Kristen Nii-Jensen

NURS 360
Kapiolani Community College

A. Tell the client his behavior is annoying others.

B. Joke to the client that the other clients will collapse
if he does not leave them alone.
C. Tell the client he must leave other clients alone.
D. Ask the client to come to the dining room for a
snack.

ATI(2013).
Mental health nursing (8th ed.)

Use a firm, calm approach.

Explain things in a short, concise manner.
Refrain from responding personally to the clients
comments.
Be consistent in approach and expectations.
Talk with other staff members about what
techniques work and do not work.
Adhere to agreed-upon limits.
Let the client know the consequences of
inappropriate behavior.
Hear and act on legitimate grievance

Catholic Filipino Female aged 52 diagnosed with

Schizoaffective disorder
BMI: 22.46 Category: Heathy
weight (Height: 154.9cm
Weight: 53.9kg
)
Food & fluid intake: Ate 75% of breakfast, drank 840 ml
fluids
Bladder & bowel status: Occasionally bowel and bladder
incontinent, requiring toileting schedule q hour
Sleep pattern: Sleeps upon exhaustion, or after PRN
benzodiazepine antipsychotic administration for 3-4 hours
at a time
Total sleep/24 hrs: 9 hours per staff
Difficulty falling asleep, Early morning awakening
Number of hours of disruption: 2
hours
Naps: When? 9/23 eve shift & 9/24 midmorning Total nap time: 3 hours

Per the DMS-V (2013) the differential between

schizoaffective disorder and acute mania with
psychosis is,
When psychotic symptoms occur exclusively
during a Mood Episode, DSM-5 indicates that the
diagnosis is the appropriate Mood Disorder with
Psychotic Features, but when such a psychotic
condition includes at least a two-week period of
psychosis without prominent mood symptoms, the
diagnosis may be either Schizoaffective Disorder
or Schizophrenia (American Psychiatric
Association, 2013).

The patient was throwing things in group home and

causing a general disturbance. Was exhibiting both
visual and audio hallucinations w/ grandiose and
religious delusions. Picked up (ambulance) from
group home on September 7, 2014 and sent to Queens
West ER, and found to have water intoxication.
Transferred to Kakela Makai on the same day. She
stated she needed to save god by destroying the world.
Per her brother symptoms escalated after Labor Day
(September 1), where patient stated concerns about
upcoming thyroid lobectomy with subsequent phone
calls becoming increasingly nonsensical. Patient
initially admitted with psychosis NOS, later
schizoaffective disorder, specifically acute mania with
psychosis

Per patient during discussion on September 10,

2014, she came to the hospital because she saved
her sisters life. Her sister had a fall and she saved
her, and they all came to the hospital. Patient was
unable to elaborate further on her diagnosis but
denies mental disorder at that time. Patient was
able to articulate that she is currently in the
hospital on September 24, 2014, but unable to state
why. When asked what she thought her diagnosis
was she stated I am losing my mind. However,
unable to continue this line of questioning before
patient began to have visual hallucinations.

1. High fall risk stand-by assist for transfers

and for ambulation
2. History of EPS, monitor for S&S and
administer diphenhydramine PRN
3. Hx of water intoxication observe intake
and output
4. Bowel and bladder incontinence related to
mania state, requires toileting every hour.
5. Thyroid nodule, scheduled lumpectomy to
r/o cancer (canceled d/t manic state)

Axis 1: Schizoaffective disorder

Axis II: Null
Axis III: Water intoxication upon admission,
Axis IV: Lives in group home with regular contact with brother,
mother and father (parents are divorced, mother lives on Molokai)
Axis V: I assessed my patient with a GAF of 18. Patient acute
mania state requires frequent reminders to eat, drink, and a
toileting schedule to prevent incontinent issues. This presents a
risk of harm to patient, and an occasional lack of hygiene. Patient
will go to toilet, change clothes, eat, and drink upon prompting.
Patient denies any homicidal or suicidal ideation, has shown no
inclination to violence nor has a history of assault. However, is
communicable but frequently incomprehensible due to flight of
thoughts, tangentially, pressured speech. Frequently influences by
delusion and hallucinations and inability to functions in all areas
in addition to risk of self-harm from manic state.

