INTRODUCTION

Substance dependence and related disorders are a national health problem. Millions of

people have a problem with alcohol and illicit drugs. And there are millions who have had to confront a

loved one’s use of alcohol and drugs. If you feel like you are the only one dealing with the problems

caused by substance use disorders, take some consolation in knowing that in 2003, an estimated 21.6

million Americans aged 12 or older, or 9.1 percent of the total population, were classified as having

substance dependence or addiction.

So, 19.4 million adults are classified with dependence or addiction – that’s roughly the

size of the state of New York (population 19 million). Of the 19.4 million adults, 14.9 million, or 76.8

percent, were employed. The rate of dependence or abuse was 10.1 percent in the Midwest, 9.7 percent

in the West, 8.6 percent in the Northeast and 8.3 percent in the South.

Here in the Philippines, according to the Dangerous Drug Board, it shows that drug

abuse is primarily an urban problem, particularly in affluent areas, practiced by unmarried youth (with

an average age of 20) from the upper socio-economic class and with longer formal education. It is also

geographically widespread in the country, spreading to the suburbs and all socio-economic class.

Persons with more formal education are projected to be most inclined to abuse drugs. Of the 411 cases,

91 percent were literate, while only five percent were illiterate. Fifty-two percent stayed in school from

11 to 15 years, 33 percent from 6 to 10 years, and only 8 percent stayed in school for five years. the

abuse of illegal drugs is also spreading from adults to college and high school student, and to “some

extent to elementary school age students.”

Studies also show that children are “constantly being exposed to the problems because

of the increased use of drugs by family members and peers”. Abuse of inhalants was resorted by

youngsters below 15 years old and males appear to be more frequent users of illegal drugs than

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females, with the ratio of 7 males to 1 female.

We, the group 1 BSN-3E, have done our psychiatric exposure in Castillones Psychiatric

Home Care for 4 weeks started from July 21, 2008 up to August 13, 2008. We have chosen Bryan to be

the subject for our case study. The practical reasons why we chose him are that his home is

conveniently accessible knowing that his house is located only in here Davao City, his mother is still

alive, he is still young, and is very responsive to us. We were also interested on him since during the

exposure he seemed to be normal and functional.

The implication of this case study in nursing is that we could get to see the root cause of

the different mental illnesses and how we could intervene and play our role as nurses. It is also in this

study that we could really get to see how different symptoms manifest and how we could establish a

therapeutic relationship to the client. It is also included in this study the present information as well as

the previous experiences of the client. There is also what we call psychodynamics or tracing the

predisposing factors which may have led to the client's present condition. There are different nursing

care plans, medical management and recommendations presented for the client's benefit.

Overall, this study aims to contribute to the nursing research particularly in mental health

nursing. This could also help in facing and dealing with the different problems and challenges in the

psychiatric nursing.

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 ACKNOWLEDGEMENT

Many people have been kind and helpful to us in finishing this case study. We would like to

extend our thanks to following:

First, to all our residents who have been so cooperative and participative in our exposure at

Castillones Psychiatric Home Care.

Second, to our subject of this case study, Mr. Bryan for sharing his experiences, thoughts, and

feelings about his illness.

Third, to the family of our client for the cooperation and hospitality they have shown to us

during the home visit especially in answering our question with regards to Bryan. Through them, we

were able to collect enough data.

Fourth, to all the nurses and staff of the Castillones Psychiatric Home Care for accommodating

and guiding us throughout the rotation.

Fifth, to our clinical instructors namely Ma'am Evangeline Ocop, Sir Richard Cheng, Ma'am

Magnolia Jadulang, and Ma'am Nancy Bargamento for imparting their wisdom and knowledge to us.

We really appreciate the patience that they have shown us despite the fact that we did many mistakes

and inconsistencies during.

Sixth, to our loving parents for their unhesitant support and continuous understanding that made

us to be determined in everything we do. We thank them for their financial support that made this case

study possible. And of course, we thank them for being our inspiration to pursue this course.

Lastly and most importantly, to the Almighty God for giving us the gift of life, knowledge and

skills that strengthens our faith and everlasting love that touches the hearts of our dear clients.

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 OBJECTIVES

At the end of this Psychiatric rotation, our group will be able to conduct a study within our four

weeks stay at the Castillones Psychiatric Home Care. This will develop our knowledge and to apply our

skills that we learned in our Psychiatric nursing concept by providing the best nursing care to our

clients. In view for this aim, we have made the following subjects:

General:

To present a case study that will enhance our knowledge and put to test our skills about

substance dependence.

Specific:

• Find and choose a suitable client to be the subject for our case study.

• Establish rapport and professional relationship to our client, his parents and significant others.

• Make an introduction that is related to the condition being studied, which includes research,

learning, and implication to the nursing process.

• Present the family health history as well as the history of past and present illness for us to know

what could be the predisposing factors that might contribute to the patient's illness.

• Search up the significant events during the different developmental stages which may contribute

to the client's present condition.

• Gather essential personal data with regard to the client and his family for the anamnesis as

foundation for the study.

• Assess client thoroughly in order to obtain a reliable mental status examination.

• Give the definition of the complete diagnosis.

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• Trace the family tree of the client that can trace familial link of the disease.

• Trace the growth and development of the client and determine if there are any developmental

tasks that he failed to accomplish.

• Identify the etiologies behind the onset of the mental behavior in order to come up with a correct

diagnosis and to give medical treatment.

• Specify the signs and symptoms of the illness.

• Discuss the psychodynamic of the client's diagnosis.

• Formulate a realistic prognosis based on the information gathered and factor affecting the client's

health condition.

• Discuss the medical management being implemented to our client to have a better collaboration

with other health care providers involving the client's treatment.

• Discuss the drugs administered to our chosen patient.

• Identify the different problem of the client to plan, evaluate, and enumerate the appropriate

nursing intervention needed by the client.

• Create relevant recommendations for the client, family and society.

• Provide appropriate health teachings specifically for the client and family a part of our holistic

care.

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 Personal Data

First Name: Bryan

Address: Blk. 1 Lot 7-B, Sulliman St., Agdao, Davao City

Age: 20

Sex: Male

Civil Status: Single

Nationality: Filipino

Religion: Roman Catholic

Occupation: None

Birthplace: Davao City

Birthdate: March 10, 1988

Educational Attainment: 1st year High School undergraduate

Family Data

Name of Father: Branijelio

Age: deceased

Occupation: N/A

Name of Mother: Merle

Age: 47

Occupation: Legal Recruiter of Al Khaleej Agency

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Name of siblings:

Cheryl Mae (27 years old)

Allan (25 years old)

Rosemelyn (24 years old)

Mark Joseph (21 years old)

Clinical Data

Patient’s Name: Bryan

Age/Sex: 20/male

Weight: 61kg

Height: 5’4”

How admitted: Decision of the mother

Attending Physician: Dra. Fatima Enriquez M.D.

Admission Date: January 29, 2008

Institution: Castillones Psychiatric Home Care

Responsible Party: Merle

Relationship: Mother

Address: Blk. 1 Lot 7-B, Sulliman St., Agdao, Davao City

Initial Diagnosis: Substance Abuse and Substance Induced Psychotic Disorder

(not indicated in the Patient’s Chart)

Final Diagnosis: Substance Dependence

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ANAMNESIS

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 B. FAMILY HISTORY

Maternal and Paternal Grand Lineage

Mrs. Merle’s family originated here in Davao City and belongs to a middle-class family. Her

parents, Carlos and Anastacia, were both strict in terms of disciplining them. They have 8 children and

each already have their own family except to their youngest child. Mrs. Anastacia has asthma while

Mr. Carlos was diagnosed with Hepatitis C.

Mrs. Merle’s brother is a drug user during his teenage years. In fact, according to Mrs. Merle

his own brother killed her husband. Mrs. Merle’s 2 sons, Mark and Bryan, indulged in the usage of

prohibited drugs since they were both influenced by biological and physiological factors which include

their environment, lifestyle, and friends. Mark was put into a rehabilitation center at the age of 17 and

was released after 6 months. Since then, he influenced Bryan to also use prohibited drugs and this

resulted to Bryan’s addiction.

Mr. Branejilio’s parents died during World War II. He was the 2nd among the 3 children of Mr.

Jose and Mrs. Lorencia. According to Mrs. Merle, she never able to meet her father and mother-in-law,

who died because of heart failure.

Father

His father belongs to a low-class family. According to Mrs. Merle, Mr. Branejilio was a strict

disciplinarian and a responsible husband and father. He worked as a family driver and his income was

not enough to support the needs of his family. However, he finds other ways to earn money such as

selling different kinds of goods. Bryan was just 11 months old when his father died at the age of 32

because he was stabbed by his own brother-in-law. Bryan grew up without seeing his father and was

longing for love and an image of a father.

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Mother

Mrs. Merle, the bread-winner of the family, whose present age is 47, works as a legal recruiter

in Al Khaleej Recruitment Agency located here Claveria Davao City.

With regards to her disciplinary actions to her children, she is strict in a way that she scolds her

kids but never hurts them physically. She is open to all her children; she is sweet, protective and a

loving mother. She has a strong personality and has a positive outlook in life. She does not easily give

up on whatever obstacles that come her way and will do everything for her family. She treats her

children equally but she said that she focused more on Bryan lately because of his condition

considering that Bryan is still at his young age and thus, needs to be guided. Being the mother and at

the same time the father of the family, she makes her best to provide the needs of her children.

C. PERSONAL HISTORY

Prenatal

Bryan was a planned baby according to Mrs. Merle; she never put any doubt on having Bryan

as their 5th child in the family. During Mrs. Merle’s pregnancy, she was taking Iron supplements and

had a proper daily exercise. The status of his parents’ relationship was normal though at times they

quarrel primarily because of money, but somehow they have managed to settle down their problems as

soon as possible. Talking things over made them calm down and feel better. His husband was very

determined and hardworking. He is the one who exerts effort to earn for their daily living. However,

both of them worked independently to support all their daily needs.

In addition, since their health center is just walking distance, she always comply her prenatal

check-ups every four weeks, and was able to receive a complete immunization. Mrs. Merle disciplined

herself in terms of what food to intake. Mostly she eats fish, vegetables and fruits, because she is aware

that these foods are healthy for her baby boy, Bryan.

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Birth

Bryan was born on March 10, 1988 at Davao Medical Center. Her mother told us that when she

had her labor she really had no difficulty since Bryan is her 5th baby and it didn’t take long before

Bryan came out of her womb. Mrs. Merle stated, “Mga 30 minutes lang man ko naglabor sa iya, basta

dali ra pud kaau sya ning gawas.” She also said that there were no complications & unusualities

observed during her delivery. Bryan was born full-term via normal spontaneous vaginal delivery

(NSVD). Bryan appeared to be a healthy and normal baby with a weight of 7.2lbs. He was then

cuddled by her mother after he was cleaned. Bryan was also able to receive a complete immunization.

Infancy & Childhood

Bryan was breastfed for 1 year and 2 months and since her mother was working, later on she

used mixed formula; while Mrs. Merle was working she uses bottle to feed Bryan and when she came

home, she again breastfed Bryan. Mrs. Merle said that when Bryan cries they immediately cuddle him,

this is one way to stop him from crying. When he reached the age of 11 months his father died. At the

same age, they were glad to hear Bryan speak the words “mama, papa.” At the age of 1 year, Bryan

learned how to stand on his own two feet but there is still supervision from his mother or his

grandparents. At the age of two, he learned how to eat all by himself and has been toilet trained by his

grandparents.

When Bryan reached the age of 4, his mother left for Dubai. Mrs. Merle went there to work.

Bryan became lonely and cried more often. His mother stayed there for 4 years, and on the year 1996

she came back to the Philippines bringing back some gifts to Bryan and her other children. This served

as an exchange of her absence during the important occasions she had missed for 4 years.

During Bryan’s early childhood, he can only stay outside of their house for quite sometime

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together with the supervision of his aunt or grandmother. When he finally enters school, he gained a lot

of friends and plays most of the time with them. Bryan also liked playing basketball. In fact, he is one

of the best basketball players in the class. He doesn’t excel at school with regards to his academic

subjects but he is good in extra curricular activities. That is why he only gets an average score in their

class and sometimes failing marks. Mrs. Merle supports Bryan all the way. She even hired an exclusive

tutor for Bryan to help him cope up his lessons.

Psychosexual

Sigmund Freud has 5 stages of psychosexual development. 1st stage is the Oral stage which is

from birth to 1 ½ years. In this stage the mouth is the center of pleasure. In this stage, Bryan has no

problem regarding the foods served to him. According to Mrs. Merle, Bryan is not a spoiled child. He

eats anything as to whatever food is given to him. The 2nd stage is the Anal stage, which is from 1 ½ to

3 years. In this stage Anus & bladder are the source of pleasure. When Bryan was 2 years old he was

already toilet trained by his grandmother since his mother was too busy working to earn much money

for the family. He knows how, when and where to use the toilet to defecate or urinate. In fact, he was

given punishments every time he defecates in a wrong place, such as beating him with the use of bare

hands. The 3rd stage is the Phallic stage which is from 4 to 6 years. In this stage the child’s genitals are

the center of pleasure. Bryan was able to identify the opposite sex and is aware of his gender. The 4 th

stage is the Latency stage, which is from 6 years old to puberty age. In this stage Energy is directed to

physical and intellectual activities. Bryan was a basketball player. He said that he really likes to get

involved in this activity because he finds it very fun and enjoy. While in the classroom setting, Bryan

only gets an average score. And the last stage is the Genital stage, which is from Puberty and after. In

this stage Energy is directed toward full sexual maturity and function and development of skills needed

to cope with the environment. Bryan becomes independent when he was 16 years old. He learns how to

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decide for himself. Also, in this stage he became conscious on his looks and even had a crush on their

school campus.

Play life

According to Mrs. Merle when Bryan was in his late childhood which is from 3 to 5 years old,

they won’t allow him to go outside their house instead they just let him play in their backyard. They

were strict to Bryan since her mother is not at home. His auntie was the one who supervised Bryan

when he wants to stroll outside, but it won’t take long. There are many children outside their house that

is why Bryan is always guarded.

In school Bryan was an active child. He earns a lot of friends. He plays with them all the time

and he is not a trouble-maker in their school. He sometimes bullies his classmates but he never harmed

anyone. Sometimes his mother would scold him because he gets wild and noisy most of the time.

Grade School

Bryan started to go to school at the age of seven. He immediately attended directly to grade one

at Agdao Elementary School until he graduated Elementary. He was an average student and had good

grades. He was an average level student since he is stubborn sometimes and doesn’t make his

assignments on time. His elder siblings serve as his tutor when he needed help in his studies.

High School

Bryan attended high school in Cabantian National High School. He didn’t finish high school

and remains at first year level because of his vices. He used to escape from school and cut classes

because he was influenced by his friends and preferred to smoke and play billiards outside the campus.

He also developed a keen interest in rock music and computer games. In addition, during this stage, he

started to take prohibited drugs that were introduced by his friends which led to auditory hallucinations.

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His hallucinations were varied and incomprehensible making him more and more irritable over time.

Eventually, he became rebellious in the sense that he goes home late, and always hangs out outside the

house or along the streets. He also drank alcohol until he got drunk. When he arrives home, he is

observed to be either high, drunk, or both.

Religious & Social Affiliations

Bryan is a Roman Catholic. He was baptized when he was 6 months old in San Pedro

Cathedral. His mother was the one who made him close to God. He always reminds Bryan to pray

before he eats and before he sleeps. Her mother also encouraged him to get involved in the fellowship

and Bible sharing in the Born Again church. Every time they went to Church Mrs. Merle always

brought Bryan with her, but when Mrs. Merle is busy Bryan doesn’t want to go to Church even though

his other relatives would convince him to go with them. However, when Bryan reached the age of 16

years old he began to lessen his affiliations towards the church. Since his friends were the ones who

manipulated him, he didn’t have sufficient time to attend mass every Sunday. Still, her mother keeps on

reminding him to pray always.

Bryan’s social life was not that fun for him. He was not that sociable, and easy to be with

because he doesn’t talk that much. His friends always approached him first that’s why in the end he had

been manipulated to do things that are really bad. His mother never thought that it would turn out to be

disastrous because it made Bryan do strange activities like talking to himself. Later on her mother knew

that Bryan was using drugs, drinking alcohol, and smoking everyday.

Occupational History

Bryan was not able to graduate High School and was admitted to the Rehabilitation Center

before he got better. Thus, he did not have the opportunity to get a job.

Marital History

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 Although Bryan claimed to have several girlfriends, there were no reports of him getting

married, having children or living with a woman in a house separate from his family’s house.

D. ONSET OF PRESENT ILLNESS

At the age of 12 years old, Bryan engaged in making friends with others. He developed peer

relationships and socialized with other people. He eventually started joining a bad crowd. He became

curious into drug usage and started on exploring different vices such as smoking, drinking alcohol,

inhaling rugby, and using drugs like shabu and marijuana. Soon after experimenting, drug usage and

alcohol intake became a habit.

With this, it affected his behavior. He changed a lot especially in relating with his family. His

family then started to observe him talking to himself even when there are people around. He started to

exhibit irritability as well.

He was first admitted in Bago Usero at the age of 18. He stayed there for 6 months. After that, it

wasn’t long until he went back to his old vices and became a rebel again.

Currently, he is admitted in Castillones Psychiatric Home Care in Maa. He was admitted there

on January 29, 2008; at the age of 20. He was taken care of under the service of Dr. Fatima Enriquez.

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 DEVELOPMENTAL THEORIES

HARRY STACK-SULLIVAN’S THEORY

Harry Stack-Sullivan was trained in psychoanalysis in the United States, but soon drifted from

the specific psychoanalytic beliefs while retaining much of the core concepts of Freud. Interestingly,

Sullivan placed a lot of focus on both the social aspects of personality and cognitive representations.

This moved him away from Freud's psychosexual development and toward a more eclectic approach.

