STUDENT NAME: JAMES KARANJA MAINA

DISGNATION: D/NURS/887/2022

TITLE: PSYCHIATRY CASE STUDY (DRUG INDUCED PSYCHOSIS)

COURSE: KENYA REGISTERED COMMUNITY HEALTH NURSING

SCHOOL: CONSOLATA NKUBU SCHOOL OF NURSING

CLASS: MARCH 2022

SUPERVISOR: MADAM GLORY

DEMOGRAPHIC DATA

PATIENTS NAME: RAPHAEL MWIRIGI

IP NO: 2022-10886

Age: 55years

Sex: Male

Religion: Christian

Occupation: Clerk

Next of Kin: Joel Matheta (Father)

PHYSICAL ADDRESS

County: Meru County

Sub County: Igembe South

Location: Makiri

Village: Mbee (Luluma)

Chief: Kagwiria

Ward: Akachiu

Admitting diagnosis – Drug induced psychosis

Date of admission: 10/04/2023

Mode of admission: Involuntary admission

Allegations

Taking bhang

Destructive and aggressiveness

Being violent
REACTION TO THE ALLEGATIONS:

The patient denied the allegations stating that he was brought to the facility due to conflict with father and other
family members. He said he hates his father so much for bringing him to the facility.

HISTORY OF PRESENTING ILLNESS

The allegations made were of gradual onset over three months characterized by aggressiveness and violent
behavior and destroying property. The allegations were aggravated by smoking bhang.

PAST MEDICAL HISTORY

The patient is a known psychiatric patient who has been on follow up for drug induced psychosis at Dr.
Muikamba Mental clinic.

He was admitted last year 2021 may with drug overdose at Meru teaching and referral hospital.

He has been in Kaaga rehabilitation Centre for behavior change.

PERSONAL HISTORY

He was born in hospital through caesarian section cried immediately after birth with no physical injuries or
abnormalities. The mother had no post-partum complication.

He was fully immunized according to KEPI schedule and had normal developmental milestones.

Early childhood experience

Grew up as a normal child raised by both parents. No history of trauma or stressful events.

Education history

Started school at the age of 4 years and completed class 8 and was an average student. Went to secondary school
and completed form 4 after which he ventured into business.

Marital status.

He is not married. He says he is young and when time comes, he will get married. No known sexual disorders or
sexually transmitted diseases but he says he experiences sexual feeling.
Employment history

After completion of form four he starred his own business. He sells cloths and he has opened a car wash, and he
says he has a lot of money, and he can’t stick to one business for more than 2 years

SOCIAL HISTORY.

He relates well with family and friends but he hates his dad for bringing him to the facility and not visiting him
frequently.

Social responsibilities at his work place. He is social and has many friends that they drink with, chew Miraa and
smoke bhang. He reports that he started smoking in primary school and continued in high school with his
friends.

HOBBIES: he says he enjoys reading the bible as he was holding one during the interview and he had written
down other books he want to read like 48 rules of life.

Habits: he likes smoking, taking alcohol especially gilbeys (GIN) and chewing Khat/Miraa and smoking bhang.

FAMILY HISTORY

His father is married to two wives and he is the lastborn in the family of three, one brother and two sister of the
second wife.

The first wife of his father also has three children two girls and one son. Both parents are alive.

The two families live separately.

TABLE SHOWING THE ORDER OF FAMILY SIBLINGS

NAME: James Kimathi

SEX: Male

OCCUPATION: High school Teacher

MARITAL STATUS LIFE STATUS: Married

He declined to give history of the other siblings of the first wife of his father.

FORENSIC HISTORY

He has never been arrested by the police

PREMORBID HISTORY

Before the illness he was a talkative and sociable. He has many friends and he relates well with them.

PHYSICAL EXAMINATION

Head – The hair looked tiny and well distributed black in color No swelling or edema on palpation.

Eyes – The eyes are well aligned with no abnormality noted No pallor or jaundice noted.

Nose- Normal in size and shape. No abnormality noted No abnormal discharge noted and there is continuity of
the septum.

Mouth – Dark lips, pink tongue, No tooth missing

Ears – Both ears have no abnormal discharge and they are

Normal in size and shape. The patient responds to sound well.

