Schizophrenia - Nursing Case Study
Pathophysiology
• Primary mechanism: Imbalance of neurotransmitters - Schizophrenia is linked to increased levels of dopamine in the brain, which is associated with hallucinations, delusions, and disorganized thoughts. Serotonin may also be involved, contributing to mood and cognition abnormalities.
• Secondary mechanism: Abnormal brain structure - Brain imaging studies often show enlarged ventricles, reduced size of certain brain regions (like the hippocampus), and less overall gray matter in people with schizophrenia. These changes may contribute to the symptoms and cognitive deficits seen in the disease.
• Key complication: Cognitive impairment - Many people with schizophrenia experience significant cognitive deficits, such as problems with memory, attention, and executive functions, which can impact daily functioning and quality of life.
Patient Profile
Demographics:
42-year-old male, freelance graphic designer
History:
• Key past medical history: Diagnosed with Schizophrenia at age 25, history of suicidal attempts, long-term tobacco use
• Current medications: Risperidone 2mg daily, Citalopram 20mg daily, Nicotine replacement therapy
• Allergies: Penicillin
Current Presentation:
• Chief complaint: Increased auditory hallucinations, paranoia, and strong agitation, difficulty sleeping
• Key symptoms: Persistent auditory hallucinations, heightened paranoia, severe restlessness, insomnia, poor concentration, reduced social interaction, lack of self-care
• Vital signs: Blood pressure 145/90 mmHg, Heart rate 105bpm, Respiratory rate 20/min, Temperature 98.6°F, Oxygen saturation 96% on room air
Section 1
Change in Patient Status:
Over the course of several weeks, the patient's symptoms have progressively worsened. His auditory hallucinations have become more persistent, and his paranoia has escalated, causing him to isolate himself more frequently from others. His agitation and restlessness have increased, leading to decreased sleep and further exacerbating his difficulty concentrating. His lack of self-care is also becoming more evident, as he appears disheveled and has lost approximately 10 pounds since his last visit, suggesting he may not be eating properly. His vital signs now show a blood pressure of 155/95 mmHg and a heart rate of 115bpm, indicating heightened anxiety and stress levels.
The patient's worsening symptoms and declining physical appearance indicate that his schizophrenia is not being adequately managed by his current medication regimen. His elevated blood pressure and heart rate also raise concerns about his cardiovascular health, which could be further compromised by his long-term tobacco use and potential poor nutrition. Furthermore, his continued social isolation and apparent neglect of self-care suggest that he may be at an increased risk of depression and suicide. This case requires careful reassessment of the patient's treatment plan and possibly the introduction of new therapeutic strategies to manage his symptoms and improve his quality of life.
Section 2
Response to Interventions:
In response to the patient's escalating symptoms, the healthcare team decided to revise his treatment plan. The psychiatrist increased the dosage of his antipsychotic medication, risperidone, and added a new antihypertensive drug, lisinopril, to manage his elevated blood pressure. A nutritional consult was also ordered to assess his nutritional status and devise a meal plan to help him regain weight. Social services were engaged to explore resources for improving his social interactions and self-care.
Within a week of these interventions, there was a noticeable change in the patient's status. His blood pressure and heart rate normalized to 130/85 mmHg and 85 bpm, respectively. He reported a decrease in the frequency and intensity of his auditory hallucinations, but his paranoia and social isolation remained unchanged. His appetite improved slightly, but he still struggled with maintaining proper self-care. Despite the improvements, the patient's overall mental and physical health remained fragile, indicating the need for continuous monitoring and reassessment of his treatment plan. The healthcare team must consider introducing cognitive-behavioral therapy or other psychosocial interventions to address his persistent paranoia and social isolation.
Section 3
Change in Patient Status:
After two weeks, the patient appeared more alert and showed slight improvement in his overall demeanor. However, he was still resistant to engaging in social activities and continued to express feelings of paranoia. His weight remained stable at 130 pounds, indicating that he was adhering to his new meal plan, but still below the desired range for his height.
During a routine check, the nurse noted that the patient's blood pressure had risen to 160/90 mmHg, and his heart rate was 110 bpm. He admitted to feeling a bit anxious, but denied having any chest pain or difficulty breathing. The patient also reported an increase in the severity of his auditory hallucinations despite the increased dosage of risperidone. His blood glucose levels were also elevated at 180 mg/dL, a possible side effect of the risperidone.
The healthcare team must reassess his medication regimen and consider the possibility of non-compliance or that the patient may be developing a resistance to the antipsychotic medication. The sudden increase in blood pressure and heart rate along with the elevated blood glucose levels could also suggest a new medical complication that needs to be addressed.
Section 4
Change in Patient Status:
During the third week of treatment, the patient's condition began to deteriorate. He became increasingly agitated and his auditory hallucinations worsened, causing him to become irritable and aggressive. Additionally, the patient started to display signs of cognitive impairment, struggling with basic tasks like remembering the names of his healthcare providers and the time of day. His blood pressure continued to fluctuate, with readings reaching as high as 170/100 mmHg, while his heart rate remained elevated at 115 bpm.
New Complications:
The nurse noticed that the patient started to show signs of tardive dyskinesia, a side effect of long-term use of antipsychotic medications, including grimacing, tongue protrusion, and uncontrolled, rapid movements of the fingers. His blood glucose levels continued to rise and were now consistently above 200 mg/dL, suggesting the patient could be developing medication-induced diabetes mellitus, a known complication of risperidone. This new development necessitated an urgent reassessment of his medication plan. The healthcare team also decided to conduct further tests to rule out any undiagnosed cardiovascular conditions that might be contributing to his persistently high blood pressure and heart rate.
Section 5
Change in Patient Status:
Despite the medical team's best efforts, the patient's condition further deteriorated. His hallucinations became more frequent and intense, resulting in violent outbursts. The healthcare team had to use physical restraints and administer intramuscular haloperidol to manage his aggressive behavior. His cognitive impairment worsened, he was unable to recognize familiar faces, and he seemed to have lost track of time completely. His blood pressure soared to 180/110 mmHg, and his heart rate was consistently above 120 bpm. The patient also started complaining about blurred vision, constant thirst, and frequent urination, consistent with uncontrolled diabetes.
New Complications:
The patient's tardive dyskinesia symptoms worsened, and he was now exhibiting signs of akathisia, restlessness and a compelling need to be in constant motion. Blood glucose levels were alarmingly high, with readings consistently above 300 mg/dL. Lab results showed an elevated HbA1c of 8.2%, indicating poor long-term blood glucose control. Moreover, the patient's urine tested positive for ketones, raising concerns about impending diabetic ketoacidosis. The ECG revealed tachycardia and non-specific ST-T wave changes, indicative of potential cardiac complications. These sudden, escalating complications necessitated an urgent multidisciplinary team meeting to reassess and modify the treatment plan.