Freud believed that anxiety was an important aspect in his theory because it represented internal

conflict between the id and the superego. Sullivan, however, saw anxiety as existing only as a result of

social interactions. He described techniques, much like defense mechanisms, that provide tools for

people to use in order to reduce social anxiety. Selective Inattention is one such mechanism.

According to Sullivan, mothers show their anxiety about child rearing to their children through

various means. The child, having no way to deal with this, feels the anxiety himself. Selective

inattention is soon learned, and the child begins to ignore or reject the anxiety or any interaction that

could produce these uncomfortable feelings. As adults, we use this technique to focus our minds away

from stressful situations.

Personifications

Through social interactions and our selective attention or inattention, we develop what Sullivan

called Personifications of ourselves and others. While defenses can often help reduce anxiety, they

can also lead to a misperception of reality. Again, he shifts his focus away from Freud and more

toward a cognitive approach to understanding personality.

These personifications are mental images that allow us to better understand ourselves and the

world. There are three basic ways we see ourselves that Sullivan called the bad-me, the good-me and

16
the not-me. The bad me represents those aspects of the self that are considered negative and are

therefore hidden from others and possibly even the self. The anxiety that we feel is often a result of

recognition of the bad part of ourselves, such as when we recall an embarrassing moment or experience

guilt from a past action.

The good me is everything we like about ourselves. It represents the part of us we share with

others and that we often choose to focus on because it produces no anxiety. The final part of us, called

the not-me, represents all those things that are so anxiety provoking that we can not even consider them

a part of us. Doing so would definitely create anxiety which we spend our lives trying to avoid. The

not-me is kept out of awareness by pushing it deep into the unconscious.

Developmental Epochs

Another similarity between Sullivan's theory and that of Freud's is the belief that childhood

experiences determine, to a large degree, the adult personality. And, throughout our childhood, the

mother plays the most significant role. Unlike Freud, however, he also believed that personality can

develop past adolescence and even well into adulthood. He called the stages in his developmental

theory Epochs. He believed that we pass through these stages in a particular order but the timing of

such is dictated by our social environment. Much of the focus in Sullivan's theory revolved around the

conflicts of adolescence. As you can see from the chart below, three stages were devoted to this period

of development and much of the problems of adulthood, according to Sullivan, arise from the turmoil

of our adolescence.

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Sullivan's Developmental Epochs

Infancy From birth to about age one, the child begins the process of developing,

Age birth to 1 but Sullivan did not emphasize the younger years to near the importance

year as Freud.

Childhood The development of speech and improved communication is key in this

Ages 1 to 5 stage of development.

Juvenile The main focus as a juvenile is the need for playmates and the beginning

Ages 6 to 8 of healthy socialization

Preadolescence During this stage, the child's ability to form a close relationship with a

Ages 9 to 12 peer is the major focus. This relationship will later assist the child in

feeling worthy and likable. Without this ability, forming the intimate

relationships in late adolescence and adulthood will be difficult.

Early The onset of puberty changes this need for friendship to a need for sexual

Adolescence expression. Self worth will often become synonymous with sexual

Ages 13 to 17 attractiveness and acceptance by opposite sex peers.

Late The need for friendship and need for sexual expression get combined

Adolescence during late adolescence. In this stage a long term relationship becomes

Ages 18 to 22 the primary focus. Conflicts between parental control and self-expression

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 are common place and the overuse of selective inattention in previous

stages can result in a skewed perception of the self and the world.

Adulthood The struggles of adulthood include financial security, career, and family.

Ages 23 up With success during previous stages, especially those in the adolescent

years, adult relationships and much needed socialization become more

easy to attain. Without a solid background, interpersonal conflicts that

result in anxiety become more commonplace.

Bryan belongs to Late Adolescence. In this stage, like Erikson, the primary focus is on love

relationships. According to Sullivan failure to form a close relationship to a peer is crucial in order to

form an intimate relationship during late adolescent.

In Bryan’s case, he didn’t have a serious relationship. He had relationships but it was all

flings.

Erik Erikson Psychosocial Development

Erik H. Erikson adapted and expanded Freud’s theory of development to include the entire

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lifespan believing that people continue to develop through life. Erikson envisions life as a sequence of

levels of achievement. Each stage signal s a task that must be achieved. The resolution of the task can

be complete, partial or unsuccessful.

Bryan is currently the young adult stage. His central task is to be intimate. In this stage, the

most important events are love relationships. Intimacy refers to one's ability to relate to another

human being on a deep, personal level. An individual who has not developed a sense of identity usually

will fear a committed relationship and may retreat into isolation. It is important to mention that having

a sexual relationship does not indicate intimacy. People can be sexually intimate without being

committed and open with another. True intimacy requires personal commitment. However, mutual

satisfaction will increase the closeness of people in a true intimate relationship.

The element for a positive outcome in this stage is that a young adult must develop intimate

relationships with others. Not resolving this conflict leaves the young adult feeling isolated. The young

adult must be willing to be open and committed to another individual.

Bryan however didn’t attain the central task. He had many friends but he didn’t have a career

because he failed to finish his studies. He had a girlfriend but then according to him, his relationships

were just flings. Somehow his relationships were just friendship.

Sigmund Freud

Oral stage

During the oral stage, the infant's primary source of interaction occurs through the mouth, so the

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rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives

pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the

infant is entirely dependent upon caretakers (who are responsible for feeding the child), the infant also

develops a sense of trust and comfort through this oral stimulation. The primary conflict at this stage is

the weaning process--the child must become less dependent upon caretakers. If fixation occurs at this

stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation

can result in problems with drinking, eating, smoking, or nail biting.

In the Oral stage, Bryan has no problem regarding to the foods served to him. According to

Mrs. Alma, Bryan is not a spoiled child. He eats anything as to whatever food is given to him.

Anal stage

During the anal stage, Freud believed that the primary focus of the libido was on controlling

bladder and bowel movements. The major conflict at this stage is toilet training--the child has to learn

to control his or her bodily needs. Developing this control leads to a sense of accomplishment.

According to Freud, success at this stage is dependent upon the way in which parents approach

toilet training. Parents who utilize praise and rewards for using the toilet at the appropriate time

encourage positive outcomes and help children feel capable and productive. Freud believed that

positive experiences during this stage served as the basis for people to become competent, productive,

and creative adults.

When bryan was 2 years old he was already toilet trained by his mother. He knows hot to use

the toilet when he wants to defecate or urinate. Somehow there is still a little guidance for Bryan’s

safety.

Phallic stage

During the phallic stage, the primary focus of the libido is on the genitals. Children also

discover the differences between males and females. Freud also believed that boys begin to view their

21
fathers as a rival for the mother’s affections. The Oedipus complex describes these feelings of wanting

to possess the mother and the desire to replace the father. However, the child also fears that he will be

punished by the father for these feelings, a fear Freud termed castration anxiety. The term Electra

complex has been used to describe a similar set of feelings experienced by young girls. Freud,

however, believed that girls instead experience penis envy.

Bryan was able to identify the opposite sex and he is aware of his gender.

Latency stage

During the latent period, the libido interests are suppressed. The development of the ego and

superego contribute to this period of calm. The stage begins around the time that children enter into

school and become more concerned with peer relationships, hobbies, and other interests. The latent

period is a time of exploration in which the sexual energy is still present, but it is directed into other

areas such as intellectual pursuits and social interactions. This stage is important in the development of

social and communication skills and self-confidence.

He said that he really likes to get involved in this activity because he finds it very fun and enjoy.

While in the classroom setting, Bryan only gets an average score but he likes to participate when there

is a question and answer portion sometimes.

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Genital stage

During the final stage of psychosexual development, the individual develops a strong sexual

interest in the opposite sex. Where in earlier stages the focus was solely on individual needs and,

interest in the welfare of others grows during this stage. If the other stages have been completed

successfully, the individual should now be well-balanced, warm, and caring. The goal of this stage is to

establish a balance between the various life areas.

Bryan becomes independent when he was 16 years old. He learns how to decide for himself.

Also, in this stage he became conscious on his looks and even had a crush on their school campus.

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 Brain Anatomy and Physiology

Brainstem

The brainstem connects the spinal cord to the remainder of the brain. It consists

of the medulla oblongata, pons, and midbrain and contains several nuclei involved

in vital body functions such as the control of heart rate, blood pressure, and

breathing. Damage to small areas of the brainstem can cause death, whereas

damage to relatively large areas of the cerebrum and cerebellum often do not

cause death.

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Medulla oblongata

The medulla oblongata is the most inferior portion of the brainstem and is

continuous with the spinal cord. It extends from the level of the foramen magnum

to the pons. The medulla oblongata contains discrete nuclei with specific

functions such as regulation of heart rate and blood vessel diameter, breathing,

swallowing, vomiting, coughing, sneezing, balabce and coordination

Pons

Immediately superior to the medulla oblongata is the pons. It contains ascending

and descending nerve tracts, as well as several nuclei. The term pons means

bridge, and it describes both the structure and function of the pons. The functions

of the pons include breathing, swaloowing, and balanced are controlled in the

lower pons as well as in the medulla oblongata. Other nuclei in the pons control

functions such as chewing and salivation.

Midbrain

The midbrain is just superior to the pons. It is the smallest region of the

brainstem. The midbrain consists of nuclei that are involved in the coordination of

eye movement and in control of pupil diameter and lens shape. It is also involved

in the regulation of the body movements.

25
Cerebellum

Cerebellum means little brain. The cerebellum is attached to the brainstem by

several large connections called cerebellar peduncles. These connections provide

routes of communication between the cerebellum and other parts of the CNS.

cerebellum is involved in balance, maintenance of muscle tone, and coordination

of fine motor movement. If the cerebellum is damaged, muscle tone decreases,

and fine motor movements become very clumsy.

Diencephalons

The diencephalons is the part of the brain between the brainstem and the

cerebrum. Its main components is the thalamus, epithalamus and hypothalamus.

Thalamus

The thalamus is by far the largest part of the diencephalons. It consists of a

cluster of nuclei and is shaped somewhat like a yo-yo. Most sensory input that

ascends through the spinal cord and brainstem projects to the thalamus. Thalamic

neurons , in turn, send their axons to the cerebral cortex. The thalamus also

influences mood and registers an unlocalized, uncomfortable perception of pain.

Epithalamus

26
The epithalamus is a small area superior to the thalamus. Its main function is the

emotional and visceral response to odors and pineal body. The pineal body

influences the onset of puberty and annual behaviors such as migration of birds.

Hypothalamus

The hypothalamus is the most superior part of the diencephalon and contains

several small nuclei which are very important in maintaining homeostasis. The

hypothalamus plays a central role in the control of body temp. hunger, and thirst,

sensations, emotional responses.

Cerebrum

The cerebrum is the largest part of the brain. Its functions include control of

voluntary motor functions, motivation, aggression, mood, and olfactory reception,

memory, auditory sensations, abstract thought and judgement

27
 ETIOLOGY

Predisposing Present Absent Rationale Justification

Factors

Age  Early age of first use. Using Bryan started drinking alcohol
alcohol or other drugs at a when he was in his 12th year and
young age greatly increases a was addicted to drugs as well.
teens risk for developing abuse
problems. One study found
that teens who had their first
alcoholic drink at age 14 Or
younger were more likely to
develop alcoholic abuse
problems that teens who had
their first drink at age 19 or
older

Gender  According to studies, men are Bryan is male in gender.

prone and more exposed of
having drug addictions and
alcohol abuse and dependence
compare to females.

Loss of  Using of drugs and having When he knew about his father’s
attachment dependence in alcohol usually death, he felt mad against his
happen due to depression uncle who said to be the one who
because of loss of loved one. killed his father.

Family use  One study found that teens Before Bryan was admitted to
substances with a family who always rehabilitation center, his brother,
28
 depend on alcohol or drugs are
three times more likely to
develop to develop an abuse
problem.
Cultural factors  Attitudes towards substance
used, patterns of use and
psychological differences to
substance vary in different
cultures
Precipitating Present Absent Rationale
Factors
Temperant and  Rebelliousness, resistance to
personality authority feelings of failure to
form close relationships are
factors that may lead a teen to
seek the effects of alcoholic
drugs. Also, sensation-seeking
and a tendency to take risk and
increases a teen’ likelihood on
developing an abused problem.
Social Factors  Such as the influence of family,
peers ad society and availability
of alcohol.
Environmental  Acceptance of alcohol use by
Factors society; availability (including
price, number of outlets, and
server practices); advertising and
marketing both nationally and
locally; and public policies
regarding alcohol and
enforcement of those policies.
Mark, was also diagnosed with
substance abuse and was also
rehabilitated.
Bryan’s religion is catholic
therefore, there was no
influences brought about his
culture related to his condition.
Justification
Bryan has an introverted type of
attitude. He usually keeps his
feelings but ones he let it all out,
he acts aggressive against the
people he hates. He also joins in
riots and other rebellious groups.
Bryan was influenced by his
peers in taking alcohol and
drugs.
Bryan and his group of friends
buy shabu and marijuana usually
at boulevard. They often spend
their money by buying drugs.
29
PSYCHODYNAMICS

30
INFANCY (birth – 18 months)

In Erik Erikson’s psychosocial theory, the central task of an infant is either trust or mistrust.

Infant’s indicator of having trust is when he/ she learn to trust others while the negative indicators are

mistrust, withdrawal and estrangement. Regarding Bryan’s infancy stage he was able to gain the

positive indicator. He was able to learn to trust others.

In connection to Freud’s five stages of development, Bryan belongs to the oral stage. At this

stage, the mouth is the center of pleasure. It serves as the major source of gratification and exploration.

The primary need is security and the major conflict is weaning or stops the baby from feeding. Bryan is

satisfied orally. He was breast fed up to one year and two months. Aside from it he was also to bottle

fed due to workload of the mother. Id was also satisfied. Whenever he cries, his mother immediately

cuddles him and gives him milk either bottle feed or breast feed. His mother directly tends to his needs

while his father died when he was still 11 months old.

EARLY CHILDHOOD ( 18 months – 3 years old)

In relation to Erik Erikson's theory Bryan is torn between autonomy or shame and doubt. Self-

control without loss of self- esteem and ability to cooperate and to express oneself are the positive

indicators of this stage. On the other hand, the negative indicators are compulsive self- restraint or

31
compliance, willfulness and defiance. Bryan, in this stage, develops shame and doubt. He was not

allowed to play outside their house, so he was not able to interact with other children of the same age.

He had a strict toilet training also. He was scolded every time he does something wrong. He is scared to

do anything because he might be punished.

In Freud's psychosexual theory, the anal stage is suited for his age. The focus is toilet training

and to learn, gain independence and control, which is manifested through excretory control. This stage

is closely related to Sullivan's theory, which states that the primary zone is anal and that the child

learns to experience a delay in personal gratification without undue anxiety. This stage is also related to

Bryan because according to Mrs. Merle, his mother, Bryan had strict toilet training at the age of 2 by

his grandparents. His grandparents took over in taking care of him because his mother is busy working.

His grandparents were strict towards discipline and protection. Bryan was reprimanded when he does

something wrong and was scolded every time he fails to defecate and urinate at the proper place and

when he needs to eliminate. On the other hand in Bryan's case he experienced a strict toilet training, he

tends to be stingy and introvert. He developed low- self esteem.

LATE CHILDHOOD (3 – 5 years old)

Erik erikson's psychosocial theory under Initiative vs. Guilt begins in the development of a

conscience, learning to manage conflict and anxiety. In Bryan's case, he was not allowed to go out and

play, was able to talk fluently, kept looking for his mother, was looking after the image of his father,

was longing for the tender, love and care of his parents and had already knew that his father died. At

the age of 5 years old, he developed fundamental skills in reading, writing, and calculating. To achieve

personal independence bryan eats alone and can dress up by himself. He also learns physical skills

necessary for ordinary games to build a wholesome attitude towards one's self as a growing organism.

According to Mrs. Merle, she left for Dubai to work as an OFW. Bryan's grandparents took the

32
responsibility to take care of him. His relatives were also tasked to guide him. And when his relatives

are away his siblings took over. His uncle implements a military discipline in which bryan commits

mistakes, he will be punished. If he done's good things, he will have a reward like giving of toys and

foods.

In Freud's psychosexual theory under phallic/oedipal stage which is from 3 to 5 years old. In

this stage, the child's genitals are the focus of interest, stimulation, and excitement. In this Bryan was

able to identify the opposite sex and he is aware of his gender. Aside from this, Bryan learns to get

along with age-mates and learns an appropriate masculine or feminine social role.

SCHOOL AGE ( 6- 12years old)

At this stage, psychosocial crisis is Industry vs. Inferiority according to Erikson’s eigth stage of

development. According to Allen and Marotz (2003), "children at this age are becoming more aware of

themselves as individuals." They work hard at "being responsible, being good and doing it right."

Children understand the concepts of space and time, in more logical, practical ways, beginning to grasp

Piaget's concepts of conservation, gain better understanding of cause and effect and understand

calendar time.

At this stage, children are eager to learn and accomplish more complex skills: reading, writing,

telling time. They also get to form moral values, recognize cultural and individual differences and are

able to manage most of their personal need and grooming with minimal assistance (Allen and Marotz,

2003).

At this stage, children might express their independence by being disobedient, using back talk

and being rebellious. If the child is allowed too little success, he or she will develop a sense of

inferiority or incompetence. Too much industry leads to narrow virtuosity (children who are not

allowed to be children). A balance between industry and inferiority leads to competency.

When Bryan reaches the age of 8, his mother went back to Philippines from Dubai but
33
continued working in Manila to earn money to support the needs of their family. Thus, Bryan’s

grandparents, aunties and uncles, including his elder siblings were responsible in taking good care of

him. As a result, Bryan was unease to interact and very shy to mingle and express his emotions and

feelings to his mother.

Bryan was pretty much closer to his grandparents and considers them as his own parents since

they are the ones who raised him up.

