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Mindanao Sanitarium and Hospital College Department of Nursing Tibanga, Iligan City 9200

Case Presentation

SCHIZOPHRENIA UNDIFFERENTIATED

In Partial Fulfillment of the Course PSYCHIATRIC NURSING

BSN 3B - Group 3

December 2011

Schizophrenia Undifferentiated

A PSYCHIATRIC NURSING CASE BOOK ..if any of you lack wisdom let Him ask of God that giveth to all men liberally and upbraideth not and it shall be given Him. James 1:5

RESEARCHERS Julie Rose Bularon Keith Stanley Canete Mohammad Ashraf Daluma Ma Rowena Dato Emmanuel Feril Hanieyah Guro Norjannah Maminta Carolain Omar Herna Jane Salcedo Lenie Tinoy

BSN 3B - Group 3

CLINICAL INSTRUCTOR Mrs. Fidela R. Villegas, RN

TABLE OF CONTENTS Title Cover Authors Table of Contents Acknowledgement Dedication Objectives Introduction i ii iii v vi 1 2-8

Chapter I: Assessment A. Psychiatric Nursing History 1. Vital Information 2. Informant 3. Chief Complaints 4. Personal Identification 5. History of Present Illness 6. History of Past Illness 7. Medications 8. Family History 9. Personality 10. Psychosexual History 11. Current Social Situation 12. Assets 13. Dreams, Fantasies and Value Systems B. Anamnesis C. Genogram D. Mini Mental Status Exam E. Comprehensive Mental Status Examination F. Physical Examination and Review of Systems G. Spiritual Assessment H. Diagnostic Studies 9 10 10 10 10 11-12 12 12 12 13 13 13 13 15-19 20-21 22-35 36-38 39-49 50 51-52

I. Nurses Progress Notes

53-55

Chapter II: Diagnosis and Analysis A. Psychodynamics B. Psychodynamics Concept Map C. Life Chart D. Diagnostic and Statistical Manual of Mental Disorder 56 57 58-60 61-62

Chapter III: Planning and Implementation A. Nursing Care Plans B. Psychotherapies C. Nurse Process Recording (NPI) 63-72 73-74 75-79

Chapter IV: Psychopharmacology Chapter V: Discharge Plan Chapter VI: Evaluation A. Prognosis B. Recommendation

80-83 84-86

87 88-89

Glossary Bibliography/ References

90 91

ACKNOWLEDGEMENT

We, the BSN 3B - Group 3, would like to extend our deepest gratitude to those people that whole-heartedly helped us and take part for the success of our case presentation in Psychiatric Nursing. This case presentation was not a product of mere mediocrity instead the combination of efforts time and dedication by each members of the group. But those courage, pursuits and sleepless nights will be nothing without the help of those people. Thank you so much! First of all to God, who protected us and guide us along the way, whichs ever faithful in making all things possible. To our parents, who not only financially supported, but also in believing in our capabilities to pursue our dreams. To our friends and loved ones who give us courage in times of despair, who draws smiles on our face in times of disappointments and reaching their hands in times of distress and failure. To our beloved clinical instructor, Mrs. Fidela Villegas, who imparted her knowledge, for guiding and leading us in the right path; for patience, for acknowledging our strengths and weaknesses and help us overcome circumstances throughout the psychiatric nursing exposure. To our CP patient, for sharing us his life, experiences, failures, success and happiness, we owe the best to you- God bless you! To our patients family and friends, thank you for accepting us with open arms and giving us information vital to this paper. Once again, thank you so much!

---- BSN Level III- Section B - Group

DEDICATION

We dedicate this case study to Mr. Schitz, who in despite of his condition, willingly cooperated and shared us his life, failures and success for this study to be possible. God Speed!

OBJECTIVES

Patient centered: Within 1 and hour of case presentation: 1. The patients diagnosis will be discussed and be fully understood by the students. 2. The patients medications and treatments will be reviewed and be reinforced appropriately. 3. The patients manifestations will be examined and will be explained their etiologies. 4. Necessary nursing interventions appropriate to the patients case will be identified and discussed.

