Schizophrenia Case Study

N290
Revised Fall 2009

NORTH IDAHO COLLEGE
Associate Degree Nursing Program
Nursing Interventions III
PSYCHIATRIC CASE STUDY
Part I

STUDENT

_____________ Date of Clinical _____________ UNIT_____________

Patient: Sam (not his real name)
A. Demographic Data
Male X Female
Age __38__ Height __6’1‖ Weight _250 Ethnicity _ Caucasian ____
Religion: _not known_____________________
Occupation: Grocery Stocking Clerk
_______________________________
Code Status: __full____________Date of Admission: __8/26/08_______________________________
List Clinical Diagnoses according to DSM-IV Classification. List all five axes:
Axis I:___ 295.30 Schizophrenia:_Paranoid Type_____________________________________
Axis II:___none________________________________________________________________
Axis III:___HTN_______________________________________________________________
Axis IV:___Occupational; Social_________________________________________________
Axis V:___10: danger of hurting others; highest level the last year: 71____________________
Allergies (Medications, Food, Latex), List: __N/A___________________________________________
Diet:____regular______________________________________________________________________
List the therapeutic program prescribed for the patient:
IPU on admission; C0; IPU program as tolerated; medication per order
Self-care Ability/Activity Level: (0 – independent; 1 – needs assistance) ___0_____________________
Specify:_______________________________________________________________________
Describe pattern of vital signs and implications for care/monitoring:
___VS bid x 3 days then daily: 164/96 on admission; P: 80 reg; T: 99; R: 18. (unable to take VS on admission due to agitation. Day 1: 154/88; all others WNL; Day 2: 148/88. ntipsychotic meds could increase effect of HTN meds; some risk for prolonged QTc interval arythmias_____________________________________________________________________

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