During this stage, Bryan can now distinguish right from wrong. He understands that telling a lie

is a bad thing and obeying his elders are good ones and the right thing to do. Bryan at this stage was

able to understand that his father was being killed by his own uncle. However, he has grudges with his

uncle but according to his mother he just let him understand that they belong to one family and must

not take revenged at all.

Bryan enters school at the age of 7. He directly enrolled at Grade 1 level at Agdao Elementary

School. He was a very participative and active child in terms of extracurricular activities. He doesn’t

excel in academic subjects however; he is the one of the best basketball player during his elementary

days. He loved to join ball games which helped him developed his self-confidence and was able to gain

social interaction with others.

Bryan was very playful inside and outside their home. He is now allowed to go out but with

supervision. He can now even go to school and went back home alone considering the fact that his

school is a walking distance from their house.

After schooling, he plays computer games and spent most of his time playing with his friends

and neighbors instead of staying at home, do some little household chores, and study his lessons. At a

very young age, used of rugby as introduced to Bryan by his elder brother and his teenage neighbors,.

At this stage, Bryan developed industry because he was able to create and explore the world

through joining social interactions to develop self-confidence and was able to distinguish right from

34
wrong since his relatives especially his grandparents had taught him proper values and sent him to

school.

ADOLESCENCE (12 to 18 years old)

The adolescent is newly concerned with how he or she appears to others. Superego identity is

the accrued confidence that the outer sameness and continuity prepared in the future are matched by the

sameness and continuity of one's meaning for oneself, as evidenced in the promise of a career. The

ability to settle on a school or occupational identity is pleasant. In later stages of Adolescence, the child

develops a sense of sexual identity.

In Erik Erikson’s Developmental Stage which is Identity vs. Role Confusion, Bryan falls under

Role Confusion. He was confused on whether what he wants to be in the future, be it a technician, an

electric engineer or an accountant. There was also lack of dedication and encouragement which led him

to stop going to school. It was during this time that he joined fraternities. He became a troublemaker

and was considered to be the black sheep of the family. The friends that he found in the fraternity that

he belonged to were bad influences to Bryan.

When Bryan was 16 years old, he was stabbed at his right lower lumbar area because of a riot.

There was also this one time wherein he was arrested and put to jail because his friends framed him up.

But he was soon released after 5 days because there were no complaints filed against him.

When his mother permanently worked in Davao, Bryan and her mother spent a lot of time

together. They would attend Sunday masses together and would even stroll and eat at malls. But since

there were times that his mother was not at home, Bryan would spend his time with his friends. His

constant contact with his friends influenced him in a way that he became a chain smoker, an alcoholic

drinker, and an addict to drugs.

YOUNG ADULTHOOD (18 – 25 years old)

In Erikson’s 6th stage of developmental theory, which is Intimacy vs. Isolation, these particular

35
stage can be associated with Bryan’s case. Bryan had a girlfriend named Joan there are conflicts in

their relationships that led to Bryan’s depression. Bryan’s way in releasing his stress is to drink and

smoke. Also, in this stage, Bryan was influenced by his older brother to use rugby for his satisfaction.

When Bryan uses rugby, there are already hallucinations experienced and Bryan also became irritable.

When his mother knew that he was using rugby and other addictive drugs her mother decided to admit

him in Bago Usero for 6 months. When Bryan had already discharged, his mother enrolled him at

Lifestream an international school. After 9 months in school, her mother decided to drop him out from

school because his mother knew that Bryan skipped classes with the influence of his friends. Bryan has

no job because he is still in high school status. Bryan had no job because he is still high school. Bryan

had started again using rugby and other addictive drugs because of this he was re-admitted at

Castillones Psychiatric Home Care. Hence, Bryan had developed isolation. Bryan had a girlfriend

before but he still considered his relationship with her as not serious. Bryan focuses more on social

groups.

36
SCHEMATIC

DIAGRAM
37
MENTAL STATUS

EXAM

38
 Mental Status Examination (Initial- 07/22/2008)

I. PRESENTATION

A. General appearance

The client stated that he is 20 years old. According to his appearance,

he is apparently 20 years old, as he has stated. His sex is obviously male.

Upon initial contact, we have established that he is indeed male

because he has masculine features. His build is average. He is neither

too thin nor too fat. He has unsatisfactory grooming. His clothes are

observed to be dirty. He wore a white sleeveless Jersey shirt and a brown

shorts. He has foul odor, dirty nails, and dandruff flakes in his hair. Upon

interviewing him, he was able to established eye contact and listens

attentively to the questions.

B. Behavior and Psychomotor Activity

He has no difficulties in general moving, walking and standing because he

is physically capable of doing so alone and doing what he wants to do. He

39
 exhibits balance Gait and Posture was erect.

He was restless and anxious because of lack of sleep the previous

night.

He was expressive of his emotions. In every subject that was

discussed his expression in sharing was very prominent.

C. Speech

His speech was understandable but there are some words that are not

pronounced correctly.

D. Attitude Towards the Examiner

When discussing a topic, he shares to a certain extent wherein he

only lengthens the discussion when he likes the topic. He is also confident

enough to ask questions to the examiner. No violent reaction towards the nurse.

II. EMOTIONAL STATE AND REACTION

A. Mood

His mood changes from time to time. Depending on the topic being

discussed, his mood changes accordingly. When the topic is one

that he likes, his mood is happy. When the topic is one that he is not

interested in, his mood shows it.

B. Affect

His affect is broad. He displays a full range of emotional expression.

When he is happy, his facial expression shows that he smiles and his eyes get

small.

40
III. PERCEPTUAL DISTURBANCE

A. Hallucination and Illusion

Upon interviewing, the client reported of not hearing voices or noises

or even seeing some things or person. There are no observable signs of

hallucinations and illusions.

B. Depersonalization and Derealization

The Client do not have any derealization and depersonalization or

depersonalized feelings about himself and surroundings.

IV. THOUGHT PROCESS

A. Stream of thought

He speaks spontaneously. When asked about a topic, he doesn't need to be

instructed to respond. However he has a flight of ideas. When

discussing a topic, he tends to stop talking about it and shifts to another

topic by asking a question to his examiner often times he talks of

situation which is not related to the topics that is currently discussed.

B. Content of Thought

He is not preoccupied. When attention is asked of him, he gives it

immediately. He experiences no delusions. Upon examination, he does not

show signs of having experiences which are unrealistic. His abstract

thinking is present. He was able to give an explanation for a proverb

41
 provided by the examiner.

V. NEUROVEGETATIVE FUNCTIONING

A. Sleep

According to him, he is able to sleep normally, but for the night before the

examination, he wasn't able to sleep early and he woke up at 6:00 in

the morning. During the examination, it was obvious that he wasn't able

to get enough sleep the previous night.

B. Appetite

The client states that he was able to eat normally, he eats 2 cups of rice and

1 serving of viand per meal for 3 meals a day with good appetite. He

also consumed food served by the students nurse.

C. Libido

The libido level is decreased. Because of lack of sleep, he wasn't able to

participate actively during the activities. He is inactive and he do not

like the activities.

VI. SENSORIUM AND COGNITION

A. Orientation

He was very oriented to place, time, person and situation. He knows

what time is it and where is he. He knows who brought him in and why he

was brought in the center. He is aware of his current condition.

B. Memory

42
 He was able to remember remote memories, as in childhood

experiences. He was able to recall his experiences when he was still a child

and where did he studied. But he wasn't able to remember the exact date of his

Birthday. He only remembers the year when he was born.

C. Calculation

The client was able to answer simple mathematical questions but after i

asked him for the third time he hesitantly answer it and says to stop asking

him such questions. He don't like to solve mathematical questions.

D. General Information

The clients know some of the General informations such as the President of

the Philippines, current City Mayor of the city and what is the trade in the

prices of Rice.

VII. INSIGHTS

He has a good insight. He stated that he was in the rehabilitation center

because he needed to get better. He also asked for the opinion of the

examiner about his chances of getting better. He knows the reasons why

he was brought there.

Mental Status Examination (Final – 08/12/2008)

I. PRESENTATION

A. General appearance
43
 The client is 20 years old. According to his appearance, he is

apparently 20 years old, as he has stated. His sex is obviously male with

a masculine features. His build is average. He is neither too thin nor too

fat. He has Satisfactory grooming. His clothes are clean and nails are

trimmed. He has taken a bath as evidence by a wet hair. No foul odor

Noted.

B. Behavior and Psychomotor Activity

He has a balanced gait and posture is erect. Normal Curvature of the

spine noted. Client was able to stand and move without assistance.

Coordinated body movements were observed as evidence by his ability to

walk and move around the activity area. He has no difficulties in general moving,

walking and standing because he is physically capable of doing so alone.

He was very active in the activities rendered by the student nurses.

He was also expressive of his emotions and feelings on the activities they

performed. In every subject that was discussed his expression in sharing was

very prominent.

C. Speech

His speech was understandable and clear. Some words are not

properly pronounced specifically the names of the student nurses.

D. Attitude Towards the Examiner

44
 When discussing a topic, he shares openly about his dreams and plans

after his admission in the rehabilitation Center. He is also confident enough to

ask questions to the examiner. He gives his own ideas and share his

experiences before and during his stay in the Center.

II. EMOTIONAL STATE AND REACTION

A. Mood

He expressed feelings to appropriate facial expression and

verbalization. Most of the time, he was very happy and shows a smiling face.

B. Affect

His affect is broad. He displays a full range of emotional expression.

When he is happy, his facial expression shows that he smiles and his eyes get

small.

III. PERCEPTUAL DISTURBANCE

A. Hallucination and Illusion

He admits that he had experienced hearing harsh sounds but he was

not able to identify what sound is it and where it is coming from.

B. Depersonalization and Derealization

The Client do not have any derealization and depersonalization. There is no

feeling of unreality and detachment from one's surroundings.

IV. THOUGHT PROCESS

A. Stream of thought

He speaks spontaneously. When asked about a topic, he doesn't need

to be instructed to respond.

45
 B. Content of Thought

He is not preoccupied. When attention is asked of him, he gives it

immediately. No delusions was experienced. Upon examination, he does not

show signs of having experiences which are unrealistic. His abstract

thinking is present. He was able to give an explanation for a proverb provided by

the examiner.

V. NEUROVEGETATIVE FUNCTIONING

A. Sleep

According to him, he is able to sleep normally, he sleeps at around 9:00pm

and wakes up at 6:00 am. The only thing that disturbs him while sleeping

are the bedbugs present in all the beds of the client.

B. Appetite

The client states that he was able to eat normally, he eats 2 cups of rice and

1 serving of viand per meal for 3 meals a day. He also eats all the food

served by the s tudent nurse.

C. Libido

The libido level is increased. He actively participate in all the activities,

from the exercise and the therapy provided by the nurse. He is the most active

among the group.

VI. SENSORIUM AND COGNITION

A. Orientation

He was very oriented to place, time, person and situation. He knows the

exact time and the date today. He even know when he was brought in

46
the center and who brought him there. He also know the reasons why he

was there and who are those people in the center. He also recognize us

as a student nurse.

B. Memory

He was able to remember remote memories, as in childhood experiences.

He can recall the activities given to them and identify which is the most

memorable. This time he already remember the exact date of his

Birthday.

C. Calculation

The same reaction was portrayed when i asked him to answer simple

equations. He don't want to solve. He only answers the first two questions.

D. General Information

The client knows some of the General informations such as the President of

our country and the Major of this City and what is the current trade of the

oil in the market.

VII. INSIGHT

He has a good insight. He stated that he was in the rehabilitation center

because he needed to get better. He is also ready and wanted to change

his life. He also believe that he can change if he will have no connections to

his old friends.

VIII. MULTI-AXIAL DIAGNOSIS

47
Axis I. Substance induced psychosis

Intoxication and withdrawal from a variety of central nervous system

depressants and stimulants may induce hallucinations or delusions, which,

when unaccompanied by insight, are the hallmarks of psychosis. A substance-

induced psychosis may, in many instances, present as an organic psychosis or

as an independent mental disorder, complicating diagnostic efforts.

Ramifications of a misdiagnosed psychotic illness are potentially long-lasting

and harmful to a patient. It is, therefore, crucial that health care providers

be aware of the complex relationship between substance abuse, psychotic

symptoms, and independent psychotic disorders.

This report addresses substance-induced psychosis, by describing

those psychotic symptoms most commonly associated with the abuse of specific

drugs and alcohol, detailing useful diagnostic techniques and outlining

treatment recommendations.

Substance dependence

One of the major substance use disorders, characterized by a maladaptive

pattern of substance use leading to clinically significant impairment or

distress, manifested by signs and symptoms such as tolerance , withdrawal,

frequently taking larger amounts of the substance over a longer period than

intended, persistent desire or effort to cut down on the substance use,

excessive time spent on activities related to the substance use and its effects,

often leading to the abandonment of social, occupational, or recreational

activities, and continued substance use despite knowledge of problems

48
likely to have been caused or exacerbated by it.

Axis II Borderline disorder

A person with a borderline personality disorder often experiences a

repetitive pattern of disorganization and instability in self-image, mood,

behavior and close personal relationships. This can cause significant distress

or impairment in friendships and work. A person with this disorder can often be

bright and intelligent, and appear warm, friendly and competent. They

sometimes can maintain this appearance for a number of years until their

defense structure crumbles, usually around a stressful situation like the breakup

of a romantic relationship or the death of a parent.

Axis III NONE

Axis IV.Educational Problem

Educational problems are experienced by people who cannot dedicate

enough focus towards schooling. They are manifested by a gradual or abrupt

decrease in performances in school. These problems may be brought about

by many factors: Example of educational problems: illiteracy; academic problems;

discord with teachers or classmates; inadequate school environment; drug

and/or alcohol abuse.

Economic problem

The economic problem, sometimes called the fundamental economic

problem, is one of the fundamental economic theories in the operation of any

49
economy. It asserts that there is scarcity, that the finite resources available

are insufficient to satisfy all human wants. The problem then becomes how to

determine what is to be produced and how the factors of production are to be

allocated. Economics revolves around methods and possibilities of solving

the economic problem. Example, extreme poverty, inadequate finances,

insufficient welfare support.

Housing problem

Housing is a buildings or other shelters in which people live. Housing could

be a problem if the structure is damage or no permanent house is available for

the family which greatly affect family lving. Example, homelessness, inadequate

housing or unsafe neighborhood.

Problems related to the social environment

The behavior of social groups is analogous to the behavior of the individual

and, of course, the largest social grouping on this planet is our world's

human society. Since at present our human society does, unfortunately,

constitute a great threat to its own survival through some pending social or

ecological disaster, we would be required to diagnose the collective

50
consciousness of the human race as being insane. All the world's many

social/environmental problems are but symptoms of humanity's general insanity.

Examples of social environment problems: death or loss of friend,

inadequate social support, living alone, discrimination, and adjustment to life

cycle transition.

Axis V

GAF=70

51
 NURSE –
PATIENT
INTERACTION

52
 Nurse – Patient Interaction

Orientation

Name of the client: Bryan

Objectives:

IX. to be able to establish a good nurse-patient interaction

X. to be able to know patient's feelings/thoughts

XI. to be able to know if the patient is knowledgeable regarding his condition and present illness

XII. to be able to know if the client has complaints or problems

53
 Date Nurse Patient Non- verbal Interpretation Analysis Nurse's
cues Feeling/thought
July 22, 2008 > “Good morning >”Good morning > He smiled and >Giving recognition – >Greeting the client Before our first
@ Bryan, ako diay si sad” established eye acknowledging, by name, indicating interaction with
8am Lou, student nurse contact indicating awareness awareness of our client, I felt
nimo karon” >Client's affect and change, or noting that i am
mood are appropriate efforts the client has prepared but
to his response made all show that when we arrive
the nurse recognizes at the center I
the client as a felt nervous and
person, as an I don't know
individual. Such what to do. I
recognition does not followed the
carry the notion of instructions
value, that is of given by the
being “good” or facilitator but my
“bad” actions are very
limited because I
> “Hi Bryan, ako > “Bryan, tawaga > He smiled and > Giving information > Informing the am afraid to
diay si Lou Bertini lang ko og Bryan” established eye - making available the client of facts commit
Benjamin imohang contact the facts that the client increases his or her mistakes.
student nurse needs knowledge about a After the
karong adlawa >Client's affect and topic or lets the duty I realize
hantod 11 am ug sa mood are appropriate client know what to that there is
sunod na upat ka to his response expect. The nurse is nothing that i
semana. So na a mi functioning as a should be afraid
dinhi sa adlaw na resource person. of. I admit that it
Lunes, Martes, Giving information is difficult to
Miyerkules. also builds trust handle client

54
Tawaga lang ko og with client. because we don't
ma'am Lou. Ikaw exactly know
unsa man gusto what is on their
nimo ipatawag? mind but all that
I have to do is to
listen and
> “Kumusta man > “Kapoy ko kay >Occasional > Making observation >It is verbalizing process the
ka? mura man ka sayo mi gimata, yawning, and – verbalizing what the what the nurse client's reactions,
gikapoy!” wala pa jud ko sigh nurse perceives perceives; feelings and
tarong tulog” >Client's affect is sometimes client statements.
appropriate to his cannot verbalize or I felt sad
response make themselves because he was
understood. Or the not yet open to
client may not be discuss some
ready to talk things especially
with regards to
>”Ngano man >“Katol ang higda- >Established eye >Exploring - delving > When client's deal his family. The
walay kay tarong anan, igang, og contact further into a subject or with topics information that
tulog” naay naga-bara sa idea superficially, I have gather are
akong ilong bantog >Client's affect and exploring can help limited and trust
dili ko ka tarong og mood are appropriate them examine the was not yet
tulog” to his response issue more fully established.
Any problem or
concern can be
better understood if
explored in depth. If
the client expresses
an unwillingness to
explore a subject ,
however, the nurse

55
 must respect his
wishes

>”Tapos unsa man >”Gi limpyohan >Established eye >General leads – > General leads
imo gibuhat?” nako ang akong contact giving encouragement indicate that the
kama, nag report to continue nurse is listening
pud ko kay >Client's affect and and following what
Fernand na igang mood are appropriate the client is saying
og naay nag-bara to his response in front taking away
sa ako ilong ” the initiative for the
interaction.

