Johannah Case Paper
Client profile:
Johannah is a 34-year-old female. Born in the Netherlands, she married an American and came to this country when she was 25 years old. About a year later, Johannah began a series of admissions to psychiatric facilities. She was diagnosed with major depression and later with schizoaffective disorder. About a month ago, Johannah stopped keeping outpatient appointments, stopped taking her medications, stopped bathing, and stopped eating, but was sleeping all the time. Johannes mood symptoms suddenly became less noticeable, and she began wandering her yard after dark, saying the neighbors were in trees. Johannah began to carry a gun to protect itself against the neighbors, who she thought were out to kill her. When she started to fire the gun into the trees, her husband got a court order to have Johannah committed for treatment.
Case study:
Two deputies, one male and one female, and her husband have brought Johannah to the hospital to be admitted. The nurse does an assessment on Johannah and discovers Johannah has been on risperdone (Risperdal) liquid, valproic acid (Depakote), and venlafaxine (Effexor XR). The psychiatrist orders these medications to be continued. At first the nurse is unable to …show more content…
get Johannah to sign consent forms to take her medication, but after a few days, she does sign the forms. By this time, her pregnancy test has come back negative, and she is started back on her usual medication.
The nurse finds Johannah to be somewhat tangential with loose associations. When the nurse assigns Johannah to attend a medication class, she refuses. When asked to interpret a proverb, she refuses.
Johannah begins to talk about her food being poisoned and being” King” of the hospital. She claims to have subjects to take care of the food and those who try to poison it.
Johannah tells the nurse that she has been hospitalized eight times previously on another mental health unit. The nurse sends a signed release of information form to the designated facility requesting copies of Johannes latest psychosocial assessment, treatment plan, and discharge summary. The requested information reveals that Johannes discharge diagnoses at the facility was schizoaffective disorder, bipolar type.
After three weeks on medication, Johannah no longer seems to have hallucinations and delusions. The psychiatrist is ready to discharge Johannah, but her Depakote level comes back low. A nurse discovers Johannah to be cheeking her morning dose and sometimes her evening dose of Depakote and has been putting the medication in a pair of shoes.
Johannah Hansen nurse and envelope with $200 and the words “Thank- you nurse” written on the outside. About this time the nurse notices that Johannah has suddenly become hyperverbal, hyperactive, intrusive, and sexually suggestive to peers and staff.
Questions
*What is schizoaffective disorder ? What are the diagnostic criteria?
According to NAMI, schizoaffective disorder resembles both schizophrenia and a serious mood (affective) disorder. The person who has this disorder will experience delusions, hallucinations, other symptoms that are characteristic of schizophrenia and significant disturbances in their mood (Duckworth, K. & Freedman, J. L., 2012). The diagnostic criteria for this disorder are outlined in the DMS-IV-TR. According to this, “people who experience more than two weeks of psychotic symptoms in the absence of severe mood disturbances – and then have symptoms of ither depression or bipolar disorder – may have schizoaffective disorder” (Duckworth, K. & Freedman, J. L., 2012). This disorder is thought to be a mix between bipolar disorder and schizophrenia.
*Do Johannah symptoms match those of schizoaffective disorder, and if so, how?
The symptoms that Johannah has that match those of schizoaffective disorder are the following: depressive symptoms including disturbed sleep and depressed mood; manic symptoms including increased energy, decreased sleep, hyperverbal, and increased impulsive behaviors; and delusions. According to NAMI, depressive symptoms, manic symptoms, delusions, and hallucinations are all symptoms of schizoaffective disorder (Duckworth, K. & Freedman, J. L., 2012).
*On what basis do you think Johannah was court committed?
Johannah was court committed on the basis that she was mentally ill and that as a result of her mental illness she posed a real and present threat of substantial harm to self and/or others (The Treatment Advocacy Center, 2011). Johannah was a threat to herself or others for the fact that she had a firearm and was firing it into a tree and using it to protect herself from her neighbors.
*Why was Johannah medication delayed, why did the nurse not start it on admission?
According to Mosby;s Drug Guide for Nursing Students, both Risperdal and Effexor XR are category C pregnancy risk, meaning that the risk cannot be ruled out. Depakote is category D pregnancy risk, meaning that there is positive evidence of risk (Skidmore-Roth, L., 2013, 930, 1081, 1092). According to the same text, category C medications are “only given after risks to the fetus are considered” and category D medications have “definite fetal risks” (Skidmore-Roth, L., 2013, 1198). The nurse may have delayed the medications for Johanna until the results from the pregnancy test came back and also because Johannah refused to sign the consent form to take her medications.
