Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example

Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example

Schizophrenia significantly impairs an individual’s thoughts, feelings, and actions. A person with Schizophrenia appears to be without a sense of reality, which increases irritability. Additionally, these individuals struggle to engage in regular everyday activities. Nonetheless, various treatment modalities exist for this disorder, and those who receive appropriate treatment can engage in school and work activities, lead independent lives, and develop long-term relationships with other people. The disease affects about 0.6 to 1.9% of adults in the US, with African-Caribbean migrants being the most affected and men indicating higher prevalence and early onset than women. This SOAP note provides a comprehensive assessment of a patient per the case study. (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Identifying Data:

Name: Sherman Tremaine (S.T.) 

DOB: November 3, 1968,

Minor: No

Age: 55 Years

Gender: Male

Accompanied by: None

SUBJECTIVE:

CC: “I was told by my sister that you would help me, and the people I see and the voices I hear won’t go away.”

HPI: S.T. is a 55-year-old male presenting at the clinic with complaints of seeing people outside that will not leave him alone. S.T. reports that he sees people watching him through the window. He sees and hears them and their shadows, and that these people think he cannot see them. The patient believes that the people outside were sent by the government to watch him because of his high taxes. S.T. reports that these visions and voices have lasted for weeks. While at the office, S.T. hints at the presence of heavy metal music that he believes the people watching him want him to think is weak although it is heavy. S.T. reports sleeping difficulties, struggling to fall or stay asleep because of the loud voices, keeping him awake for days. The patient also reports those people watch him through the TV screen and attempt to poison his food. The patient thinks he tricked those people by ensuring everything is locked in the fridge, out of reach. S.T. reports not going to the grocery because they play loud and heavy music and that he is being followed there. S.T. states he was prescribed Haldol, Thorazine, Risperidone, and Seroquel, which he does not take, perceiving them as poison. S.T. is positive for diabetes, which he manages using metformin. S.T. states that the doctors told him he has a fatty liver, which he has never seen, and he believes the doctors were informed by aliens. S.T. reports that his sister and the government are working together to ensure he does not stay alone by tapping his phone.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Past Psychiatric History:

General statement: S.T. has previously been assessed for and diagnosed with Schizophrenia per the prescribed medications.

Caregiver: S.T. has his sister as the caregiver.

            Hospitalization: S.T. was hospitalized thrice when he was 20.

Medication trials: S.T. denies previous medical trials

Psychotherapy or Previous Psychiatric Diagnosis: S.T. has a previous Schizophrenia diagnosis.  

Substance Current Use: S.T. smokes daily, three packs per day. S.T. drinks a 12-pack weekly, with yesterday being the last time he used alcohol. S.T. last used marijuana three years ago after his mother’s death. S.T. denies cocaine or drug use.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Medical History: S.T. has diabetes.

• Current Medications: S.T. is using metformin to manage his diabetes.  
• Allergies: None reported.
• Reproductive Hx: None reported.

Development Milestones: Not reported.

Health Promotion: Not reported.

Legal History: S.T. denies any legal history of DUIs from using drugs and alcohol. S.T. denies any conviction but reports almost being convicted when he could not stop calling 911 to report the people watching him outside.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Family Psychiatric/Substance Use History: S.T. reports a father’s history of paranoid schizophrenia, which he was hospitalized for and a mother’s history of anxiety. S.T. reports no suicide cases by blood relatives.

Psychosocial History: S.T. was raised by his mother and sister, but lives alone now. S.T. reports no previous marriage or children. His highest education level is 10^th grade and is not working. He enjoys smoking and drinking pop. S.T. states that his father was rough on them before dying.  

ROS:  

General: S.T. denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: S.T. denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Skin: No rash or itching.

Cardiovascular: S.T. denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: S.T. denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

Genitourinary: S.T. denies burning on urination, urgency, hesitancy, odor, and odd color.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Neurological: S.T. denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

Musculoskeletal: S.T. denies muscle, back pain, joint pain, or stiffness.

Hematologic: S.T. denies anemia, bleeding, or bruising.

Lymphatics: No enlarged nodes. No history of splenectomy.

Endocrinologic: S.T. denies Sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.

Psychiatric: S.T. believes people are watching him through the window and the TV screen and he can see and hear them. S.T. has sleeping difficulties, struggling to sleep or stay asleep because of the loud voices keeping him awake for days. S.T. denies any self-harm or suicidal thoughts or intentions.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

OBJECTIVE:

Vital signs: Stable

Temp: 98.5F

            B.P.: 120/70

            P: 85

             R.R.: 17.5

             O2: Room air

             Pain: 0/10

             Ht: 5’8 feet

             Wt: 258 lbs

             BMI: 39.2

             BMI Range: Obese

Physical Exam:

General appearance: S.T. is alert and oriented to self. S.T. is not oriented to time, date, and place. S.T. appears modestly dressed, although with untidy hair. S.T. appears overweight, also indicated by the BMI implying obesity. S.T. converses and engages with the interviewer regularly and responds well to most questions, needing no intervention. The patient indicated appropriate attention levels throughout the interview.  (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.