> “Bryan, katong > “Nasuko jud ko >With angry > Encouraging > The nurse asks the
gidala ka diri sa eh, ikaw daw i- face and serious expression – asking the client to consider
center unsa man rehab dili baka client to verbalize what people or events in
imo gibati?” maglagot!” he or she perceives light of his or her
>Client's affect and own values. Doing
mood are appropriate so encourages the
to his response client to make his or
her own appraisal
rather than to accept
the opinion of
others.

> “Bryan, ingni ko >” Daghan ko >With broad > Exploring – delving > When client's deal
sa imohang bisyo, ang last kay affect and with further into a subject or with topics
experience bago ka akong gibunalan action idea superficially,
na admit diri beh.” among kapitbahay” >Client's affect and exploring can help
mood are appropriate them examine the

56
 to his response issue more trully.

> “Unsa paman imo > “Naka-agi sad ko >He is serious > General leads –
gipang buhat sa ug dung-gaban, ug with stubbing giving encouragement
una?” naka dung-gab sad action to continue
ko” >Client's affect and
mood are appropriate
to his response
> General leads
indicate that the
nurse is listening
and following what
the client is saying
in front taking away
the initiative for the
interaction.

> “Sa tan-aw nimo > “Addict man gud >With eye > Focusing – > The nurse
unsa man jud ang ko ug daghan ko contact concentrating on a encourages the
rason nganong bisyo” single point client to concentrate
gidala ka diri?” >Client's affect and his or her own
mood are appropriate energies on a single
to his response point.

> “Kung ikaw > “Dili man, ma >With eye > Voicing doubt – > Another means of
pangotan-on sa flip man gud ko contact expressing uncertainty responding to
imong gipang himo kung makagamit about the reality of the distortion of reality
normal ba na sya o ko. Kung dili ko client's perception is to express doubt.
dili?” makagamt ma Such expression
lobat ko” permits the client to
become aware that
others do not
necessarily perceive

57
 events in the same
way or draw the
same conclusion.

>”Ma flip ka kung >”O, ing-ana >Established eye >Restating – repeating >The nurse repeats
maka gamit ka og akong ma feel” contact the main idea what the client has
mura ka og ma expressed said in
lobat.” >Client's affect and approximately or
mood are appropriate nearly the same
to his response words the client has
used. This
restatement lets the
client know that he
communicated the
idea effectively.
This encourages the
client to continue.
Or if the client has
been misunderstood,
he can clarify his
thoughts.

> Giving information > Informing the

>”Ah, sige Bryan, >” Ok, salmat >Established eye - making available the client of facts
ato lang ni ipadayon sad!” contact and the facts that the client increases his or her
atong isturyahanay smiling needs knowledge about a

58
ugma. Mag-balik >Client's affect and topic or lets the
man mi ugma mga mood are appropriate client know what to
8am. Salamat!” to his response expect. The nurse is
functioning as a
resource person.
Giving information
also builds trust
with client.

59
 Nurse – Patient Interaction

Termination

Name of the client: Bryan

Objectives:

XIII. to be able to established nurse-patient interaction

 to be able to know patient's feelings/thoughts

 to be able to know the clients reaction regarding the activities rendered

 to be able to prepare the client for the culmination day

60
 Date Nurse Patient Non- verbal Interpretation Analysis Nurse's
cues Feeling/thought
August 12, “Good morning Good morning sad Smiling and >Giving recognition – >Greeting the client I had a great
2008 Bryan” Blue” established eye acknowledging, by name, indicating experience
@ contact indicating awareness awareness of during my
8am >Client's affect and change, or noting exposure. I was
mood are appropriate efforts the client has able to establish
to his response made all show that a trusting
the nurse recognizes relationship
the client as a towards my
person, as an client. My skills
individual. Such in dealing with
recognition does not the clients are
carry the notion of improved and i
value, that is of was able to boost
being “good” or my self-
“bad” confidence.
I was
able to
>”kumusta naman >”Ok lang, happy > Established >Making observations >Sometimes client appreciate the
ka Bryan, happy kay naa napud mo” eye contact and – verbalizing what the cannot verbalize or purpose and
lagi karong adlawa” smiling nurse perceives make themselves beauty of life.
understood. Or the During
client may not be my four week
ready to talk duty he became
more open and
expressive of his
thoughts plan
and dreams.

61
 I felt
happy because
he followed
>”naganahan ka sa >”O, nalingaw jud >Client shows a >Encouraging >The nurse asks the directions and
atong mga activities ko” happy smile and expression client to consider very active in all
nato karon? established eye >Client's affect and people and events in the activities
contact mood are appropriate light of his own rendered by the
to his response values. Doing so student nurses.
encourages the
client to make his
own appraisal rather
than to accept the
opinion of others

>”Unsa ang >”Mas lingaw >Smiling and >Encouraging >Comparing ideas,

kalahian sa mga karon kay bibo og established eye comparison – asking experiences, or
activities nato karon nalipay ang tanan” contact that similarties and relationships brings
sa dati? differences be noted out many recurring
>Client's affect and themes. The client
mood are appropriate benefits fro making
to his response these comparisons
because he might
recall past coping
strategies that were
effective
remember that he
has survived a
similar situation.

62
>Napansin nako >“ O ako pa!” >Established eye >Making observations >sometimes client
gusto jud ka contact and –verbalizing what the cannot verbalize or
musayaw, kay smiling nurse perceives make themselves
energetic kaayo ka understood. Or the
sa practice para sa client may not be
culmination” ready to talk

>Ka memorize naka >“O” >Energetic and >Exploring – delving
sa sayaw para ugma smiling further into a subject or
sa culmination? idea
>Client's affect and
mood are appropriate
to his response
> When client's deal
with topics
superficially,
exploring can help
them examine the
issue more fully
Any problem or
concern can be
better understood if
explored in depth. If
the client expresses
an unwillingness to
explore a subject ,
however, the nurse
must respect his
wishes

>Sa mga practices >” Sa sayaw kay >Established eye >Focusing – >The nurse
nato para sa daghan og steps, contact concentrating on a encourages the
culmination asa ka pero ok lang siya single point client to concentrate

63
dapit nalisudan? Sa kay naka practice his energies on a
parade and yells or man ko” single point, which
sa sayaw? may prevent a
multitude of factors
or problems from
overwhelming the
client. It is also a
useful technique
when a client jumps
from one topic to
another.

>Bryan balik mi >”Salamat pud” >smiling , > Giving information > Informing the
ugma 8am gihapon established eye - making available the client of facts
para sa atong contact and the facts that the client increases his or her
culmination day, wave needs knowledge about a
salamat sa >Client's affect and topic or lets the
cooperation” mood are appropriate client know what to
to his response expect. The nurse is
functioning as a
resource person.
Giving information
also builds trust
with client.

64
PSYCHOTHERAPIES

65
PSYCHOTHERAPY

Psychotherapy is an interpersonal, relational intervention used

by trained psychotherapists to aid clients in problems of living. This

usually includes increasing individual sense of well-being and reducing

subjective discomforting experience. Psychotherapists employ a range

of techniques based on experiential relationship building, dialogue,

communication and behavior change and that are designed to improve

the mental health of a client or patient, or to improve group

relationships (such as in a family). Psychotherapy may be performed

by practitioners with a number of different qualifications, including

psychologists, marriage and family therapists, licensed clinical social

workers, licensed associate professional counselors, licensed

professional counselors, psychiatric nurses, and psychiatrists.

OCCUPATIONAL THERAPY

Occupational therapy is the use of productive or creative activity

in the treatment or rehabilitation of physically, cognitively, or

emotionally disabled people. The use of meaningful occupation to

assist people who have difficulty in achieving a healthy and balanced

lifestyle and to enable an inclusive society so that all people can

participate to their potential in daily occupations of life.

Most commonly, occupational therapist and occupational therapy

assistants work with people with disabilities to enable them to

66
maximize their skills and abilities. Occupational therapy gives people

the skills for the job of living life to its fullest. This also reflects the

intent of the OBRA law of 1993 to provide clients with rehabilitation to

their maximum functional ability.

On our first occupational therapy which was bracelet making and

dying a shirt, the clients were given materials which include nylon and

beads for bracelet making. They are also given t-shirts and dies for

designing t-shirts. Bryan accomplished the therapy and was able to

appreciate his work. He was also excited to show it to his co-clients.

For our second occupational therapy which is chandelier making, they

were given a nylon, small basket, yarn, and some colored papers. The

clients were happy in looking their work so as Bryan.

MUSIC AND DANCE THERAPY

Music and dance therapy is the clinical and evidence-based use of music

interventions and dance steps to accomplished individualized goals with in a therapeutic

relationship. it also involves the use of music to facilitate relaxation, expression of

feelings, and outlet of tension. Music therapy is the use of music by a trained professional

to achieve therapeutic goals that include, motor skills, social and interpersonal

development, cognitive development, self awareness, and spiritual enhancement. Dance

therapy, or dance movement therapy is the psychotherapeutic use of movement (and

dance) for emotional, cognitive, social, behavioral and physical conditions

67
(www.adta.org, 2008). It is a form of expressive (creative arts) therapy. Certified dance

therapists hold a masters level of training.

Dance therapy is founded on the premise that the body and mind are an interrelated

continuum, that the state of the body may affect mental and emotional wellbeing in

manifold ways. In contrast to artistic dance, which is usually concerned with the aesthetic

appearance of movement, dance therapy explores the nature of all movement. Through

observing and altering the kinesthetic movements of a client, dance movement therapists

diagnose and help solve various psychological problems.

Last August 11, 2008, we had our music and dance therapy

which was facilitated by the group 1. The theme of the therapy was

“Noon at Ngayon” which focuses the music of the past and its

counterpart music in the present. Music was first introduced to the

residents of Mabunga and followed by the dance therapy. The songs of

“Sumayaw, Sumunod” and “Toyang” were introduced to the clients.

Like Bryan, other clients cooperate in singing the songs. Bryan was

able to participate in the therapies because we saw him enjoying

singing and dancing. He was also able to follow the steps during dance

therapy. During music therapy, Bryan was able to sang and participate

in one of the games which is the “Singing bee”. He was able to sang

the missing lyrics and show willingness to join the game.

ART THERAPY

Art therapy is a form of expressive therapy that uses art

68
materials, such as paints, chalk, and markers. It helps clients to

express their feelings through art and show their mental capability on

how they put reality into a piece of art. Art therapy combines

traditional psychotherapeutic theories and techniques with an

understanding of the psychosocial aspects of the creative process,

especially the affective properties of the different art materials.

As a mental health profession, art therapy is employed in many

clinical settings with diverse populations. Art therapy can be found in

non-clinical settings as well, such as in art studios and in workshops

that focuses on creativity development.

The purpose of art therapy is much the same as any other

psychotherapeutic modality: to improve or maintain mental health and

emotional well-being. But whereas some of the other expressive

therapies utilized the performing arts for expressive purpose s, art

therapy generally utilizes drawing, painting, sculpture, photography,

and other forms of visual art expression.

Last August 5, 2008, our group prepared an activity related to art

therapy. The theme was “Friendship Day” and was its main activity

was to decorate a piece of used bottle with different colorful art

materials and aside from that, they were also tested to draw anything

related to the theme. Bryan, as a part of the group, he drew trees and

some like forest to express his feelings about his friends. Bryan also

designed his bottle and able to explain his work to the other clients.

69
RECREATIONAL THERAPY

Recreational therapy contributes to the broad spectrum of health

care through treatment, education, and the provision of adapted

recreational opportunities. All of which and in improving and

maintaining physical, cognitive, emotional, and social functioning,

preventing secondary health conditions, enhancing independent living

skills, and overall quality of life.

In our recreational therapy, out theme was “Sports fest’ which is

the main activity was more on games and one of the games was”

Shoot that airplane”. Bryan was able to participate in the activities and

in that game, he was able to shoot the airplane in a small circle maid

up of wood. The therapy tests their concentration on a particular thing

and how to accomplish a task using their efforts.

MILIEU THERAPY

A form of psychotherapy, usually conducted in a hospital or other

facility that can function as a therapeutic community and provide a

stable environment, in which personal growth and behavior change

may be promoted through interaction of individuals within the total

therapeutic environment.

Every therapy, we always change the environment of our clients

so that they may able to appreciate our theme and able to understand

it. Bryan was also able to appreciate the things that we did for him and

70
for the other residents in Mabunga.

GROUP THERAPY

Group therapy is a form of psychotherapy in which one or more

therapists treat a small group of clients together as a group. The term

can legitimately refer to any form of psychotherapy when delivered in

a group format, including Cognitive behavioral therapy or Interpersonal

therapy, but it is usually applied to psychodynamic group therapy

where the group context and group process is explicitly utilized as a

mechanism of change by developing, exploring and examining

interpersonal relationships within the group. Group therapy can form

part of the therapeutic milieu of a psychiatric in-patient unit or

ambulatory psychiatric Partial hospitalization.

We also had our group therapy during the groupings of the

clients. Bryan, as a member of their group, he is always cooperating

and help the group to win in the game and the therapy also test Bryan

and the clients on how to understand and have teamwork.

71
 DEFINITION OF
COMPLETE DIAGNOSIS

SUBSTANCE DEPENDENCE

Substance abuse and dependence refer to any continued pathological use of a

72
medication, non-medically indicated drug (called drugs of abuse), or toxin. They

normally are distinguished as follows.

Substance abuse is any pattern of substance use that results in repeated adverse

social consequences related to drug-taking-for example, interpersonal conflicts, failure to

meet work, family, or school obligations, or legal problems. Substance dependence,

commonly known as addiction, is characterized by physiological and behavioral

symptoms related to substance use. These symptoms include the need for increasing

amounts of the substance to maintain desired effects, withdrawal if drug-taking ceases,

and a great deal of time spent in activities related to substance use.

Substance abuse is more likely to be diagnosed among those who have just begun taking

drugs and is often an early symptom of substance dependence. However, substance

dependence can appear without substance abuse, and substance abuse can persist for

extended periods of time without a transition to substance dependence.

http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?

requestURI=/healthatoz/Atoz/ency/substance_abuse_and_dependence.jsp

A pattern of behavioural, physiologic, and cognitive symptoms that develop due to

substance use or abuse; usually indicated by tolerance to the effects of the substance and

withdrawal symptoms that develop when use of the substance is terminated.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?substance+dependence

http://dictionary.webmd.com/terms/substance-dependence

Definition: Substance dependence is when a person has developed a tolerance for a

particular substance (needing increased amounts to experience the effects) and has

73
withdrawal symptoms when not using the substance for a period of time. People often

cope with GAD by using substances, which can lead to even more complicated problems.

http://gad.about.com/od/glossary/g/substancedep.ht

(drug dependence)

Use of a drug for a reason other than which it was intended or in a manner or in

quantities other than directed. Drug dependence is a compulsion to take a drug to produce

a desired effect or prevent unpleasant effects when the drug is withheld. Risk factors for

drug abuse include: low self esteem, inability to deal with stress and emotional

instability. Juveniles use drugs due to peer pressure. Signs of drug use in children

include: a change in friends or group, long absences from home, poor performance in

school, seclusion, stealing, lying, criminal behaviour, deteriorating family relationships,

signs of drug intoxication and changes in behaviour. Commonly abused drugs include

narcotic analgesic agents, benzodiazepines, cocaine, amphetamines, barbiturates,

marijuana, LSD and phencyclidine. Many labs now offer quick and inexpensive urine

drug screening. Psychological counseling and parental support will be necessary in

children with this problem.

http://cancerweb.ncl.ac.uk/cgi-bin/omd?drug+dependence

Drug dependence (addiction) is compulsive use of a substance despite negative

consequences which can be severe; drug abuse is simply excessive use of a drug or use of

74
a drug for purposes for which it was not medically intended.

Physical dependence on a substance (needing a drug to function) is not necessary or

sufficient to define addiction. There are some substances that don't cause addiction but do

cause physical dependence (for example, some blood pressure medications) and

substances that cause addiction but not classic physical dependence (cocaine withdrawal,

for example, doesn't have symptoms like vomiting and chills; it is mainly characterized

by depression).

http://www.drkoop.com/ency/93/001522.html

What is Drug Addiction?

Drug addiction such as alcohol, heroin, meth, marijuana, prescription drugs or any other

substance or addictive item means that the individual is physically, mentally, or both

physically and mentally dependent on the item. They will get withdrawal and/or tolerance

symptoms when they don't use the substance. Tolerance means that one needs higher

quantities of a substance over time to reach the desired effects.

http://www.drug-rehabs.org/ia.php?aid=24

Substance-induced Psychotic Disorder

Prominent psychotic symptoms (i.e., hallucinations and/or delusions) determined to be

75
caused by the effects of a psychoactive substance is the primary feature of a substance-

induced psychotic disorder. A substance may induce psychotic symptoms during

intoxication (while the individual is under the influence of the drug) or during withdrawal

(after an individual stops using the drug).

http://www.minddisorders.com/Py-Z/Substance-induced-psychotic-disorder.html

Substance-induced

Brought about by a physical material

(Merriam-Webster’s Pocket Dictionary, copyright 1995, p. 172)

Psychotic Disorder

A serious mental disorder in which the mind does not function normally and the

ability to deal with reality is impaired or lost.

http://www.weightwise.com/p/10286/Default.aspx

Substance-induced Psychotic Disorder (combination)

A serious mental disorder in which the mind does not function normally and the

ability to deal with reality is impaired or lost all of which brought about by a substance.

76
 DIFFERENTIAL
DIAGNOSIS

Substance Dependence Criteria (304.90 Substance Dependence)

Substance dependence is defined as a maladaptive pattern of substance use leading to
clinically significant impairment or distress, as manifested by three (or more) of the
following, occurring any time in the same 12-month period:

77
Tolerance, as defined by either of the following: (a) A need for /
markedly increased amounts of the substance to achieve
intoxication or the desired effect or (b) Markedly diminished effect
with continued use of the same amount of the substance.

