Disorder Analysis Project

GNRS 584
Brenna Sandberg
Raquel McCarthy

PICOT Question
Do patients with schizophrenia who receive therapy/
interventions have better medication adherence than
patients with schizophrenia who do not receive
therapy/interventions over the course of one year?

Dynamics of Schizophrenia

Psychosocial dysfunction

Depreciation of independent living

Failure to maintain quality of life

Decreased cognitive/occupational
performance

Inability to perceive reality

accurately

Biological/neurobiological factors

Brain structure abnormalities

Diathesis-stress model

Anderson, Ford, Robson, Cassis, Rodrigues, & Gray, 2010.

Halter, 2014.
Jelastopulu, Giourou, Merekoulias, Mestousi, Moratis, & Alexopoulos, 2014.

Dynamics of Schizophrenia

Two or more of the following symptoms

present for 6 months and include at
least 1 month of active symptoms:

Delusions

Hallucinations

Disorganized speech

Grossly disorganized speech

Catatonic behavior

Negative symptoms

Rule out other mental illnesses

Not attributable to substance use/

medical conditions
American Psychiatric Association, 2013.

Patient Introduction

53-year-old, Mexican-American female

Single, never married, and has 9 biological children

History of instability with jobs and housing

Relied on prostitution for income

8th grade education

Long psychiatric history of hospitalizations

1994-Present

Wears garish, eccentric makeup

Maintains eye contact

Currently adhering to medication regimen, history of non-compliance

Receives 1 injection monthly for psychosis

Currently resides in ILF housing with a roommate

DSM-IV-TR Diagnoses
Axis I Schizophrenia, Paranoid Type 295.30
Cocaine Dependence, continuous 304.21
Amphetamine Dependence, continuous 304.41
Alcohol Abuse, continuous, 305.01
Axis II No diagnosis, V71.09
Axis III Breast cancer, in remission, and HIV
Axis IV C. Educational Problems
D. Occupational Problems
A. Primary Support Group
D. Problems related to Social Environment
F. Economic Problems
Axis V GAF - 30
American Psychiatric Association, 2013.

Mental Status Exam Findings

Positive symptoms

Auditory hallucinations
Command hallucinations
Paranoid delusions

Negative Symptoms

Flat affect
Anhedonia
Inattention/ distracted easily
Poor decision-making skills
Impaired judgment
Poor insight
Hopelessness
Avolition
Inability to maintain job
Halter, 2014.

Medication Table
Medication

Classification

Action

Dosage and
Route

Side Effects

Rationale for
Patient

Abilify Maintena
(Aripiprazole)

Atypical
antipsychotic
(dopamine system
stabilizers DSSs,
dopamine agonist)

Provides partial agonist

activity at dopamine and
serotonin (5-HT1A)
receptors and antagonist
activity at serotonin
(5-HT2A) receptor

400 mg IM once a
month

Most common:
weight gain,
headache, agitation,
nervousness, anxiety,
insomnia, nausea,
vomiting, dizziness,
and somnolence.

Indicated for patients

with Schizophrenia.
Poses a low risk for
EPS. Maintains
stability in patients
with schizophrenia.
Reduces positive and
negative symptoms.

300 mg (one tab)

PO qd

Frequent (35-10%):
headache, nausea, malaise,
fatigue, nasal disturbances,
diarrhea, cough,
musculoskeletal pain,
neuropathy, insomnia,
anorexia, dizziness, fever,
chills; Occassional (9-5%):
depression, myalgia,
abdominal cramps,
dyspepsia, arthralgia

Patient is HIV
positive, used to
prevent progression
of disease to AIDS.

Therapeutic: Decreases
schizophrenic behavior;
improves cognitive
function, positive
symptoms, and negative
symptoms.

Triumeq
(lamivudine/abacavir)

Antiviral

Inhibits HIV reverse

transcriptase by viral
DNA chain termination.
Inhibits
Therapeutic: Slows HIV
replication, reduces
progression of HIV
infection

Lehne, 2016.

Nursing Diagnoses
1. Nonadherence to medication regimen related to
Schizophrenia, as evidenced by verbalization of
non-compliance.
2. Ineffective management of therapeutic regimen related
to lack of understanding of not following the prescribed
treatment plan, as evidenced by persistence of
symptoms.
3. Deficient knowledge related to medication
non-compliance, as evidenced by lack of integration of
treatment plans into daily activities.
Varcarolis, 2010 .

