Mr. Thompson, a patient with schizophrenia, is experiencing persistent auditory hallucinations and heightened paranoia despite compliance with Risperidone and Sertraline. Which of the following actions should the nurse prioritize to address the exacerbation of his symptoms?

B) Suggest a switch to Clozapine due to its efficacy in treatment-resistant schizophrenia.

A) Increase the dosage of Risperidone to enhance its effectiveness.

B) Suggest a switch to Clozapine due to its efficacy in treatment-resistant schizophrenia.

C) Recommend the addition of cognitive-behavioral therapy for psychosis (CBTp) to his treatment plan.

D) Advise the addition of a benzodiazepine to manage his anxiety and insomnia.

Mr. Thompson, a patient with schizophrenia, is experiencing persistent auditory hallucinations and increased paranoia despite adherence to Risperidone and Sertraline. His negative symptoms, such as flat affect and social withdrawal, are also prominent. As a nurse, which of the following interventions should be prioritized to address both positive and negative symptoms while considering his overall well-being?

C) Suggest the addition of Cognitive Behavioral Therapy for Psychosis (CBTp) to his treatment plan.

A) Increase the dosage of Risperidone to enhance symptom control.

B) Recommend switching to Clozapine for its efficacy in treatment-resistant schizophrenia.

C) Suggest the addition of Cognitive Behavioral Therapy for Psychosis (CBTp) to his treatment plan.

D) Advise discontinuation of Sertraline to reduce potential drug interactions.

Mr. Thompson, a patient with schizophrenia, is experiencing an acute exacerbation of psychotic symptoms despite adherence to Risperidone. His fasting blood glucose level is elevated, and he exhibits signs of metabolic syndrome. Which nursing intervention is most appropriate to address both his mental health symptoms and emerging metabolic issues?

B) Collaborate with the healthcare provider to consider switching to Aripiprazole and implement a lifestyle modification plan.

A) Increase the dose of Risperidone to better control his psychotic symptoms.

B) Collaborate with the healthcare provider to consider switching to Aripiprazole and implement a lifestyle modification plan.

C) Encourage Mr. Thompson to reduce his medication intake to lower his blood glucose levels.

D) Focus solely on cognitive behavioral therapy for psychosis (CBTp) to manage his hallucinations and paranoia.

A nurse is assessing Mr. Thompson, who is experiencing an acute exacerbation of auditory hallucinations and paranoia. Considering his current symptoms and treatment regimen, which nursing intervention is most appropriate to prioritize for Mr. Thompson at this time?

C) Collaborate with the healthcare team to discuss the potential benefits of switching to Aripiprazole and initiating CBTp.

A) Encourage Mr. Thompson to participate in a daily social group to reduce social isolation.

B) Educate Mr. Thompson about the importance of adhering to his current medication regimen despite side effects.

C) Collaborate with the healthcare team to discuss the potential benefits of switching to Aripiprazole and initiating CBTp.

D) Focus on lifestyle modifications to manage Mr. Thompson’s elevated blood glucose and cholesterol levels.

Mr. Thompson is undergoing treatment with Aripiprazole and is set to begin Cognitive Behavioral Therapy for psychosis (CBTp). As a nurse, which intervention should you prioritize to support Mr. Thompson's treatment plan?

C) Coordinate with the therapist to integrate relaxation techniques into Mr. Thompson's CBTp sessions.

A) Educate Mr. Thompson about the benefits and side effects of Aripiprazole to improve adherence.

B) Encourage Mr. Thompson to engage in daily physical activity to enhance cardiovascular health.

C) Coordinate with the therapist to integrate relaxation techniques into Mr. Thompson's CBTp sessions.

D) Monitor Mr. Thompson's blood glucose levels weekly to detect any changes promptly.

Mr. Thompson, who is undergoing treatment with Aripiprazole and experiencing persistent psychotic symptoms, is also enrolled in a Cognitive Behavioral Therapy for psychosis (CBTp) program. What is the most appropriate nursing intervention to enhance the effectiveness of his treatment plan?

A) Encourage Mr. Thompson to engage in daily journaling to track his thoughts and progress in therapy.