Neck – No distended jugular veins and the thyroid gland

Not distended. Tonsils palpable not enlarged/inflamed

No scars observed.

Chest – Normal in size and shape and regular breathing

Patterns. No scars on the chest. 20 breaths per

Minutes and pulse rate 84 beats per minute. S1 S2 heart sound heard.

Back – No scars and there is continuity of the spinal cord.

No pain on palpation

Upper limbs – Both arms are present, equal in size and no scars

Noted capillary refill is <3 seconds.

Abdomen – Has no distention of abdomen, no scars noted. Bone

Sounds present on auscultation. No tenderness on palpation

No mass felt on palpation.

Genitalia – Normal morphology. No inguinal swelling and lymph nodes not enlarged.

Lower limbs – Both present and equal in size. No edema.

General appearance-well-built body and he looks healthy

Vital signs and observations

Blood pressure 118/76 mmhg

Pulse rate 84

Respiration rate 20 breaths per minute

MENTAL STATUS ASSESSMENT

1. General appearance

Mode of dressing. The patient was well dressed with a t shirt, Jacket and a pair of Jeans. He looked good and
was appropriately dressed.

Personal hygiene

His hair was short and clean- he appeared well kempt.

Facial expression – masked

Eye contact – Not maintained

Behavior – restless and abusive

Level of consciousness - alert.

Attitude towards the nurse – Uncooperative

2. Psychomotor behavior.

Gait – steady

Posture – upright

Ticks and mannerism absent

3. Speech– Tone – High

Speed – Normal

Volume – pressured

4. Affect – Appropriate

5. Mood – Euthymic

6. Thought content-Had linear organized thought content. No thought insertions no phobias and no suicidal
ideas.

The patient had no flight of ideas, No thought blocks, No poverty of ideas.

7. Perceptions

I asked him whether he was hearing some voices he said No and had none even on admission.

The patient had no hallucinations or illusions.

8. Cognition;

Orientation

He was oriented to time, person and place

Concentration

He had good concentration and as the time of interview he was playing a game with another patient.

Memory

Recent memory, immediate and remote memory were intact.

Abstract reasoning.

Had a good abstract reasoning.

He was able to interpret a proverb. (Asiyefunzwa Na mama ufunzwa Na ulimwengu).

9. Judgment

Had good judgment.

I gave the patient a scenario of a burning house and a little kid inside and also a bag full of money inside. I
asked him what he will save first and he said he would save the kid first.
10. Insight.

He was not aware of his mental sickness and he believed he was not sick on admission but during the interview
he says he knows he is sick and will take his medication.

PLAN

Admit psychiatry unit for management

MANAGEMENT – PHARMACO THERAPY.

The patient was put on midazolam 10mg intravenous stat.

Midazolam

Classification is a benzodiazepine

Mode of action Acts on the central nervous system at many levels to produce generalized central
nervous systems depression. It sedates and give anxiolytic effects.
Dosage: 10mg intravenously or intramuscularly
Side effects
Drowsiness: Midazolam can cause excessive sleepiness and drowsiness, especially when administered in higher
doses. This effect can persist for several hours after taking the medication.

Impaired coordination: Midazolam can affect motor skills and coordination, leading to unsteady movements or
clumsiness.

Confusion and memory problems: Some individuals may experience confusion, disorientation, or memory
impairment while taking midazolam. These effects are more likely to occur in higher doses or in elderly
patients.

Headache: Headaches can occasionally occur as a side effect of midazolam use.

Dizziness and lightheadedness: Midazolam can cause dizziness and a feeling of lightheadedness, particularly
when standing up or changing positions quickly.

Respiratory depression: Midazolam, like other benzodiazepines, can suppress breathing in high doses or when
combined with other medications that have a similar effect, such as opioids. This effect is more common in
individuals with respiratory conditions or those taking other central nervous system depressants.
Nausea and vomiting: Some people may experience gastrointestinal symptoms such as nausea and vomiting
after taking midazolam.

Allergic reactions: Although rare, some individuals may have an allergic reaction to midazolam. Signs of an
allergic reaction may include rash, itching, swelling, severe dizziness, or difficulty breathing. Immediate
medical attention should be sought if these symptoms occur.

