Sultanate of Oman

Ministry Of Health

Oman College of Health science

Bachelor of Science in Nursing

Mental Health Nursing (Practicum)

Case Study
Schizoaffective disorder

Submitted by:

Student Name: Samah Juma Al-Hamad

Student No: BSCN 672

Submission date: 22/04/2021

Submitted to: Ms. Anju

I. ASSESSMENT (15 marks)

 A. General Information (1 Mark)
Patient’s Initial Only M. A Age 36 years old
Hospital Al Masarrah Hospital Ward Female 1 (acute ward)
Sex Female Race Omani
Spiritual
Occupation Not Occupied Muslim
Belief/Affiliation
 Primary  Secondary  College
Education
 Others: please specify:
 Single Married Divorce Separated
Marital Status
 Others: please specify:

Diagnosis (admitting & Schizophrenia disorder since 2000

current) Schizoaffective disorder

B. Chief Complaints (As given by the patient and/or relatives) (1 mark)

Patient was brought by her parents due to she started to be aggressive toward her family members,
hitting them, and became verbally abusive. She has suspiciousness toward her family that they want
to poison her, she was feel jealous from her sisters who are married. Also, she has self-muttering,
and delusion with no hallucinations. She has poor sleep and crying spells.

C. HISTORY OF PRESENT ILLNESS: (2 Marks)

M. A 36yrs old female knowing case of schizoaffective disorder, brought to hospital by her parents
on 03/03/2021, she did not has any medical or surgical history. She feel hostile toward her family
especially her sister and aunt, she said that her aunt does not like her and treat her unfairly, she
believe that her family spying against her, also she has suspiciousness toward her family, she think
that her family are the reason of her grandfather death, Her behavior became more aggressive if one
of her sisters get engage. No auditory/ visual hallucination, she has paranoid delusion, lough in
between, and poor sleeping. At recent days, the patient became more aggressive toward the patients
and staff, they put her in restrain and give her SOS, and also she has mood swings, irritability,
shouting, and harming other.

D. Past History (2 marks)

 Medical
The patient did not have
any medical history like
DM or HTN
Surgical Psychiatry
The patient has schizophrenia disorder
since 2000 she was following Ibn sina
but currently following in SQUH, her
The patient did not have any last admission in SQUH was 2018.
surgical history She had schizoaffective disorder her last
admission in Al Massrah was 2/10/2020.

E. Family History in general and in Mental Illness (1 mark)

General Mental Illness

Based on the patient her grandmother has There are no mental illness in the patient family
hypertension and died from it.

F. Social Data (1 Mark)

The patient has 3 brothers and 3 sisters, and she is the older one, two of her sister get married and
one of them taking care of her in addition to her mother, and her brothers are single, she lives with
her parent in Bahla. She has slight bad relationship with her sister “Siham” and her aunt, the other
family members her does not problems with them, she also has suspiciousness toward her family
members. The patient reported that: “I love them and I do not know why they put me in the hospital,
I want to back home”. Moreover, the patient said she does not has friends and her relationship with
her neighbor is calm and they did not have problems with her.

G. Psychiatric Signs/Symptoms (6 marks)

Admission Present
Insomnia
Tiredness
Poor self-care AEB patient has bad odor.
Physical (2) Poor self-hygiene
Scaly patches, red skin, and stubborn
Poor sleeping
dandruff in the scalp and under the ears.

Patient was isolate her-self in her

The patient still isolate her-self, became
room, has paranoid delusion and
Psychosocial (2) aggressive, fight and harming other
suspicious toward other (patients,
patients, and has paranoid delusion.
staff, and family).

Patient still isolate her-self and has

Patient was crying, isolate her-self,
suspicious toward others, lough in
Psychiatric (2) suspicious, and has paranoid
between, mood swings, irritable, and has
delusion.
paranoid delusion.

H. Psychiatric Diagnosis (1 mark)

Definition:
Schizoaffective disorder is a mental health condition in which a person experiences psychotic
symptoms of schizophrenia, such as delusions, hallucinations, disorganized thinking, or flat affect,
along with symptoms of a mood disorder, such as depression and/or mania.
verywellmind. 2020. The Difference Between Schizophrenia and Schizoaffective Disorder. [Online] Available at:
<https://www.verywellmind.com/schizophrenia-versus-schizoaffective-disorder-2953129> [Accessed 14 April 2021].

