Haloperidol [antipsychotic]: decrease in hallucinations, delusions, agitation, hostility, and insomnia

Lurasidone [antipsychotics]: decrease in schizophrenia symptoms & depressive episodes in bipolar disorder.

Lorazepam [antianxiety agent]: increase sense of well being.

Lamotrigine [anticonvulsants]: decrease seizure activity and delay mood episodes.

Topiramate [anticonvulsant/mood stabilizer]: remission of manic symptoms.

Fluticasone [anti inflammatory steroidal]: manage of asthma symptoms.

Levothyroxine [hormones]: resolve hypothyroidism symptoms.

Oxybutynin [anticholinergics]: relief of bladder spasm and associated symptoms.

Pantoprazole [anti ulcer agent]: decrease in abd pain, heartburn, and gastric irritation.

Salbutamol [bronchodilators]: prevent/relief of bronchospasm.

Dumpit, I. B., shija, M., & R, J. (2024, April 29). 6 schizophrenia nursing care plans. Nurseslabs. https://nurseslabs.com/schizophrenia-nursing-care-plans/ 

Kenneth, A., & Mensah, B. (2024, April 29). Insomnia & sleep deprivation nursing care plan and management. Nurseslabs. https://nurseslabs.com/insomnia/#h-assessing-the-client-s-sleep-history

Makic, M., & Martinez-Kratz, M. (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook An Evidence-Based Guide to Planning Care 13th ed. Elsevier Inc.

Wagner, M. (2023, January 9). Schizophrenia nursing diagnosis & care plan. NurseTogether. https://www.nursetogether.com/schizophrenia-nursing-diagnosis-care-plan/ 

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK541012/#article-28758.r3

In the case of the 42-year-old female patient, her presentation with racing thoughts, delusions, auditory hallucinations, and mood disturbances, along with a history of bipolar disorder I, depression, and anxiety disorder, aligns with a diagnosis of schizoaffective traits. The current treatment regimen includes clozapine, lamotrigine, lorazepam, lurasidone, haloperidol, and other medications aimed at managing psychotic symptoms, stabilizing mood, and addressing comorbidities such as diabetes mellitus type 2 and hypothyroidism. Close monitoring and ongoing support are crucial for optimizing the patient's well-being and functioning. The treatment of schizoaffective disorder typically involves both pharmacotherapy and psychotherapy, (Wy & Saadabadi, 2023).

·   Depression symptoms: Feeling empty, sad, or worthless, having a poor appetite, losing, or gaining weight, or sleeping too much or too little.

·   Hallucinations: Sensing things that are not real, such as hearing voices

·   Mania or sudden, out-of-character jumps in energy levels or happiness, racing thoughts, talking more or faster than usual, a decreased need for sleep.

·        Poor decision-making

·        Mood-stabilizers: Patients who have periods of distractibility, indiscretion, grandiosity, a flight of ideas, increased goal-directed activity, decreased need for sleep, and who are hyper-verbal fall under the bipolar-specifier for schizoaffective disorder.

·        Antidepressants: Used to target depressive symptoms in schizoaffective disorder.

·      Individual therapy: This type of treatment aims to normalize thought processes and better help the patient understand the disorder and reduce symptoms.

·        Family and/or group therapy: Family involvement is crucial in the treatment of this schizoaffective disorder.

·        ECT (Electroconvulsive Therapy) is usually a last resort treatment. However, not only has it been used in urgent cases and treatment resistance, but it should also merit consideration in augmentation of current pharmacotherapy

•Admitted with schizoaffective traits.

•20-year history of bipolar disorder.

• Patient experienced auditory hallucinations of Jesus and God talking to her.

•Patient is experiencing confusion; wandered to the neighbour's house prior to admission.

•Patient’s mother stated she noticed a decline in the patient’s ability to perform ADLs, decreased appetite and decreased sleep.

· Altered sleep-wake cycle: Patient's admission note mentions confusion and wandering behavior during the night, indicating disruptions in the normal sleep-wake cycle.

· Psychotic symptoms: Auditory hallucinations and delusions, such as believing in a romantic relationship with Jesus Christ, can disrupt sleep and lead to impaired sleep patterns.

· Medication side effects: Certain medications, such as clozapine and lorazepam, can cause sedation and impact sleep quality.

·  Monitoring sleep patterns allows for timely identification of any changes or improvements, facilitating appropriate interventions.

2. Collaborate with Pt’s inter-professional healthcare team to adjust medication timing: Coordinate with the team to optimize the timing of medications such as clozapine and lorazepam to minimize sedative effects during the night and promote better sleep quality.

·  Adjusting medication timing can help minimize sedative effects during the night, promoting better sleep quality without compromising therapeutic efficacy.