B) Suggest that Mr. Thompson increase his dose of Aripiprazole to a higher therapeutic level.

C) Advise Mr. Thompson to avoid all social interactions until his symptoms completely resolve.

D) Recommend Mr. Thompson discontinue CBTp sessions if he finds them overwhelming.

Mr. Thompson, who is undergoing treatment with Aripiprazole and Cognitive Behavioral Therapy for psychosis, reports occasional dizziness and fatigue. What is the most appropriate initial nursing intervention to address these symptoms?

B) Advise Mr. Thompson to rise slowly from sitting or lying positions to prevent dizziness.

A) Instruct Mr. Thompson to increase his sodium intake to manage potential orthostatic hypotension.

B) Advise Mr. Thompson to rise slowly from sitting or lying positions to prevent dizziness.

C) Suggest that Mr. Thompson reduces his physical activity to minimize fatigue.

D) Encourage Mr. Thompson to drink more water to prevent dehydration.

Two weeks into Mr. Thompson's Cognitive Behavioral Therapy for psychosis (CBTp) program, he reports occasional dizziness and fatigue. Which nursing action is most appropriate to address these new symptoms and ensure his safety?

B) Advise Mr. Thompson to rise slowly from sitting or lying positions to prevent orthostatic hypotension.

A) Instruct Mr. Thompson to increase his fluid intake to manage potential dehydration.

B) Advise Mr. Thompson to rise slowly from sitting or lying positions to prevent orthostatic hypotension.

C) Suggest Mr. Thompson reduce his participation in community group activities to avoid overexertion.

D) Recommend Mr. Thompson discontinue Aripiprazole until his symptoms resolve.

A nurse is reviewing the care plan for Mr. Thompson, who has been diagnosed with orthostatic hypotension secondary to Aripiprazole use. Which nursing intervention should be prioritized to address the potential risk for falls in Mr. Thompson?

B) Advise Mr. Thompson to rise slowly from a sitting or lying position.

A) Educate Mr. Thompson on the importance of increasing sodium intake.

B) Advise Mr. Thompson to rise slowly from a sitting or lying position.

C) Encourage Mr. Thompson to participate in strenuous exercise to improve circulation.

D) Suggest Mr. Thompson use a cane or walker when ambulating.

A nurse is reviewing the care plan for Mr. Thompson, a patient with schizophrenia experiencing orthostatic hypotension, likely due in part to his medication regimen. Which of the following nursing interventions should be prioritized to address Mr. Thompson's orthostatic hypotension and minimize its impact on his daily activities?

B) Encourage Mr. Thompson to increase his fluid intake and perform gradual position changes.

A) Administer a higher dose of Aripiprazole to enhance symptom control and observe for changes.

B) Encourage Mr. Thompson to increase his fluid intake and perform gradual position changes.

C) Recommend Mr. Thompson to engage in vigorous physical activities to improve overall cardiovascular health.

D) Suggest reducing Mr. Thompson's participation in community activities to prevent dizziness.

Schizophrenia - Nursing Case Study

Pathophysiology

• Primary mechanism: Dopamine dysregulation - Schizophrenia is largely associated with an imbalance in dopamine activity, particularly hyperactivity in the mesolimbic pathway, contributing to positive symptoms like hallucinations and delusions.

• Secondary mechanism: Glutamate dysfunction - There is also evidence of reduced NMDA receptor function, impacting glutamatergic signaling. This may lead to negative symptoms and cognitive deficits by disrupting synaptic plasticity and neural connectivity.

• Key complication: Neurodevelopmental alterations - Abnormal brain development, including cortical thinning and ventricular enlargement, often precedes symptom onset and may underlie the structural and functional brain abnormalities seen in schizophrenia.