II. Treatment (5 marks)

Drugs Physical Psychosocial
(1 mark) (2 marks) (2 marks)

1- Haloperidol (Injection) As the nurse said that they use Family therapy
2- Promethazine (Injection) exercises as physical therapy
3- Olanzapine (Tablet) for the patients.
4- Clonazepam (Tablet)
5- Procyclidine (Tablet) ECT
6- Sodium Valproate (Tablet)

III. Review of Literature of Present Mental Illness and the Treatment Received (6 marks)

Literature Patient
Genetic (The patient has anatomical
Genetic
abnormality (micro adenoma in
Biochemical influences
pituitary gland)).
Physiological influences
Etiology (2) Environmental influences (The patient
Psychological aspects
lived in stressful life event, her
Environmental influences
condition worsen when one of her
Theoretical Integration
sisters get engage, so she fell joules).
Signs and Positive symptoms: Positive symptoms:
Symptoms (2) 1- Content of thought: 1- Content of thought: Delusions
Delusions, religiosity, paranoia, (paranoid), Paranoia (joules type).
magical thinking.
2- Form of thought: Circumstantiality
2- Form of thought: (Ask the patient one question in
Associative looseness, neologisms, different ways to get the answer).
concrete thinking, clang association,
ward salad, circumstantiality, 3- Perception:
tangentiality, mutism, and Patient does not has hallucinations or
perseveration. illusions.

3- Perception: 4- Sense of self: Depersonalization

Hallucinations, illusions. (Patient feel that she is ugly).

Negative symptoms:
4- Sense of self: 1- Affect: Inappropriate affect (patient
 Echolalia, echopraxia, identification
and imitation, depersonalization.
Negative symptoms:
1- Affect:
Inappropriate affect, bland or flat
affect, apathy.
2- Volition:
Inability to initiate goal-directed
activity, emotional ambivalence,
deteriorated appearance.
3- Interpersonal Function and
Relationship to the external World:
Impaired social interaction, social
isolation.
4- Psychomotor Behavior
Anergia, waxy flexibility, posturing,
pacing and rooking.
5- Associated Features:
Anhedonia, regression.
(Townsend, 2014, pg346-349)
Psychological Treatment:
1- Individual psychotherapy.
2- Group therapy.
3- Behavior therapy.
4- Social skills training.
Social Treatment:
1- Milieu therapy.
Treatment (2) 2- Family therapy.
3- Program of assertive.
4- Community treatment.
5- The recovery.
Organic Treatment:
1- Psychopharmacology.
(Townsend, 2014, pg358-363)
became aggressive toward her sisters
when they engaged instead of being
happy for them).
2- Volition: Deteriorated appearance
(Patient has self-care deficit).
3- Interpersonal Function and
Relationship to the external World
(Patient has Impaired social interaction
and social isolation).
4- Psychomotor Behavior: Pacing and
rooking (patient is pacing back and
forth along the corridor).
5- Associated Features:
Patient does not has anhedonia or
regression.
Psychological Treatment:
None
Social Treatment:
1- Family therapy.
Organic Treatment:
 Psychopharmacology.
1- Haloperidol (Injection)
2- Promethazine (Injection)
3- Olanzapine (Tablet)
4- Clonazepam (Tablet)
5- Procyclidine (Tablet)
6- Sodium Valproate (Tablet)
IV. PSYCHIATRIC NURSING – DRUG STUDY (10 Marks)

