CAPSTONE PROJECT

SCHIZOAFFECTIVE
WITH BIPOLAR DISORDER
Naomi Masuda, NURS 360 PMH
Professor Chat Augustin

WHAT IS SCHIZOAFFECTIVE?
Schizoaffective disorder is a mental disorder that contains both psychosis
and mood disturbance.
Most of the time, mania or depression coexists with the psychotic
symptoms, but there must be at least one 2-week period during which
there are only psychotic episodes.
Its usually onsets late in life
Unknown cause, but many believe that combination of biologic, genetic,
and environmental factors contribute.

SYMPTOMS
Schizoaffective

Schizoaffective

with mania

Depressive type

No eating, weight loss, or both

Rapid & pressured speech

Inability to sleep

Increased risk behaviors, substance use, and impulsiveness

Irritability & agitation

Marked increase in social, work, or sexual activity

Loss of interest in usual activities

Poor judgment

Binge spending sprees

Lack of energy & motivation

Low self-esteem & feeling of worthlessness

Feeling of invulnerability & grandiose sense of self-importance

Distractibility

Inability to sleep

Feeling guilty

Inability to think or concentrate

May perseverate regarding suicide & death

Delusions

Hallucinations

Hallucinations

Disorganized thinking

Agitation

Grossly disorganized

Bizarre behaviors

Delusions

Immobile

Lack of speech or incoherent speech

DSM-V: SCHIZOAFFECTIVE

CASE STUDY
76 y/o female was diagnosed with schizoaffective disorder with bipolar
type. She has heard voices since she was child. She has been married with
her husband over 50 years, and has no children. She is a very religious,
goes to church and likes to read the Bible.
Husband called EMS and sent her TAMC d/t worsening of her paranoid
secondary to poor medication adherence. According to her husband, her
condition was worse than hes ever seen in the last 50years. She was
transferred to QMC and admitted d/t paranoid delusion which she claimed
that her husband poisoned and tried to kill her. She also believes that
olanzapine causes bone marrow suppression, so she stopped taking it
before this relapse.

CASE STUDY IN RELATION TO DSM-V

<Psychosis symptoms>
Experiencing paranoid delusions
Believes that husband poisoned and tried to kill her.
Believes that olanzapine causes bone marrow suppression and stopped taking it. Now
refusing to take all the medications.
Believes that hospital foods are poisoned by husband and cause itchy skin when she eats
them.

Experiencing auditory and visual hallucinations

Reports that she heard voices since she was child.
However, she denies having auditory and visual hallucinations during the shift.

Demonstrating disorganized speech, such as incoherence, tangential, and flight of ideas

<Manic symptoms>
Pressured speech
Flight of idea
Distractibility

EVIDENCED BASED NURSING

PRACTICE:

RE: Safety: Risk for injury / fall

Medication contribute greatly to risk among the elderly people and fall is significant leading
cause of injuries, hospitalization and deaths in the elderly. (Huang, et al. 2012)
In addition to the physical changes, aging is altering their pharmacokinetics and
pharmacodynamics thus elderly people are more risk of potential drug toxicity. (Huang, et al.
2012)
The drugs that associate with the fall incidents in the elderly are psychotropic drugs,
benzodiazepines, atypical antipsychotics, antidepressants, antiepileptics, antiparkinsonian,
cholinesterase inhibitors and memantine, opioids, antihypertensive and carediovascular
medications, glucose control medications and alcohol. (Huang, et al. 2012)

RE: Disturbed thought process/: Impaired judgment and insight

74% of patients who were diagnosed with schizophrenia chose to discontinue their
antipsychotic medications over 18 months. (Morrison, et al., 2011)
40-50% of schizophrenia patients are not medication compliant. (Huang, et al. 2012)

FOUR PRIORITY NEEDS AND CONCERNS WITH

INTERVENTIONS
1.

P: Safety: Risk for injury/fall

E: Positive A/V hallucination and paranoid delusions. Unsteady gait and requires walker.