Benzhexol – trihexyphenidyl

Classifications Is an anticholinergic agent

Mode of action works by binding to and blocking muscarinic receptors, which are specific receptors for
acetylcholine found in the central nervous system (CNS) and peripheral tissues. By inhibiting the action of
acetylcholine on these receptors, Benzhexol reduces the excessive cholinergic activity in the brain and helps to
restore the balance between dopamine and acetylcholine.

Dosage 5mg OD

Indications

Parkinson's disease

Extrapyramidal symptoms

Contraindications of Benzhexol:

Hypersensitivity: Benzhexol should not be used in individuals who have a known hypersensitivity or allergy to
trihexyphenidyl or any of its components.

Narrow-angle glaucoma: Benzhexol is contraindicated in individuals with narrow-angle glaucoma, as it can

increase intraocular pressure and worsen the condition.

Urinary retention: It is contraindicated in individuals with urinary retention, as it may exacerbate the problem.
Bowel obstruction: Benzhexol should be avoided in individuals with a known or suspected bowel obstruction, as
it can further impair gastrointestinal motility.
Side effects of Benzhexol:

Dry mouth: Dry mouth is a common side effect of Benzhexol. Patients should be encouraged to maintain good
oral hygiene and stay hydrated.

Blurred vision: Benzhexol can cause blurred vision or other visual disturbances. Patients should exercise caution
while performing tasks that require clear vision, such as driving or operating machinery.

Constipation: Benzhexol can slow down bowel movements and lead to constipation. Adequate fluid intake and
dietary fiber can help alleviate this side effect.

Urinary retention: Benzhexol can impair bladder function and lead to urinary retention. Patients with a history
of urinary problems should be closely monitored.

Confusion and cognitive changes: Benzhexol can cause confusion, memory problems, and cognitive changes,
particularly in higher doses or in elderly patients.

Nursing implications for Benzhexol:

Assessment: Nurses should assess the patient's medical history, current medications, and allergies before
administering Benzhexol. Special attention should be given to conditions such as glaucoma, urinary retention,
and bowel obstruction.

Patient education: Nurses should provide education to patients about the medication's purpose, dosage, and
potential side effects. Patients should be informed about strategies to manage dry mouth, blurred vision,
constipation, and urinary retention.

Monitoring: Regular monitoring of vital signs, including blood pressure and heart rate, is important. Nurses
should also monitor for potential adverse effects such as confusion, cognitive changes, and urinary retention.

Medication administration: Nurses should ensure accurate administration of Benzhexol according to the
prescribed dosage and schedule. They should also assess the patient's response to the medication and report any
significant changes to the healthcare provider.

Interdisciplinary collaboration: Nurses should collaborate with the healthcare team, including physicians and
pharmacists, to ensure appropriate medication management, monitor for drug interactions, and adjust the dosage
as necessary.

Clopixol 200mg stat- monthly

Classification Is a thioxanthene neuroleptics.

Mode of action

It helps correct chemical imbalances in the brain. It acts by antagonizing of D1 and D2 dopamine receptors.

Indication

Schizophrenia: Clopixol is primarily indicated for the treatment of schizophrenia, a chronic mental disorder
characterized by distorted thoughts, perceptions, and behaviors.

Contraindications of Clopixol:

Hypersensitivity: Clopixol should not be used in individuals who have a known hypersensitivity or allergy to
zuclopenthixol or any of its components.

Severe central nervous system depression: It is contraindicated in individuals with severe central nervous system
depression caused by alcohol, sedatives, opioids, or other depressant medications.

Coma: Clopixol should not be used in individuals in a comatose state.

Blood dyscrasias: It is contraindicated in individuals with a history of blood dyscrasias (abnormalities in blood
cell counts) or bone marrow depression.

Parkinson's disease: is contraindicated in individuals with Parkinson's disease, as it may worsen the symptoms
of the condition.

