In my nursing practice, I work with a patient who has the signs of a mental disorder that falls under the DSM-5 classification. JG is a Hispanic male, DOB 6/19/1978, who came to the hospital with Medicaid coverage. The resident has no support system in the community and relies on the DHS shelter system for support. JG came to the hospital due to multiple seizures, which were probably caused by stress; he had a seizure disorder before 22. JG was sent to the telemetry floor for monitoring where he was given antiepileptic medications. Later the patient was transferred to the regular medical level where he was medically cleared for discharge. When the patient came to the hospital, it was discovered that he had schizophrenia, depressive, and anxiety disorders previously. The patient readily took medication to reduce the symptoms of schizophrenia and even asked for a dose increase after the incident when he was rude to the staff.
After some time in the hospital, JG, who had previously denied his depression, confusion, and short-term memory problems, admitted to having some sleep and short-term memory problems. He also noted that he felt disappointed as he lost his independence due to illness and expressed a desire for recovery. It is important to note that after a few weeks of hospitalization, symptoms associated with memory and sleep problems decreased, but the patient’s depression and anxiety did not leave. He also needs to continue treatment for schizophrenia, which has a long history and complicates his life.
To sum it up, JG is an alert and oriented person with some cognitive impairments but can make his basic needs known. He kept in touch with his family, as his niece serves as his support system. JG expressed feelings of sadness at times due to his current medical condition, loss of independence, lack of family support, and being in a nursing facility. His transfer to another SNF is on hold; he was referred to the Open Doors transition program; the resident remains in the facility as LT.
Noteworthy, JG reported a history of psychiatric and psychotherapy treatment since childhood. He was diagnosed with major depressive disorder, paranoid schizophrenia, anxiety disorder due to a known physiological condition, insomnia due to other mental disorders. He was reportedly on prescribed psychotropic medications – Abilify, Trazadone, Xanax. JG also reported a history of substance abuse, including using cannabis at age 11, cocaine at age 13, and heroin until the age of 39 and alcohol abuse. These all ended with his last drug overdose at the age of 39. The resident was born and raised in Puerto Rico, married in Puerto Rico at 21. He was married for about five years and had an 11-year-old daughter who lives in Puerto Rico. JG moved to NYC in his 20s, earned credits towards an Associate Degree in Business, worked for a moving company, and before more recent illness, and hospitalization lived in a shelter and then in an adult home.
After several weeks of JG’s hospitalization, he was diagnosed with: major depressive disorder, recurrent, moderate; anxiety disorder due to known physiological condition; schizophrenia, unspecified. These diagnoses are consistent with those in record – schizophrenia and anxiety disorder, with the latest overall assessment and the latest results on the PHQ-9 depression screen. It was suggested that the diagnosis of schizophrenia should be verified, since this is a chronic mental illness, by requesting past psychiatric records, or by having the nurse obtain a detailed psych history from the family. Besides, as an alternative, PASRR level 2 should be required.
JG must continue to take psych meds since the benefits of meds outweigh their risks. Besides, the patient has a high risk of morbidity, which in schizophrenia relates to an increased risk of suicidal behavior. Simultaneously, JG’s hospital history records indicated that the patient did not report or show suicidal behavior. The patient has hyperlipidemia and quadriplegia; therefore, this factor should be considered when choosing medicines without the adverse effects of increasing blood lipids.
Even though the patient is diagnosed with a major depressive disorder and anxiety disorder, the most crucial diagnosis is schizophrenia, since it causes anxiety and depression. According to scholars, “Schizophrenia is a psychotic illness in which the individual loses contact with reality and often experiences hallucinations, delusions, or thought disorders” (Rajesh & Tampi, 2018). According to the history of the patient’s stay in the hospital, he once experienced hallucinations. As a result, JG showed an episode of socially destructive behavior – he insulted the nursing staff and threw himself out of bed. JG did not show delusions, although his emotional state sometimes led to alogia (Flanagan et al., 2012). Upon arrival at the hospital, the patient also had a confusion of thoughts, since he could not provide information about his medical history, particularly about the places of previous inpatient treatment.
Criteria for schizophrenia described in the DSM-5 include signs and symptoms of at least six months ‘duration, present in the patient’s history (Rajesh & Tampi, 2018). It is unknown whether and when he had at least one month of active-phase positive and negative symptoms. Therefore, it is necessary to treat schizophrenia, since complete remission will become the main reason for the onset of the patient’s mental health. Attention must be paid to major depressive disorder and anxiety disorder in terms of symptom relief.