*Why does the nurse asked Johannah to interpret a proverb?
According to Haynes, Resnick, Dougherty, and Althof, “asking a patient to interpret proverbs is a traditional method of assessing abstract thinking ability” (1993, 523). Some common proverbs that are used include “The grass is greener on the other side”, “Don’t count your chicken’s before they hatch”, “People who live in glass houses shouldn’t throw stones”, and “A rolling stone gathers no moss” (Mental Status Examination, 10). **www.brown.edu
Does Johannah have hallucinations and/or delusions? What makes you think so?
Delusion: “a persistent false psychotic belief regarding the self of persons or objects outside the self that is maintained despite indisputable evidence to the contrary” (Merriam-Webster Online Dictionary, 2014). Hallucination: “something (such as an image, a sound, or a smell) that seems real but does not really exist and that is usually caused by mental illness or the effect of a drug” (Merriam-Webster Online Dictionary, 2014).
According to these definitions, I would say that Johannah suffers from delusions. She believes that her neighbors are out to kill her despite the obvious fact that they are not. She doesn’t seem to suffer from an image, sound, or smell that seems real but doesn’t actually exist.
*What is age of onset, the male to female ratio, and the prevalence of schizoaffective disorder?
According to NAMI, schizoaffective disorder affects about 1 in 100 people.
“Schizoaffective disorder appears to have a broad age of onset in adults” (Abrams, Rojas, & Arciniegas, 2008). Out of 900 people diagnosed with this disorder, about one third developed the condition between the ages of 25-35, one third developed it prior to age 25, and one third developed it after age 35 (Abrams, Rojas, & Arciniegas, 2008). The broad range of age of onset can be attributed to this condition being similar to both schizophrenia, which has a younger age of onset, and bipolar disorder, which has a later age of onset. According to Abrams, Rojas, and Arciniegas, about two thirds of persons with this disorder are female (2008). So this disorder occurs more in
females.
*Discuss the current theories of ideology, treatment, and prognosis of schizoaffective disorder.
According to Mayo Clinic, “people with schizoaffective disorder generally respond best to a combination of medications and counseling” (2014). The medications that are prescribed for these patients relieve psychotic symptoms, stabilize mood, and treat depression. The only medication that is currently approved by the FDA for the treatment of schizoaffective disorder is paliperidone (Invega), an antipsychotic drug (Mayo Clinic, 2014). The medications that are used include antipsychotics (paliperidone, clozapine, risperidone, olanzapine, and haloperidol), mood-stabalizing medications (lithium, divalproex, carbamazepine, and valproate), and antidepressants (citalopram, fluoxetine, and escitalopram). The two types of psychotherapy used are psychotherapy and counseling to help create plans, solve problems, and maintain relationships or family or group therapy to help with social isolation (Mayo Clinic, 2014).
According to the National Institutes of Health, “people with schizoaffective disorder have a greater chance of going back to their previous level of function than do people with most other psychotic disorders. However, long-term treatment is often needed, and results can vary from person to person” (Rogge, T., 2013).
As a nurse, what would you identify as the most important problems for Johannah at this time? Johannah’s most important problems at this time include her not talking her medications appropriately and her current impulsive behaviors of being hyperverbal, hyperactive, intrusive, and sexually suggestive to peers and staff. These behaviors suggest that Johannah is not ready to be discharged from the mental hospital.
What goals and interventions do you suggest for Johannah for the problems you identified under question 9 ?
Since there is no cure for this disorder, recovery shouldn’t be the focus of the treatment plan. The main goal is long-term treatment that is both holistic and stable. Having stable social support and a good treatment network will increase the likelihood that Johannah will be compliant with medication regimen. One intervention to do with Johannah would be to make sure that she is actually taking her medications. At the same time, it would be important to reiterate to her that taking her medication will help her to get better and to get out of the hospital. Another intervention would be to work with Johannah in developing her interpersonal skills to help her develop healthy relationships with others and her family.
*What are the possible explanations for Johannah giving the nurse an envelope with money in it? How would you respond to this gift offer if you were a nurse?
The best explanation of this behavior is that it is related to Johannah’s manic symptoms. One part of manic or mood symptoms is an increase in impulsive behaviors such as gambling or spending large amounts of money (Duckworth, K. & Freedman, J. L., 2012). Johannah is being extravagant with money; she is overgenerous in her thanks to the nurse. As the nurse in this situation, I would try to avoid direct confrontation with the patient. Directly confronting the patient about the inappropriateness of the gift may make her defensive and aggressive. I would try to focus on the good intent of the gift and try to make Johannah understand that her thanks is all that is required and money is not necessary in this situation.
