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You are working on the inpatient unit at the local psychiatric hospital. Your first patient for the day is Asher Cohan, a 42-year-old man with a history of schizophrenia. His father, Daniel, has brought Asher in for treatment. This is his third psychiatric admission in two years. Daniel tries to tell you what’s happening while Asher is present. Both of their pronouns are he.

While Daniel is talking, you can hear Asher talking in the background, sometimes you can hear his words, but the speech is not very understandable. Transcript of his speech is at the bottom of this page.

Daniel: I’m so thankful a bed is available for Asher. I love my son so much, but my wife and I can’t have him in the house anymore. He needs more help.

[sigh] Asher stopped taking his Seroquel and melatonin a week ago when he told us was feeling “so good he didn’t need the medication anymore.” Which has happened before, and why he’s been here before. And what can we do? We try to keep life normal, trying to get him to help around the house, such as with the groceries and cooking.

But as expected, things went downhill as soon as he stopped his medication. Yesterday, we made soup and then he said, “They told me to put eggs in. I have to egg.” And he grabbed a raw egg and cracked over my soup bowl.

He’s been responding to internal stimuli and talks to himself a lot. He said he’s a secret spy and the government has bugged our home through our security system. He recently broke his phone because it was being used by a conspiracy to control him. Asher thinks it’s his responsibility to debug our house and therefore stays awake for most nights to design a plan to undo it. He’s afraid they will come in the house during the night and put a mind control chip in him.

To be honest, when he does talk, I don’t understand half the things he tells me. It a word salad I heard it called…and doesn’t make much sense. When he does it, he talks on and on and on, like he’s doing right now.

Asher? Asher? The nurse would like to talk with you now.

Asher, can you pay attention please?

Asher: Huh? Whuh? Can I go … home now? I need to get it back. They say I must go do it right now. With rainbow blowing in trees, system can be fixed and that’s happening. They destroying lies to make robots for …

Asher’s background speech: I…I know they see, I mean unicorns murder rainbows but not no-no, no unicorns can see me that’s dumb. They, you know THEY see brie me please. Can’t sleep, rainbow murder don’t they, may get us. Maybe dad was taken. Is dad robot to kill me? Must, must stay up pay up so they can’t track us frack us. Eyeballs painted in the basement. Must stay up, death bots, maybe dad will get me. Tracking! That’s how they find you. Eyeballs changed. Then someone then say it but no one, nothing admits and that is when you know… [yawns, immediately claps hands over mouth] Damn I’m tired wired mired. Do rainbows tire wire mire? What color are their eyeballs? No, no room for bots to learn return burn kill me. In me Dad looks normal today, is he back? If you feel it behind you it’s THEM. He could come back? I should ask him if they about the rainbows in him. What if it not him? I’ll check his eye. No rainbows inside I hope pope cope

Daniel departs after saying goodbye to Asher, who barely acknowledges his dad.

Medical Notes

While you review Asher’s chart, the nurse changes Asher into the hospital-issued uniform.

Vital signs: BP 148/72, HR 88, R 18, pulse ox 98%
Height: 6′ 1″
Weight: 180 pounds
Appearance: Unkempt, poor hygiene, not dressed for the weather
Blood work: A1C 6.2, total cholesterol 188 mg/dl, HDL 22 mg/dl, LDL 176 mg/dl
Triglycerides: 148 mg
All other lab results are within normal limits.
Prescribed medications: Seroquel 400 mg BID for psychosis and melatonin 6 mg for sleep
The intake department documented that his current symptoms include auditory hallucinations, disorganized speech, and diminished emotional expression.
Medication
After a detailed assessment, you confirm that Asher meets the criteria for schizophrenia and is demonstrating both positive and negative symptoms. Now it’s time to consider medications that you would start while he is inpatient in the hospital.
Daniel is listed as Asher’s legal guardian for medical purposes, so you call him to discuss some options. Daniel’s main concern is that he and his wife are afraid Asher will not stay on his medication again. You discuss with Daniel starting a long-acting injection. After explaining what a long-acting injection is, Daniel agrees that this sounds like a great idea. Choose a long-acting injection medication and complete Asher Cohen Medication (Word).
Asher agrees to take the injection. Over the next week, the nursing staff report that he is attending groups. Each day that passes, Asher does seem to be more coherent and less delusional.

 

 

 

Asher Cohen Medication (Word).

Medication Name (Brand and Generic) (5 points)

What long-acting injection do you prescribe for Asher? Provide your rationale.

 

Targeted Symptoms (10 points)

Provide mechanism of action, targeted receptors, specific brain regions, and which symptoms the chosen medication improves.

 

Dosing (10 points)

Starting dose, maintenance dose, and how you would take Asher off the medication. Start with the package instructions and include any changes specific to Asher.

 

Medication Cost (5 points)

Contact at least two pharmacies for cost of this medication out-of-pocket.

 

Patient Education (5 points)

Include both patient and family education. Explain side effects (for example, if a medication causes dizziness, explain why). 
Discharge
Social work is trying to plan for discharge. You want Asher to attend a partial hospitalization program (PHP). Look up PHP programs/day programs in your area that you would recommend for Asher. Fill out Asher Cohen PHP (Word). Find out what are their start/stop times, any transportation services that might be needed (if his parents cannot take him), and whether they accept insurance? If there are no such programs in your town/city, reach further out until you find at least one.

Asher Cohen PHP (Word)

Program (5 points)

Name, location, times, and benefit/goal of PHP program

 

Transportation Services (2.5 points)

Do they provide transportation? Is public transportation available? Cost of transportation (include any variation across age, disability, Medicare, veteran status)?

 

Insurance (2.5 points)

What insurance do they accept? List all insurances accepted, including public assistance.

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURS 665

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