| Course | NR 607 Diagnosis & Management in Psychiatric-Mental Health III Practicum |
|---|---|
| Week | 5 |
| Paper type | Case analysis |
| Length | About 1,100 words, 4 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 607 Week 5
Case Analysis: Is K.A.'s Schizophrenia Treatment-Resistant? Testing Four Antipsychotic Trials for Adequacy, Adherence and Access Before Reopening the Diagnosis and Weighing Clozapine
Student Name
College of Nursing, Chamberlain University
NR 607: Diagnosis & Management in Psychiatric-Mental Health III Practicum
Instructor Name
Month Day, Year
Case Analysis: Is K.A.'s Schizophrenia Treatment-Resistant? Testing Four Antipsychotic Trials for Adequacy, Adherence and Access Before Reopening the Diagnosis and Weighing Clozapine
The Question
After six years and four antipsychotics, K.A. still hears voices most days. Is this treatment-resistant schizophrenia, and should clozapine be offered?
Was the Trial a Real One
The TRRIP group's criteria count a trial only if the drug reached a therapeutic dose, ran six weeks or longer and at least four in five doses were actually taken (Howes et al., 2017); resistance needs two such failed trials with different agents.
Risperidone, 4 mg daily, 10 months. Dose in the therapeutic range; duration long enough. Adherence: K.A. said in 2021 that doses were missed "some weeks" because of sexual side effects; no pharmacy data from that year. Adequate on dose and duration; adherence uncertain.
Olanzapine, 15 mg daily, 14 months. Dose adequate; duration adequate. Adherence: pharmacy fills show about 60% of doses. Not adequate. It also produced marked weight gain, one of the largest among antipsychotics in comparative data (Huhn et al., 2019), so it is not an option to retry.
Aripiprazole, 15 mg daily, 6 weeks, inpatient. Dose adequate; six weeks is the minimum; adherence confirmed by nursing administration. Adequate, but stopped for restlessness, which may have masked any benefit.
Paliperidone palmitate, 156 mg monthly by injection, three years. Adherence guaranteed when injections are given. But records show five missed or late injections in three years, including two before the 2025 admission. In the last six months, every injection was on time. Dose: 156 mg monthly is a standard maintenance dose; K.A.'s voices persist at it.
Adherence Before Resistance
Two of the four trials have adherence problems. The injection has been given reliably for six months, which is the cleanest trial so far. Access also matters: K.A. relies on one bus line to reach the clinic, and missed injections in the past coincided with a bus route change and a period without a phone.
Counting strictly: aripiprazole was adequate; paliperidone over the last six months is adequate; risperidone was probably adequate. That makes two or more properly delivered trials, with different drugs, and the voices still present.
Reopening the Diagnosis
Schizoaffective disorder: no mood episodes meeting criteria outside psychotic episodes. Not supported.
Substance-induced psychosis: K.A. smokes cannabis most evenings. Voices began at 21 with daily use since 17, and they persist on days K.A. reports not using. Cannabis is unlikely to be the only cause, but daily use probably worsens symptoms.
Medical causes: brain imaging in 2019 was normal; thyroid and other tests normal.
The diagnosis of schizophrenia stands.
What Else Is Running
Cannabis, as above. Housing instability: the two relapses after periods of disruption suggest stress worsens symptoms, and a move is due next month. Tobacco: K.A. smokes 10 cigarettes a day, which matters for clozapine, since smoking lowers clozapine blood levels, and stopping smoking can raise them sharply.
Why Access Belongs in the Analysis
A person who cannot reach the clinic for an injection has not had an adequate trial, whatever the prescription says. K.A.'s missed injections line up with a bus route change, a lost phone and a move. Writing them up as nonresponse would have been wrong; writing them up as nonadherence would also have been incomplete, since K.A. was willing to have the injection. The analysis counts only the last six months, when the clinic texted reminders the day before and K.A.'s sister drove K.A. when the bus was unreliable.