Student - Centered: After 1 and hours of case presentation, the presentors will be able to:

1. Present the case clearly, with validity and consistency. 2. Identify the precipitating and predisposing factors that contributed to the development of the patients condition. 3. Identify the signs and symptoms displayed by the patient and trace their causes. 4. Discuss appropriate nursing interventions in helping the client to achieve recommended goals. 5. Answer questions and clarifications politely, and be able to recognize suggestions raised both by the CIs and the critique group. After 1 and hour of case presentation, the critique group will: 1. Have full understanding of the patients case. 2. Ask sensible questions or make clarifications of the vague datas. 3. Make necessary suggestions for the improvement of the study.

INTRODUCTION: Schizophrenia

Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long lasting. The disorder usually begins before age 25, persists throughout life, and affects persons of all social classes. Although schizophrenia is discussed as if it is a single disease, it probably comprises a group of disorders with heterogeneous etiologies, and it includes patients whose clinical presentations, treatment response, and courses of illness vary. There is no laboratory test for schizophrenia.

HISTORY Eugene Bleuler Bleuler coined the term schizophrenia. He chose the term to express the presence of schisms between thought, emotion, and behavior in patients with the disorder. Bleuler stressed that, unlike Kraepelin's concept of dementia precox, schizophrenia need not have a deteriorating course. This term is often misconstrued, especially by lay people, to mean split personality. Split personality, called dissociative identity disorder, in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) differs completely from schizophrenia. The Four As Bleuler identified specific fundamental (or primary) symptoms of schizophrenia to develop his theory about the internal mental schisms of

patients. These symptoms included associational disturbances of thought, especially looseness, affective disturbances, autism, and ambivalence,

summarized as the four As: associations, affect, autism, and ambivalence. Bleuler also identified accessory (secondary) symptoms, which included those symptoms that Kraepelin saw as major indicators of dementia precox: hallucinations and delusions.

SYMPTOMS The symptoms of schizophrenia are divided into two major categories: positive or hard symptoms/signs and negative or soft symptoms/signs.
Positive Hard Symptoms Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation Associative looseness: Fragmented or poorly related thoughts and ideas Delusions: Fixed false beliefs that have no basis in reality Echopraxia: Imitation of the movements and gestures of another person whom the client is observing Flight of ideas: Continuous flow of Negative or Soft Symptoms Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feelings of indifference toward

people, activities, and events Blunted affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

verbalization in which the person jumps rapidly from one topic to another Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality Ideas of reference: False impressions that external events have special meaning for the person

Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

TYPES The following are the types of schizophrenia according to the DSM-IV-TR (APA, 2000). The diagnosis is made according to the clients predominant symptoms: Schizophrenia, paranoid type: characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior. Schizophrenia, disorganized type: characterized by grossly

inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type: characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echopraxia. Schizophrenia, undifferentiated type: characterized by mixed

schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior Schizophrenia, residual type: characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations.

ETIOLOGY 1. Physiological a. Genetics. Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population. Whereas the lifetime risk for developing schizophrenia is about 1 percent in most population studies, the siblings or offspring of an identified client have a 5 to 10 percent risk of developing schizophrenia (Ho, Black, & Andreasen, 2003). Twin and adoption studies add additional evidence for the genetic basis of schizophrenia. b. Histological Changes. Jonsson and associates (1997) have suggested that schizophrenic disorders may in fact be a birth defect, occurring in the hippocampus region of the brain, and related to an influenza virus encountered by the mother during the second trimester of pregnancy. The studies have shown a disordering of the pyramidal cells in the brains of schizophrenics, but the cells in the brains of nonschizophrenic individuals appeared to be arranged in an orderly fashion. Further research is required to determine the possible link between this birth defect and the development of schizophrenia. c. The Dopamine Hypothesis. This theory suggests that schizophrenia (or schizophrenia-like symptoms) may be caused by an excess of dopaminedependent neuronal activity in the brain. This excess activity may be related to increased production or release of the substance at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms (Sadock & Sadock, 2003). d. Anatomical Abnormalities. With the use of neuroimaging

technologies, structural brain abnormalities have been observed in individuals with schizophrenia. Ventricular enlargement is the most consistent finding; however, sulci enlargement and cerebellar atrophy are also reported.