Withdrawal, as manifested by either of the following: (a) The /

characteristic withdrawal syndrome for the substance or (b) The
same (or closely related) substance is taken to relieve or avoid
withdrawal symptoms.

X
The substance is often taken in larger amounts or over a longer
period than intended.

/
There is a persistent desire or unsuccessful efforts to cut down or
control substance use.

/
A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects.

/
Important social, occupational, or recreational activities are given
up or reduced because of substance use.

The substance use is continued despite knowledge of having a /

persistent physical or psychological problem that is likely to have

78
 been caused or exacerbated by the substance (for example, current
cocaine use despite recognition of cocaine-induced depression or
continued drinking despite recognition that an ulcer was made
worse by alcohol consumption).

85.71%

Substance-Induced Psychotic Disorder

(292.11 Substance-Induced Psychotic Disorder, With Delusions)

(292.12 Substance-Induced Psychotic Disorder, With Hallucinations)

When there is evidence that alcohol or other drugs directly cause hallucinations or
delusions not associated with delirium diagnosis of this substance related disorder may be
appropriate.
Diagnostic criteria for Substance-Induced Psychotic Disorder

A. Prominent hallucinations or delusions. Note: Do not include x

hallucinations if the person has insight that they are substance
induced.

B. There is evidence from the history, physical examination, or laboratory findings of

either (1) or (2):

(1) the symptoms in Criterion A developed during, or within a month /

of, Substance Intoxication or Withdrawal

(2) medication use is etiologically related to the disturbance /

C. The disturbance is not better accounted for by a Psychotic Disorder

that is not substance induced. Evidence that the symptoms are

79
 better accounted for by a Psychotic Disorder that is not substance
induced might include the following: the symptoms precede the
onset of the substance use (or medication use); the symptoms /
persist for a substantial period of time (e.g., about a month) after
the cessation of acute withdrawal or severe intoxication, or are
substantially in excess of what would be expected given the type or
amount of the substance used or the duration of use; or there is
other evidence that suggests the existence of an independent non-
substance-induced Psychotic Disorder (e.g., a history of recurrent
non-substance-related episodes).

D. The disturbance does not occur exclusively during the course of a

delirium. Note: This diagnosis should be made instead of a
diagnosis of Substance Intoxication or Substance Withdrawal only /
when the symptoms are in excess of those usually associated with
the intoxication or withdrawal syndrome and when the symptoms
are sufficiently severe to warrant independent clinical attention.

80%

Substance Abuse Criteria (305.90 Substance Abuse)

Substance abuse is defined as a maladaptive pattern of substance use leading to clinically
significant impairment or distress as manifested by one (or more) of the following,

80
occurring within a 12-month period:

Symptoms

Recurrent substance use resulting in a failure to fulfill major role

obligations at work, school, or home (such as repeated absences or
poor work performance related to substance use; substance-related /
absences, suspensions, or expulsions from school; or neglect of
children or household).

Recurrent substance use in situations in which it is physically

hazardous (such as driving an automobile or operating a machine X
when impaired by substance use)

Recurrent substance-related legal problems (such as arrests for X

substance related disorderly conduct)

Continued substance use despite having persistent or recurrent

social or interpersonal problems caused or exacerbated by the /
effects of the substance (for example, arguments with spouse about
consequences of intoxication and physical fights).

50%

Note: The symptoms for abuse have never met the criteria for dependence for this class
of substance. According to the DSM-IV, a person can be abusing a substance or
dependent on a substance but not both at the same time.

Schizophrenia
Schizophrenia, a term introduced by Bleuler, names a persistent, often chronic and
usually serious mental disorder affecting a variety of aspects of behavior, thinking, and
emotion. Patients with delusions or hallucinations may be described as psychotic.

81
Thinking may be disconnected and illogical. Peculiar behaviors may be associated with
social withdrawal and disinterest.

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less if successfully
treated):

(1) delusions X

(2) hallucinations /

(3) disorganized speech (e.g., frequent derailment or X

incoherence)

(4) grossly disorganized or catatonic behavior X

(5) negative symptoms, i.e., affective flattening, alogia, or X

avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations
consist of a voice keeping up a running commentary on the person's behavior or thoughts,
or two or more voices conversing with each other.

82
B. Social/occupational dysfunction: For a significant portion of
the time since the onset of the disturbance, one or more
major areas of functioning such as work, interpersonal
relations, or self-care are markedly below the level achieved /
prior to the onset (or when the onset is in childhood or
adolescence, failure to achieve expected level of
interpersonal, academic, or occupational achievement).

C. Duration: Continuous signs of the disturbance persist for at

least 6 months. This 6-month period must include at least 1
month of symptoms (or less if successfully treated) that meet
Criterion A (i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms. During these X
prodromal or residual periods, the signs of the disturbance
may be manifested by only negative symptoms or two or
more symptoms listed in Criterion A present in an attenuated
form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion:

Schizoaffective Disorder and Mood Disorder With Psychotic
Features have been ruled out because either (1) no Major
Depressive, Manic, or Mixed Episodes have occurred X
concurrently with the active-phase symptoms; or (2) if mood
episodes have occurred during active-phase symptoms, their
total duration has been brief relative to the duration of the
active and residual periods.

E. Substance/general medical condition exclusion: The

disturbance is not due to the direct physiological effects of a X
substance (e.g., a drug of abuse, a medication) or a general
medical condition.

83
 F. Relationship to a Pervasive Developmental Disorder: If
there is a history of Autistic Disorder or another Pervasive
Developmental Disorder, the additional diagnosis of X
Schizophrenia is made only if prominent delusions or
hallucinations are also present for at least a month (or less if
successfully treated).

20%

Substance-Induced Anxiety Disorder (292.89 Substance-Induced Anxiety

Disorder)

The diagnosis of this Anxiety Disorder is made when there is evidence that persistent

anxiety symptoms, including Panic Attacks, obsessions, or compulsions have arisen out

of use of or withdrawal from either prescribed or "recreational" drug use.

Diagnostic criteria for Substance-Induced Anxiety Disorder

A. Prominent anxiety, Panic Attacks, or obsessions or compulsions X

predominate in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of

either (1) or (2):

(1)the symptoms in Criterion A developed during, or within 1 month X

of, Substance Intoxication or Withdrawal

(2) medication use is etiologically related to the disturbance X

84
 C. The disturbance is not better accounted for by an Anxiety Disorder
that is not substance induced. Evidence that the symptoms are
better accounted for by an Anxiety Disorder that is not substance
induced might include the following: the symptoms precede the
onset of the substance use (or medication use); the symptoms X
persist for a substantial period of time (e.g., about a month) after
the cessation of acute withdrawal or severe intoxication or are
substantially in excess of what would be expected given the type or
amount of the substance used or the duration of use; or there is
other evidence suggesting the existence of an independent non-
substance-induced Anxiety Disorder (e.g., a history of recurrent
non-substance-related episodes).

D. The disturbance does not occur exclusively during the course of a /

Delirium.

E. The disturbance causes clinically significant distress or impairment X

in social, occupational, or other important areas of functioning.

16.67%
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or

Substance Withdrawal only when the anxiety symptoms are in excess of those usually

associated with the intoxication or withdrawal syndrome and when the anxiety symptoms

are sufficiently severe to warrant independent clinical attention.

Substance-Induced Mood Disorder (292.84 Substance-Induced Mood

Disorder)

85
This Substance Related Mood Disorder is diagnosed when the clinician believes a drug or
other chemical substance or Withdrawal from a drug causes symptoms suggestive of a
Manic, Mixed, Hypomanic, or Major Depressive episode.

Diagnostic criteria for Substance-Induced Mood Disorder

A. A prominent and persistent disturbance in mood predominates in the clinical

picture and is characterized by either (or both) of the following:

(1)depressed mood or markedly diminished interest or pleasure in all, X

or almost all, activities

(2)elevated, expansive, or irritable mood X

B. There is evidence from the history, physical examination, or laboratory findings of

either (1) or (2):

(1) the symptoms in Criterion A developed during, or within 1 month X

of, Substance Intoxication or Withdrawal

(2) medication use is etiologically related to the disturbance X

C. The disturbance is not better accounted for by a Mood Disorder that

is not substance induced. Evidence that the symptoms are better
accounted for by a Mood Disorder that is not substance induced X
might include the following: the symptoms precede the onset of the
substance use (or medication use); the symptoms persist for a
substantial period of time (e.g., about a month) after the cessation of
acute withdrawal or severe intoxication or are substantially in

86
 excess of what would be expected given the type or amount of the
substance used or the duration of use; or there is other evidence that
suggests the existence of an independent non-substance-induced
Mood Disorder (e.g., a history of recurrent Major Depressive
Episodes).

D. The disturbance does not occur exclusively during the course of a /

Delirium.

E. The symptoms cause clinically significant distress or impairment in X

social, occupational, or other important areas of functioning.

16.67%

Substance Intoxication Delirium (291.0 Alcohol; 292.81 Amphetamine [or

Amphetamine-Like Substance]; 292.81 Cannabis; 292.81 Cocaine; 292.81 Hallucinogen;

292.81 Inhalant; 292.81 Opioid; 292.81 Phencyclidine [or Phencyclidine-Like

Substance]; 292.81 Sedative, Hypnotic, or Anxiolytic; 292.81 Other [or Unknown]

Substance [e.g., cimetidine, digitalis, benztropine])

Medications and other drugs including alcohol as well as other chemical toxins can cause

Delirium associated with Intoxication. There must be evidence that the substance is

present in the body and that the delirium has arisen from it.

87
Diagnostic criteria for Substance Intoxication Delirium
X

A. Disturbance of consciousness (i.e., reduced clarity of awareness of

the environment) with reduced ability to focus, sustain, or shift
attention.

X
B. A change in cognition (such as memory deficit, disorientation,
language disturbance) or the development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours

to days) and tends to fluctuate during the course of the day.

D. There is evidence from the history, physical examination, or laboratory findings of

either (1) or (2):
X

(1) the symptoms in Criteria A and B developed during Substance

Intoxication

(2) medication use is etiologically related to the disturbance*

0.00%

88
DOCTOR’S
ORDER

89
Date Doctor's Order
Remarks
Ordered Rationale
1/29/2008 >please admit patient under my service To establish a
designated doctor
to which all
pertinent
DONE
information
regarding the
patient will be
referred to.
>DAT To signify that
the patient has
no restrictions
DONE
regarding intake
of solid or liquid
foods.
>Laractyl 20g 1 tab now To control mania,
nausea and
vomiting and to DONE
treat
schizophrenia.

90
 >Depakote 500mg 1 tab @ am To treat certain
types of seizures
DONE
and convulsions.

>Akineton 200 mg 1 tab @ am To treat certain

side effects (eg,
involuntary
DONE
movements)
caused by certain
medicines.
>Solian 200 mg 2 tabs 2x a day To treat acute
manic episodes in
bipolar affective DONE
disorder and
schizophrenia.
>Solian 20g 1 tab To treat acute
1/30/08
manic episodes in
bipolar affective DONE
disorder and
schizophrenia.

91
 >Depakote 50g 1 tab every morning To treat certain
types of seizures
DONE
and convulsions.

>Fluanxol (Fluphentixol CCG) To alleviate

psychotic
features like DONE
paranoia and
hallucinations.
>con’t meds To maintain
optimum health.
DONE

01/31 >Fluanxol 0.5 cc ml now – 9:30 am To alleviate

/08
psychotic
features like DONE
paranoia and
hallucinations.

92
 >con’t meds To maintain
optimum health.
DONE

2/07 >con’t Solian 20g To treat acute

/08
manic episodes in
bipolar affective DONE
disorder and
schizophrenia.
>Depakote 50g 1 tab every morning To treat certain
types of seizures
DONE
and convulsions

2/19 >con’t meds To maintain

/08
optimum health.
DONE

>Depakote 50g 1 tab every morning To treat certain

types of seizures
DONE
and convulsions

93
 02/29 >Fluanxol 0.5 cc ml now 8:30 am To alleviate
/08
psychotic
features like DONE
paranoia and
hallucinations.
03/03 >Lithium Bicarbonate 450g To treat manic
/08
states and bipolar
DONE
disorder.

>Solian 20g 1 hs ½ tab hs To treat acute

manic episodes in
Hold Depakote
bipolar affective DONE
disorder and
schizophrenia.
03/05 >con’t meds To maintain
/08
optimum health.
DONE

94
 03/13 >con’t meds – Depakote 500g 1 tab OD To maintain
/08 as soon as in – Solian 2mg ½ tab
optimum health
and to treat
DONE
certain types of
seizures and
convulsions
03/27 >please contact mother for meds To involve
/08
significant other
in the therapeutic DONE
regimen in
decision making.
04/02 >con’t meds – please contact mother ASAP To maintain
/08
optimum health
and to involve
significant other DONE
in the therapeutic
regimen in
decision making.

95
 04/06 >con’t meds To maintain
/08
optimum health.
DONE

04/19 >con’t meds To maintain

/08
optimum health.
DONE

04/28 >please contact mother for possible discharge To involve

/08 and for his meds
significant other
in the therapeutic DONE
regimen in
decision making.
04/30 >please contact mother: discharge after To involve
/08 settling all obligations
significant other
in the therapeutic DONE
regimen in
decision making.

96
 05/06 >increase Lithium 450g TID To treat manic
/08
states and bipolar
DONE
disorder.

>con’t Laractyl 100g hs To control mania,

nausea and
vomiting and to DONE
treat
schizophrenia.
>contact mother To involve
significant other
in the therapeutic DONE
regimen in
decision making.
05/16 >con’t meds To maintain
/08
optimum health.
DONE

97
 05/17 >con’t present medication To maintain
/08
optimum health.
DONE

05/27 >con’t meds To maintain

/08
optimum health.
DONE

06/10 >con’t all meds To maintain

/08
optimum health.
DONE

>please contact mother to see me ASAP to To involve

answer all my text messages and phone calls
significant other
in the therapeutic DONE
regimen in
decision making.
07/07 >contact mother to see me ASAP To involve DONE
/08
significant other
in the therapeutic
regimen in

98
 decision making.
>restrain patient PRN To avoid inflicting
pain to himself
DONE
and to others.

07/13 >con’t all meds To maintain

/08
optimum health.
DONE

>contact mother ASAP To involve

significant other
in the therapeutic DONE
regimen in
decision making.
07/23 >con’t meds To maintain
/08
optimum health.
DONE

99
 >please contact mother to talk to me personally To involve
significant other
in the therapeutic DONE
regimen in
decision making.
07/29 >Diphenhydramine 1 tab BIP x 5 days To reduce
/08
difficulty in falling
asleep and to
treat
DONE
extrapyramidal
side effects of
typical
antipsychotics.
>Vitamin C 1 tab OD Required for the
growth and
development of DONE
tissues in all parts
of the body.

100
>increase fluid intake To prevent from
dehydration.
DONE

101
DRUG
STUDY

102
GENERIC NAME:

Amisulpride

BRAND NAME:

Solian

CLASSIFICATION:

Atypical antipsychotic

MODE OF ACTION:

Solian tablets and solution contain the active ingredient amisulpride, which is a
type of medicine known as an atypical antipsychotic. It is used to treat schizophrenia.

Amisulpride works in the brain, where it affects a neurotransmitter called dopamine.

Neurotransmitters are chemicals that are stored in nerve cells and are involved in
transmitting messages between the nerve cells.

Dopamine is a neurotransmitter known to be involved in regulating mood and behaviour,

amongst other things. Schizophrenia is associated with an overactivity of dopamine in the
brain, and this may be associated with the delusions and hallucinations that are a feature
of this disease.

Amisulpride works by blocking the receptors in the brain that dopamine acts on. This
prevents the excessive activity of dopamine and helps to control psychotic illness.

People with schizophrenia may experience 'positive symptoms' (such as hallucinations,

disturbances of thought, and hostility) and/or 'negative symptoms' (such as lack of
emotion and social isolation). Amisulpride has been shown to be effective for relieving
both positive and negative symptoms of schizophrenia, whereas the conventional
antipsychotics are usually less effective against the negative symptoms.

Amisulpride is also used by specialists to treat episodes of mania in people with the
psychiatric illness, bipolar affective disorder (manic depression), though this is an
unlicensed use of the medicine.

DOSAGE:

Adults

• The usual dose is between 50mg and 800mg each day

103
 • Your doctor may start you on a lower dose if necessary

• If necessary your doctor can prescribe up to 1200mg each day

• Doses up to 300mg each day can be taken as a single dose. Take the dose at the
same time each day

• Doses above 300mg should be taken as half in the morning and half in the
evening

Elderly

• Your doctor will need to keep a close check on you as you are more likely to have
low blood pressure or sleepiness due to this medicine

People with kidney problems

• Your doctor may need to give you a lower dose

Children under 15 years of age

Solian Solution should not be given to children under 15 years of age

INDICATION:

Amisulpride is indicated for the treatment of acute and chronic schizophrenic

disorders, in which positive symptoms and or negative symptoms are prominent
including patients characterized by predominant negative symptoms.

CONTRAINDICATION:
• Elderly people

• Decreased kidney function

• Abnormal heart rhythm (seen as a 'prolonged QT interval' on the heart monitoring

trace or ECG)

• Slow heart rate of less than 55 beats per minute (bradycardia)

• Low blood potassium levels (hypokalaemia)

• History of epilepsy

• Parkinson's disease

104
 • Children under 15 years of age

• Tumour of the adrenal gland (phaeochromocytoma)

• Tumours which grow rapidly in the presence of the hormone prolactin, eg

tumours of the pituitary gland, breast cancer

• Pregnancy

• Women who could get pregnant, unless effective contraception is used to prevent
pregnancy

• Breastfeeding

DRUG INTERACTION:

It is important to tell your doctor or pharmacist what medicines you are already
taking, including those bought without a prescription and herbal medicines, before you
start treatment with this medicine. Similarly, check with your doctor or pharmacist before
taking any new medicines while taking this one, to ensure that the combination is safe.