The Question of a Higher Dose First
Some clinicians would raise the paliperidone dose before considering clozapine. The current dose is standard, and evidence that higher doses help resistant illness is limited. Raising the dose would increase side effects, including raised prolactin, which ended K.A.'s risperidone trial, since paliperidone is closely related to risperidone. That history argues against it.
The Verdict
K.A. meets a reasonable definition of treatment-resistant schizophrenia: two or more adequate trials, including six months of reliable injections at a standard dose, with persisting positive symptoms causing distress and limiting function. Cannabis and stress are contributing and should be addressed, but they do not explain the full picture.
What the Sister Added
K.A.'s sister confirmed that the voices were present even during the eighteen stable months, at a lower level, which supports persisting rather than relapsing symptoms. The sister also confirmed the dates of the missed injections and the reasons, which matched the nursing notes.
What the Analysis Ruled Out Quickly
Medicine interactions lowering paliperidone levels: none of K.A.'s medicines interact. Absorption problems: not relevant for an injection. Wrong injection technique: nursing records show correct deltoid and gluteal sites and volumes. These were checked because each can make an adequate prescription into an inadequate trial, and none had been checked in the record before. All three were clear, which strengthens the conclusion that the persisting voices are not a delivery problem.
Options With Their Cost
Clozapine. The only antipsychotic with consistent evidence of superiority in treatment-resistant schizophrenia, established in a landmark trial against chlorpromazine (Kane et al., 1988). Costs: weekly blood counts at first, because of the risk of a low neutrophil count; constipation, which can be dangerous; weight gain; drooling; sedation; rare heart inflammation in the early weeks, needing monitoring. K.A.'s smoking means dose changes if K.A. starts or stops smoking. K.A.'s baseline neutrophil count is low, which needs a separate opinion before starting.
Higher paliperidone dose. Possible, but evidence for dose increases beyond the standard range in resistant illness is weak, and side effects rise.
Another antipsychotic. A fifth trial of a non-clozapine drug is unlikely to succeed where four have not.
Adding a second antipsychotic. Common in practice, weak evidence, more side effects.
Addressing cannabis. Should happen whatever else is chosen. K.A. is willing to cut down but not stop.
Recommendation
Offer clozapine, after a hematology opinion on the low baseline neutrophil count and once housing is secure, since the first weeks need weekly blood tests and reliable contact. Continue paliperidone until clozapine is established, then taper. Address cannabis and tobacco with K.A. now.
What K.A. Said
K.A. had heard of clozapine from a hospital roommate and was worried about "all the blood tests." After hearing that the tests become monthly after the first six months, K.A. said, "If it stops the voices, I'll do it."
References
Howes, O. D., McCutcheon, R., Agid, O., de Bartolomeis, A., van Beveren, N. J. M., Birnbaum, M. L., Bloomfield, M. A. P., Bressan, R. A., Buchanan, R. W., Carpenter, W. T., Castle, D. J., Citrome, L., Daskalakis, Z. J., Davidson, M., Drake, R. J., Dursun, S., Ebdrup, B. H., Elkis, H., Falkai, P., ... Correll, C. U. (2017). Treatment-resistant schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. American Journal of Psychiatry, 174(3), 216-229. https://doi.org/10.1176/appi.ajp.2016.16050503
Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: A systematic review and network meta-analysis. The Lancet, 394(10202), 939-951. https://doi.org/10.1016/S0140-6736(19)31135-3
Kane, J., Honigfeld, G., Singer, J., & Meltzer, H. (1988). Clozapine for the treatment-resistant schizophrenic: A double-blind comparison with chlorpromazine. Archives of General Psychiatry, 45(9), 789-796. https://doi.org/10.1001/archpsyc.1988.01800330013001
The Chamberlain NR 607 Week 5 instructions
Before anything is called resistant, the Week 5 analysis establishes that the trials were real: a dose in the therapeutic range, held long enough to judge, with the person actually taking it. A surprising share of apparent non-response turns out to be a prescription filled twice, an unreported side effect or a pharmacy the person cannot reach. Only then reopen the diagnosis and ask what else is running, such as substances or medical conditions. List options with the monitoring and costs they bring. Most rubrics mark down resistance declared without showing trials were adequate, adherence and access skipped and options listed without their monitoring burden. Cost every option, including monitoring.