2. Environmental a. Sociocultural Factors. Many studies have been conducted that have attempted to link schizophrenia to social class. Indeed epidemiological statistics have shown that greater numbers of individuals from the lower socioeconomic classes experience symptoms associated with schizophrenia than do those from the higher socioeconomic groups (Ho, Black & Andreasen, 2003). This may occur as a result of the conditions associated with living in poverty, such as congested housing accommodations, inadequate nutrition, absence of prenatal care, few resources for dealing with stressful situations, and feelings of hopelessness for changing ones lifestyle of poverty. An alternative view is that of the downward drift hypothesis (Sadock & Sadock, 2003). This hypothesis relates the schizophrenics move into, or failure to move out of, the low socioeconomic group to the tendency for social isolation and the segregation of self from otherscharacteristics of the disease process itself. Proponents of this notion view poor social conditions as a consequence rather than a cause of schizophrenia. b. Stressful Life Events. Studies have been conducted in an effort to determine whether psychotic episodes may be precipitated by stressful life events. There is no scientific evidence to indicate that stress causes schizophrenia. It is very probable, however, that stress may contribute to the severity and course of the illness. It is known that extreme stress can precipitate psychotic episodes (Goff, 2002). Stress may indeed precipitate symptoms in an individual who possesses a genetic vulnerability to schizophrenia. Sadock and Sadock (2003) state: The stress can be biological, environmental, or both. The environmental component can be either biological (e.g., an infection) or psychological (e.g., a stressful family situation) (p. 477). Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse.

EPIDEMIOLOGY In the United States, the lifetime prevalence of schizophrenia is about 1 percent, which means that about 1 person in 100 will develop schizophrenia during their lifetime. The Epidemiologic Catchment Area study sponsored by the National Institute of Mental Health reported a lifetime prevalence of 0.6 to 1.9 percent. According to DSM-IV-TR, the annual incidence of schizophrenia ranges from 0.5 to 5.0 per 10,000, with some geographic variation (e.g., the incidence is higher for persons born in urban areas of industrialized nations). Schizophrenia is found in all societies and geographical areas, and incidence and prevalence rates are roughly equal worldwide. In the United States, about 0.05 percent of the total population is treated for schizophrenia in any single year, and only about half of all patients with schizophrenia obtain treatment, despite the severity of the disorder. In The Philippines, sixty percent (60%) of the case of mental illness is schizophrenia. It is equally prevalent in men and women and paranoid type schizophrenia is the most common form. Onset of the case is between 15-25 years old with few patients aged after 50 years old.

RECENT UPDATES New research identifies the brain chemicals and circuits involved in mental illnesses like schizophrenia, depression, and anxiety, giving potential new directions to their treatment. In addition, research with children shows that earlylife depression and anxiety changes the structure of the developing brain. The findings were presented at Neuroscience 2011, the Society for Neuroscience's annual meeting and the world's largest source of emerging news about brain science and health. One in 17 Americans suffer from a serious mental illness, such as schizophrenia, major depression, or bipolar disorder, making it one of the leading

causes of disability. Yet science is only beginning to understand the underlying physical causes of these diseases. New findings shows Childhood anxiety and depression alter the way the amygdala connects to other regions of the brain. This finding may help explain how early life stress can lead to future emotional and behavioral issues.