Patient Profile

Demographics:

32-year-old male, software engineer

History:

• Key past medical history: Diagnosed with schizophrenia 5 years ago, history of depression

• Current medications: Risperidone 3 mg daily, Sertraline 50 mg daily

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Increasing auditory hallucinations and paranoia

• Key symptoms: Delusions of persecution, auditory hallucinations, social withdrawal, decreased motivation, insomnia

• Vital signs: Blood pressure 145/92 mmHg, heart rate 102 bpm, temperature 98.6°F, respiratory rate 18 breaths per minute

Section 1

During the initial assessment, the healthcare team notes several pertinent findings that build upon the patient's current presentation. The patient, Mr. Thompson, exhibits flat affect and a significant reduction in verbal communication, consistent with negative symptoms of schizophrenia. Despite being compliant with his current medication regimen of Risperidone and Sertraline, he reports persistent auditory hallucinations and heightened paranoia, particularly fearing surveillance at his workplace. His social withdrawal has also intensified, leading to absenteeism and strained relationships with colleagues. Additionally, he mentions difficulty concentrating and completing tasks, which is impacting his performance as a software engineer.

Physical examination reveals elevated blood pressure at 145/92 mmHg and tachycardia with a heart rate of 102 bpm, indicating mild autonomic dysregulation possibly exacerbated by stress and poor sleep. His respiratory rate is within normal limits at 18 breaths per minute, and his temperature is stable at 98.6°F. A review of systems highlights ongoing insomnia and reduced appetite, contributing to his overall fatigue and decreased motivation.

These findings suggest the need for reevaluation of his treatment plan to address the exacerbation of positive symptoms and the persistence of negative symptoms. Mr. Thompson’s case presents an opportunity for clinical reasoning, focusing on potential adjustments in pharmacologic management, such as considering a different antipsychotic with a broader receptor profile or augmenting his current therapy to better target his symptoms. Additionally, exploring non-pharmacologic interventions, such as cognitive-behavioral therapy for psychosis (CBTp) and supportive psychotherapy, may also be beneficial. This assessment sets the stage for further diagnostic evaluation to rule out any underlying medical conditions that could be contributing to his current status and to ensure comprehensive care.

Section 2

During a follow-up visit, Mr. Thompson presents with new complications that warrant immediate attention. Despite adherence to his medication regimen, he reports an escalation in his auditory hallucinations, now hearing voices that are more commanding and distressing. His paranoia has intensified, with Mr. Thompson becoming convinced that his home is bugged with surveillance devices, which he insists on dismantling. His social withdrawal has deepened, and he has not left his house for work in over a week, citing fear of being persecuted by colleagues. This exacerbation suggests a possible acute psychotic episode, necessitating a reassessment of his treatment strategy.

Laboratory tests reveal a slightly elevated fasting blood glucose level of 112 mg/dL, raising concerns about potential metabolic side effects from Risperidone, which could be contributing to his stress and agitation. His lipid profile shows mildly increased total cholesterol at 210 mg/dL, further indicating the need for metabolic monitoring and lifestyle interventions. Additionally, his blood pressure remains elevated at 150/95 mmHg, and his heart rate is persistently high at 105 bpm, confirming ongoing autonomic dysregulation.

The healthcare team considers these findings in the context of Mr. Thompson's overall health and treatment goals. A discussion unfolds regarding the potential switch to an antipsychotic with a more favorable metabolic profile, such as Aripiprazole, which might better manage his positive symptoms while minimizing metabolic risks. Concurrently, the implementation of a structured CBTp program is proposed to help Mr. Thompson address his paranoia and hallucinations more effectively. This multifaceted approach aims to stabilize his mental health status and prevent further deterioration, while also addressing the emerging metabolic issues.

Section 3

Following the healthcare team's decision to transition Mr. Thompson to Aripiprazole, he begins the new medication regimen, and initial assessments are conducted to evaluate its impact. Within two weeks, Mr. Thompson reports a slight reduction in the intensity of his auditory hallucinations and a modest improvement in his paranoia. However, the improvements are not as pronounced as hoped. His anxiety about being monitored remains, and he continues to express concerns about surveillance devices in his home. Additionally, Mr. Thompson's social withdrawal persists, though he has managed to step outside briefly for short walks, indicating some progress.

During a follow-up visit, Mr. Thompson's vital signs show a slight improvement in blood pressure, now at 145/90 mmHg, but his heart rate remains elevated at 102 bpm. Laboratory results reveal a marginal decrease in fasting blood glucose to 110 mg/dL and a stable cholesterol level, suggesting that the metabolic profile of Aripiprazole may be slightly more favorable. Despite these positive signs, Mr. Thompson continues to experience stress related to his persistent symptoms and social isolation, which may still be contributing to his autonomic dysregulation.