Cardiovascular: S.T. has a regular heartbeat and rhythm, has audible murmurs and other sounds from his chest, a constant heart rate, and his capillaries refill in two seconds.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is regular and constant.  (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Psychiatric: S.T. manifests an unsound, imposing, and delusional thought process. S.T. presents with auditory and visual hallucinations and a fair memory.   

Neuropsychological testing: S.T. struggles to engage in regular everyday activities. 

Labs: Neutrophils 68%, Lymphocytes 22%, Monocytes 7%, GGT 36, Total cholesterol 211, Phosphate 5.2.

Diagnostic Results:

Positive and Negative Syndrome Scale (PANSS)

PANSS is used to diagnose schizophrenia and schizoaffective disorder per the DMS-5 criteria. His test was performed to assess delusions, irrational thoughts, hallucinations, mania, hostility, impaired affect, catatonia, anxiety, impaired attention, lack of insight, and depressive symptoms. A test score of 95 indicated S.T. was markedly ill.  (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

ASSESSMENT:

Mental Status Examination:

S.T. is a 55-year-old male presenting at the clinic with complaints of seeing and hearing people who are watching through the window and the TV screen. The patient cooperated with the interviewer, answering all questions to the best of his ability. S.T. was alert and oriented to self by could not correctly state the time, date, or place. S.T. was dressed modestly, only his air was unkempt. S.T. had a clear and constant for most of the interview but appeared pressured and rambling at times. S.T. appeared to have a flight of ideas and was hyperverbal. His thought process was irrational, delusional, and grandiose and his mood was congruent. S.T. indicated auditory and visual hallucinations and no self-harm or suicidal ideation. His memory was fair and concentration adequate. S.T. indicated a markedly impaired judgment and insight.   (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Diagnostic Impression:

1. F20. 0 Schizophrenia, paranoid type (Confirmed Diagnosis)
2. F22 Delusional disorder
3. F251 Schizoaffective disorder
4. F20. 0 Schizophrenia, paranoid type (Confirmed Diagnosis):

S.T. manifests at least three of the five primary Schizophrenia symptoms per the DMS-5 criteria, including delusions, disorganized speech, and verbal disorganization. Per the data collected, it is difficult to determine whether S.T. experiences any negative symptoms of affective flattening, avolition, and anhedonia. S.T.’s unkempt hair might hint he is struggling to take care of himself. The data provided is insufficient to assess other functional domains, including interpersonal relationships. The data is also inclusive in assessing the length of symptoms as S.T. reports experiencing them for weeks and weeks. A diagnosis of Schizophrenia would require the patient to exhibit consistent evidence of disturbance for a minimum of 6 months and a minimum of 1 month of symptoms or less if the patient is receiving treatment (Hany et al., 2023). S.T. presents with typical Schizophrenia symptoms that support the diagnosis. The Schizophrenia type is paranoid due to the constant and marked persecutory delusions that people are watching, following, positing, and plotting against him.     (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

• F22 Delusional Disorder:

Delusional disorder is also a possible diagnosis per the presenting signs and symptoms. S.T. experiences marked delusional thoughts, which are mistaken beliefs based on wrong or irrational perceptions of objective reality when presented with contradictory information (Joseph & Siddiqui, 2023). An individual is diagnosed with delusional disorder when delusional thoughts occur for a month or more without the implication of any emotional, psychological, medical, substance-related, or other mental health conditions (Joseph & Siddiqui, 2023). Individuals with this disorder also lack self-awareness and experience troublesome illusions and cannot accept that these delusions or illusions are irrational or wrong. Persecutory, jealous, or erotomanic delusions often increase the risk of agitation and violent conduct. Additionally, delusion disorder can co-occur with anxiety and/or depression. This diagnosis was refuted because S.T. indicated significant Schizophrenia symptoms and has a history of the disease.   (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

• F251 Schizoaffective Disorder:

Schizoaffective disorder is a warranted diagnosis because S.T. presents with delusions and hallucinations, which are among the primary symptoms of the disorder. Per the DMS-5 criteria, for a person to be diagnosed with schizoaffective disorder: A. An individual must meet the criteria for Schizophrenia and experience a major mood disorder, either manic or depressive, for an uninterrupted period during the illness and the major depressive episode must indicate a depressed mood. Criterion A includes a month, or less if the patient is under treatment, of experiencing at least one of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms, including diminished emotional expression or avolition (Wy & Saadabadi, 2023). Criterion B includes hallucinations or delusions occurring for at least two weeks or more without the patient experiencing a significant mood disorder during this time. Criterion C includes the presence of symptoms consistent with a major mood episode for the majority of the time during active and residual episodes of the disorder. Criterion D includes no implications of substance use or underlying conditions in the disturbance. Schizoaffective disorder diagnosis was refuted because S.T. did not meet the above criteria, especially the lack of major mood episodes.     (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)       

Reflection:

Lessons

The student had encountered several Schizophrenia patients before this encounter. Per the experience, assessing Schizophrenia patients is challenging because collecting comprehensive and accurate data without intervention is difficult. The patient presents with irrational thoughts and irregular speech, making assessment challenging. The company of a capacitated individual is recommended. Nonetheless, this encounter presented a unique opportunity to understand Schizophrenia and its impact on patients better. This is the only encounter in which the patient was unproblematic, cooperative, and answered all questions to the best of his ability, although was not oriented, to time, date, and place. If I were to see the patient again, I would request the presence of the sister for further insights into his life.    (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Ethical/Legal Considerations

Such encounters present several legal and ethical issues, including informed consent and autonomy, self-determination, patient privacy and confidentiality, maintaining objectivity and honesty, and respect of persons. The practitioner must ensure the patient is in a capacity to answer questions and make informed decisions or else request a surrogate for informed consent. Involving a surrogate might violate patient autonomy but necessary when the patient cannot make informed decisions. The patient has dignity regardless of state of illness; hence the need to respect him and treat him with dignity. The practitioner must remain objective and be honest with the patient regarding his condition despite the patient’s beliefs, delusions, and hallucinations to build trust (Varkey, 2021). The practitioner should secure patient data and ensure privacy and confidentiality when discussing with others about the patient.   (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Health Promotion and Disease Prevention

            S.T. has previously been assessed for and diagnosed with Schizophrenia per the current medication. However, the S.T. does not take them, claiming they are poison. It implies the disease has not been treated and managed appropriately. The patient would benefit from a medication plan with reminders to help improve medication adherence. Involving a third party would be necessary if the patient continues to avoid the medications. S.T. has diabetes and is using medication to manage it. The patient would benefit further from meal plans, including more vegetables and proteins and less sugary and fatty foods, regular physical activity, and weight management, which could also help enhance mental health (Akhaury & Chaware, 2022). A supportive environment would also benefit the patient and help promote a quality life, improve medication adherence, and enhance overall health and well-being.    (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)            

Case Formulation and Treatment Plan:

S.T. reports seeing and hearing people who he believes are watching him through the window and the TV screen. He believes these people are also following him, want to poison him, and are plotting against him. S.T. also hears loud metal music, which he says the people watching him are playing. These indications confirmed Schizophrenia, paranoid type. Combining psychotherapy and medications would be more effective than using only one modality. The treatment plan seeks to alleviate the symptoms and manage the disease by minimizing negative effects. Improving the quality of life is the ultimate objective. (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Pharmacological Intervention

S.T. should be prescribed either Risperidone 1 mg BID , Aripiprazole 10 mg qAM, Quetiapine 25 mg BID x 1 day, Olanzapine 10 mg qday (preferentially HS), Ziprasidone 20 mg BID with food (full meal), or Paliperidone 6 mg qday to help alleviate Schizophrenia symptoms.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Psychotherapy

Psychotherapy seeks to enhance the quality of life by addressing the functional domains that allow an individual to perform regular everyday activities. Psychotherapy will help address concerns like the family relationship with the sister using family-based therapy and self-care using cognitive behavioral and interpersonal therapies (Stevović et al., 2022). Psychotherapy will also help reduce relapse risk. S.T. would benefit from life and social skills training and coaching to live a more independent life, take care of himself, become physically active, and be more involved in everyday activities (Stevović et al., 2022). In addition, cognitive remediation and psychoeducation will help address the mudded thoughts, memory problems, and distorted behavior.  (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Patient Education and Nurse Interventions

• Assess the patient for drug interactions.
• Review the patient regularly to identify any signs of drug-induced movement problems from prolonged exposure to antipsychotics.(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)
• Educate patients about medications, potential side effects, when to report side effects to the clinician, and the importance of medication adherence.  (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Follow-up: The patient should follow up after two weeks. 

References

Akhaury, K., & Chaware, S. (2022). Relation Between Diabetes and Psychiatric Disorders. Cureus, 14(10), e30733. https://doi.org/10.7759/cureus.30733(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

Hany, M., Rehman, B., & Azhar, Y. (2023, March 20). Schizophrenia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example). https://www.ncbi.nlm.nih.gov/books/NBK539864/

Joseph, S. M., & Siddiqui, W. (2023, March 27). Delusional Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539855/(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)

National Institute of Mental Health (NIMH). (2023, May). Schizophrenia. (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)https://www.nimh.nih.gov/health/topics/schizophrenia

Stevović, L. I., Repišti, S., Radojičić, T., Sartorius, N., Tomori, S., Kulenović, A. D., Popova, A., Kuzman, M. R., Vlachos, I. I., Statovci, S., Bandati, A., Novotni, A., Bajraktarov, S., Panfil, A. L., Maric, N., Delić, M., & Jovanović, N. (2022). Non-pharmacological interventions for schizophrenia-analysis of treatment guidelines and implementation in 12 Southeast European countries. Schizophrenia (Heidelberg, Germany), 8(1), 10. (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)https://doi.org/10.1038/s41537-022-00226-y

Varkey B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: international journal of the Kuwait University, Health Science Centre, 30(1), 17–28. (Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)https://doi.org/10.1159/000509119

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective Disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/(Assessing a Patient with Psychosis and Associated Disorders and Medication-Induced Movement Disorders-A Comprehensive Nursing Paper Example)