PSYCHIATRIC NURSING HISTORY

A. Preliminary Identifications Name: Gender: Adress: Birthday: Birth Place: Age: Height: Weight: Marital Status: Occupation: Language: Ethnicity: Nationality: Religion: Siblings: Education: Attending Physician: Diagnosis: Source of Information: Mr. Schitz Male Poblacion, Consolacion, Cebu November 24, 1984 Inondayan, Southern Leyte 27 years old 54 Not assessed Single N/A Cebuano Cebuano Filipino Roman Catholic 9 College Undergraduate (1st year level only) Dr. Jose Lim Coruna, Psychiatrist DSM-IV-TR: Schizophrenia Undifferentiated Type Patient - 40% Patients Mother - 50% Chart - 10%

Informants:

Name: Mrs. Mommy Age: 68 yrs old Relationship: Mother Length of acquaintance: 26 yrs. Interviewers impression or Reliability: 95 %

Chief Complaints: Gidala namo siya sa ospital kay nikalit ra siyag pandapat sa bata, iyang pag-umangkon, iya dayon kong gisumbag ug gisipa as verbalized by the clients mother. Personal Identification: Patient has a scar, which measures about 1 and inch, on his forehead just above his left eyebrow. He has a three little moles on the left side of his forehead. He only have 2 upper teeth left (one left canine tooth and one left incisor tooth). History of Present Illness: Patients mother reported that when Mr. Schitz was around 5-6 years old, he was greatly affected of his parents separation. He became more silent and introvert. When he was about 11-12 years old, he was injured, he fell off from his bicycle and got a 1 and inch wound on his forehead, just above his left eyebrow. When he was in college, after the first semester of his freshman year, he dropped out because he was threatened of the people inviting him to join a fraternity. When he was about 17 years old, he worked at SM as a maintenance personnel and quitted after 2 months. He stayed at home for several years being financially dependent on his mother and siblings. He then had a job at Happyherbs as a salesman but eventually quitted after a month.He rarely had friends of the same age and spent his time mostly in his room, watching TV, listening to music, and reading books and magazines. He rarely interacted with the people around him and this bothered his mother. In 2007, he had a check up

at the Community Hospital and was prescribed with medications (name physician and of drugs prescribed cant be recalled). Last October 2011, he was admitted at VSMMC because he of persecutory delusions. He was diagnosed of Schizophrenia, paranoid type. He was then discharged after 2 weeks (exact date cant be recalled) with maintenance medications of Risperidone 2mg/tab and Biperiden 2mg/tab, with improved condition. Patient was apparently well until 4 days PTA. Patient was noted to be irritable, dali saputon, init kaayo ug ulo as claimed by his mother. 3 days PTA, patient became physically violent, associated with irritability and was talking to self. Hours PTA, patient hit a child and punched and kicked his mother. Nikalit ra siyag pandapat sa bata, iya kong gisumbag ug gisipa as verbalized by his mother, thus sought admission. History of Past Illness: Patients mother claimed that patient received a complete immunization during childhood (which may include BCG, DPT, Hep B, vaccines and Polio Drops). She also claimed that patient experienced childhood illnesses such as chickenpox, measles and mumps. She also claimed that patient easily get sick when he was still a child, and his primary health caregiver was a physician (name cant be recalled). No known allergies were reported. He hasnt undergone any surgical procedures. When he was about 6 years old, her mother started give him over the counter drugs at times when he was ill. He never met any serious accidents except the time he fell off from his bicycle which caused his scar on his forehead. He is non-hypertensive, non-diabetic and non-asthmatic. He was not diagnosed of any medical condition. He was not an alcoholic drinker but he smoked cigarette, he usually consumed at least 3 sticks a day.

Previous Admission: Patient was never admitted due to medical condition. In October 2011, rior to his recent admission, he was admitted at VSMMC with the diagnosis of Schizophrenia, paranoid type. Medications: Biperiden 2mg/tab, 1 tab daily Risperidone 2mg/tab, 1 tab BID Family History: Patient belonged to a family of moderate living. His father was a police officer in Leyte and his mother was a plain housewife. He is the tenth child and the youngest among his siblings. His father was described by his mother as a very authoritative individual. When the patient was still in his mothers womb, his father used to lock his mother because he was accusing her of having an affair, igihan kaayo iyang amahan, lakan ko niya sa kwarto adtong nagburos pako ni Mr. Schitz as verbalized by his mother. At the age of 5-6 years old, his father had an affair with another woman and this caused his parents separation.His mother could no longer tolerate his husbands infidelity so she left Leyte together with her 10 children and went to Consolacion, Cebu, where they are currently residing. His mother took the sole responsibility to sustain their living because his father never supported them financially. Mr. Schitz has a very strong relationship with his siblings and to his mother, they were his primary and only support system because he rarely had friends. His siblings started to get married one by onel and moved out from their house. Now, only him and his mother were left in their house. Personality: Patient was not an out going person but a quiet individual. His social interaction was poor and he rarely talked to other people. He dont have friends of his age, he liked playing with kids in their neighborhood. He preferred