Name of
No Classification Dose Route Frequency Action Possible side effects Nurse’s Responsibilities
Drug/Generic
. (1 mark) (1 mark) (1 mark) (1 mark) (1 mark) (2 Marks) (2 marks)
(1 mark)
Alters the Seizures, drowsiness, 1- Be alert for new
effects of restlessness, tardive seizures or increased
dopamine in the dyskinesia, blurred seizure activity,
Haloperidol Antipsychotic 5 Mg IM SOS CNS. Also has vision, dry eyes, especially at the onset of
anticholinergic respiratory depression, drug treatment.
and alpha- hypotension, tachycardia, 2- Monitor signs of
1 adrenergic urinary retention, hypersensitivity
blocking amenorrhea, anemia, reactions.
activity. neuroleptic malignant 3-Assess BP periodically,
Diminished syndrome, assesses heart rate, ECG,
signs and hypersensitivity and heart sounds.
symptoms of reactions.
psychoses.
Blocks the Neuroleptic malignant 1- Monitor and report
effects of syndrome, confusion, signs of neuroleptic
Promethazine Antiemetics, 25 Mg IM SOS histamine. Has disorientation, sedation, malignant syndrome.
Antihistamines an inhibitory dizziness, extrapyramidal 2- Assess motor function,
Sedative/ effect on the reactions, fatigue, and be alert for
hypnotics chemoreceptor insomnia, nervousness, extrapyramidal reactions.
trigger zone in blurred vision, diplopia, 3- Monitor unusual
2 the medulla, tinnitus, bradycardia, weakness and fatigue that
resulting in hypertension, might be due to anemia.
antiemetic hypotension, tachycardia, 4- Assess dizziness and
properties. constipation, drug- drowsiness that might
Alters the induced hepatitis, dry affect gait, balance, and
effects of mouth, photosensitivity, other functional
dopamine in the rashes, blood dyscrasias. activities.
CNS.
 Antagonizes Neuroleptic malignant 1- Monitor and report
dopamine and syndrome, seizures, signs of neuroleptic
Olanzapine Antipsychotics 20 Mg Oral HS serotonin type 2 dizziness, insomnia, malignant syndrome.
Mood stabilizers in the CNS. mood changes, 2- Be alert for new
Also has personality disorder, seizures or increased
3
anticholinergic, tardive dyskinesia, seizure activity.
antihistaminic, dyspnea, orthostatic 3- Assess heart rate,
and anti–alpha1- hypotension, tachycardia, ECG, and heart sounds,
adrenergic constipation, dry mouth, and Assess BP.
effects. nausea, tremor.
Produces Behavioral changes, 1- Monitor daytime
sedative effects drowsiness, fatigue, drowsiness.
Clonazepam Anticonvulsants 0.5 Mg Oral BID in the CNS, by slurred speech, 2- Assess balance and
stimulating nystagmus, palpitations, risk of falls
4 inhibitory constipation/ diarrhea, 3-Monitor unusual
gamma-amino dysuria, anemia, weakness and fatigue that
butyric acid leukopenia, might be due to anemia.
receptors. thrombocytopenia,
ataxia.
Inhibits neuronal Anxiety, insomnia, 1- Check the vital signs
reuptake of weakness, impaired RR,PR and BP and report
5 Mg Oral BID serotonin in the concentration, mental for any abnormality
Procyclidine Antianxiety CNS, thus depression, blurred 2- Check if the patient
agents potentiating the vision, chest pain, have any allergy from the
Antidepressants activity of
edema, palpitations, medication
serotonin; has
5 little effect on orthostatic hypotension, 3- Assess blood pressure
norepinephrine or tachycardia, vasodilation, (BP) periodically and
dopamine. nausea, decreased compare to normal
appetite, dyspepsia, values and Report a
flatulence, sweating, sustained increase in BP.
pruritus, weight gain/
loss, myalgia, tremor.
 Increase levels SUICIDAL 1- Watch for signs of
of gamma- THOUGHTS, dizziness, hepatotoxicity or
amino butyric headache, insomnia, pancreatitis.
Sodium Anticonvulsants 1500 Mg Oral Split dose acid (GABA), confusion, depression, 2- Be alert for suicidal
Valproate (Mood an inhibitory peripheral edema, visual thoughts and ideology;
stabilizer) neurotransmitter disturbances, notify the physician
in the CNS HEPATOTOXICITY, immediately if the patient
PANCREATITIS, exhibits signs of
abdominal pain, depression or other
anorexia, diarrhea/ changes in mood and
constipation, increased behavior.
6
appetite, alopecia, rashes, 3- Be alert for signs of
weight gain, increased ammonia levels
thrombocytopenia, (hyperammonemia).
HYPERAMMONEMIA, 4- Assess dizziness,
HYPOTHERMIA, ataxia, or tremor that
tremor, ataxia might affect gait,
balance, and other
functional activities.
5- Monitor daytime
drowsiness, confusion, or
anxiety.