Inside the NR 607 Week 5 example
The sample applies the consensus criteria to each trial: risperidone adequate on dose and duration but uncertain on adherence, olanzapine inadequate at 60% of doses, aripiprazole adequate but short, and paliperidone adequate for the last six months of reliable injections. A section counts access problems as failures of delivery. Delivery faults such as interactions and injection technique are ruled out. Schizoaffective disorder, substance-induced psychosis and medical causes are reconsidered. Cannabis, housing and tobacco are named as contributors. A higher dose is rejected given the prolactin history. Options are costed, with clozapine recommended after hematology review and stable housing, and the person's view recorded.
Reading the NR 607 Week 5 grading rubric
The dearest loss is declaring resistance without showing the trials were adequate; this analysis tests each trial against the criteria. Skipping adherence and access costs the next share, and here missed injections are traced to transport, a lost phone and a move. Options without monitoring lose a row, while clozapine's blood tests, constipation and heart risk are listed. Substance use left unexamined loses marks, and cannabis and tobacco are weighed, including tobacco's effect on clozapine levels. Rejecting a higher dose with a reason from the person's own history earns the reasoning criterion. Including the sister's account strengthens the evidence that symptoms persisted between relapses. Recording the person's view of clozapine shows the recommendation was discussed, not imposed.
Common NR 607 Week 5 mistakes, and how to avoid them
Weak NR 607 Week 5 analyses call illness treatment-resistant after counting medicines, without checking whether each trial was taken as prescribed. Others ignore transport, phones and housing when doses are missed. Many list clozapine without its monitoring needs. Substance use and smoking are often left out. Few explain why a higher dose of the current drug was not tried first. Check every trial for dose, duration and adherence, count access problems as delivery failures, reopen the diagnosis and cost each option. If your patient's trials differ, list them with dates and doses, and an analysis on these criteria can be drafted. Check for interactions and injection technique before calling a trial a failure.
Get a NR 607 Week 5 example written to your instructions
Send the Week 5 prompt from your classroom and the case your section supplied, and a custom example is written to that case and returned inside 24 to 48 hours. The first one is free. Rubrics help most here, because analysis weeks are weighted in odd ways.
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NR 607 Week 5 questions, answered
Does an analysis have to reach a recommendation?
It has to reach a position, which is not the same as certainty. Most prompts want a defensible next step with the reasoning visible, including what remains unknown. A paper that surveys the options and declines to choose reads as avoidance, while one that chooses and then names the evidence that would overturn the choice reads as clinical thinking.
How is this different from the earlier management courses?
The unit of analysis has changed. Earlier work sat with a single decision or a single revision. Here the subject is a course of illness running over months, with more than one service involved and a colleague, not a grader who already knows the case, as the assumed reader. That shift is what most of the marking rewards.
Can I say the previous clinician got it wrong?
Yes, if it is argued rather than asserted, and phrased as what the record shows rather than as a verdict on a person. What was known at the time matters, and a decision reasonable then can look poor now. Analyses that grade a predecessor read badly. Ones that find the point where evidence stopped supporting the plan read well.
Where can I find a free NR 607 Week 5 sample paper?
The full case analysis testing whether schizophrenia is treatment-resistant before recommending clozapine is on this page.
Why does smoking matter for clozapine in the NR 607 Week 5 analysis?
Smoking lowers clozapine blood levels, and stopping smoking can raise them sharply, so dose changes may be needed if smoking changes.