Side effects of Clopixol:

Extrapyramidal symptoms

Sedation and drowsiness

Anticholinergic effects

Weight gain and metabolic effects

Nursing implications for Clopixol:

Assessment: Nurses should conduct a thorough assessment of the patient's medical history, including allergies,
existing medical conditions, and current medications. Special attention should be given to conditions such as
Parkinson's disease and blood dyscrasias

Medication administration: Nurses should ensure accurate administration of Clopixol according to the
prescribed dosage and schedule. It may be administered orally or via intramuscular injection.
Monitoring: Regular monitoring of vital signs, including blood pressure, heart rate, and temperature, is
important. Nurses should also monitor for side effects such as extrapyramidal symptoms, sedation, and
anticholinergic effects.

Patient education: Nurses should provide education to patients and their families about the purpose of Clopixol,
expected side effects, and the importance of compliance with the prescribed treatment regimen. Patients should
be aware of the potential for sedation and the need to avoid activities that require alertness.

Collaborative care: Nurses should collaborate with the healthcare team, including psychiatrists and pharmacists,
to ensure appropriate medication management, monitor for drug interactions, and adjust the dosage as necessary.

Aripiprazole

Classification Aripiprazole is a partial agonist at D2 receptors.

Dosage 10 or 15 mg once daily.

Mode of action

It acts as an antipsychotic by lowering dopaminergic neurotransmission in the mesolimbic pathway and

enhancing dopaminergic activity in the mesocorticolimbic pathway.

Indications of Aripiprazole:

Schizophrenia: Aripiprazole is indicated for the treatment of schizophrenia in adults and adolescents aged 13
years and older.

Bipolar disorder: Aripiprazole is used as an adjunctive treatment to stabilize mood in patients with bipolar
disorder, either as an add-on to existing mood stabilizers or as monotherapy.

Major depressive disorder: Aripiprazole can be prescribed as an add-on treatment to an antidepressant for the
management of major depressive disorder when other treatments have not been effective.

Contraindications of Aripiprazole:

Hypersensitivity: Aripiprazole should not be used in individuals with a known hypersensitivity or allergy to
aripiprazole or any of its components

Dementia-related psychosis: Aripiprazole is contraindicated in the treatment of dementia-related psychosis due

to an increased risk of cerebrovascular adverse events and mortality.
Side Effects of Aripiprazole:

Extrapyramidal symptoms (EPS): Aripiprazole may cause EPS, including tremors, dystonia, akathisia, and
parkinsonism-like symptoms.

Metabolic effects: Aripiprazole has been associated with metabolic changes such as weight gain, dyslipidemia,
and increased blood sugar levels.

Sedation and drowsiness: Aripiprazole can cause sedation and drowsiness. Patients should be advised to use
caution while driving or operating machinery.

Orthostatic hypotension: Aripiprazole may lead to a drop in blood pressure upon standing up, resulting in
dizziness or lightheadedness.

Hyperprolactinemia: Aripiprazole may increase prolactin levels, which can lead to symptoms such as breast
enlargement, lactation, and menstrual irregularities.

Nursing Considerations for Aripiprazole:

Assessment: Nurses should conduct a comprehensive assessment of the patient's medical history, including
allergies, existing medical conditions, and current medications

Medication administration: Nurses should ensure accurate administration of aripiprazole according to the
prescribed dosage and schedule.

Monitoring: Regular monitoring of vital signs, including blood pressure and heart rate, is important. Nurses
should also monitor for side effects such as EPS, metabolic changes, sedation, and orthostatic hypotension.

Patient education: Nurses should provide education to patients and their families about the purpose of
aripiprazole, expected side effects, and the importance of compliance with the prescribed treatment regimen.

Collaborative care: Nurses should collaborate with the healthcare team, including psychiatrists and pharmacists,
to ensure appropriate medication management, monitor for drug interactions, and adjust the dosage as necessary.

Carbamazepine.

Classification An anticonvulsant and a mood stabilizer

Mode of action

Acts by enhancement of Sodium channel inactivation by reducing high frequency repetitive firing of action
potential and action on synaptic transmission. It’s used as.
Dosage: 200mg BD

Indications

Epilepsy: Carbamazepine is commonly prescribed as an anticonvulsant medication to manage seizures

associated with epilepsy. It can be effective in controlling various types of seizures, including partial seizures,
generalized tonic-clonic seizures, and mixed seizure patterns.

Trigeminal neuralgia: Carbamazepine is considered a first-line treatment for trigeminal neuralgia, a chronic pain
condition that affects the trigeminal nerve, causing intense facial pain. It helps to reduce the frequency and
severity of the pain attacks associated with this condition.