V. NURSING CARE PLAN (2 Actual & 1 Potential) (15 Marks)

 EXPECTED
NURSING DIAGNOSIS GOAL NURSING INTERVENTIONS RATIONALE
OUTCOME
(PES) (1 mark) (1 mark) (1.5 mark) (0.5 mark)
(1 mark)
1- Reinforce and focus on reality. 1- Discussions that focus on the
Disturbed Thought STG: Discourage long rumination about false ideas are purposeless and Goal is met, after
Processes By the end of clinical the irrational thinking. Talk about useless, and may even aggravate the nursing
R/T duty (three days) the real events and real people. the psychosis. intervention the
Inability to trust patient will recognize 2- Do not argue or deny the belief. 2- Arguing with the client or patient was able to
AEB: and verbalize that Use “reasonable doubt” as a denying the belief serves no verbalization
1- Delusional thinking false ideas occur at therapeutic technique: “I useful purpose, because reflect thinking
(Paranoid delusion) time of increase understand that you believe this is delusional ideas are not processes oriented
2- Inability to anxiety true, but I personally find it hard to eliminated by this approach, and in reality.
concentrate accept”. the development of a trusting
LTG: 3- Convey you acceptance of relationship may be impeded.
By the time of client’s need for the false belief, 3- It is important to communicate
discharge from while letting him/her know that you to the client that you do not accept
treatment, the client do not share the belief. the delusion as reality.
will experience 4- Help client try to connect the 4- If the client can learn to
(verbalize evidence false beliefs to times of increased interrupt escalating anxiety,
of) no delusional anxiety. Discus techniques that delusional thinking may be
thinking. could be used to control anxiety prevented.
(e.g., deep breathing exercises, or 5- Verbalization of feeling in non-
other relaxation exercises). threatening environment may help
5- Assist and support client in client come to terms with long
his/her attempt to verbalize feelings unresolved issue.
of anxiety, fear, or insecurity.

V. NURSING CARE PLAN (2 Actual & 1 Potential) (15 Marks)


NURSING DIAGNOSIS GOAL
(PES) (1 mark) (1 mark)
Insomnia STG:
R/T By the end of clinical duty
Delusional thinking (three days) the patient
AEB: will fall asleep within 30
min of retiring and sleep 5
1- Patient did not sleep at hours without awakening,
the night. with use of sedative if
2- Patient sleep during day needed.
time.
LTG:
By the time of discharge
from treatment, the client
will be able to fall asleep
within 30 min of retiring
and sleep 6-8 hours
without a sleeping aid.
V. NURSING CARE PLAN (2 Actual & 1 Potential)
NURSING
INTERVENTIONS
(1.5 mark)
1- Keep strict records of
sleeping patterns.
2- Discourage sleep during
the day.
3- Limit intake of
caffeinated drinks such as
tea, coffee, and colas.
4- Administer
antipsychotic medication
at bedtime.
5- Inhibit the patient from
daytime naps unless
needed
RATIONALE EXPECTED OUTCOME
(0.5 mark) (1 mark)
1- Accurate baseline data
are important in planning Goal was met, after the
care to assist client with nursing intervention the
this problem. patient was able to fall
asleep within 30 min of
2- To promote more restful retiring and sleep 5 hours
sleep at night. without awakening, with
use of sedative if needed.
3- Caffeine is a CNS
stimulant and may
interfere with the client’s
achievement of rest and
sleep.
4- So client does not
become drowsy during the
day.
5- Napping can disrupt
normal sleep pattern;
however, older patients do
better with frequent naps
during the day to counter
their shorter nighttime
sleep schedules.
(15 Marks)
 NURSING EXPECTED
NURSING DIAGNOSIS GOAL RATIONALE
INTERVENTIONS OUTCOME
(PES) (1 mark) (1 mark) (0.5 mark)
(1.5 mark) (1 mark)
1- Decrease environmental 1- Helps decrease escalation of
Risk for violence : STG: stimuli (e.g., by providing anxiety and manic symptoms.
Directed others By the end of clinical duty a calming environment or Goal met, after nursing
R/T (three days) the patient assigning a private room). 2- Removal the dangerous intervention the patient
Lack of trust will verbalize control of objects prevents the client in able to verbalize control
(suspiciousness of others) feelings and Complies 2- Remove the all the agitated, confused state, from of feelings and
AEB: dangerous objects from the using them to harm others. Complies with the
with the treatment
1- Patient has client environment. 3- Early detection and treatment plan
suspiciousness toward her plan. intervention of escalating
family. 3- Observe client behavior mania will prevent the
2- Patient feel joules from LTG: frequently. Do this while possibility of harm to others.
her sisters. By the time of discharge carrying out routine
from treatment, the client activities. 4- Complies with the treatment
will not harm others. plan will decrease the chance
4- Encourage the client to of agitation and harming
Complies with the others.
treatment plan and take the
medication on time. 5- Close observation is
important, because then
5- Observe the patient’s appropriate interventions can
behaviors. be given immediately and to
always make sure that patients
are safe.
VI. Health Education (5 marks)

PATIENT (2.5 Marks) FAMILY (2.5 Marks)

