How to solve a nursing schizophrenia essay

Bianca Chandler is a 14-year-old Black teenager (pronouns she/her/hers) who lives with her maternal grandmother, Peace Chandler, age 70, who is her legal guardian. Bianca was diagnosed with schizophrenia two years ago during a series of three psychiatric admissions when she was experiencing auditory hallucinations and paranoid delusions. She was placed on Risperdal (risperidone) 2 mg BID.

Peace brings Bianca to you for an outpatient evaluation. She reports that Bianca has been experiencing more auditory hallucinations, refuses to shower or bathe, and is not sleeping at night. She reports that Bianca has refused to attend church lately, something very important to her close-knit, extended Southern Baptist family.

Her granddaughter\’s appearance is always unkempt.
Bianca has poor interpersonal skills and does not interact much with you, but she does answer questions. Her affect is flat and presents as depressed. She is not suicidal or homicidal. Her grandmother monitors her medication and assures you that Bianca is taking it as directed.

Questions

From your perspective as Bianca\’s psychiatric nurse practitioner, answer the following questions in a four page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.

1. Based on the DSM-5, what are the criteria for schizophrenia in patients Bianca\’s age? Does Bianca meet the criteria for a schizophrenia diagnosis? Why?

2. What screening tool or instrument would you use to help determine the severity of Bianca\’s symptoms? Please include how to score it and what determines a positive or negative score.

3. What treatment plan would you use to manage Bianca\’s symptoms? What level of care would you recommend? How would you coordinate that care and monitor her progress? What type of therapy would you recommend? Provide the rationale to support these recommendations.

4. How would you work with the family as a unit? What issues would you prioritize and why?

Case Study: Bianca Chandler solved

Schizophrenia is a chronic disabling condition that has significant negative effects on the life of affected patients and families. Very early-onset schizophrenia (VEOS) represents the development of the disease before 13 years of age and its severity worsens over time (Grover & Avasthi, 2019)). Bianca Chandler is a 14-year-old female patient seeking medical care due to worsening symptoms of schizophrenia. She was diagnosed with the disease 2 years ago after a series of psychiatric admissions and has been on risperidone 2 mg BID. Today, the patient presents with more auditory hallucinations, difficulty sleeping, diminished interest in social activities, a disheveled appearance, and she appears depressed.

Schizophrenia Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies schizophrenia as a mental condition characterized by a range of behavioral, cognitive, and emotional dysfunctions (American Psychiatric Association (APA), 2013). The individuals with this disorder will vary considerably in many features including impairment in social and occupational functioning. Overall, schizophrenia spectrum and other psychotic disorders present with abnormalities in five key domains including disorganized thinking, delusions, hallucinations, disorganized motor behavior, and negative symptoms (Grover & Avasthi, 2019). The diagnosis of this condition for children and adolescents uses the same approach as used for adults. However, a thorough assessment and family history taking should be done because children and adolescents may present with odd behavior.

An individual with schizophrenia will experience different symptoms over a certain period to meet the diagnosis. The person must experience delusions, hallucinations, disorganized speech, catatonic behavior, or negative symptoms for a significant portion of time for at least one month (APA, 2013). During this time, the individual’s level of functioning relate to work, self-care, or interpersonal relationships is affected. Children may fail to achieve the desired level of academic or interpersonal functioning. Apart from these key features, the signs of disturbance must persist for at least 6 months with some periods in between manifesting with residual symptoms (APA, 2013). When making the diagnosis of schizophrenia, the provider must ensure that the disturbance is not explained by schizoaffective disorder, depression, or bipolar mood disorder (Grover & Avasthi, 2019). The disturbances can also not be attributed to the physiological effects of substances like drugs or medications.

The diagnostic criteria for schizophrenia that Bianca is modeling include hallucinations, delusions, emotional expression difficulties, and disturbance in self-care. Bianca displays negative symptoms like flat affect and has lost interest in interaction and performance of other activities like going to church. Most patients with early-onset schizophrenia exhibit features of thought disturbance, hallucinations, and flat affect (Grover & Avasthi, 2019). In children, the early onset of the disease is often chronic and persistently debilitating, with worse outcomes than those with delayed onset. Although Bianca meets the criteria for the diagnosis of schizophrenia, I believe the most appropriate diagnosis is schizoaffective disorder. The schizoaffective disorder presents with symptoms of schizophrenia accompanied by major mood episodes like mania or depression with depressed mood (Miller & Black, 2019). Hallucinations and delusions that are typical for schizophrenia patients must occur for at least two weeks in the absence of mood symptoms in patients with schizoaffective disorder (Miller & Black, 2019). Bianca displays symptoms like lack of sleep, loss of interest in enjoyable activities like going to church, flat affect, and presents as depressed.