3. Implement sleep hygiene measures: Encourage the patient to maintain a consistent sleep schedule, avoid stimulating activities before bedtime, and create a comfortable sleep environment to facilitate relaxation and improve sleep quality. (Porwal et al., 2021)

·  Implementing sleep hygiene measures creates an environment conducive to sleep, enhancing the patient's ability to achieve restorative sleep. 

4. Provide education on relaxation techniques: Teach the patient relaxation techniques such as deep breathing exercises, progressive muscle relaxation, or guided imagery to promote relaxation and reduce anxiety, which can contribute to improved sleep patterns.

·  Teaching relaxation techniques empowers the patient to manage anxiety and stress, promoting relaxation and facilitating sleep initiation and maintenance.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, DSM-5. (5th ed.). Washington, DC: APA 

Centre of Addiction and Mental Health. (n.d.). Psychosis. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/psychosis

Halpepe, K. (n.d.). Clozapine Monitoring [Figure].

Kunyk, D., Peternelj-Taylor, C and Austin, W. (2023). Psychiatric and mental health nursing for Canadian practice. 5th edition. Wolters Kluwer. 

Nuguru, S. P., Rachakonda, S., Sripathi, S., Khan, M. I., Patel, N., & Meda, R. T. (2022). Hypothyroidism and Depression: A Narrative Review. Curēus (Palo Alto, CA), 14(8), e28201–e28201. https://doi.org/10.7759/cureus.28201

Osser, D. N. (2022). Mania With Psychosis vs Schizophrenia vs Schizoaffective Disorder, Bipolar Type. The Psychiatric Times, 39(1), 26.

• Psychosis which is a primary symptom of schizophrenia and mood disorder based on a full affect demonstrated by the pt with a mood change from being sad to elated from the start to the end of shift is a concurrent occurrence and monitor potential alternating symptoms.

• auditory: pt. stated unconsistent hearing a voiced of God and a choir singing; Jesus talking to her while performing her ADLs “don’t give up”;

• command; pt. states following auditory hallucinations telling her to go on walks

Delusions:

• erotomania, pt. stated being in a romantic relationship with Jesus Christ; 

• mood-congruent delusion during manic episode with racing thoughts about heaven being on top of a mountain;

• reference, pt. interpreted male patients leaving the dining room as “Jesus leaving her”.

• control, per command hallucinations with the belief of auditory hallucinations controlling her behaviour

• guilt, verbalized self-blame over the reference of “Jesus leaving her”.

Anxiety/agitation:

• difficulty concentrating and rationalized by pt. by “thoughts get blocked”, which may indicate thought blocking in assessing for thought process & hesitant to engage in conversation, however memory is intact;

• crying noted by the pt. on the belief that Jesus left her; self-reported “some anxiety”

Unorganized behaviour:

• confusion Hx before admission and going into neighbour’s house while listening to meditation music;

• avoided eye contact except when expressing feelings;

• guarding position when asked how the patient was hesitant to talk in a conversation

• Paranoid schizophrenia: even that auditory hallucinations are present, monitor auditory command hallucinations with the potential of self-harm to a severe extent of paranoia or any persecutory form of delusion.

• Pt. demonstrates partial insight with seeking treatment for self-reported symptoms of spiritual distress but does not understand that symptoms of auditory command hallucinations are not real; pt. is compliant with medication.

• Anhedonia: inability to feel pleasure from self-engaging activities observed from pt: coloring, reading and watching TV

• Apathy: consistent inability to respond emotionally as appropriately

• Family Hx

• Diathesis stress concept to genetic predisposition

• Hormonal changes (endocrine)

• Alcohol/substance abuse

• Chronic illness (medical) or psychiatric comorbidities r/t neurochemical dysregulation

- Mania S&S

• Elated euphoric affect observed at end of shift (MSE);

• Racing thoughts expressed by pt about auditory hallucinations and mood-dependent delusions about heaven being on top of a mountain before admission;

• Inability and decreased appetite and sleep before admission;

• Unorganized thinking with wandering into neighbour’s house then listened to meditation music; Hx of wandering with Dx bipolar type 1.

• Anhedonia (inability to feel pleasure);

• Significant unintentional wt’ loss and loss of energy

Mania symptoms

• Prone to agitation, irritation or distraction (continue assessing of safety risk for any changes);

• Flight of ideas with assessing thought content & rapid rate of speech (subsequent MSE)

- Performing subsequent MSE, mental status examination

- Focused mood disorder questionnaire (15-question via self-reporting) to examine altered mood

- DM2; check BGM which may affect neurological status especially if hypoglycemic as evidenced by lack of appetite

- Clozapine monitoring for agranulocytosis (low neutrophils & WBC, high Temp) & myocarditis (troponin I, HsCRP)

• (obtain baseline VS, labs; daily VS/assess S&S infection, myocarditis/review labs; weekly bloodwork) (Halpepe, n.d.)