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  1. Bianca Chandler Case Study    



    Bianca Chandler is a 14-year-old African American female who lives with her maternal grandmother, Peace Chandler, age 70, who is her legal guardian. Bianca was diagnosed with schizophrenia two years ago during a series of three psychiatric admissions when she was experiencing auditory hallucinations and paranoid delusions. She was placed on Risperdal (risperidone) 2 mg BID.

    Peace brings Bianca to you for an outpatient evaluation. She reports that Bianca has been experiencing more auditory hallucinations, refuses to shower or bathe, and is not sleeping at night. She reports that Bianca has refused to attend church lately, something very important to her close-knit, extended Southern Baptist family. Her granddaughter’s appearance is always unkempt.

    Bianca has poor interpersonal skills and does not interact much with you, but she does answer questions. Her affect is flat and presents as depressed. She is not suicidal or homicidal. Her grandmother monitors her medication and assures you that Bianca is taking it as directed.

    From your perspective as Bianca’s psychiatric nurse practitioner, answer the following questions in a two- to three-page double-spaced paper (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

    Based on the DSM-5, what are the criteria for schizophrenia in patients Bianca’s age? Does Bianca meet the criteria for a schizophrenia diagnosis? Why?
    What screening tool or instrument would you use to help determine the severity of Bianca’s symptoms? Please include how to score it and what determines a positive or negative score.
    What treatment plan would you use to manage Bianca’s symptoms? What level of care would you recommend? How would you coordinate that care and monitor her progress? What type of therapy would you recommend? Provide the rationale to support these recommendations.
    How would you work with the family as a unit? What issues would you prioritize and why?



Subject Nursing Pages 5 Style APA


Bianca Chandler Case Study


            Based on the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) of 2013 by the American Psychiatric Association (APA) the following criteria must be met so as to accurately diagnose schizophrenia: The DSM-5 criteria for schizophrenia include a person experiencing two or more symptoms such as delusions, disorganized speech, hallucinations, catatonic behavior or being completely disorganized, and negative symptoms such as diminished emotional expression for at least one month. Besides, level of functioning in one or more areas such as academics, occupation, interpersonal relations, work, and/or self-care drop compared to the level before onset of the disease. In addition, signs of disturbances tend to go on form six months or longer. It is also important to note that the disturbance should not be explained by substance use or drug abuse and other disorders such as depressive or bipolar disorder, or schizoaffective disorder (APA, 2013). The DSM-5 criteria for schizophrenia are applicable to patients across different ages including children, adolescents, and adults. Therefore, it is appropriate for Bianca’s age (APA, 2013). Bianca meets the criteria for schizophrenia since she presence with a number of symptoms including auditory hallucinations, reduced level of self-care, paranoid delusions, lack of sleep, poor interpersonal skills, refusal to go to church, and depression. Bianca has been presenting with some of the above symptoms for more about two years thus it qualifies the criteria for presentation of symptoms for at least six months (APA, 2013).

            The Positive and Negative Syndrome Scale (PANSS) will be utilized to determine the severity of Bianca’s symptoms. PANSS balances representation of both positive and negative symptoms. The tool has three components include negative, positive, and cognitive or general psychopathology. Negative syndrome is scored in accordance to deficits in affective, social, and cognitive functions, including passive withdrawal and blunting of affect. Positive syndrome is characterized by symptoms such as hallucinations, delusions, and disorganized thinking. General psychopathology comprised of many cognitive deficits including poor attention, disorientation, active social avoidance, and lack of insight. Negative and positive subscales each is composed of seven items and the general psychopathology subscales contain 16 items; each item is scored from 1 to 7 (1-absent, 2-minimal, 3-mild, 4-moderate, 5-moderate severe, 6-severe, 7-extreme). Therefore, the least scores for both negative and positive syndrome is 7 each and maximum is 49 each, while 16 is the minimum score for the general psychopathology subscale and its maximum score is 112.  The total maximum sore for the three subscales is 210 points. A minimum score indicates absence of symptoms while a maximum score indicates presence of the extreme form of the disease. The average score for each subscale is used to compare positive and negative symptoms in terms of the level of severity (absence of symptoms to extreme presentations) (Leucht et al., 2019).

            Formulation of treatment plan for managing Bianca’s symptoms include decisions regarding level of treatment and treatment setting, areas to be addressed, and treatment to be used. Treatment plan will be developed through consultation with Bianca, Bianca’s grandmother (Peace Chandler) and members of a multidisciplinary team. She needs to be assessed for substance/drug induced disorders and other organic mental health conditions (Grover & Avasthi, 2019). The possibility of other psychiatric comorbidities and the level of function as well as education history need to be established. Investigations that need to be done include blood glucose and lipid levels, hemogram, renal function test, liver function test, electrocardiogram, serum calcium, thyroid function test, neuroimaging, and metabolic profile to rule out other issues and to inform decisions relating to the choice of additional medications (Grover & Avasthi, 2019). Besides, her treatment history including response to the current mediation (Risperdal (risperidone) 2 mg BID), side effects, compliance, and prognosis need to be established. Chandler’s caregiving burden, distress, and coping should also be assessed. Similar, Bianca’s psychological assessment will focus on aspects such as her social networks, social support, coping, environment, family environment, distress, and stigma. The level of care recommended for Bianca is an inpatient care setting so as to be managed by a multidisciplinary team. The rationale for choosing an inpatient treatment setting is that Bianca presents with insomnia and is unable to care for self (Grover & Avasthi, 2019).

            The type of treatment recommended for Bianca include consideration for change of current mediation or administration of additional medications, non-pharmacological management (psychosocial interventions and psycho-education), and electroconvulsive therapy. Risperidone appears ineffective considering persistence of symptoms. Combined pharmacotherapy and non-pharmacological approach leads to improved prognosis and better management of the condition (Grover & Avasthi, 2019). Chandler should be included in any decision that will be met and given all relevant information relating to management of Bianca’s condition. These include the choice of the antipsychotic medication to use based on cost and affordability, side effect profile, family and patient preference, past treatment response, and psychiatric comorbidity. Similarly, liaison with other specialists may be necessary (Grover & Avasthi, 2019). Other issues that need to be utilized include assessment and minoring of her nutritional status since she may fail to eat and drink normal or maintain healthy dietary habits. Refusal to eat may put the patient’s life at risk. Side effects of medications such as weight gain, hyperprolactinemia, rise in cholesterol levels, hyperglycemia, and extrapyramidal side effects (Grover & Avasthi, 2019).



American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Grover, S., & Avasthi, A. (2019). Clinical practice guidelines for the management of schizophrenia in children and adolescents. Indian J Psychiatry, 61(Suppl 2), 277-293. https://dx.doi.org/10.4103%2Fpsychiatry.IndianJPsychiatry_556_18

Leucht, S., Barabassy, A., Laszlovsky, I., Szatmari, B., Acsai, K., Szalai, E., Harsanyi, J., Earley, W., & Nemeth, G. (2019). Linking PANSS negative symptoms scores with the clinical global impressions scale: understanding negative symptom scores in schizophrenia. Neuropsychopharmacology, 44, 1589-1596. https://www.nature.com/articles/s41386-019-0363-2




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