Case Study
Situation: Parker Allen, a 28-year-old male, was admitted to a locked behavioral unit in the hospital today for paranoia, psychosis, and violent behavior after he became violent with his landlord. He threw a table at the landlord when she came to his apartment to address a noise complaint by another tenant. She then called the police, who brought him to the emergency room.
Background: Parker has a three-year history of schizophrenia. He has a Master’s degree in Engineering, and works as a software developer. Parker was diagnosed with schizophrenia shortly after he completed graduate school when he became very isolated and paranoid of those around him. His first psychiatric hospitalization occurred about one year after his diagnosis with schizophrenia when he experienced auditory hallucinations and paranoid delusions. He has tried various medications, but reports he doesn’t like the way they make him feel and they make it difficult for him to concentrate on his work. His currently prescribed medications include olanzapine 10 mg and venlafaxine extended release (XR) 75 mg daily, but he states he recently stopped taking his medications.
Assessment: Since arriving in the behavioral health unit, Parker has been withdrawn. He states, “the nurses can see my thoughts,” and explains that is why he he has been staying in his room and covering his head with a blanket.
Sometimes Parker answers questions, but does so inappropriately. He tells the nurse, “I’m pretty sure you are all here to kill me, and you’re starting with the hospital food. I know how this is going to go down.” The nursing staff can only speak with Parker in short bits because he either refuses to talk or is distracted easily. He has a disheveled, dirty appearance and has refused to shower since arriving on the unit. His hair is disheveled and his beard is in need of a trim.
The nursing assistant reports that he refused to eat his dinner when he arrived on the unit, but did drink a few sips of water from a sealed water bottle. His vital signs are: Temperature, 37.0°C; Heart rate, 76 beats/min; Respiratory rate, 18 breaths/min; Blood pressure, 128/79 mmHg; and SpO2, 95%.
When the nurse enters Parker’s room, Parker is sitting on his bed, wrapped in a blanket with most of it covering his face, facing away from the nurse and looking towards the window. As he is greeted, Parker makes no movements and does not turn to the nurse’s voice. He is mumbling quietly to himself. The nurse walks around to face Parker, and greets him again. He responds quietly, but does not make eye contact and answers with apprehension.
He appears very guarded and suspicious, keeping his arms wrapped around himself with the blanket. Beneath the blanket, the nurse can see that he is dressed in layers of clothing and has body odor.
The nurse asks Parker if he has having suicidal thoughts. For most questions the nurse asks, Parker repeats the question back to the nurse. He rarely answers the nurse’s questions and appears distracted. Parker becomes agitated when asked about hallucinations and states that he is hearing voices that tell him that the food he has been given is poisoned. He reports the voices have been constant since his arrival in the hospital, but at home he could get the voices to go away by listening to music in his headphones.
The nurse notices that Parker makes bizarre statements like, “The bammerhoff got me,” and speaks in tangential language. The nurse recalls from previous documentation in the electronic medical record that Parker’s landlord told the police that several other neighboring tenants in the apartment building had complained that there was loud, strange-sounding music and noises coming from his apartment into late hours of the night.
Parker does not tolerate the assessment for very long. After 15 minutes, he refuses to answer any more questions, stating, “You better find the cook. They are poisoning all of us.” At that time, he lays down in his bed and pulls the covers over his head. The nurse informs Parker that they will return soon with a snack for him and thanks him for his time. He does not respond but continues to mumble in a low speech under the covers in his bed.
Reflective Questions:
1. What CUES do you recognize as important for planning Parker’s care?
2. What is your hypothesis for Parker based on this information?
3. Write a SMART goal for Parker based on his priority nursing problem at this time.
4. What are your priority nursing interventions for Parker?
5. How will you evaluate if your interventions have been effective?
6. What symptoms require continued monitoring?