Bipolar disorder: Carbamazepine is sometimes used as a mood stabilizer in the treatment of bipolar disorder. It
can help to prevent or reduce the intensity of manic and depressive episodes associated with this condition.

Neuropathic pain: Carbamazepine may be prescribed to manage neuropathic pain, which is caused by nerve
damage or dysfunction. It can help relieve pain associated with conditions such as diabetic neuropathy, post
herpetic neuralgia (pain following shingles), and other nerve-related pain syndromes.

Alcohol withdrawal: Carbamazepine may be used as part of a comprehensive treatment plan to manage alcohol
withdrawal symptoms, such as seizures and tremors.

Other off-label uses: Carbamazepine may also be used off-label for certain conditions such as
attention-deficit/hyperactivity disorder (ADHD), aggressive behavior, certain types of nerve-related pain, and
certain psychiatric disorders.

Contraindications

Hypersensitivity: Carbamazepine should not be used in individuals who have a known hypersensitivity or
allergy to carbamazepine or any of its components.

Bone marrow suppression: Carbamazepine can cause bone marrow suppression, leading to a decrease in the
production of blood cells. Therefore, it is contraindicated in individuals with known bone marrow suppression,
such as those with a history of significant blood cell disorders or bone marrow depression.

History of agranulocytosis: Agranulocytosis is a severe condition characterized by a significant reduction in

white blood cells. Carbamazepine should not be used in individuals with a history of carbamazepine-induced
agranulocytosis or other medications known to cause this condition.
Concurrent use with monoamine oxidase inhibitors (MAOIs): Combining carbamazepine with MAOIs, a type of
antidepressant, can lead to a potentially dangerous interaction.

Porphyria: Carbamazepine can exacerbate symptoms of certain types of porphyria, a group of rare genetic
disorders that affect the production of heme, a component of hemoglobin. Therefore, it is contraindicated in
individuals with a history of porphyria or a known diagnosis of porphyria.

Recent myocardial infarction: Carbamazepine can have effects on the heart, and its use is generally not
recommended in individuals who have had a recent myocardial infarction (heart attack).

Pregnancy and breastfeeding: Carbamazepine use during pregnancy and breastfeeding may have potential risks
to the developing fetus or newborn.

Side effects

Drowsiness and dizziness.

Nausea

Blood disorders

Liver problems

Hyponatremia

Nursing considerations for carbamazepine include:

Monitoring: Nurses should regularly monitor vital signs, including blood pressure, heart rate, and respiratory
rate, as well as potential side effects such as drowsiness and dizziness. Regular laboratory tests, including
complete blood counts and liver function tests, should be conducted.

Medication administration: Nurses should ensure accurate administration of carbamazepine according to the
prescribed dosage and schedule.

Patient education: Nurses should provide information to patients and their families about the potential side
effects of carbamazepine and what to do if they occur.

Drug interactions: Carbamazepine can interact with other medications, such as oral contraceptives and
anticoagulants. Nurses should review the patient's medication profile and monitor for potential drug interactions,
coordinating with the other healthcare provider as needed.
Pregnancy and breastfeeding: Nurses should advise women of childbearing age about the potential risks of
carbamazepine during pregnancy and the importance of using effective contraception. For breastfeeding
mothers, the potential risks and benefits should be discussed, as carbamazepine can be excreted in breast milk.

NUTRITION

The patient had good appetite; he had no difficulties in feeding. He was served with porridge every day in the
morning at 6.30 am and at 10 am served with tea. The patient remained active most of the day, moving around,
talking a lot, and singing with fellow patients. The patient remained energetic throughout the day. Lunch time he
was given lunch and a lot of safe drinking water and at 6 pm every day he was provided with Ugali and cabbage.
The food however lacked greens and fruit which is also essential for the patient.

HYGIENE

I encouraged the patient to take a both at least once a day, in the morning when he wakes up as they are
provided with hot water and to change in a clean hospital uniform.

NURSING MANAGEMENT THROUGH NURSING PROCESS

NURSING CARE PLAN OF MY CLIENT.