Johannah is a 34-year-old female. Born in the Netherlands, she married an American and came to this country when she was 25 years old. About a year later, Johannah began a series of admissions to psychiatric facilities. She was diagnosed with major depression and later with schizoaffective disorder. About a month ago, Johannah stopped keeping outpatient appointments, stopped taking her medications, stopped bathing, and stopped eating, but was sleeping all the time. Johannes mood symptoms suddenly became less noticeable, and she began wandering her yard after dark, saying the neighbors were in trees. Johannah began to carry a gun to protect itself against the neighbors, who she thought were out to kill her. When she started to fire the gun into the trees, her husband got a court order to have Johannah committed for treatment.
Case study:
Two deputies, one male and one female, and her husband have brought Johannah to the hospital to be admitted. The nurse does an assessment on Johannah and discovers Johannah has been on risperdone (Risperdal) liquid, valproic acid (Depakote), and venlafaxine (Effexor XR). The psychiatrist orders these medications to be continued. At first the nurse is unable to …show more content…
get Johannah to sign consent forms to take her medication, but after a few days, she does sign the forms. By this time, her pregnancy test has come back negative, and she is started back on her usual medication.
The nurse finds Johannah to be somewhat tangential with loose associations. When the nurse assigns Johannah to attend a medication class, she refuses. When asked to interpret a proverb, she refuses.
Johannah begins to talk about her food being poisoned and being” King” of the hospital. She claims to have subjects to take care of the food and those who try to poison it.
Johannah tells the nurse that she has been hospitalized eight times previously on another mental health unit. The nurse sends a signed release of information form to the designated facility requesting copies of Johannes latest psychosocial assessment, treatment plan, and discharge summary. The requested information reveals that Johannes discharge diagnoses at the facility was schizoaffective disorder, bipolar type.
After three weeks on medication, Johannah no longer seems to have hallucinations and delusions. The psychiatrist is ready to discharge Johannah, but her Depakote level comes back low. A nurse discovers Johannah to be cheeking her morning dose and sometimes her evening dose of Depakote and has been putting the medication in a pair of shoes.
Johannah Hansen nurse and envelope with $200 and the words “Thank- you nurse” written on the outside. About this time the nurse notices that Johannah has suddenly become hyperverbal, hyperactive, intrusive, and sexually suggestive to peers and staff.
Questions
*What is schizoaffective disorder ? What are the diagnostic criteria?
According to NAMI, schizoaffective disorder resembles both schizophrenia and a serious mood (affective) disorder. The person who has this disorder will experience delusions, hallucinations, other symptoms that are characteristic of schizophrenia and significant disturbances in their mood (Duckworth, K. & Freedman, J. L., 2012). The diagnostic criteria for this disorder are outlined in the DMS-IV-TR. According to this, “people who experience more than two weeks of psychotic symptoms in the absence of severe mood disturbances – and then have symptoms of ither depression or bipolar disorder – may have schizoaffective disorder” (Duckworth, K. & Freedman, J. L., 2012). This disorder is thought to be a mix between bipolar disorder and schizophrenia.
*Do Johannah symptoms match those of schizoaffective disorder, and if so, how?
The symptoms that Johannah has that match those of schizoaffective disorder are the following: depressive symptoms including disturbed sleep and depressed mood; manic symptoms including increased energy, decreased sleep, hyperverbal, and increased impulsive behaviors; and delusions. According to NAMI, depressive symptoms, manic symptoms, delusions, and hallucinations are all symptoms of schizoaffective disorder (Duckworth, K. & Freedman, J. L., 2012).
*On what basis do you think Johannah was court committed?
Johannah was court committed on the basis that she was mentally ill and that as a result of her mental illness she posed a real and present threat of substantial harm to self and/or others (The Treatment Advocacy Center, 2011). Johannah was a threat to herself or others for the fact that she had a firearm and was firing it into a tree and using it to protect herself from her neighbors.
*Why was Johannah medication delayed, why did the nurse not start it on admission?
According to Mosby;s Drug Guide for Nursing Students, both Risperdal and Effexor XR are category C pregnancy risk, meaning that the risk cannot be ruled out. Depakote is category D pregnancy risk, meaning that there is positive evidence of risk (Skidmore-Roth, L., 2013, 930, 1081, 1092). According to the same text, category C medications are “only given after risks to the fetus are considered” and category D medications have “definite fetal risks” (Skidmore-Roth, L., 2013, 1198). The nurse may have delayed the medications for Johanna until the results from the pregnancy test came back and also because Johannah refused to sign the consent form to take her medications.
