Video Case Study - Schizophrenia

Nurse Kit works on an inpatient psychiatric unit and is caring for Albert, a 31-year-old with a history of schizophrenia, paranoid type, who was recently admitted for psychotic symptoms.

After settling Albert in his room, Nurse Kit goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Albert’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.First, Nurse Kit recognizes important cues, including Albert’s vital signs, which are temperature of 37 C, or 98.6 F, heart rate 98 beats per minute, respirations 22 breaths per minute, and blood pressure 136/82 mmHg.

Nurse Kit notices that Albert appears disheveled, restless, and is looking back and forth suspiciously across the room.Nurse Kit: Hi Albert, how are you doing today?

Albert: There’s a man coming after me, I’ve seen him watching me from inside the closet. Nurse Kit turns to look inside the closet, which is empty.

Nurse Kit: That sounds scary. Although I don’t see anyone else here with us, I’m here to support you and keep you safe.Next, Nurse Kit analyzes these cues.

They review the electronic health record, or EHR, and read that Albert has visited the emergency department three times in the past month for symptoms associated with his schizophrenia.

Nurse Kit knows the development of schizophrenia is related to both genetic and environmental factors that disturb the brain’s structure and balance of neurotransmitters like dopamine and glutamate, leading to disabling alterations in behavior, emotions, thinking, and perception, like delusions and hallucinations.

Nurse Kit realizes that Albert needs management of his acute episode of schizophrenia.Now, using the information they’ve gathered, along with Albert’s medical history, Nurse Kit chooses a priority hypothesis of altered perception.

Then, Nurse Kit generates solutions to address Albert’s altered perception that will include pharmacologic and nonpharmacologic interventions; and establishes the expected outcome that after intervening, Albert will report feeling safe in his environment by the end of the shift.Nurse Kit then takes action to implement these solutions.

They report their assessment findings to the health care provider who orders olanzapine by intramuscular, or IM, injection.

As Nurse Kit prepares the olanzapine, they ask another nurse to stand out of sight near Albert’s door in case he becomes agitated or violent.

Nurse Kit then re-enters the room.Nurse Kit: Hi Albert, I’m back and I have some medicine that’ll help you feel safe and more comfortable.

Albert: I’m scared; that man is coming for me. He’s right there behind you!

Nurse Kit: I understand that must be very frightening. I don’t see a man behind me, so you're safe here and no one is going to hurt you.

Albert: Are you sure? Nurse Kit: Yes, I am.

I’m going to give you this medicine as a shot in your leg, is that okay? Albert: Okay.

I’ve had those before. Please don’t let him get me!

Nurse Kit then administers the injection according to the principles of safe medication administration and stays by Albert’s bedside to monitor his response.

Several minutes later, Albert becomes drowsy and falls asleep. While Albert sleeps, Nurse Kit takes measures to decrease stimulation in the room by dimming the lights and turning off the television.

At the end of their shift, Nurse Kit checks Albert to evaluate the outcome of their actions. Nurse Kit takes Albert’s vital signs, which are temperature 37 C, or 98.6 F, heart rate 72 beats per minute, respirations 16 breaths per minute, and blood pressure 124/76 mmHg.

Albert appears tired, but comfortable, and is no longer fixated on the closet. Nurse Kit: Hi Albert, are you feeling any better?

Albert: Yeah, I’m just groggy. Nurse Kit: Okay.

Do you see anything or anyone in the room that’s making you feel unsafe? Albert: No.

I don’t think so. That man who was in my closet is gone.

I’m safe now. Nurse Kit: Yes, you are, and that’s good to hear.Alright, as a quick recap…Nurse Kit recognized and analyzed cues related to Albert’s altered perception and prioritized hypotheses and generated solutions to address this problem.

Nurse Kit then implemented pharmacologic and nonpharmacologic measures to reduce Albert’s visual hallucinations, and evaluated Albert’s outcomes and compared them to the expected outcome.

Since Albert reported feeling safe in his environment by the end of the shift, Nurse Kit determined that the