As for the etiology and epidemiology, there is still no consensus in scientific circles on this score. According to scientists, genetics has a vital role in the etiology of schizophrenia (Rajesh & Tampi, 2018). Simultaneously, genetic variation responsible for the disease has not yet been discovered. Environmental factors that may have a role include being born and raised in an urban area, cannabis use, infection with Toxoplasma Gondi, obstetric complications, central nervous system infections in early childhood, and advanced paternal age. Scientists are also studying patients’ experiences with schizophrenia to improve the criteria for this disease (Flanagan et al., 2012). Because the study participants demonstrate an abundant emotional inner life and a goal-oriented attitude, the treatment of schizophrenia will likely be seriously redefined. Nursing theories described below can provide a sound basis for such a revision.
Treatment Plan and Therapy Modality
When drawing up a future treatment plan, attention should be paid to the facts set out below. Once, during several weeks of hospitalization, the patient exhibited behavior symptoms by throwing himself off the bed, spitting on staff, and hallucinating. Besides, the patient has a nutritional problem or potential nutritional problem related to the diagnosis of schizophrenia, major depression, hyperlipidemia, quadriplegia. Therefore, he is prescribed a therapeutic diet and assistance with feeding, particularly encouraging meal intake and completion. The nurse will also need to monitor his diet, make meal consumption records, and monitor weights weekly or monthly. However, diet consistency and supplements should follow the doctor’s prescription. It should also be borne in mind that the patient has actual and potential for fluid deficit related to schizophrenia and major depression diagnosis.
Therefore, it is recommended to administer medications as ordered while also providing monitoring for meds’ side effects and effectiveness. Besides, the nurse should encourage the resident to drink fluids of choice and report to the doctor on fluid deficit symptoms. These symptoms may include decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips. Other related symptoms are furrowed tongue, new-onset confusion, dizziness on sitting or standing, increased pulse, headache, fatigue or weakness, dizziness, fever, thirst, recent or sudden weight loss, dry or sunken eyes. This aspect is critical, given hyperlipidemia, quadriplegia diagnosis, and the observed patient’s falls. The nurse must also offer drinks during one-to-one visits while ensuring that all beverages comply with diet and fluid restrictions and consistency requirements.
It is necessary to develop approaches based on nursing theories applicable to psychiatric nursing in treating schizophrenia and associated anxiety and major depressive disorder. In this case, the patient’s emotional state’s peculiarities must be taken into account, since patients with schizophrenia tend to experience many powerful emotions (Flanagan, 2012). In particular, with a worsening of the symptoms of schizophrenia, JG presents a depressed and anxious mood with excessive worry and restlessness, verbalized sadness with sleep difficulties, shame, and life regrets. He also notes significant difficulty adjusting to the loss of previous independent ambulation and current need for nursing home placement.
Since the patient has sufficient cognitive capacity to benefit from psychotherapy, he will have individual psychotherapeutic sessions 1-5 times a month and support from a psychologist. The treatment plan should also focus on overcoming the target psychological symptoms of anxiety, depression, frustration, guilt, and shame. Equally important is working with sleep problems, as well as functional and behavioral challenges. In particular, the patient demonstrates adjustment difficulty, difficulties with daily living activities, emotional and social isolation, and unrealistic expectations.
Thus, therapeutic goals should focus on improving adjustment to illness, functional decline or loss, increasing acceptance of assisted daily living care or improving self-care, reducing anxiety, reducing depression. Other goals include reducing emotional and social isolation or withdrawal, reducing unrealistic expectations, and reducing frustration. It will imply specific clinical interventions of affect regulation therapy, cognitive exercise and skill-building, coping skills training, life review therapy, supportive psychotherapy, and validation therapy. Suggested behavioral approaches to psychotherapeutic sessions should be focused on providing empathic listening and statements to facilitate adjustment and a sense of support, and providing simple concrete explanations when conducting care and procedures. The psychotherapist should also encourage the patient’s participation in pleasant activities, provide positive reinforcement, provide redirection, and consider follow-up psychiatry.
