Psychosis and Schizophrenia - Case Study Example

?Psychosis and Schizophrenia Psychosis and Schizophrenia Nursing 504 Advanced Pharmacology CC: Patient: “People are following me. I do not have anything wrong with me; I think those people want something from me.” Parents: “Gerald’s behavior is progressively odd. We think that he may have ingested some kind of drug during his friend’s birthday party which happened two weeks ago.” HPI: Two weeks ago, Gerald began insisting on keeping all the lights on in the house 24 hours/day and staying up most of the night. Over the past week he has become increasingly frightened, claiming his ex-girlfriend has bugged his room so she can blackmail him and that an old roommate is sending him threatening messages on the radio. For the past two days he has not slept at all, only eats food out of cans that he himself has opened, and refuses to leave the house. PPH: He was hospitalized for five days in July of 2007 for a “nervous breakdown” after being fired from a summer job. His parents indicate that at that time, he was talking to himself all the time and not thinking clearly. He was treated with Haloperidol but they cannot remember the dose. They said he was much better after leaving the hospital but only took the medicine for a few weeks because it made him feel stiff and slowed down. PMH: Not significant, only the usual childhood illnesses SH: Graduated high school in upper third of his class and participated in extra-curricular and social activities. Began having academic difficulties this year and is now down to part-time status after failing two classes last semester. He has returned to live at home with his parents because he could not get along with his roommate. Non-smoker; social drinker Meds: Was on Haloperidol on July 2007, but stopped abruptly due to side effects Current Meds: None PE: WNL Vitals - BP 120/70, P 88, RR 17, T 98.6, Ht 5’7” Wt 100 kg Heart- NRRR HEENT - PERRLA, EOMI, fundi benign Neck - no bruits, no JVD, no thyromegaly Lungs – CTA Abd- +BS, No masses or bruits MS/Ext - nl ROM, muscle strength 5/5 in UE and LE, no peripheral edema Neuro - all cranial nerves intact Labs: Chem 7 - WNL HEME 18 - WNL UA - WNL Urine Drug Screen (+) for cannabinoids MSE: Appearance = poorly groomed white male who appears his stated age Behavior = hypervigilant and suspicious but cooperative Speech = slightly pressured and rambling Thought Process = tangential with occasional interruptions suggesting thought blocking Thought Content = positive for auditory hallucinations and ideas of reference Affect = anxious Cognition = A&O x 3, recent and remote memory intact I. AP Note A. Present Problem Gerald is brought to the hospital by his parents due to his odd behavior which includes false beliefs, sleeplessness and irrational suspicions which increase in frequency over the past two weeks. B. Risk Factors Puberty History of psychiatric problem Previous intake of antipsychotic drug Substance abuse C. Assessment 1. Evaluation Gerald is brought by his parents to the hospital due to his peculiar behavior. Two weeks ago, he started exhibiting persecutory delusions and insisted on keeping their house lights on all the time. He was reportedly seen awake on most nights. Gerald also had delusions of reference wherein he accuses his ex-girlfriend of bugging his room and his former roommate to be sending threat messages over the radio. Gerald is awake for more than 48 hours now and manifests paranoia by eating only self-opened canned foods. His persecutory delusion has led me to refuse leaving their house. The presence of delusions, hallucinations and disorganized speech, according to DSM-IV-TR, places Gerald in the classification of Paranoid type of Schizophrenia. However, by considering that his urine drug screen tested positive for cannabinoids, thorough diagnosis of his symptoms is needed to rule out the physiologic etiology of substance abuse. He needs pharmacological intervention appropriate for Schizophrenia with co-morbidity of substance abuse. Gerald also needs to be included in a program for substance withdrawal. The participation of Gerald’s family in the said program is needed to facilitate total withdrawal from substance abuse. An understanding on the significance of adherence to treatment must be achieved by Gerald’s family. Previous medication: Haloperidol, dosage unknown 2. Determine appropriateness of previous medication Haloperidol – Appropriate but has side effects particularly pseudoparkinsonism (a) Indications: Neuroleptic agent for delusions and hallucinations of schizophrenia (b) Interactions: Haloperidol has known drug interactions with CNS depressant drugs, sedatives, hypnotics, strong analgesics and alcohol. It is to be used in caution with patients using anticoagulants and those in predominant psychotic depression. (c) Drug dose: Oral dose of Haloperidol as a neuroleptic agent may be given 10-20 mg daily. Chronic dose of 1-3 mg TID, may be increased to 10-20 mg TID depending on the response. (d) Compliance: Due to muscle stiffness and slow movements, Gerald stopped taking Haloperidol abruptly without proper follow up. The dosage of Haloperidol is not clear to Gerald’s parents and can be indicative of improper administration of Haloperidol after Gerald’s discharge. (e) Outcome: Presence of side effects, failure to follow up and substance abuse has led Gerald’s schizophrenic symptoms to exacerbate. Currently, Gerald needs to be enrolled in detoxification program. His present symptoms can be managed by antipsychotic drugs. Gerald’s parents must be well educated about the necessity of the program and the significance of adherence to treatment. They must be well informed about the possible side effects and must be instructed to observe for symptoms needing immediate intervention and follow up. (f) Adverse Effect: In his previous intake of Haloperidol, Gerald manifested Parkinsonism as evidenced by his muscle stiffness and slowed movements. 