*Why does the nurse asked Johannah to interpret a proverb?
According to Haynes, Resnick, Dougherty, and Althof, “asking a patient to interpret proverbs is a traditional method of assessing abstract thinking ability” (1993, 523). Some common proverbs that are used include “The grass is greener on the other side”, “Don’t count your chicken’s before they hatch”, “People who live in glass houses shouldn’t throw stones”, and “A rolling stone gathers no moss” (Mental Status Examination, 10). **www.brown.edu
Does Johannah have hallucinations and/or delusions? What makes you think so?
Delusion: “a persistent false psychotic belief regarding the self of persons or objects outside the self that is maintained despite indisputable evidence to the contrary” (Merriam-Webster Online Dictionary, 2014). Hallucination: “something (such as an image, a sound, or a smell) that seems real but does not really exist and that is usually caused by mental illness or the effect of a drug” (Merriam-Webster Online Dictionary, 2014).
According to these definitions, I would say that Johannah suffers from delusions. She believes that her neighbors are out to kill her despite the obvious fact that they are not. She doesn’t seem to suffer from an image, sound, or smell that seems real but doesn’t actually exist.
*What is age of onset, the male to female ratio, and the prevalence of schizoaffective disorder?
According to NAMI, schizoaffective disorder affects about 1 in 100 people.
“Schizoaffective disorder appears to have a broad age of onset in adults” (Abrams, Rojas, & Arciniegas, 2008). Out of 900 people diagnosed with this disorder, about one third developed the condition between the ages of 25-35, one third developed it prior to age 25, and one third developed it after age 35 (Abrams, Rojas, & Arciniegas, 2008). The broad range of age of onset can be attributed to this condition being similar to both schizophrenia, which has a younger age of onset, and bipolar disorder, which has a later age of onset. According to Abrams, Rojas, and Arciniegas, about two thirds of persons with this disorder are female (2008). So this disorder occurs more in
females.
*Discuss the current theories of ideology, treatment, and prognosis of schizoaffective disorder.
According to Mayo Clinic, “people with schizoaffective disorder generally respond best to a combination of medications and counseling” (2014). The medications that are prescribed for these patients relieve psychotic symptoms, stabilize mood, and treat depression. The only medication that is currently approved by the FDA for the treatment of schizoaffective disorder is paliperidone (Invega), an antipsychotic drug (Mayo Clinic, 2014). The medications that are used include antipsychotics (paliperidone, clozapine, risperidone, olanzapine, and haloperidol), mood-stabalizing medications (lithium, divalproex, carbamazepine, and valproate), and antidepressants (citalopram, fluoxetine, and escitalopram). The two types of psychotherapy used are psychotherapy and counseling to help create plans, solve problems, and maintain relationships or family or group therapy to help with social isolation (Mayo Clinic, 2014).
According to the National Institutes of Health, “people with schizoaffective disorder have a greater chance of going back to their previous level of function than do people with most other psychotic disorders. However, long-term treatment is often needed, and results can vary from person to person” (Rogge, T., 2013).
As a nurse, what would you identify as the most important problems for Johannah at this time? Johannah’s most important problems at this time include her not talking her medications appropriately and her current impulsive behaviors of being hyperverbal, hyperactive, intrusive, and sexually suggestive to peers and staff. These behaviors suggest that Johannah is not ready to be discharged from the mental hospital.
What goals and interventions do you suggest for Johannah for the problems you identified under question 9 ?
Since there is no cure for this disorder, recovery shouldn’t be the focus of the treatment plan. The main goal is long-term treatment that is both holistic and stable. Having stable social support and a good treatment network will increase the likelihood that Johannah will be compliant with medication regimen. One intervention to do with Johannah would be to make sure that she is actually taking her medications. At the same time, it would be important to reiterate to her that taking her medication will help her to get better and to get out of the hospital. Another intervention would be to work with Johannah in developing her interpersonal skills to help her develop healthy relationships with others and her family.
*What are the possible explanations for Johannah giving the nurse an envelope with money in it? How would you respond to this gift offer if you were a nurse?
The best explanation of this behavior is that it is related to Johannah’s manic symptoms. One part of manic or mood symptoms is an increase in impulsive behaviors such as gambling or spending large amounts of money (Duckworth, K. & Freedman, J. L., 2012). Johannah is being extravagant with money; she is overgenerous in her thanks to the nurse. As the nurse in this situation, I would try to avoid direct confrontation with the patient. Directly confronting the patient about the inappropriateness of the gift may make her defensive and aggressive. I would try to focus on the good intent of the gift and try to make Johannah understand that her thanks is all that is required and money is not necessary in this situation.