S: Assess for mental status and confusion or agitation. Establish rapport, encourage client
to express feelings at each shift. Contract for safety at the beginning of each shift. Provide
assistance for ADLs as needed. Reassess as needed.
2. P: Disturbed thought process: Impaired judgment and insight
E: Refusing prescribed medication due to false belief of olanzapine causing bone marrow
suppression, isolation from husband due to the beliefs of she is going to be hurt by them.
S: Monitor and assess for mental status. Assess the thoughts and feelings. Maintain safety.
Orient the client continuously with clear concrete statements. Establish rapport and build trust
with the client, utilize cognitive-behavioral therapy to improve symptoms and functioning, and
encourage to take prescribed medications.

FOUR PRIORITY NEEDS AND CONCERNS WITH INTERVENTIONS

3. P: Disturbed sensory perception: Incongruent with actual stimuli
E: Positive auditory/visual hallucination.
S: Monitor for verbal/nonverbal behaviors associated with hallucinations and assess
for the feelings. Maintain safety. Orient the client continuously with clear concrete
statements. Establish rapport and build trust with the client utilize cognitive therapy to
improve symptoms and functioning, and encourage to take prescribed medications.
4. P: Hygiene
E: Client appears disheveled with uncombed hair
S: Remind client to maintain grooming and the importance of hygiene, especially in
related to diabetes. Client directed to perform self-care with assistance from staff.

# _1__
CARE PLAN Priority
Nursing Diagnosis: Risk for injury/fall
P: Safety: Risk for injury/fall
E: Positive auditory and visual hallucination and delusion. Unsteady gait and walker use.
S: Assess for mental status, confusion/agitation. Establish rapport, encourage client to express feelings,
contract for safety at each shift. Provide assistance for ADLs as needed. Reassess as needed.
LT goal: Client will be free from injury/fall during admission.
ST goal: Client will be free from injury/fall by the end of the shift.

Scientific Rationale

Intervention & Frequency

(In complete sentences!)

(Reference in APA format, including page number)

Evaluation

Provide and maintain a structured, safe

environment (milieu) for the client (Sommer,
et al., 2013, p. 121). Lock appropriate doors
and windows all the time. Remove harmful
objects from the clients environment
(Fortinash & Holodday Worret, 2007, p. 338).

It decreases anxiety and distracts the client

from constant delusional thinking and
hallucination (Sommer, et al., 2013, p. 121).
All of these actions provide for a safe
environment and prevent falls and injury
(Fortinash & Holoday Worret, 2007, p. 338)

Structured and safe environment was maintained by

staff and nursing student. The client didnt
demonstrate increased anxiety or confusion/agitation
during the shift.

Use clear, concrete statements rather than

abstract, general statements (Fortinash &
Holodday Worret, 2012, p. 283).

The patient is not always able to understand

complex messages, and, as such, the patient
sometimes will develop misperceptions or
hallucination. Individuals with schizophrenia
generally respond better to concrete
message during the acute phase (Fortinash
& Holoday Worret, 2012, p. 283)

Staff and the nursing student maintained clear and

concrete statements to communicate with the client.
The client was free from aggressive or self-injurious
behavior during the shift.

Assess the clients weakness or impaired

mobility, and provide assistance as needed.

Physiological changes (among older adults)

in cardiovascular reflexes can result in
orthostatic hypotension (Huang, et al., 2012,
p.362). When antipsychotic medication was
used for more than 90days, it was associated
with an increased risk of falls and fractures
(Huang, et al., 2012, p. 365)

The clients mobility and strength were assessed at

the beginning of the shift and prn. The client denied
feeling of dizziness or weakness, she was assisted by
staff and the nursing student as needed during the
shift.

Teach the client to get up and/or change

position slowly to prevent fall/injury.

According Huang, et al., antipsychotics and

The client verbalized understanding of the
antihypertensives used in the elderly is one
importance of moving slowly.
of the causes of drug related falls.
Teaching the client to rise slowly from beds
or chairs to avoid the risk of falling (Fortinash
& Holoday Worret, 2012, p. 571).