1- Educate the patient to avoid taking any
medication without the psychiatrist's
prescription, it may cause a contradiction with
the antipsychotic medication.
2- Explain to the patient the side effect of the
antipsychotic medication.
3- Encourage the patient to not stop taking the
medication suddenly that may effect on patient's
health.
4- Encourage the patient to see the social worker
improve the relationship with her family; if she
wants.
5- Motivate the patient to do something that she
likes to avoid stressful situations.
1- Educate the family on how to pay attention to
the patient.
2- Educate the family on how to deal with the
delusion that the patient believes in.
3- Explain to the family the importance of
supportive services to the schizoaffective patient
to help him to get well and make his condition
become stable especially from the family.
4- Encourage the family to help the patient to
accept her psychiatric condition.
5- Induce the family to avoid the stressful
situation that may worsen the patient's condition.
6- Provide an explanation to the family about the
importance of adherence to the medication to
improve the patient's condition.

VII. Conclusion (2 marks)

In conclusion, In this case, the patient is 36 years old female diagnosed with a schizoaffective
disorder which is a mental illness that can affect thoughts, mood, and behavior. Also may have
symptoms of bipolar disorder and schizophrenia. These symptoms may be mania, depression, and
psychosis. In addition, this case gives me a chance to experience many signs of schizoaffective in
reality because the patient, in this case, displays signs like delusion (toward her family and staff) and
mood swings (sometimes she keep calm and sometimes she became aggressive and shouting toward
the patients and staff). Moreover, learned about the medication that used for schizoaffective patients
depends on the patient status. Finally, this experience gives me the confidence in dealing with
patients with schizoaffective and other mental problems with the importance of caution while dealing
with them.

VIII. Prognosis (1 mark)

The outcome of the schizoaffective is difficult to predict, it depends on the individual, medication
response, and therapeutic support available. In case the patient incompliance with the medications or
did not receive adequate support that may lead to many problems like; Suicide, suicide attempts, or
suicidal thoughts. Social isolation, Family, and interpersonal conflicts. Moreover, there are several
factors that have been associated with a more positive outcome such as female gender, absence of
brain abnormality, no family history of psychiatric illness.
Evidence:

Summary:
Electroconvulsive therapy (ECT) is an effective treatment for many depressive disorders, and it less
treatment of used for psychotic disorders. The last literature shows that ECT can be a useful strategy
for a lot of psychotic disorders, including treatment-resistant schizophrenia. The aim of this review is
to test the literature of ECT to treat schizophrenia with an initial focus on the effectiveness of it, its
impact on cognitive function, the role of maintenance ECT, and the potential role of neuroimaging
biomarkers to provide more precise ECT treatment strategies. In this review, they evaluate the
literature about ECT strategy to treat schizophrenia in a safe manner, but they should to be attention
that the ECT may cause cognitive impairment so they must always be careful. They did several
studies to explore the effectiveness of ECT as a physical treatment for schizophrenia, and they found
that patients who treated with ECT had significantly reduced rates of psychiatric hospitalization
during the post-treatment period. This effect was more pronounced in patients treated with higher
doses of antipsychotics or with clozapine.

It relates to my patient that they use Electroconvulsive therapy (ECT) to reduce the symptoms of
schizoaffective disorder and to treat it, and it was effective for her as she had reduced her psychiatric
hospitalization as the last hospitalization for her 5 months ago, and she uses antipsychotics
medications.

IX. References (2 Marks)

1- Verywellmind. 2020. The Difference Between Schizophrenia and Schizoaffective Disorder.

[Online] Available at: <https://www.verywellmind.com/schizophrenia-versus-schizoaffective-
disorder-2953129> [Accessed 14 April 2021].
2- Townsend, M. C. (2014). Essentials of psychiatric mental health nursing: concepts of care in
evidence-based practice. 6th ed. Philadelphia: F.A. Davis Co. Pg (346-349), (358-363), (351-356).
3- F.A. Davis PT Collection. 2021. [Online] Available at:
<https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139006167> [Accessed 16
April 2021].
4- Molecular Neuropsychiatry, 2019. Electroconvulsive Therapy and Schizophrenia: A Systematic
Review. [Online] 5(2), pp.75–83. Available at: <https://pubmed.ncbi.nlm.nih.gov/31192220/>
[Accessed 21 April 2021].

Actual Marks = Marks Obtained _________ X 15% = ____________

61

Student Signature: ________________________

Teacher Signature: ________________________

Date: _______________________