exacerbated paranoia
- Preoccupation with sins
- Delusions of thought manipulation
- Mood disruption and anhedonia
Nursing Interventions
- Born and raised in Pawtucket, Rhode Island.
- No Family History of mental illness.
- Age: 47 Marital Status: single, never married
- Religion: catholic Education: 3 college degrees
- Occupation: unemployed
- Medical Dx: HTN, obesity, asthma
- Attended CCRI for degree in Engineering
- Attended URI: for masters degree in Business
- Attended PC: for degree in Theology
According to a study done in 2011 by the Departments of Psychiatry at Duke and Yale University, insomnia is highly prevalent in patients with schizophrenia and schizoaffective d/o. This high prevalence offers information on the association between insomnia and higher body weight, and links to night eating.
Outcome Identification
Medication Review Continued...
PRN Orders:
- By the end of the week, R.R. will communicate with the nurse when AH are present and any factors that preceded them. (Varcarolis, 2014)
- R.R will consistently avoids acting upon his AH.
- By discharge, R.R. will report a decrease in AH. (Varcarolis, 2014)
Lorazepam (Ativan) 1mg PO q1hr
Anxiolytic: to treat anxiety.
Lorazepam (Ativan) 2mg IM q1hr
Anxiolytic: to treat severe anxiety.
Trazodone (Oleptro) 50mg PO
SSRI: to treat insomnia.
R.R. has been diagnosed with obesity and hypertension.
Nursing Diagnoses
In order of priority:
Risk for self-directed harm or other direct harm R/T depressed mood and auditory hallucinations AMB preoccupation with sins and evidence of self-directed harm.
Nonadherence to medication regiment R/T anosognosia AMB verbalization of nonadherence. (Varcarolis, 2014)
Disturbed sensory perception R/T positive symptoms of schizophrenia AMB non-command auditory hallucinations. (Varcarolis, 2014)
Continued...
References:
Physical and Psychiatric History
Duckworth, Ken MD (Nov. 2012). Schizoaffective Disorder. Retrieved from http://www.nami.org/Template.cfm?Section=By_Illness&Template=/ContentManagement/ContentDisplay.cfm&ContentID=23043
Medication Review:
Medication Review Continued...
Standing orders:
Physical:
PRN Orders:
Psychiatric:
Halter, M.J.(2014). Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. St. Louis, Missouri: Elsevier.
- 2 younger sisters, 1 mother
- Currently lives with mother
- Support system consists of family, described as "okay"
- Attends mass regularly
- Hobbies include studying theology. Hopes to one day become a theology professor.
- Current stressors are his illness, and unemployment
- Use of deep breathing and walking for coping strategies.
Nursing Evaluation
Citalopram (Celexa) 20mg daily PO
SSRI: symptoms of Major Depression
- May cause seizures, SI, Dizziness, chest pain, hypertension, sexual dysfunction, nausea, vomiting, weight gain, and headaches.
- Takes 2-4 weeks to achieve therapeutic effects. (Varcarolis, 2014)
Olanzapine (Zyprexa) 10mg PO bedtime, 5mg PO AM
Atypical (2nd Gen) Antipsychotic: +&- symptoms of schizophrenia.
- Need to monitor for EPS.
- May cause weight gain and agranulocytosis. (Varcarolis, 2014)
By the end of the week, R.R. was able to tell the nurses when he was experiencing AH and preceding factors were identied.
Benzotropine (Congentin) 1mg IM q1hr
Anticholinergic: to treat EPS specifically Pseudoparkinsonism.
Benzotropine (Congentin) 2mg IM q1hr
Anticholinergic: to treat severe EPS specifically Pseudoparkinsonism.
Haloperidol (Haldol) 2mg PO q1hr
Typical antipsychotic: to treat psychosis
Haloperidol (Haldol) 5mg IM q1hr
Typical antipsychotic: to treat severe agitation.
- Hypertension
- Obesity
- Asthma
Palmese, L., DeGeorge, P., Ratliff, J., Srahari, V., Wexler, B., Krystal, A., Tek, C. (2011). Insomnia is frequent in schizophrenia and associated with night eating and obesity. Retrieved from http://www.sciencedirect.com/science/article/pii/S0920996411004282#
At discharge, R.R. reported decreased AH. When he does hear AH he listens to music and takes a walk.
Past admission to Butler Hospital in 2008 R/T acute psychotic symptoms.
Rogge, Timothy MD (2 Feb 2013). Schizoaffective Disorder. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000930.htm.