Order: risperidone M 2mg translingual BID

Drug class: atypical antipsychotic
Pts target sx: psychosis
Total 24h dose: 4mg
Recommended range: 1-2 mg/day max: 8mg : L M H Max
Current Side effects: disinhibition, EPS symptoms prior night per staff
Order: clonazepam (klonopin) 1mg oral TID
Drug class: benzodiazepine
Pts target sx: anxiety
Total 24h dose: 3mg
Recommended range: 1-2mg/day divided maxL 4mg : L M
H Max
Current Side effects: glassy eyed appearance, slurred speech, hallucinations
note: use of this this drug can increase risperidone levels
Order: divalproex dr (Depakote) 500 mg BID oral 750mg at bedtime
Drug class: Pts target sx:
Total 24h dose: 1250 mg Recommended range: 750mg/day in divided doses or
25mg/kg/day (pt 53.9*25=1,347.5 mg): L M H Max
Current Side effects: hallucinations is a side effect, but may be symptomatic with
schizoaffective disorder

Order: lorazepam 1 mg Q6h PRN NTE: 6mg/day

Drug class: benzodiazepine
Pts target sx: agitation, anxiety
Total 24h dose: 2mg
Recommended range: 2-6mg/day divided doses
:LMH
Max
Current Side effects: Hallucinations, unsteadiness, weakness, restlessness,
hallucinations, confusion, sleep disturbances
Order: haloperidol 5mg PO Q4h PRN NTE 20mg/day
Drug class: typical antipsychotic
Pts target sx: Severe psychosis
Total 24h dose: 15mg
Recommended range:3-5mg BID or TID, may need up to
100mg/day : L M H Max
Current Side effects: EPS prior night per staff, insomnia, restlessness, agitation,
confusion, acerbation of psychotic symptoms

Order: diphenhydramine cap 25mg oral Q 3hour PRN

Drug class: antihistamine
Pts target sx: EPS
Total 24h dose: 25mg Recommended range: 25-50mg TID or QID (max 300mg/day) :
L M H Max
Current Side effects: confusion and excitement

Normal

9/7
WBC: 9.06
RBC: 3.65 10^6/ml
HCT: 12.3 g/dl
HGB: 36.4%
Platelets: 228, 000
Creatinine: 1.2 mg/dl
NA+:145 meq/l
K+: 3.6 meq/l
Cl-:107 meq/l
9/16
AST: 18 iu/l
ALT:18 iu/l
Alk Phos: 56 iu/l
Total bilirubin: 0.4 mg/dl
Albumin 4.3 mg/dl
Valproic acid: 120 mcg/ml
TSH 2.19 mciu/ml
9/23
Valproic Acid: 107 mcg/ml

Abnormal

9/7
BUN: 25 elevated
GFR: 50 low
9/18
Valproic Acid: 141 mcg/ml

CBC with differential to asses for

agranulocytosis. However, most recent
assessment by resident stated CBC within
normal limits, but not seen under labs. There
was nothing concerning PT, PTT< or INR as
Depakote can result in prolonged bleeding

1. Follow-up on orthostatic BP orders 9/23

2. Continue with Klonopin 1mg TID and
Ativan 1mg PRN q6h
3. Start Depakote 9/23 2100 monitor for
therapeutic effect for acute psychosis
4. Continue to monitor for signs and symptoms
of EPS
5. Discharge to group home once patient can go
48 hours without any PRN medication for
psychosis & agitation

Patient is to be discharged to group home in Ewa Beach

once she has stabilized. The owner of the group home is
amenable to her return. Patient must be instructed on
dangers of water toxicity. Should articulate understanding
of adequate amounts of water, and taught alternative
technique to satiate thirst associated with anticholinergic
effect of medications such as chewing sugar-free gum.
Though patient reports medication compliance, group home
owner may be instructed to keep eye on patient if it is with
in her scope of responsibilities. Family can also monitor
patient for signs of increasing mania or psychosis, and to
encourage patient to check with physician when this first
happens.
Group home owner and family can also be taught to
monitor for signs of EPS and NMS to prevent life
threatening complications or severe disabilities.