First Intervention
Use therapeutic nursing techniques in a peer support program to share feelings in an
atmosphere of acceptance (Varcarolis, 2010).
Rationale: Peers have a distinctive role in enhancing medication adherence by providing problem-solving and
mutual support. Mental health nurses are in a position to encourage peer support in the clinical and outpatient
environment (Boardman et al, 2013).

Evaluation:

Client will attend at least one peer support meeting/session by next monthly visit.
By 1 year, client will attend weekly peer support meeting/session.

Boardman, McCann, & Kerr, 2014.

Varcarolis, 2010.

Second Intervention
Encourage patient to participate in decision-making process regarding
her plan of care (Varcarolis, 2010).
Rationale: Allowing client to participate in care can give her a sense of control and the
opportunity to choose interventions that she might decide to try. Trained nurses are able
to guide clients through problem-solving strategies to generate solutions and overcome
medication noncompliance (Beebe et al, 2014).

Evaluation:

By month 1, client will identify 3 personal difficulties regarding

medication adherence.
By month 3, client will be able to generate 3 solutions to be
compliant.
By month 1 year, client will problem solve and implement
solutions using decision making skills to remain compliant.

Beebe, Smith, & Phillips, 2014.

Varcarolis, 2010.

Third Intervention
Ask patient to share her rationale for nonadherence to the prescribed regimen
(Varcarolis, 2010).
Rationale: Asking for patients rationale helps identify areas of misunderstanding or poor insight. Improved
insight is likely to lead to increased adherence (Novick et al, 2015).

Evaluation:
By month 1, client will acknowledge poor
insight/misunderstanding as rationale for
nonadherence.
By 1 year, client will have increased awareness of
disorder.
Novick, Montgomery, Treuer, Aguado, Kraemer, & Haro, 2015.
Varcarolis, 2010.

Conclusion

Schizophrenia is characterized by positive and negative symptoms.

Medication adherence is extremely important to managing these

symptoms and improving quality of life.

All 5 of our articles found nonadherence is a main cause for relapse,

rehospitalization, increased cost of medical resources, reduces quality
of life, and increased burden on patients family.

Peer support, texting, and phone calls gives client the ability to
participate in their plan of care and improve symptoms as well as
problem solving skills to overcome non-adherence.

Insight has the strongest association to increased medication

adherence.

References
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders: DSM-5 (5th ed.). Washington, D.C: American
Psychiatric Association.
Anderson, K. H., Ford, S., Robson, D., Cassis, J., Rodrigues, C., & Gray, R.
(2010). An exploratory, randomized controlled trial of adherence therapy
for people with schizophrenia. International Journal of Mental Health
Nursing, 19(5), 340-349. doi:10.1111/j.1447-0349.2010.00681.x
Beebe, L., Smith, K. D., & Phillips, C. (2014). A comparison of telephone and
texting interventions for persons with schizophrenia spectrum disorders.
Issues In Mental Health Nursing, 35(5), 323-329.
doi:10.3109/01612840.2013.86341

References
Boardman, G., McCann, T., & Kerr, D. (2014). A peer support programme
for enhancing adherence to oral antipsychotic medication in consumers
with schizophrenia. Journal of Advanced Nursing, 70(10), 2293-2302.
Halter, M.J. (2014). Varcarolis foundations of psychiatric mental health
nursing. (7th ed.). St. Louis, MO: Sanders Elsevier.
Hegeds, A., Kozel, B. (2014). Does adherence therapy improve
medication adherence among patients with schizophrenia? A systematic
review. International Journal of Mental Health Nursing, 23, 490-497.

References
Jelastopulu, E., Giourou, E., Merekoulias, G., Mestousi, A., Moratis, E., &
Alexopoulos, E. C. (2014). Correlation between the Personal and Social
Performance scale (PSP) and the Positive and Negative Syndrome Scale
(PANSS) in a Greek sample of patients with schizophrenia. BMC
Psychiatry, 14(1), 197-203. doi:10.1186/1471-244X-14-197
Lehne, Richard (2016). Pharmacology for Nursing Care (9th ed). Pp. 330
St. Louis, Missouri: Saunders.

References
Novick, D. Montgomery, W., Treuer, T., Aguado, J., Kraemer, S., & Haro, J.M.
(2015). Relationship of insight with medication adherence and the impact
on outcomes in patients with schizophrenia and bipolar disorder: Results
from a 1-year European outpatient observational study. BMC Psychiatry,
15, 189. doi 10.1186/s12888-015-0560-4
Varcarolis, E. (2010 ). Manual of psychiatric nursing care plans. (5th ed.). St.
Louis, MO: Sanders Elsevier.