This medicine must not be taken with any of the following medicines, as this
combination could cause a serious abnormal heart rhythm known as torsades de pointes:

• certain medicines used to treat abnormal heart rhythms (antiarrhythmics) such as

quinidine, disopyramide, procainamide, amiodarone, sotalol

• bepridil

• cisapride

• sultopride

• thioridazine

• erythromycin given by injection into a vein (intravenous)

• vincamine given by injection into a vein (intravenous)

• halofantrine

• pentamidine

105
 • sparfloxacin

• terfenadine.

This medicine must also not be used in combination with levodopa, as these two
medicines oppose the effect of each other.

The following medicines should be used with caution in combination with this medicine,
as they may increase the risk of abnormal heart rhythms:

• beta-blockers, eg propranolol

• calcium channel blockers, eg diltiazem, verapamil

• clonidine

• digoxin

• thiazide diuretics, eg bendroflumethiazide

• loop diuretics, eg furosemide

• stimulant laxatives, eg bisacodyl

• amphotericin B given by injection into a vein

• corticosteroids, eg prednisolone

• tetracosactide

• lithium

• other antipsychotic medicines, eg haloperidol, pimozide

• antidepressants, eg imipramine.

There may be an increased risk of drowsiness and sedation if this medicine is taken with
any of the following (which can also cause drowsiness):

• alcohol

• tricyclic antidepressants, eg amitriptyline

106
 • opioid painkillers, eg morphine, codeine, dihydrocodeine

• benzodiazepines, eg diazepam

• sedating antihistamines, eg chlorphenamine

• sleeping tablets.

This medicine may enhance the blood pressure-lowering effects of certain medicines
used to treat high blood pressure (antihypertensives). If you are taking medicines for high
blood pressure you should tell your doctor if you feel dizzy or faint after starting
treatment with this medicine, as your blood pressure medicines may need adjusting.

This medicine may oppose the effect of dopamine agonists used to treat Parkinson's
disease, eg bromocriptine, cabergoline, ropinirole, apomorphine.

SIDE EFFECTS:

Medicines and their possible side effects can affect individual people in different
ways. The following are some of the side effects that are known to be associated with this
medicine. Because a side effect is stated here, it does not mean that all people using this
medicine will experience that or any side effect.

• Difficulty in sleeping (insomnia)

• Anxiety and agitation

• Sleepiness

• Disturbances of the gut such as constipation, nausea, vomiting or abdominal pain

• Dry mouth

• Increased blood prolactin (milk producing hormone) level (hyperprolactinaemia).

Sometimes this can lead to symptoms such as breast enlargement, production of
milk and stopping of menstrual periods.

• Impotence

• Weight gain

• Abnormal movements of the hands, legs, face, neck and tongue, eg tremor,
twitching, rigidity (extrapyramidal effects)

107
 • Increased salivation

• Low blood pressure (hypotension)

• Slow heart rate (bradycardia)

• Abnormal heart beats (arrhythmias)

NURSING RESPONSIBILITIES:

• This medicine may cause drowsiness. If affected do not drive or operate

machinery. Alcohol should be avoided.

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Watch for evidence of NMS

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Consult your doctor immediately if you experience abnormal movements,

particularly of the face, lips, jaw and tongue, while taking this medicine. These
symptoms may be indicative of a rare side effect known as tardive dyskinesia, and
your doctor may ask you to stop taking this medicine, or decrease your dose.

• Consult your doctor immediately if you experience the following symptoms while
taking this medicine: high fever, sweating, muscle stiffness, faster breathing and
drowsiness or sleepiness. These symptoms may be due to a rare side effect known
as the neuroleptic malignant syndrome, and your treatment may need to be
stopped.

• Use exactly as directed

• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

108
• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from light.

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

109
GENERIC NAME:

Lithium

BRAND NAME:

Lithobid solvay

CLASSIFICATION:

Alkali metal
MODE OF ACTION:
Lithium is used for the treatment of manic/depressive (bipolar) and depressive
disorders. Lithium is a positively charged element or particle that is similar to sodium and
potassium. It interferes at several places inside cells and on the cell surface with other
positively charged atoms such as sodium, potassium, calcium, and magnesium which are
important in many cellular functions.
Lithium interferes with the production and uptake of chemical messengers by
which nerves communicate with each other (neurotransmitters). Lithium also affects the
concentrations of tryptophan and serotonin in the brain. In addition, lithium increases the
production of white blood cells in the bone marrow. Lithium's effects usually begin
within 1 week of starting treatment, and the full effect is seen by 2 to 3 weeks.
Lithium has been used since the 1950's. The FDA approved lithium carbonate, the
most common preparation, in 1970.
DOSAGE:
Doses vary widely and are adjusted based on measurements of the levels of
lithium in the blood. Recommended blood levels are 06-1.2 mEq/L. Early in therapy,
dose adjustments are made as often as every 5 to 7 days to establish the correct dose.
Most patients require 900-1200 mg daily in 2-3 divided doses. Patients with kidney
diseases excrete less lithium from the body and, therefore, require lower doses.
INDICATION:
Lithium is used for treating manic episodes due to bipolar disorder (manic-
depressive illness). It is also combined with antidepressants to treat depression.
CONTRAINDICATION:

• Contraindicated if therapy can’t be closely monitored

• Avoid using it in pregnant patient unless benefits outweigh risks

110
 • Use with caution in patients receiving neuromuscular blockers and diuretics; in
elderly or debilitated patients; and in patients with thyroid disease, seizure
disorder, infection, renal or CV disease, severe debilitation or dehydration, or
sodium depletion.
DRUG INTERACTIONS:
Non-steroidal anti-inflammatory drugs (NSAIDs), [for example, ibuprofen
(Motrin, Advil), naproxen Naprosyn, Aleve), indomethacin (Indocin), nabumetone
(Relafen), diclofenac (Voltaren, Cataflam, Arthrotec), ketorolac (Toradol)], reduce the
kidney's ability to eliminate lithium and lead to elevated levels of lithium in the blood and
lithium side effects. Blood concentrations of lithium may need to be measured for 4 to 7
days after an NSAID is either added or stopped during lithium therapy. Aspirin and
sulindac (Clinoril) do not appear to affect lithium concentrations in the blood.
Diuretics (water pills) should be used cautiously in patients receiving lithium. Diuretics
that act at the distal renal tubule, [for example, hydrochlorothiazide (Hydrodiuril),
spironolactone (Aldactone), triamterene (Dyrenium; Dyazide, Maxzide)], can increase
blood concentrations of lithium. Diuretics that act at the proximal tubule, [for example,
acetazolamide (Diamox)], are more likely to reduce blood concentrations of lithium.
Diuretics such as furosemide (Lasix) and bumetanide (Bumex) may have no affect on
lithium concentrations in blood.
ACE inhibitors, [for example, enalapril (Vasotec), lisinopril (Zestril, Prinivil), benazepril
(Lotensin), quinapril (Accupril), moexipril (Univasc), captopril (Capoten), ramipril
(Altace)], may increase the risk of developing lithium toxicity, by increasing the amount
of lithium that is reabsorbed in the tubules of the kidney and thereby reducing the
excretion of lithium.
When carbamazepine (Tegretol) and lithium are used together, some patients may
experience side effects, including dizziness, lethargy, and tremor. Central nervous system
side effects also may occur when lithium is used with antidepressants, [for example,
fluoxetine (Prozac) sertraline (Zoloft), and paroxetine (Paxil), fluvoxamine (Luvox),
amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin)].
Medications which cause the urine to become alkaline (the opposite of acidic) can
increase the amount of lithium that is lost into the urine. This results in lower blood
concentrations of lithium and reduces the effects of lithium. Such drugs include
potassium acetate, potassium citrate (Urocit-K), sodium bicarbonate, and sodium citrate
(Bicitra, Cytra-2, Liqui-Citra, Oracit, Shohl's).
Caffeine appears to reduce serum lithium concentrations, and side effects of lithium have
increased in frequency when caffeine is consumed.
Both diltiazem (Cardizem-CD, Tiazac, Dilacor-XR) and verapamil (Calan-SR, Isoptin-
SR, Verelan, Covera-HS) have been reported to have variable effects on lithium levels in
blood. In some patients there may be decreased lithium blood levels and in others lithium
toxicity.

111
Methyldopa (Aldomet) may increase the likelihood of lithium toxicity.
Various reactions have resulted when lithium is administered with phenothiazines, [for
example, chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine)
or with haloperidol (Haldol)]. Such reactions have included delirium, seizures,
encephalopathy, high fever or certain neurologic reactions that affect movement of
muscles, called extrapyramidal symptoms.
Lithium can cause goiter or hypothyroidism. The use of lithium with potassium iodide
can increase the likelihood of this adverse reaction.
The use of the beta blocker, propranolol (Inderal), with lithium can lead to a slow heart
rate and dizziness. Other beta blockers, [for example, metoprolol (Lopressor), atenolol
(Tenormin)] also may interact with lithium and be associated with a slow heart rate.
SIDE EFFECTS:
The most common side effects that can occur in persons taking lithium are fine hand
tremor, dry mouth, altered taste perception, weight gain, increased thirst, increased
frequency of urination, mild nausea or vomiting, impotence, decreased libido, diarrhea,
and kidney abnormalities. Many of the gastrointestinal side effects (nausea, taste
alterations, diarrhea) often disappear with continued therapy. Additionally, they may be
less common if lithium is taken in divided doses with meals. If diarrhea or excessive
urination lead to dehydration, lithium toxicity is possible. Lithium can also cause changes
in the electrocardiogram, low blood pressure, and decreased heart rate.
The following side effects suggest that lithium blood levels may be too high, and that
the dose of lithium may need to be reduced (after confirmation by measurement of
lithium levels in blood):

• loss of appetite,

• visual impairment,

• tiredness; muscle weakness,

• muscle fasciculations (twitches),

• tremor,

• unsteady gait,

• confusion, seizure,

• arrhythmias,

112
 • slurred speech,

• coma.
About 1 in every 25 persons who receives lithium develops a goiter (an enlarged
thyroid gland). Hypothyroidism (low thyroid hormone levels) has been reported. Signs of
hypothyroidism may include:

• dry rough skin,

• hair loss,

• hoarseness,

• mania,

• mental depression,

• increased sensitivity to cold, and

swelling of the feet, lower legs, and neck.

NURSING RESPONSIBILITIES:

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Watch for evidence of NMS

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Use exactly as directed

• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

113
• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from light.

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

114
GENERIC NAME:

Chlorpromazine Hydrochloride

BRAND NAME:

AKA Thorazine, Largactil, Laractyl

CLASSIFICATION:

Antiemetics/ antivertigo, Antipsychotics, Phenothiazines

MODE OF ACTION:

The precise mechanism whereby the therapeutic effects of chlorpromazine are

produced is not known. The principal pharmacological actions are psychotropic. It also
exerts sedative and antiemetic activity. Chlorpromazine has actions at all levels of the
central nervous system-primarily at subcortical levels-as well as on multiple organ
systems. Chlorpromazine has strong antiadrenergic and weaker peripheral anticholinergic
activity; ganglionic blocking action is relatively slight. It also possesses slight
antihistaminic and antiserotonin activity.

INDICATION:
• For the management of manifestations of psychotic disorders.

• To control nausea and vomiting.

• For relief of restlessness and apprehension before surgery.

• For acute intermittent porphyria.

• As an adjunct in the treatment of tetanus.

• To control the manifestations of the manic type of manic-depressive illness.

• For relief of intractable hiccups.

For the treatment of severe behavioral problems in children (1-12 years of age)
marked by combativeness and/or explosive hyperexcitable behavior (out of proportion to
immediate provocations), and in the short-term treatment of hyperactive children who
show excessive motor activity with accompanying conduct disorders consisting of some
or all of the following symptoms: impulsivity, difficulty sustaining attention,
aggressivity, mood lability, and poor frustration tolerance.

CONTRAINDICATION:

115
 • Do not use in patients with known hypersensitivity to phenothiazines.

• Do not use in comatose states or in the presence of large amounts of central

nervous system (CNS) depressants (alcohol, barbiturates, narcotics, etc.).
• Use cautiously in ill or dehydrated children
• Use cautiously in elderly or debilitated patients and in patients with hepatic or
renal disease
• Also use cautiously in those exposed to extreme hear or cold

DRUG INTERACTION:

• Acetylcholinesterase inhibitors (central): May increase the risk of antipsychotic-

related extrapyramidal symptoms; monitor.

• Aluminum salts: May decrease the absorption of phenothiazines; monitor

• Amphetamines: Efficacy may be diminished by antipsychotics; in addition,

amphetamines may increase psychotic symptoms; avoid concurrent use

• Anticholinergics: May inhibit the therapeutic response to phenothiazines and

excess anticholinergic effects may occur; includes benztropine, trihexyphenidyl,
biperiden, and drugs with significant anticholinergic activity (TCAs,
antihistamines, disopyramide)

• Antihypertensives: Concurrent use of phenothiazines with an antihypertensive

may produce additive hypotensive effects (particularly orthostasis)

• Bromocriptine: Phenothiazines inhibit the ability of bromocriptine to lower serum

prolactin concentrations

• CNS depressants: Sedative effects may be additive with phenothiazines; monitor

for increased effect; includes barbiturates, benzodiazepines, opioid analgesics,
ethanol and other sedative agents

• CYP2D6 inhibitors: May increase the levels/effects of chlorpromazine. Example

inhibitors include delavirdine, fluoxetine, miconazole, paroxetine, pergolide,
quinidine, quinine, ritonavir, and ropinirole.

• CYP2D6 substrates: Chlorpromazine may increase the levels/effects of CYP2D6

substrates. Example substrates include amphetamines, selected beta-blockers,

116
 dextromethorphan, fluoxetine, lidocaine, mirtazapine, nefazodone, paroxetine,
risperidone, ritonavir, thioridazine, tricyclic antidepressants, and venlafaxine.

• CYP2D6 prodrug substrates: Chlorpromazine may decrease the levels/effects of

CYP2D6 prodrug substrates. Example prodrug substrates include codeine,
hydrocodone, oxycodone, and tramadol.

• Epinephrine: Chlorpromazine (and possibly other low potency antipsychotics)

may diminish the pressor effects of epinephrine

• Guanethidine and guanadrel: Antihypertensive effects may be inhibited by

chlorpromazine

• Levodopa: Chlorpromazine may inhibit the antiparkinsonian effect of levodopa;

avoid this combination

• Lithium: Chlorpromazine may produce neurotoxicity with lithium; this is a rare

effect

• Metoclopramide: May increase extrapyramidal symptoms (EPS) or risk.

• Phenytoin: May reduce serum levels of phenothiazines; phenothiazines may

increase phenytoin serum levels

• Propranolol: Serum concentrations of phenothiazines may be increased;

propranolol also increases phenothiazine concentrations

• Polypeptide antibiotics: Rare cases of respiratory paralysis have been reported

with concurrent use of phenothiazines

• QTc-prolonging agents: Effects on QTc interval may be additive with

phenothiazines, increasing the risk of malignant arrhythmias; includes type Ia
antiarrhythmics, TCAs, and some quinolone antibiotics (moxifloxacin)

• Sulfadoxine-pyrimethamine: May increase phenothiazine concentrations

• Tricyclic antidepressants: Concurrent use may produce increased toxicity or

altered therapeutic response

117
 • Trazodone: Phenothiazines and trazodone may produce additive hypotensive
effects

• Valproic acid: Serum levels may be increased by phenothiazines

SIDE EFFECTS:

You may experience excess drowsiness, lightheadedness, dizziness, or blurred

vision (use caution driving or when engaging in tasks requiring alertness until response to
drug is known); dry mouth, upset stomach, nausea, vomiting, anorexia (small frequent
meals, frequent mouth care, sucking lozenges, or chewing gum may help); constipation
(increased exercise, fluids, fruit, or fiber may help); postural hypotension (use caution
climbing stairs or when changing position from lying or sitting to standing); urinary
retention (void before taking medication); ejaculatory dysfunction (reversible); decreased
perspiration (avoid strenuous exercise in hot environments); or photosensitivity (use
sunscreen, wear protective clothing and eyewear, and avoid direct sunlight). Report
persistent CNS effects (trembling fingers, altered gait or balance, excessive sedation,
seizures, unusual movements, anxiety, abnormal thoughts, confusion, personality
changes); chest pain, palpitations, rapid heartbeat, or severe dizziness; unresolved urinary
retention or changes in urinary pattern; altered menstrual pattern, change in libido,
swelling or pain in breasts (male or female); vision changes, skin rash, irritation, or
changes in color of skin (gray-blue); or worsening of condition.

NURSING RESPONSIBILITIES:

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Watch for evidence of NMS

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Use exactly as directed

118
• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from light.

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

119
GENERIC NAME:

Divalproex sodium

BRAND NAME:

Depakote

CLASSIFICATION:

Carboxylic acid derivative

MODE OF ACTION:

Unknown. Probably facilitates the effects of the inhibitory neurotransmitter GABA.

DOSAGE:

Adults and children, initially 15mg/kg P.O. or I.V. daily; then increase by 5 to 10
mg/kg daily at weekly intervals up to maximum of 60mg/kg daily.

INDICATION:

This is indicated for the treatment of simple and complex absence seizures, mixed
seizures type, complex partial seizures, mania and prevent migraine headache.

CONTRAINDICATION:

• Contraindicated in patients hypersensitive to drug and in those with hepatic

disease or significant hepatic dysfunction, and in patients with a urea cycle
disorder.
• Safety and efficacy of depakote in children younger than age 10

DRUG INTERACTION:

• Carbamazepine: may cause carbamazepine CNS toxicity: may decrease valproic

acid level and cause loss of seizure control.