Screening Tool or Instrument

The Brief Psychiatric Rating Scale (BPRS) is a tool used by clinicians and researchers to measure the severity of psychopathological symptoms. The tool is available in three versions; 6-item BPRS, 18-item BPRS, and 24-item BPRS (Zanello et al., 2013). The preference of choosing either tool depends on the clinical presentation of the patient and the urgency of the assessment. Overall, the administration of the tool and complete assessment takes about 20 to 30 minutes. The key areas of assessment include somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerism and posturing, grandiosity, and depressive mood (Zanello et al., 2013). The tool will also elicit responses in other areas like disorientation, excitement, blunted affect, unusual thought content, motor retardation, hallucinations, hostility, and suspiciousness. During the assessment, the healthcare provider rates the responses from 1(not present) to 7 (extremely severe). Sometimes a zero score is administered for items not assessed depending on the patient’s presentation and clinician’s preferences.

The BPRS tool was designed to assess the severity of schizophrenic states and other psychotic disorders to provide clinicians with a way to assess patient change. Five items including tension, emotional withdrawal, mannerisms and posturing, motor retardation, and uncooperativeness are based on observation while the other items are based on the patient’s verbal report. The total scores range from 18 to 126 (Zanello et al., 2013). This tool is important because it lacks redundancy in items and is quickly administered to guide treatment. During interpretation of the scores, mildly ill individuals will have a score of 31, moderately ill a score of 41, and markedly ill a score of 53.

Treatment Plan

The treatment plan for Bianca will involve both pharmacological and psychological interventions. I will re-evaluate Bianca’s medications and include other options that could manage the depression symptoms observed. I would then refer the patient to a psychotherapist because she can benefit from other interventions like social skills training and family therapy to help in coping. The level of treatment I would recommend is outpatient care because Bianca does not display exaggerated symptoms or other symptoms like suicidal thoughts. I would recommend the change of medication from risperidone to Seroquel because of the depression and insomnia observed. Seroquel is FDA approved for the management of schizophrenia for children aged 13 to 17 years and is observed to provide relief to symptoms like insomnia and depression (Stahl, 2017). The type of therapy that I would recommend for Bianca is cognitive-behavioral therapy (CBT). This approach focuses on enhancing the understanding of illness and improving insight into psychotic experiences (Grover & Avasthi, 2019). CBT will help Bianca to cope with residual psychotic symptoms and reduce the degree of preoccupation with delusional beliefs.

Working with the Family

During care delivery, I will educate the patient and her grandmother on side effects like sedation, dizziness, and restlessness. I will establish baseline data like weight and BMI to monitor other side effects like weight gain and advise the grandmother to seek medical attention in case symptoms escalate (Grover & Avasthi, 2019). I will inform the family that children with early-onset schizophrenia can exhibit severe symptoms that require regular evaluation, treatment, and family support. The areas of priority will include ongoing psychosis and varying mood state observed in the patient. I will prioritize these issues because mood changes can lead to undesirable outcomes like suicide.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Grover, S., & Avasthi, A. (2019). Clinical practice guidelines for the management of schizophrenia in children and adolescents. Indian J Psychiatry, 61(Suppl 2), 277-293. https://dx.doi.org/10.4103%2Fpsychiatry.IndianJPsychiatry_556_18

Kang-Yi, C. D., Chao, B., Teng, S., Locke, J., Mandell, D. S., Wong, Y. I., & Epperson, C. N. (2020). Psychiatric diagnoses and treatment preceding schizophrenia in adolescents aged 9-17 years. Frontiers in Psychiatry, 11, 487. https://doi.org/10.3389/fpsyt.2020.00487

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 31(1), 47–53. https://pubmed.ncbi.nlm.nih.gov/30699217/

Stahl, S. (2017). Prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). Cambridge University Press.

Zanello, A., Berthoud, L., Ventura, J., & Merlo, M. C. (2013). The brief psychiatric rating scale (version 4.0) factorial structure and its sensitivity in the treatment of outpatients with unipolar depression. Psychiatry Research, 210(2), 626–633. https://doi.org/10.1016/j.psychres.2013.07.001

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