3. Additional Information Needed There is no definitive laboratory test for the diagnosis of Schizophrenia. It is most often diagnosed by a psychiatrist through a set of criteria and through the clinical manifestation of the patient. However, there are several diagnostic tests that can help in diagnosing and establishing baseline data for the patient: Blood toxic screen Brain imaging through CT Scan or MRI Determination of social issues and environmental stress can also help in assessing the predisposing factors that led to the symptoms. 4. Desired Therapeutic Outcomes (a) Short Term Goals For hospitalization: Maintenance of stable vital signs Absence of hallucination and delusion Patient cooperativeness through daily intake of medication Absence of rare and serious side effects particularly, pseudoparkinsonism Education of parents regarding drug side effects Improvement in sleep-wake cycle as evidenced by sleeping at night and being awake during the day In addition to the above mentioned goals, For home: Observance of proper healthy diet Performance of routine daily activities which includes personal grooming Refrain from alcohol and substance use Awareness of parents on serious side effects to observe and report Adherence to medication treatment Proper follow up check up (b) Long Term Goals Proper sleep-wake cycle Absence of delusions and hallucinations Participation on social activities without substance use Performance of daily activities Continuation of school education Improvement in the quality of life D. Plan (P) 1. Recommendations (a) Non Pharmacological therapy Enrollment in a detoxification program Stop substance abuse Solicitation of cooperation from the patient and his family through proper education Counseling and stress reduction techniques once the detoxification process is ongoing Schedule of follow up psychiatric check up Provision of information regarding the necessity of adherence to treatment regimen and the consequences of failure to such adherence (b) Pharmacologic therapy Reported history of side effects particularly pseudoparkinsonism, due to intake of Haloperidol can be attributed to high doses of the drug. Haloperidol can be started on its lowest dosage. Strict observance of adverse reactions must be observed. Anticholinergic or dopaminergic effects can be counteracted. In absence of progressive response to Haloperidol, or in the event of extrapyramidal symptoms, Haloperidol can be switched to an Aripiprazole. First generation antipsychotics like Haloperidol are known to exert extrapyramidal side effects. Hence, second generation antipsychotics like Aripiprazole can be given. The drugs are to be given at its lowest dose first and the patient’s response to medication will then be observed. This pharmacologic intervention, alongside with detoxification and psychosocial modification, is expected to improve patient condition. 1. Haloperidol – CNS Drug; Neuroleptic Agent This can be administered for Gerald’s episodes of acute paranoia as evidenced by delusions of reference and hallucinations during initial confinement. IV dose: Initial IV doses can be administered for acute paranoia. 5-10mg IV or IM can be given initially. This can be repeated hourly until sufficient control is achieved. Maximum dose is 60 mg/day. Strict observance of extrapyramidal symptoms must be made to determine continuance of Haloperidol as a daily antipsychotic medication. PO dose: Lowest initial dosing can be administered 1-3 mg TID. In the absence of serious side effects, dosing can be increased to 10-20 mg TID depending on patient response. E or AE Parameter Method Goal Alter Tx When/If E Management delusion and hallucination Pt exhibits decrease in frequency of delusion and hallucination through verbalization and journal Absence delusion and hallucination No improvement in patient response; increasing frequency and severity of delusion & hallucinations AE Dry mouth Pt or patient’s parents’ monitoring and reporting at follow ups Absence of tolerable state of dry mouth Pt develops blisters due to dry mouth and starts fine, worm-like tongue movements AE Dizziness Pt and/or his parents reports it through check up No dizziness Mental confusion and frequent loss of balance AE Blurred vision Pt reports blurring of vision during follow up No disturbance in vision Decreased vision especially at night and reported seeing everything with a brown tint 2. Aripiprazole – Second generation anti psychotic Second generation anti psychotics, particularly Aripiprazole are reported to have low incidence of extrapyramidal symptoms and very low anticholinergic side effects. PO Dose: An initial dose of tablet can be given at 10-15 mg OD to a maximum of 30 mg daily dose without regard to meal. Patient must be advised not to take alcohol. E or AE Parameter Method Goal Alter Tx When/If E Management delusion and hallucination Pt exhibits decrease in frequency of delusion and hallucination through verbalization and journal Absence delusion and hallucination No improvement in patient response; increasing frequency and severity of delusion & hallucinations AE Headache Pt logbook for monitoring of BP Absence or tolerable state headache Hypertensive episodes AE Pain on extremities Pt and/or his parents reports it through check up Absence of pain Intolerable pain and occurrence of involuntary sudden movements of the extremities AE Dizziness Pt and/or his parents reports it through check up No dizziness Mental confusion and frequent loss of balance References Rubin, A., Springer, D. & Trawver, K. (2010). Clinician’s guide to evidence-based practice: Psychosocial treatment of schizophrenia. Hoboken, NJ: John Wiley& Sons, Inc. Conley, R. & Kelly, D. (2007). Pharmacological Treatment of Schizophrenia (3rd ed.) 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