120
 • Lamotrigine: may increase lamotrigine level; may decrease valproate level.
• Phenobarbital: may increase Phenobarbital level.may increase clearance of
valproate
• Phenytoin: may increase or decrease phenytoin level: may decrease valproate
level.
• Rifampin: may decreases valproate level.
• Warfarin: may displace warfarin from binding sites.
• Zidovudine: may decrease zidovudine clearance

SIDE EFFECTS:

Side effects of this drug includes asthenia, dizziness, headache, insomnia,

nervousness, somnolence, tremor, abnormal thinking, amnesia, ataxia, depression,
emotional upset, fever, chest pain, edema, hypertension, hypotension, tachycardia,
blurred vision, diplopia, nystagmus, pharyngitis, rhinitis, tinnitus, abdominal pain,
anorexia, diarrhea, dyspepsia, nausea, vomiting, pancreatitis, constipation, increased
appetite, bone marrow suppression, hemorrhage, thrombocytopenia, bruising, petechiae,
hepatotoxicity, weight gain and loss, dyspnea, bronchitis, alopecia, flu syndrome,
infection, rash etc.

NURSING RESPONSIBILITIES:

• Obtain liver function tests results, platelet count, and PT and INR before starting
the therapy, and monitor these values periodically

• Don’t give syrup to patients who need sodium restriction

• Adverse reaction may not be caused by valproic acid alone

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Tell patient to take drug with food or milk to reduce adverse GI effects

• Advise patient not to chew capsules; irritation of mouth and throat may result

121
• Tell patient that capsules may be either swallowed whole or carefully opened and
contents sprinkled on a teaspoonful of soft food. Tell patient to swallow
immediately without chewing.

• Consult your doctor immediately if you experience abnormal movements,

particularly of the face, lips, jaw and tongue, while taking this medicine. These
symptoms may be indicative of a rare side effect known as tardive dyskinesia, and
your doctor may ask you to stop taking this medicine, or decrease your dose.

• Consult your doctor immediately if you experience the following symptoms while
taking this medicine: high fever, sweating, muscle stiffness, faster breathing and
drowsiness or sleepiness. These symptoms may be due to a rare side effect known
as the neuroleptic malignant syndrome, and your treatment may need to be
stopped.

• Use exactly as directed

• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from reach of children

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

122
GENERIC NAME:

Flupenthixol

BRAND NAME:

Fluanxol

CLASSIFICATION:

antipsychotic

MODE OF ACTION:

Fluanxol (generic name flupenthixol) is an antipsychotic that may be prescribed

to alleviate psychotic features such as paranoia and hallucinations sometimes associated
with extreme mood swings in those with bipolar disorder (manic depression)..

DOSAGE:
Injection
Flupenthixol is administered by deep i.m. injection, preferably in the gluteus
maximus. Flupenthixol is NOT for i.v. use.
As a long acting depot preparation, flupenthixol has been found useful in the maintenance
treatment of non agitated chronic schizophrenic patients who have been stabilized with
short acting neuroleptics and might benefit from transfer to a longer acting injectable
medication. The changeover of medication should aim at maintaining a clinical outcome
similar to or better than that obtained with the previous therapy. To achieve and maintain
the optimum dose, the changeover from other neuroleptic medication should proceed
gradually and constant supervision is required during the period of dosage adjustment in
order to minimize the risk of overdosage or insufficient suppression of psychotic
symptoms before the next injection.
Patients not previously treated with long acting depot neuroleptics should be given an
initial test dose of 5 mg (0.25 mL) to 20 mg (1.0 mL). An initial dose of 20 mg (1.0 mL)
is usually well tolerated; however, a 5 mg (0.25 mL) test dose is recommended in elderly,
frail and cachectic patients, and in patients whose individual or family history suggests a
predisposition to extrapyramidal reactions. In the subsequent 5 to 10 days, the therapeutic
response and the appearance of extrapyramidal symptoms should be carefully monitored.
Oral neuroleptic drugs may be continued, but in diminishing dosage, during this period.

123
In patients previously treated with long acting depot neuroleptics who displayed good
tolerance to these drugs, an initial dose of 20 to 40 mg (1.0 to 2.0 mL) may be adequate.
Subsequent doses and the frequency of administration must be determined for each
patient. There is no reliable dosage comparability between a shorter acting neuroleptic
and depot flupenthixol, and, therefore, the dosage of the long acting drug must be
individualized.
Except in particularly sensitive patients, a second dose of 20 (1.0 mL) to 40 mg (2.0 mL)
can be given 4 to 10 days after the initial injection. Subsequent dosage adjustments are
made in accordance with the response of the patient, but the majority of patients can be
adequately controlled by 20 to 40 mg (1.0 to 2.0 mL) of flupenthixol 2% every 2 to 3
weeks. The optimal amount of the drug has been found to vary with the clinical
circumstances and individual response. Doses greater than 80 mg (4.0 mL) are usually
not deemed necessary, although higher doses have been used occasionally in some
patients.
Although the response to a single injection usually lasts for 2 to 3 weeks, it may last for 4
weeks or more, particularly when higher doses are used. Since higher doses increase the
incidence of extrapyramidal reactions and other adverse effects, the amount of drug used
should not be increased merely in order to prolong the intervals between injections. With
higher doses there may also be more variability in the action of flupenthixol and,
therefore, unit dose increments should not exceed 20 mg (1.0 mL). After an appropriate
dosage adjustment is achieved, regular and continuous supervision and reassessment is
considered essential in order to permit any further dosage adjustments that might be
required to ensure use of the lowest effective individual dose and avoid troublesome side
effects.
Patients who require higher doses of flupenthixol to control symptoms of schizophrenia
and/or those who complain of discomfort with a large injection volume may be
administered flupenthixol 10% (100 mg/mL) in preference to flupenthixol 2% (20
mg/mL).
As with all oily injections it is important to ensure, by aspiration before injection, that
inadvertent intravascular injection does not occur.
Tablets:
The dosage should be individualized and adjusted according to the severity of
symptoms and tolerance to the drug. The initial recommended dose is 1 mg, 3 times
daily. This may be increased, if necessary by 1 mg every 2 to 3 days until there is
effective control of psychotic symptoms. The usual maintenance dosage is 3 to 6 mg
daily in divided doses, although doses of up to 12 mg daily or more have been used in
some patients.
During the initial therapeutic period, disturbance of sleep may occur, especially in those
patients who have previously received neuroleptics possessing a marked sedative effect.
In this event, the evening dose may be reduced.

124
Until further clinical evidence is available, it is not recommended for use in children.
Following stabilization on flupenthixol dihydrochloride tablets, patients may be treated
with flupenthixol decanoate administered by the i.m. route.

INDICATION:
The maintenance therapy of chronic schizophrenic patients whose main
manifestations do not include excitement, agitation or hyperactivity.
CONTRAINDICATION:
In patients with known hypersensitivity to the thioxanthenes. The possibility of cross-
sensitivity between the thioxanthenes and phenothiazine derivatives should be
considered.
Flupenthixol is also contraindicated in the presence of CNS depression due to any cause,
comatose states, suspected or established subcortical brain damage, blood dyscrasias,
pheochromocytoma, liver damage, cerebrovascular or renal insufficiency, and severe
cardiovascular disorders. It is not indicated for the management of severely agitated
psychotic patients, psychoneurotic patients or geriatric patients with confusion and/or
agitation. As with phenothiazines, flupenthixol should not be used concomitantly with
large doses of hypnotics due to the possibility of potentiation.
Pregnancy and Lactation:
Safety in pregnancy has not been established. Therefore, it should not be administered to
women of childbearing potential or during lactation, unless, in the opinion of the
physician, the expected benefit to the patient outweighs the potential risk to the fetus or
child.
Children:
Safety and efficacy in children have not been established, and its use is not recommended
in the pediatric age group.
DRUG INTERACTION:
There may be an interaction between flupenthixol and any of the following:

• epinephrine

• levodopa

• medications that cause drowsiness

• methyldopa

• metoclopramide

• other schizophrenia medications

• pemoline

125
 • pimozide

• promethazine

• quinidine

• tricyclic antidepressants

• trimeprazine
If you are taking any of these medications, speak with your doctor or pharmacist.
Depending on your specific circumstances, your doctor may want you to:

• stop taking one of the medications,

• change one of the medications to another,

• change how you are taking one or both of the medications, or

• Leave everything as is.

ADVERSE EFFECTS
Extrapyramidal symptoms have occurred in up to 30% of patients. Flupenthixol shares
many of the pharmacologic properties of other thioxanthenes and phenothiazines.
Therefore, the known adverse reactions of these drugs should be borne in mind when
flupenthixol is used.
CNS:
Extrapyramidal symptoms, including hypo- and hyperkinetic states, tremors,
pseudoparkinsonism, dystonia, hypertonia, akathisia, oculogyric crises, opisthotonos,
hyperreflexia and tardive dyskinesia (see below). The symptoms, if they are to occur,
usually appear within the first few days of drug administration and can usually be
controlled or totally curtailed by reduction in dosage and/or standard anticholinergic
antiparkinsonian medication. The incidence of extrapyramidal symptoms appears to be
more frequent with the first few injections of flupenthixol, and diminish thereafter. The
routine prophylactic use of antiparkinsonian medication is not recommended.
Extrapyramidal reactions may be alarming, and patients should be forewarned and
reassured.
Other CNS effects reported with flupenthixol include restlessness, insomnia, overactivity,
psychomotor agitation, hypomania, epileptiform convulsions, headache, drowsiness,
somnolence, depression, fatigue, and anergia.
Persistent Tardive Dyskinesia:
As with other antipsychotic agents, tardive dyskinesia may appear in some patients on
long-term therapy or may occur after drug therapy has been discontinued. The risk seems
to be greater in elderly patients on high dose therapy, especially females. The symptoms

126
are persistent and in some patients appear to be irreversible. The syndrome is
characterized by rhythmical involuntary movements of the tongue, face, mouth, or jaw
(e.g. protrusion of tongue, puffing of cheeks, puckering of mouth, chewing movements).
Sometimes these may be accompanied by involuntary movements of the extremities.
There is no known effective treatment for tardive dyskinesia; antiparkinsonian agents
usually do not alleviate the symptoms of this syndrome. It is suggested that all
antipsychotic agents be discontinued if these symptoms appear. Should it be necessary to
reinstitute treatment, or increase the dosage of the agent, or switch to a different
antipsychotic agent, the syndrome may be masked. The physician may be able to reduce
the risk of this syndrome by minimizing the unnecessary use of neuroleptic drugs and
reducing the dose or discontinuing the drug, if possible, when manifestations of this
syndrome are recognized, particularly in patients over the age of fifty. It has been
reported that fine vermicular movements of the tongue may be an early sign of the
syndrome and if the medication is stopped at that time, the syndrome may not develop.
Autonomic Nervous System:
Dry mouth, blurred vision, constipation, excessive salivation, excessive perspiration,
nausea, difficulty in micturition, dizziness, palpitations and fainting have been observed
with flupenthixol but are uncommon. Miosis, mydriasis, paralytic ileus, polyuria, nasal
congestion, glaucoma, tachycardia, hypotension, hypertension, fluctuations in blood
pressure, non specific ECG changes and cardiac arrhythmias have been reported with
related drugs. If hypotension occurs, epinephrine should not be used as a pressor agent
since a paradoxical further lowering of blood pressure may result.
Metabolic and Endocrine:
Weight change, galactorrhea, elevation in serum prolactin levels, impotence, loss of
libido, and sexual excitement have been reported with flupenthixol. Related drugs have
been also associated with breast enlargement, menstrual irregularities, false positive
pregnancy tests, peripheral edema, gynecomastia, hypo- and hyperglycemia and
glycosuria.
Toxic and Allergic:
Eosinophilia, jaundice and increased levels of AST (SGOT), ALT (SGPT) and alkaline
phosphatase have been reported with flupenthixol. Other antipsychotic drugs have been
associated with leukopenia, agranulocytosis, thrombocytopenic or nonthrombocytopenic
purpura, hemolytic anemia and pancytopenia. If any soreness of the mouth, gums or
throat or any symptoms of upper respiratory infection occur and confirmatory leukocyte
count indicates cellular depression, therapy should be discontinued and other appropriate
measures instituted immediately.
Skin reactions, such as pruritus, rash, urticaria, erythema, seborrhea, eczema, exfoliative
dermatitis, and contact dermatitis have been reported with flupenthixol or related drugs.
The possibility of anaphylactoid reactions occurring in some patients should be borne in
mind.

127
NURSING RESPONSIBILITIES:

• Obtain liver function tests results, platelet count, and PT and INR before starting
the therapy, and monitor these values periodically

• Don’t give syrup to patients who need sodium restriction

• Adverse reaction may not be caused by valproic acid alone

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Tell patient to take drug with food or milk to reduce adverse GI effects

• Advise patient not to chew capsules; irritation of mouth and throat may result

• Tell patient that capsules may be either swallowed whole or carefully opened and
contents sprinkled on a teaspoonful of soft food. Tell patient to swallow
immediately without chewing.

• Consult your doctor immediately if you experience abnormal movements,

particularly of the face, lips, jaw and tongue, while taking this medicine. These
symptoms may be indicative of a rare side effect known as tardive dyskinesia, and
your doctor may ask you to stop taking this medicine, or decrease your dose.

• Consult your doctor immediately if you experience the following symptoms while
taking this medicine: high fever, sweating, muscle stiffness, faster breathing and
drowsiness or sleepiness. These symptoms may be due to a rare side effect known
as the neuroleptic malignant syndrome, and your treatment may need to be
stopped.

128
• Use exactly as directed

• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from reach of children

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

129
GENERIC NAME:

biperiden hydrochloride

BRAND NAME:

Akineton

CLASSIFICATION:

Anticholinergic agent

MODE OF ACTION:

Biperiden has an atropine-like blocking effect on all peripheral structures which

are parasympathetic-innervated (e.g. cardiovascular and visceral organs). It also has a
prominent central blocking effect on M1 receptors. It works by helping to correct the
chemical imbalance thought to cause Parkinson-type disorders.

DOSAGE:

Strictly individual. Oral, and in some countries, IV and IM use is possible. The
usual oral daily doses are between 2 and 16mg. If possible, patients should be started
with a low initial dose which is increased slowly.

INDICATION:
Biperiden is used for the adjunctive treatment of all forms of Parkinson's disease
(postencephalitic, idiopathic, and arteriosclerotic). It seems to exert better effects in the
postencephalitic and idiopathic than in the arteriosclerotic type. Biperiden is also
commonly used to improve parkinsonian signs and symptoms related to antipsychotic
drug therapy. It relieves muscle rigidity, reduces abnormal sweating and salivation,
improves abnormal gait, and to lesser extent, tremor.
CONTRAINDICATION:
130
 • Hypersensitivity to biperiden
• Narrow angle glaucoma
• Ileus
• Caution : Patients with obstructive diseases of the urogenital tract, patients with a
known history of seizures and those with potentially dangerous tachycardia
• It can cause an acute organic psychosyndrome. Due to that some drug addicts
make use of it.
DRUG INTERACTIONS:
• Other anticholinergic drugs (e.g. spasmolytics, antihistamines, TCAs) : Side
effects of biperiden may be increased.
• Quinidine : Increased anticholinergic action (particular on AV conduction).
• Antipsychotics : Long term use of biperiden may mask or increase the risk of
tardive dyskinesia.
• Pethidine (meperidine) : Central effects and side effects of pethidine may be
increased.
• Metoclopramide : Action of metoclopramide is decreased.
• Alcohol : Risk of serious intoxication.
SIDE EFFECTS:
Dose-dependent side effects are frequent. Particularly geriatric patients may react with
confusional states or develop delirium.
• CNS : Drowsiness, vertigo, headache, and dizziness are frequent. With high doses
nervousness, agitation, anxiety, delirium, and confusion are noted. Biperiden may
be abused due to a short acting mood-elevating and euphoriant effect. The normal
sleep architecture may be altered (REM sleep depression). Biperiden may lower
the seizure-threshold. Some instances of dementia have been noted to correllate
with chronic administration of anticholinergic medications such as Biperiden for
Parkinson's disease.[1]
• Peripheral side effects : Blurred vision, dry mouth, impaired sweating, abdominal
discomfort, and obstipation are frequent. Tachycardia may be noted. Allergic skin
reactions may occur. Parenteral use may cause orthostatic hypotension.
• Eyes : Biperiden causes mydriasis with or without photophobia. It may precipitate
narrow angle glaucoma.

131
NURSING RESPONSIBILITIES:

• Obtain liver function tests results, platelet count, and PT and INR before starting
the therapy, and monitor these values periodically

• Don’t give syrup to patients who need sodium restriction

• Adverse reaction may not be caused by valproic acid alone

• Obtain baseline blood pressure before therapy and monitor regularly

• Don’t withdraw drug abruptly unless required by severe adverse reactions

• Protect liquid concentrations from light. Dilute with fruit juice, milk or semisolid
food just before giving

• Monitor patient for tardive dyskinesia which may occur after prolonged use

Teach patient:

• Tell patient to take drug with food or milk to reduce adverse GI effects

• Advise patient not to chew capsules; irritation of mouth and throat may result

• Tell patient that capsules may be either swallowed whole or carefully opened and
contents sprinkled on a teaspoonful of soft food. Tell patient to swallow
immediately without chewing.

• Consult your doctor immediately if you experience abnormal movements,

particularly of the face, lips, jaw and tongue, while taking this medicine. These
symptoms may be indicative of a rare side effect known as tardive dyskinesia, and
your doctor may ask you to stop taking this medicine, or decrease your dose.

• Consult your doctor immediately if you experience the following symptoms while
taking this medicine: high fever, sweating, muscle stiffness, faster breathing and
132
 drowsiness or sleepiness. These symptoms may be due to a rare side effect known
as the neuroleptic malignant syndrome, and your treatment may need to be
stopped.

• Use exactly as directed

• Do not increase dose or frequency.

• Do not discontinue this medication without consulting prescriber.

• Tablets may be taken with food.

• Do not take within 2 hours of any antacid.

• Store away from reach of children

• Avoid alcohol or caffeine and other prescription or OTC medications not

approved by prescriber.

• Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict

fluid intake.

• May turn urine red-brown (normal).

• Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to

become pregnant. Breast-feeding is not recommended.

133
 NURSING
CARE PLAN

134
135
DATE CUES NEE NURSING OBJECTIVES NURSING EVALUATIO
D DIAGNOSIS INTERVENTIONS N
A Subjective: R Dysfunctional Within 3-4hrs 1. Determine GOAL MET
U “pirmi wala O Family Processes span of care, understanding of
G akong mama L related to abuse of patient will be current situation The patient
U sa balay, kay E substances. able: and previous was able to
S nagatrabaho - • To methods of understand
T man gud siya R initiate coping with life’s how to take
mao na maka- E and plan problems. action to
12, gawas gawas L ® Psychosocial, for ® provides info on change his
jud k okay A spiritual, and necessar which to base behavior that
2008 wala man T physiological y present plan of care. contributes to
mubawal sa I functions of the lifestyle client’s
@ ako.” O family unit are changes 2. Assess current substance
as verbalized N chronically • To level of abuse.
by the patient. S disorganized which understa functioning of
10:15 H leads to conflict, nd the family members
am Objective: I denial of problems, side ® Affects
 Close P resistance to effects if individual’s ability to
family change, ineffective substanc cope with situation
communica P problem solving, es are
tion A and a series of self being 3. Determine extent
 Loss of T perpetuating abused of enabling
control of T crises. • To set behaviors being
using drugs E Bibliography: goals evidenced by
 Inability R Nurse’s pocket that family members,
to express N guide. 10 edition
th
requires explore with each
once anger by Doenges, changes individual and
and Moorhouse and within his client.
problem. Murr. habit and ® Enabling is doing
to be for the client what
able to he/she needs to do
live for self. People want

136
without to be helpful and do
drugs. not want to feel
powerless to help
their loved one stop
substance use and
change the behavior
that is so
destructive.

4. Identify and
discuss sabotage
behaviors of
family members.
® Even though
family members
verbalize a desire for
the individual to
become substance
free, the reality of
interactive dynamics
is that they may
unconsciously not
want the individual
to recover because
this would affect the
family members’
own role in the
relation.
5. Encourage
participation in
the therapeutic
writing; e.g.,
journaling,

137
 guided, or
focused.
® Serves as a
release for feelings,
helps move
individual forward in
treatment process.

6. Provide factual
information to
client and family
about the efforts
of addictive
behaviors on the
family and what
to expect after
discharge.
® Many clients are
not aware of the
nature of addiction.
If client is using
legally obtained
drugs, he or she may
believe this doesn’t
constitute abuse.

138
DATE CUES NEED NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
J S: “naay naga A Ineffective airway Within 1-2 hours 1. Check Vital Signs. Goal Met
U bara na sip-on sa C clearance related to of care, client will ® Serves as baseline data.
L akong ilong ug gi- T retained mucous be able to At the end of my
Y ubo pud ko bantug I secretions. expectorate 2. Position client in a high back shift, the client is
wala kaayo ko V phlegm. rest position. able to
22, nakatulog” I ® There is an ® Gives airway which increases expectorate
T accumulation of air supply. phlegm.
2008 O: Y mucous.
>restlessness - 3. Encourage client to drink lots of
@ noted E fluids.
>cough noted X ® Fluids liquefy secretions.
8:00am >nasal secretions E
noted R 4. Encourage deep breathing and
>RR:28 C coughing exercise.
I ® Helps in expectorating phlegm.
S
E 5. Administer expectorants as
ordered by doctor.
P ® Expectorants aids in carrying
A out phlegm.
T
T
E
R
N

139
DATE CUES
A Subjective:
U C
G The client verbalizes
U “Kapoy may guy
S maligo”.
T I
22 , Objective:
2008 > foul odor noted
@ > nails are not
trimmed and unclean
8:00am
> clothes are dirty
NEEDS NURSING
DIAGNOSIS
A Self – care deficit
specifically
T bathing/hygiene
I related to decreased
V motivation as
evidenced by poor
T general appearance.
Y increased with time.
- ® Self-care is
E personal health
X maintenance. It is
E any activity of an
R individual, family
C or community, with
I the intention of
S improving or
E restoring health, or
treating or
P preventing disease.
A It is exercising to
T maintain physical
T fitness and good
E mental health. It is
R also may expanded
N to include the
practices used by
the client to
promote health, the
individual
responsibility for
self, a way of
OBJECTIVES NURSING INTERVENTION EVALUATION
After my 3 hour 1. Determine existing conditions August 22.2008 @
span of care the affecting ability of individual to 11:00
client will be able care for own needs.
to verbalize ® To identify causative factors. Goal Met:
knowledge of
health care 2. Note whether deficit is temporary The client was
practices. or permanent, should decrease or able to verbalize
knowledge of
® To assess degree of disability. health care
practices.
3. Promote client participation in
problem identification and decision
making
® Enhance commitment to plan,
optimizing outcomes.
4. Provide for communication
among those who are involve in
caring for the client.
® Enhance coordination and
continuity of care.
5. Assist with necessary adaptations
to accomplish Activities of Daily
Living. Begin with familiar, easy
accomplished task.
® Encourage client and build on
successes.
6. Assist the client to become aware
of rights and responsibilities in
140
thinking. Self care health/ health care and to assess
deficit is the own health strengths – physical,
impaired ability to emotional, and intellectual.
perform bathing ® For the Client to become aware
and hygiene. responsibilities.

Bibliography: 7. Support client in making health –

related decisions and assist in
Nurse's Pocket developing self-care practices and
Guide 10th edition goals that promote health.
by Doenges, ® To facilitate clients ability in
Moorhouse and setting goals
Murr
8. Provide for ongoing evaluation
of self-care program, identifying
progress and needed changes.
® To Monitor development of self
care.

141
DATE CUES NEEDS NURSING OBJECTIVES NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
J Subjective: S Sleep pattern Within span of care 1. Encourage the patient to regulate At the end of my shift:
U “kapoy ko L disturbances the patient will be sleeping patterns by rising at the same
L kay sayo mi E related to able to: time every day and getting the same GOAL MET
Y gimata, E environmental amount of rest each night.
wala pa jud P factors such as ® To develop good sleeping habits. The client identifies
ko tarong bed bugs and  Identify appropriate
22, tulog” as poor ventilation appropriate 2. Develop a bedtime schedule for the interventions to
verbalized R interventions patient to follow, such as taking a warm promote sleep.
by the E to promote bath, eating a light snack and drinking a
2008 client. S ®Time-limited sleep glass of milk, listening to music, and
T disruption of reading.
@ Objective: sleep (natural, ® To provide a consistent schedule that
periodic the patient identifies with sleep.
8am >frequent P suspension of
yawning A consciousness) 3. Observe or obtain feedback
T amount and from clients regarding usual
>black T quality bedtime, routines, number of
circle under E hours of sleep, time of rising,
the eye R and environmental needs
N Bibliography: ® To determine usual sleep pattern and
>daytime provide comparative baseline.
nap page 502, Nurse's
Pocket Guide by 4.Encourage the patient to avoid
Marilynn E. daytime napping
Doenges, Mary ® To avoid further disruption of the
Frances patient's sleep patterns
Moorhouse, Alice
C. Murr 5. Discuss the role played by diet and
exercise
® To minimize the effects of food,
drink, and overexertion.

142
6. Assess the patient's current sleep
patterns and the duration of the problem
® To help the patient identify problem
areas

7. Discuss previous methods the patient

has used to promote sleep.
® To encourage the use of successful
cooping methods and the development
of new skills.

8. Assess the patient's life stressors over

the past year. Use tools such as the
social readjustment rating scale.
® To evaluate potential problem areas
and determine the amount of stress the
patient is experiencing.

9. Encourage the patient to express his

or her feelings in a daily journal or
through conversation.
® To increase the patient's awareness of
his or her feelings and to provide an
opportunity to discover the relation
between these feelings and the ability to
get a restful night's sleep.

10. Discuss options the patient

has if he or she awakens during
the night.
® To increase the patient's feeling of
control over the situation and improve

143
his or her problem solving.

11. Limit fluid intake in evening if

nocturia is a problem
® To reduce need for nighttime
elimination.

12. Discuss/ implement effective age

appropriate bedtime rituals ( e.g. going
to bed the same time each night,
drinking warm milk)
® To enhance client's ability to fall
asleep, reinforce that bed is the place to
sleep.

144
145
PROGNOSIS

146
 Poor Fair Good justification
Onset of illness √ The onset of
illness wasn’t
god because he
wasn’t given an
immediate care.
He started using
drugs when he
was still 12 years
old but he was
first admitted in
the year 2007.
Duration √ The duration of
the client’s
illness is 3 years.
Precipitating
factors

a. temperament √ Bryan has an

personality introvert
attitude. He has a
high risk of
having substance
abuse problem.

b. Social √ Our client uses

drugs because of
peer pressure.
But now, the
client’s mother
has threatened
his friends to
stay away from
him.

C. Environment √
They live in a
place where
there are many
drug addicts as

147
 well as his
friends who
pressures him to
use them. Drugs
are also
available.
Any depressive √ Noted signs of
features any depressive
afeatures are not
present. The
client is active in
activities
especially in
parlor games and
is competitive
but not
hyperactive.
The client is
active in the way
that he is
coordinated with
his actions and
she gets ahead of
the rest of his
co-team player
Mood and affect √ During the
activities, we
didn’t find it
hard to make
him join us. He
was
participative.
Attitudes and √ At first He didn’t
willingness to want to be
take admitted to the
medications and rehabilitation
treatments center. His
mother had to
trick him so that
he will be
brought at the
rehabilitation
center. But now,
he said he is
taking the
medications that

148
 are prescribed to
him because he
wants to be
cured.
Family support √ The client’s
support group is
ranked as good
for the family as
a whole. They
cared enough to
send him into the
rehabilitation
Center. They
also buy the
client’s needs.
They are also
updated or
knowledgeable
on how to take
care of him.

General Prognosis:

Good:3x3=9

Fair:1x2=2

Poor: 1x5=5

Total: 19 divided by 9= 1.7(fair prognosis)

In conclusion, we rated the prognosis of our patient as fair prognosis with the average of

1.9. It is because when the symptoms of substance abuse were seen to the client he wasn’t

immediately admitted to the rehabilitation center. There is also a high risk that the client

will be able to return to his vices because he lives near his friends.

Recommendation
149
To the student nurses

Our job is to elevate the health status of our patient. It can only be done through

proper care and teachings to the patient. We should understand that they are different

from us so we should be patient enough in handling them because their needs are

different from others. It is not enough that we only talk to them without any background

about psychiatric nursing because mentally ill patients need therapeutic communication

for us to be able to have a positive interaction with them. Also, being sensitive is badly

needed in psychiatric nursing because through that we will be able to sense their thoughts

and feelings.

To the client

The client should understand his situation. Being in the rehabilitation center is the

best way for him to avoid his peers who influenced him to use substances that are bad for

his health. Taking his prescribed medication would also help him recover fast from his

illness.

To the family

150
 Understanding is the key to give him a full support. His family is considered to be

his primary support system so their presence during his rehabilitation state is of great

importance. They should make the client feel that he is loved and cared by them. After

his recovery, holistic care from the family should not stop in order for him not to search

that from others who might not be a good influence to him.

To the Community

A community is a group of interacting organisms sharing an environment. From

the definition, a group of organisms sharing an interaction means that every organism in a

community is able to affect one another. Therefore, if something goes wrong to a member

of the community, it serves as an alarm to the community and they will be aware of what

will happen to them. If provided with proper care, clients may return to live in the

community. People around the community must be attentive to the needs of others. The

community can provide support programs essential for the enhancement of the clients

who are in the hospital. The community can also offer available resources such as

hospital facilities in order to improve client’s quality of life. In order to achieve it, the

people itself in the community must be aware of what is happening to their fellow people.

REFERENCES
151
Principles and Practice of Psychiatric Nursing – 3rd Edition by Stuart and Sundeen

Essentials of Anatomy and Physiology by Seeley

Fundamentals of Nursing by Kozier

Psychiatric Mental Health Nursing 4th Edition by Sheila L. Viedebecks

Mental Health, Delmars rapid Nursing Intervention

Nurse’s pocket guide by Marilynn E. Doenges, Mary Frances Moorhouse

Nursing 2008 Drug Handbook by Lippincott

Psychiatric Nursing by Manfreda and Krampitz

An outline of psychiatric Nursing by Jesusa b.Lava

Diagnostic and Statistical Manual of Mental Disorders 4th edition

Blackwell’s Nursing Dictionary

http://www.weightwise.com/p/10286/Default.aspx

(Merriam-Webster’s Pocket Dictionary, copyright 1995, p. 172)

http://www.minddisorders.com/Py-Z/Substance-induced-psychotic-disorder.html

http://www.drug-rehabs.org/ia.php?aid=24

http://www.drkoop.com/ency/93/001522.html

http://cancerweb.ncl.ac.uk/cgi-bin/omd?drug+dependence

http://gad.about.com/od/glossary/g/substancedep.ht

http://cancerweb.ncl.ac.uk/cgi-bin/omd?substance+dependence

http://dictionary.webmd.com/terms/substance-dependence

http://www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI
=/healthatoz/Atoz/ency/substance_abuse_and_dependence.jsp

Reference: Bacon A, Granholm E, Withers N.

San Diego Joint Doctoral Program in Clinical Psychology, San

152
Diego

http://www.ncbi.nlm.nih.gov/pubmed/10085193

http://www.encyclopedia.com/doc/1O87-substancedependence.html

http://www.netdoctor.co.uk/medicines/100002424.html

http://www.drugs.com/pdr/depakote.html

http://www.drugs.com/cdi/akineton.html

http://www.wikipedia.org/wiki/Diphenhydramine

http://www.nlm.nih.gov/medlineplus/ency/article/002404.html

http://www.wikipedia.org/wiki/Lithium_carbonate

http://www.natrapharm.com/products-laractyl.html

153
 Appendices
CASTILLIONES PSYCHIATRIC HOME CARE

July 31, 2008

To whom it may concern,

Good day!

We, the students of Ateneo de Davao University- College of

Nursing of section 3E-1, would like to ask permission to conduct a
home visit to our dear client, Mr. Bryan Borongan, to gather complete
information this coming AUGUST 06, 2008 for our case study to comply
our requirements in Nursing Care Management.

We chose Mr. Bryan Borongan because first and foremost he has

a very ideal case to be studied. Second, the location of his home is
very convenient and accessible for us, the students and lastly because
of his age related to our generation.

We hope for your support and approval to make this case study
possible.

Thank you and God bless.

These are the following who will conduct a home visit:

Agustin, Jennifer Irene Labastida, Blance

Balasa, Geleez Lim, Stephanie
Beniga, Albert Leighton Madrazo, Benedict
Benjamin, Lou Bertini Mangitngit, Jeferson
Bermudez, Mae Valerie Margaja, Dominique
Buctuanon, Cherie Mae Maulion, Jhon Carls
Capistrano, Camille Mendoza, Kathreen Glaiza
Cirunay, Leonel Richard Nalzaro, Sheena
Vonn Olalo, Angeli
Cosare, Cherie Joy

________________
Mr. Richard Cheng, RN.
(Clinical Instructor)

154
________________
Ms. Evangeline Ocop, RN.
(Clinical Instructor)

July 31, 2008

Ms. Fatima Enriquez, MD

Good day!

We, the students of Ateneo de Davao University- College of

Nursing of section 3E-1, would like to ask permission to conduct a
home visit to our dear client, Mr. Bryan Borongan, to gather complete
information this coming AUGUST 06, 2008 for our case study to comply
our requirements in Nursing Care Management.

We chose Mr. Bryan Borongan because first and foremost he has

a very ideal case to be studied. Second, the location of his home is
very convenient and accessible for us, the students and lastly because
of his age related to our generation.

We hope for your support and approval to make this case study
possible.

Thank you and God bless.

These are the following who will conduct a home visit:

Agustin, Jennifer Irene Nalzaro, Sheena

Balasa, Geleez Olalo, Angel
Beniga, Albert Leighton
Benjamin, Lou Bertini
Bermudez, Mae Valerie
Buctuanon, Cherie Mae
Capistrano, Camille
Cirunay, Leonel Richard
Vonn
Cosare, Cherie Joy
Labastida, Blance
Lim, Stephanie
Madrazo, Benedict
Mangitngit, Jeferson
Margaja, Dominique
Maulion, Jhon Carls
Mendoza, Kathreen Glaiza

155
Ateneo de Davao University
August 5, 2008
College of Nursing

Dear Ma'am Patria Manalaysay,

Good day to you.

We comprise half of the students of BSN 3E (groups 1 and 3). We are

currently undergoing our exposure in Psychiatric Nursing at Mabunga
Rehabilitation Center, Maa Davao City. Among the residents, we have
chosen Mr. Bryan Borongan as our patient for our case study.

Tomorrow, August 6, 2008, we are going to conduct our home visit in

lieu of our Psychiatric Nursing Exposure which is supposedly from 8:00 to
11:00 am. Instead, we are going to two locations which are; (1) Damosa,
where Bryan's sister is located and (2) Claveria, where Bryan's mother is
working.

We are submitting this letter to inform you of our activity tomorrow

and to avoid any conflict which concerns our location during the above
mentioned date.

Thank you very much for taking time to read our letter. Have a nice
day, and may God bless you.

Your
s truly,
B
SN 3E
Group 1
and Group 3

Group 1 Group 3
Agustin, Jennifer Labastida, Blance
Balasa, Geleez Lim, Stephanie
Beniga, Albert Madrazo, Benedict
Benjamin, Lou Mangitngit, Jeferson
Bermudez, Mae Margaja, Dominique
Buctuanon, Cherie Maulion, John
Capistrano, Camille Mendoza, Glaiza
Cirunay, Lionel Nalzaro, Sheena
Cosare, Cherie Olalo, Angeli

Noted by:

Evangeline Ocop, RN.