During psychotherapy sessions, the therapist can draw attention to some of the methods and approaches proven to be useful when working with psychotic patients. In particular, according to Freud and Jung’s psychoanalytic theory, the relationship between therapist and patient is a fundamental element of psychiatric nursing (Pehlivan and Güner, 2016). Moreover, psychiatric nurses can solve patients’ mental health problems through strong therapeutic relationships with them and by using empathy.
Further, according to Developmental theories, a nurse can help patients who feel hopeless and depressed because of not providing care for themselves by exploring their existing power and skills. According to Interpersonal Relations theory, a therapist should aim to rehabilitate patients’ interpersonal experiences and ensure their positive relationships (Pehlivan and Güner, 2016). Then, Cognitive-Behavioral approaches imply that nurses can change patient’s feelings, opinions, and behaviors and teach them skills to cope with mental disorder symptoms through nursing practices based on Skinner’s and other behavioral theories. Moreover, Skinner’s principles and behavioral methods are highly useful in changing targeted behaviors and states and are especially effective in patients with chronic mental disorders.
According to Social Theories, the therapist can take into account the social factors of the patient’s life and his relationship with the family social roles. As part of Nursing Theories, patients incapable of maintaining their self-care should receive nursing care (Pehlivan and Güner, 2016). For JG, the most important will be to support his daily activities and monitor his nutrition. Finally, in the course of therapy sessions, according to Nursing Theories, the therapist should focus on discussing the patient’s experiences and how these experiences matter to them, rather than focus on the patient’s concerns.
During the hospital stay, the patient’s condition improved, although he also showed exacerbations and expressed sadness about the need to stay in the hospital. In particular, the patient’s short-term memory improved, and his speech became richer. At the same time, a more significant reduction in symptoms of depression and anxiety should be reached. In this regard, medical personnel’s attentive and responsive attitude is essential, since stigma and irritation of health workers are often the reason for the exacerbation of anxiety and depression in patients (Potter & Bockenhauer, 2000). Besides, according to scientists, there is a stigma in society against patients who have schizophrenia, as well as anxiety and depressive disorders.
In particular, most people believe that patients with anxiety and depressive disorder are to blame for their condition and could control their state if they wanted to. Since this is far from the truth, such an attitude can aggravate the health of patients. Another unfortunate trend is the perception of schizophrenic patients as unable to heal (Hasan & Musleh, 2017). It is also not true, so the hospital staff will need to work hard to get JG into permanent remission and help him achieve mental health. It should not be overlooked that his schizophrenia is the reason why JG developed anxiety and depressive disorders.
Psychopharmacology Rationale and Therapy
The patient is currently taking second-generation antipsychotics Abilify, Trazadone, Xanax. These medications have no side effects associated with increased blood lipids and glucose (Rajesh & Tampi, 2018). It was decided to continue taking these medications since their positive impact overweighs potential risks. The goal of taking medication is to minimize symptoms, monitor patient’s parameters to assess med effectiveness, and avoid deterioration. When administering medication, the nurse can adjust her understanding according to the Biological Theories approach, according to which mental disorder occurs due to physical and chemical changes in the brain (Pehlivan and Güner, 2016). The goal of drug treatment is correcting the chemical imbalance, and nurses need to know the positive and adverse effects of treatment with psych meds.
Flanagan, E. H., Solomon, L. A., Johnson, A., Ridgway, P., Strauss, J. S., & Davidson, L. (2012). Considering DSM-5: The personal experience of schizophrenia in relation to the DSM-IV-TR criteria. Psychiatry: Interpersonal & Biological Processes, 75(4), 375-386.
Hasan, A. H., & Musleh, M. (2018). Self‐stigma by people diagnosed with schizophrenia, depression, and anxiety: Cross‐sectional survey design. Perspectives in Psychiatric Care, 54(2), 142-148.
Pehlivan, T., & Güner, P. (2016). The use of theories in psychiatric nursing-II. Journal of Psychiatric Nursing/Psikiyatri Hemsireleri Dernegi, 7(2), 100-104.
Potter, M. L., & Bockenhauer, B. J. (2000). Implementing Orlando’s nursing theory: A pilot study. Journal of Psychosocial Nursing and Mental Health Services, 38(3), 14-21.
Rajesh, R., & Tampi, R. (2018). Schizophrenia: ensuring an accurate Dx, optimizing treatment. Journal of Family Practice, 67(2), 82-88.