1:1 focused mental status exam with patient

Reminders to eat her breakfast and drink fluids
Q15 minute safety checks
Frequent refocusing and redirections for manic state
Frequent reminders to stay off the floor for safety
reasons
Standby assist for patient sit-to-stand and ambulation
Assess for signs and symptoms of EPS and NMS
inform RN about possible pseudo parkinsonism AEB
shuffling gait, slowed movements, and unsteady
posture
Inform RN about patient reports of disturbed sleeping
pattern

Priority #1
1. P: Risk for injury
E: Patients presenting with acute mania and
psychosis can be agitated, have poor judgment, and
experience hallucinations and delusions that increase
their risk for injury (Schultz & Videbeck, 2009, p. 203).
S: Patient rolling on floor, history of throwing
objects, patient falling to ground to pray, kicking at
door frame, crawling under desks and scratching wood
with finger nails.
Short Term Goal: Patient will be free from injury
during this shift.
Long Term Goal: Patient will be free of agitation,
restlessness, and hyperactivity before discharge

Intervention & Frequency

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including page number)

Evaluation

Decrease environmental stimuli whenever

possible. Remove stimuli and isolate patient,
providing a private room may be beneficial.

The clients ability to deal with stimuli is impaired (Schultz

& Videbeck, 2009, p. 205).

Patient will be directed away from milieu and

placed in a quiet private room away from
stimuli, staying free of harm and free from
harming others.

Give simple direct explanations. Do not argue

with the client.

The client is limited in the ability to deal with complex

stimuli. Stating a limit tells the client what is expected.
Arguing interjects doubt and undermines limits (Schultz &
Videbeck, 2009, p. 205).

Patient will be able to understand simple and

comply direct statements such as be quiet,
speak softer, lets go to the quiet room.

Provide consistent, structured environment. Let

the client know what is expected of him or her.
Set goals with the client as soon as possible.

Consistency and structure can reassure the client. The client

must know what is expected before her or she can work
towards meeting those expectations (Schultz & Videbeck,
2009, p. 205).

Patient will be able to verbalize goals, or to

acknowledge goals. When goals are not met,
specific consequences will be implemented.
Environment will be structured, and schedule
will be told to patient in a timely manner.

Administer PRN medication judiciously,

preferably before the clients behavior becomes
destructive.

Medication can help the client regain self-control but should

not be used to control the clients behaviors for the staffs
convenience or as a substitute for working with clients
problems (Schultz & Videbeck, 2009, p. 204).
Berk et al. (2010) finds early interventions in bipolar
symptoms decreases the risk for persistent unremitting
illness.

Patient will be administered PRN medication

before manic state becomes self or other-directed
harmful when reorientation and distractions fail
to decrease aggression and anxiety.

Priority #2
Self-care deficit: feeding, hygiene, toileting
Priority #3
Disturbed sensory perception: Visual and
auditory
Priority #4
Disturbed thought process
Priority #5
Disturbed sleeping pattern

Patient has been medication compliant per

herself, history and physical, and family,
presents with no history of alcohol or drug
abuse per family and negative screenings upon
multiple admissions into Kakela, HSH, and
Castle hospital, has a stable home environment
to return to, and family support that checks in
with her. Her last episode was six years ago
per her brother. The patient has some college
education, and a prior work history as a school
cleaner.

Patient continues to decompensate despite

several changes in medication, and ability to
care for self without frequent interventions is
impaired, as seen in the increased mania states
from September 10 to September 24. Though in
a stable home, she does not currently live with
family, and mother lives on Molokai. Father
and brother contact patient mainly through
phone. The patient is unmarried but fixated on
her dead husband, has not worked in many
years, and will have difficulty transitioning
back into work force at her current age.