AN

NURSING DIAGNOSIS: DISTURBED THOUGHT PROCESS

P: Disturbed thought process: Impaired judgment and insight
E: Refusing prescribed meds d/t false belief of the med causing bone marrow suppression, isolation from husband d/t the beliefs
that she is going to be hurt by him.
S: Monitor and assess for mental status. Assess the thoughts & feelings. Maintain safety. Orient the client continuously with clear
concrete statements. Establish rapport & build trust w the client, utilize cognitive therapy to improve symptoms & functioning,
encourage to take prescribed meds.
LT goal: Demonstrate thoughts and ideas with absence of delusions by the discharge
ST goal: Remain free from actual and potential harm by self or others by the end of the shift

Intervention & Frequency

Intervene immediately to protect client from

harm or client, others, and the environment,
as a result of disturbed thoughts.

Spend time and listen actively to the client,

and allow her to express feelings and
thoughts.

Focus on the meaning/feeling/intent of the

clients delusion rather than only the words or
content.

Teach deep breathing exercise to reduce

anxiety related to paranoid delusion.

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

Evaluation

The first priority of the nurse is to maintain the

safety of the client, others, and the environment
through appropriate therapeutic interventions
(Fortinash & Holoday Worret, 2007, p. 126).
According to Morrison, et al., cognitive therapy
decrease psychiatric symptoms (hallucination and
delusion) in patients who refuse to take
antipsychotic medication (p.5).
Active listening helps to build trust. This help the
patient to express emotions (Fortinash & Holoday
Worret, 2013, p. 283)

The client/s safety was monitored, and staff

and the student nurse redirected and
distracted as needed. The client did not
demonstrate aggressive behavior and
remained free from injury during the shift.

Focusing on intent and feelings versus content helps

to better meet the clients needs, reinforces reality,
and discourages false beliefs. (Fortinash & Holoday
Worret, 2007, p. 127)

The client was able to verbalize her fear and

anxious feelings, although she continued
having delusions during the shift.

This help to lessen anxiety and distract the client

from focusing on the anxiety. (Fortinash & Holody
Worret, 2013, p. 197)

The client verbalized understanding of the

purpose, and was able to demonstrate it with
the student nurses instruction.

Staff and the student nurse actively listen to

the client during the shift. The client was
able to verbalize her feelings and thoughts.

IMPLICATIONS OF CARE
Legal
Confidentiality
Not able to release
information to the clients
husband since she is refusing.

Right to be informed and review

the patients right

Because of the clients

diminished mental status and
cognitive function, variety of
educational methods should be
used to inform her of her rights
and be repeated as a part of the
treatment.

Moral

Ethical

Self-Awareness and separating

ones discriminations in order to
provide quality of care to all
clients equally.

Autonomy
The client is refusing to take
all medications

Respect the choice, but

educate and encourage
medication compliance

REFERENCES
Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American
Psychiatric Association.
Fortinash, K. M., & Holoday-Worret, P. A. (2013). Psychiatric mental health nursing (5th ed.). St. Louis
MO: Elsevier Mosby.
Fortinash, K. M., & Holoday-Worret, P. A. (2007). Psychiatric mental health nursing care plans (5th ed.).
St. Louis MO: Elsevier Mosby.
Huang, A. R., Mallet, L., Rochefort, C. M., Eguale, T., Buckeridge, D. L., & Tamblyn, R. (2012).
Medication-Related Falls in the Elderly: Causative Factors and Preventive Strategies. Drugs & Aging,
29(5), 359-376 18p. doi:10.2165/11599460-000000000-00000
Malaspina, D., et al., Schizoaffective Disorder in the DSM-5, Schizophr. Res. (2013), Retrieved from
http://dx.doi.org/10.1016/j.schres.2013.04.026
Morrison, A. P., Hutton, P., Wardle, M., Spencer, H., Barratt, S., Brabban, A., ... Turkington, D. (2011).
Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic
medication: an exploratory trial. Psychological Medicine , 42(05), 1049-1056.
10.1017/S0033291711001899
Sommer, S., Johnson, J. M., Roberts, K. K., Redding, S. R., Churchill, L., Henry, N. J., & McMichael, M. G.
(n.d.). RN mental health nursing review module: Edition 9.0.