The healthcare team discusses the need for a more comprehensive intervention strategy to address Mr. Thompson's ongoing challenges. It is determined that integrating a structured Cognitive Behavioral Therapy for psychosis (CBTp) program will be crucial in helping him develop coping mechanisms for his distressing symptoms. The team also decides to conduct regular monitoring of his metabolic parameters and cardiovascular status to ensure that any emerging complications are promptly addressed. This integrated approach aims to provide a more holistic management plan, focusing on both psychotic symptoms and physical health, setting the stage for subsequent evaluations of his progress.

Section 4

Two weeks after Mr. Thompson's integration into the Cognitive Behavioral Therapy for psychosis (CBTp) program, the healthcare team conducts another follow-up assessment to evaluate his response to the interventions. During this visit, Mr. Thompson reports a noticeable decrease in the frequency of his auditory hallucinations, though he still experiences them intermittently. His anxiety about being monitored has diminished slightly, allowing for more extended periods of engagement in therapy sessions. However, he continues to express concerns about surveillance, indicating that residual paranoia persists. Mr. Thompson has started participating in short community group activities facilitated by the therapy team, suggesting an incremental improvement in his social withdrawal.

Clinical evaluations reveal a notable decrease in his heart rate, now at 94 bpm, and a further reduction in blood pressure to 138/88 mmHg. His fasting blood glucose level has stabilized at 108 mg/dL, reflecting a slight but positive trend towards improved metabolic regulation. These findings suggest that the combination of Aripiprazole and CBTp may be contributing positively to both his psychological and physical health. Nevertheless, the healthcare team remains vigilant, aware that Mr. Thompson's stress and residual symptoms could impact his progress.

Despite these encouraging signs, a new complication arises. Mr. Thompson begins to report occasional dizziness and fatigue, prompting the healthcare team to consider potential orthostatic hypotension as a side effect of his medication regimen. This development necessitates a careful reevaluation of his current treatment plan, including a review of his medication dosage and a potential adjustment in his CBTp sessions to address these symptoms. The team plans to monitor his blood pressure and heart rate more frequently, particularly during positional changes, to better understand the underlying causes of his symptoms and ensure his safety and well-being. This evolving situation presents an opportunity for clinical reasoning to optimize Mr. Thompson's comprehensive care plan, balancing the benefits of his current treatments with the need to minimize adverse effects.

Section 5

In the days following the identification of Mr. Thompson's dizziness and fatigue, the healthcare team conducts a series of diagnostic tests to evaluate the potential cause of these symptoms. Orthostatic vital signs are measured, revealing a significant drop in blood pressure from 138/88 mmHg while seated to 110/70 mmHg upon standing, confirming a diagnosis of orthostatic hypotension. This drop is accompanied by an increase in heart rate from 94 bpm to 112 bpm, further supporting the diagnosis. Additionally, Mr. Thompson's recent laboratory tests show a slight decrease in serum sodium levels, now at 133 mEq/L, which could be contributing to his symptoms of dizziness and fatigue.

Given these findings, the clinical team convenes to reassess Mr. Thompson's medication regimen. While the benefits of Aripiprazole in reducing his auditory hallucinations and paranoia are evident, the team recognizes the need to address the potential side effects contributing to his orthostatic hypotension. A decision is made to adjust the dose of Aripiprazole, coupled with the introduction of non-pharmacological interventions such as increased fluid intake and gradual position changes to mitigate symptoms. The team also considers the use of supportive stockings to prevent blood pooling in the lower extremities.

The team schedules Mr. Thompson for more frequent follow-up visits to closely monitor his response to these adjustments. The goal is to maintain the therapeutic benefits of his current treatment while minimizing adverse effects, ensuring that Mr. Thompson's engagement in CBTp and community activities is uninterrupted. This approach underlines the importance of clinical reasoning in tailoring interventions to meet the evolving needs of the patient, highlighting the dynamic nature of managing schizophrenia and its complications.