Date/ ASSESS NURSING GOALS/ NURSI RATION IMPLEM

Time MENT DIAGNOS EXPECTED N G ALE ENTATIO EVALU
DATA IS OUTCOME INTER N AT ION
VE
NTION
10AM On Risk for Goal Offer Individua Individual Goal
28/06/20 assessme violence individ l psychothera partially
To protect
23 nt, patient related to ual psychoth py offered met
patient from
verbalize range psychot erapy to the
causing any
s reactions. herapy permits patient at
harm to
increased to the the 10:30 am.
others and
hatred patient patient to Patient
self during
towards and ventilate accepted to
hospital stay.
his father, encoura his forgive his
Outcome
looks ge him feelings father
Patient will
very to and
verbalize
 angry relief from forgive arrive at
when hating his his a solution
talking mother and father of
about the will appear problems
incidence relaxed Teach without
, and has when talking patient much
muscle about the on guidance.
tensions. conflicts. proper
Patient will conflict Forgiving
demonstrate resoluti his father
proper on on will bring
conflict skills about
solving skills psycholo
gical
relief and
relaxatio
On
n.
assessme
Disturbed Goal Encour Warm At 4pm Goal on
nt, patient
sleep Patient to age the bath Patient going
verbalize
pattern sleep at least patient promotes encouraged
s sleeping
related to for 6 hours to take relaxatio to be taking
late and
10AM perceptual per night in a warm n to bath before
waking
29/06/20 and 48 hours bath encourag going to
up early,
23 cognitive E/Outcome. before e sleep. bed
sleeping
less than Impairment Patient will bedtime Low At 4pm
six hours as verbalize stimulati Patient
.
per night evidenced getting ons will encouraged
Let the
and by patient adequate allow to sleep in a
patient
making verbalizatio sleep at patient to quiet corner
sleep in
noise at n n of night. relax and of the room
the area
night sleeping Patient will get to avoid
of the
late and not make adequate disturbance.
room
waking up noise at sleep at
with
early. night. night.
 At 3pm
low
Naps discouraged
stimulat
during patient
ion
daytime from taking
will unnecessar
Discour
make y naps
age
patient during
patient
lack daytime
from
enough
taking
sleep at
naps
night
during
the day
2/07/202 On Knowledge Goal Discuss Provides At 10:30AM Goal
3 assessme deficit Patient to the knowledg partially
Discussed
10AM nt, related to gain relation e base met
with the
patient lack of knowledge ship of from
patient the
asking information and insight substan which
relationship
questions and of his own ce use patient can
of
about her information condition to make
substance
condition misinterpret during current informed
use and
ations hospitalizati situatio choice
mental
evidenced on n.
illness at
by patient E/Outcome. Review
11am. we
asking the
Patient will discussed
questions conditi
verbalize the
on and
understandin condition
prognos
g of own and
is and
condition prognosis at
future
and
expecta
participate in
 treatment tions the same
program togethe time.
including the r with
plan for the
Long- patient
term care.
Involve
patient
in his
care
such as
drugs
used for
treatme
nt

PSYCHOTHERAPY.

INDIVIDUAL THERAPY.

During the management of my client, I frequently offered individual psychotherapy where we

discussed various issues which were disturbing him such as, helping him understand why he was
admitted and to gain insight of his illness, because on admission he lacked insight and did not
agree that he was mentally sick. And needed medical assistance.

We discussed drug compliance with my patient. Initially he did not understand why he was being
injected with drugs and he had declined taking oral drugs because he felt he was not sick. After
several sessions on importance of medication he agreed to comply.
DISCHARGE PLAN FOR THE CLIENT.

My client has hot fully recovered and was still in the ward. I talked to him about abstinence from
substance abuse so that after discharge he will not relapse and get admitted again. I explored
various ways of avoiding substance abuse, problem solving skills and stress coping mechanism
in order to avoid going back to substance abuse.

I discussed with him advantages of taking drug as advised and effects of poor drug adherence.

He was ready to continue taking medication as advised after discharge.

He also agreed to continue attending outpatient clinic as per the appointments after discharge.

We discussed about avoiding friends who encourage him to take drug substances as they mean
no good in his life.

I discussed with his family members (father) about accepting him back after discharge and
supporting him to avoid relapses.