schizophrenia - Nursing Case Study

Pathophysiology

• Primary mechanism: Neurotransmitter imbalance - Schizophrenia is primarily linked to an imbalance of dopamine, a neurotransmitter that helps regulate emotions and thought processes. Overactivity of dopamine in certain brain areas may lead to hallucinations and delusions.

• Secondary mechanism: Brain structure abnormalities - Research shows individuals with schizophrenia often have unusual brain structures like enlarged ventricles or decreased gray matter volume. These structural abnormalities may impact cognitive function and behavior.

• Key complication: Negative symptoms - These include reduced motivation, social withdrawal, and blunted affect. They are due to decreased activity in certain brain areas and can severely impact a patient's quality of life.

Patient Profile

Demographics:

28, Female, School Teacher

History:

• No significant past medical history

• Currently not on any medications

• No known allergies

Current Presentation:

• Chief complaint: Hearing voices that others do not hear

• Key symptoms: Auditory hallucinations, occasional feelings of paranoia, reduced social engagement and emotional expression, difficulty concentrating

• Vital signs: Blood pressure 120/80, heart rate 68 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, oxygen saturation 98%

Section 1

Change in Patient Status:

The patient reported an increase in auditory hallucinations, hearing voices more frequently and intensely. She also shared that these voices are often negative and command her to perform harmful actions, causing her significant distress. Her paranoia also appears to have worsened, as she reported feeling as though she's being watched or followed, even in her own home. Despite these changes, her vital signs remain stable: Blood pressure 120/80, heart rate 70 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, oxygen saturation 98%.

During a routine physical examination, it was noted that the patient's hygiene has declined. She has lost significant weight, her BMI is now 18.0 kg/m2, down from 21.0 kg/m2 three months ago. These changes suggest an escalation in negative symptoms, including social withdrawal and a decrease in motivation for self-care. This situation necessitates a revision in her care plan to manage these worsening symptoms and ensure her safety.

Section 2

Change in Patient Status:

During a follow-up appointment, the patient appeared to be more withdrawn and less responsive to questions. She reported continued auditory hallucinations, now with increased frequency and intensity. She also expressed an increase in feelings of paranoia, stating that the voices are commanding her to isolate herself from everyone, including her treatment team. Her vitals are still stable: Blood pressure 110/70, heart rate 68 bpm, respiratory rate 18 breaths per minute, temperature 98.7°F, oxygen saturation 96%.

Despite the increase in hallucinations and paranoia, the patient has managed to maintain some level of self-care. She has started to keep a journal, as suggested by her therapist, documenting the times and contexts in which she experiences hallucinations. However, she has lost additional weight, her BMI is now 17.5 kg/m2, indicating that her nutrition and eating habits continue to decline. This further deterioration in her condition necessitates a re-evaluation of her medication regimen, as well as the implementation of a nutritional intervention to address her weight loss.

Section 3

Change in Patient Status:

At her subsequent visit, the patient seems even more disconnected and barely acknowledges the health team's presence. She reports that the voices are becoming more insistent, telling her not to trust anyone, leading her to refuse her medications lately. Her vitals remain stable: Blood pressure 112/72, heart rate 70 bpm, respiratory rate 19 breaths per minute, temperature 98.5°F, oxygen saturation 95%.

Her self-care appears to be deteriorating further. She has stopped writing in her journal and has become increasingly neglectful of her personal hygiene. Her weight continues to drop, her BMI is now 16.8 kg/m2, signaling that her nutritional status is worsening. She appears gaunt and her skin has lost its elasticity, indicating possible dehydration. This alarming decline calls for immediate intervention, including a possible change in her medication regimen, implementation of a more aggressive nutritional plan, and consideration of inpatient care for closer monitoring and support. The team will have to approach this with care, considering her increasing distrust and refusal to cooperate.

Section 4

Change in Patient Status:

Upon further examination, the health team observes an increased disorientation in the patient. She now has difficulty distinguishing between reality and her hallucinations, often interacting with the voices she hears. Her speech is becoming increasingly disorganized, and she seems unable to focus on any task at hand. Her eye contact is fleeting and she becomes agitated when directly addressed.

The team notices a visible tremor in her hands, a potential side effect from her previous medication which she has now refused to take. Her vital signs remain stable: Blood pressure 113/75, heart rate 72 bpm, respiratory rate 18 breaths per minute, temperature 98.7°F, oxygen saturation 94%. The team's priority is to address her worsening mental state as well as the physical symptoms that have developed due to her refusal of medication, lack of nutrition and potential dehydration. These developments will require the team to reassess her treatment plan and consider new interventions.

Section 5

Change in Patient Status:

The team performs a follow-up assessment, observing further disorientation in the patient. Her hallucinations have become more vivid, often leading her to have complex interactions with imagined figures. The patient’s speech has further deteriorated, now marked by frequent derailment and incoherence. She displays signs of distress when addressed, often responding with tangential or unrelated answers.

Her visible hand tremors have also increased in intensity, leading to difficulty in performing basic tasks such as feeding herself. Vital signs remain stable: Blood pressure 110/75, heart rate 70 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, oxygen saturation 93%. However, she has lost 2 kg in the last week and her skin turgor test indicates potential dehydration. The health team recognizes the urgent need to re-evaluate her medication regimen, address her nutritional status and ensure hydration, in addition to managing her advancing mental health symptoms.