spending his time alone in his room. He was also shy and dont feel good receiving gifts from other people except from his mother. Psychosexual History: Patient never experienced intimate relationships before as claimed by his mother. But patient claimed that he has a long-term relationship with a girl since elementary and he called her Lucilou. When asked where is she now, he replied naa sa Japan. Current Social and Living Situations: Mr. Shitz is financially dependent on his mother. He live with her in a bungalo house in Consolacion, Cebu. His siblings give him money but he always refuses to recieve anything from them. Assets: Patient has good facial features, he is quiet good looking. He is good in english as claimed by his mother. He also like assembling things. Prior to admission, he was collecting motorcycle parts to assemble one for himself. Dreams/Fantasies and Values: Patient dreamt of being a mechanical engineer. He enrolled at the University of Cebu but dropped after the first semester. Since then he became fearful of going to school. Now, when asked about his dreams, his only answer was gusto ko muuli. What is important to him now is to go home and be with his mother.

ANAMNESIS
Psychosocial History Psychosexual History Cognitive Stages of Development Stages Tasks Fixations

Stages
Prenatal and Perinatal

History
During pregnancy, the patients mother seldomly had her prenatal check-ups. She claimed that she hadnt taken any drugs or medications during the course of her pregnancy. She delivered him in full term via normal spontaneous vaginal delivery (NSVD) in their house with the help of a manghihilot. No known birth defects or complications were reported. Adtong nagburos ko niya, igihan kayo iyang amahan, iya kong lock-an sa kwarto

Stages

Age

Tasks

Stages

Age

Tasks

Infancy and Early Childhood

On infancy stage, the patient was dependent on his mother in order to meet his needs. He was breast fed from birth to 1 month and then bottle fed afterwards. He was weaned when he was around 6-7 months old. In times when his mother needs to go somewhere, the patients elder sisters were the one to look after him and provide his needs. He had good appetite and no troubles in sleeping. He started walking and standing when he was around 10 to 12 months. His first word was mama. When he was

Trust Vs. Mistrust

0-18 mos Infancy)

Viewing the world as safe and reliable; relationships nurturing, stable and dependable. (Videbeck, p.53) Palangga kaayo nako na siya (referring to the patient), siya man gud akong kamanghuran nga anak, pero usahay mabiyaan nako

Oral

0 -18 mos.

Establishing trust. Isa ra ka bulan nako na siya gibreastfed kay wala naman goy mugawas nga gatas sa akong totoy, gibottlefed nalang nako as verbalized by the mother. Thumb sucking?, wala man answered by his mother when asked if

Infancy

Primary need for bodily contact and tenderness Prototaxic mode dominates (no relation between experiences) Primary zones are oral and anal. If needs are met, infant has sense of wellbeing; unmet needs lead to dread and

- Smokes - Fearful - Mistrusting

about 2 to 3 years old, he had his bladder and anal control trained. No unusual behaviors were noted during infancy and early childhood, as claimed by his mother.

sa balay pag naa koy importante nga lakaw, iyang mga ate ra dayon ang magbantay niya. Autonom y Vs. Shame and Doubt 18 - 36 mos. (Toodler ) Achieving a sense of control and free will. Adtong bata pa siya kay magpuyo ra jud na siya unya magdula siya ra usa, pasagdaan ra pud nako siya Anal 18 - 36 mos.

the patient demonstrated

anxiety.

Toilet Training and developing sense of independence and control. Wa jud ko nagproblema ana niya sa bata pa siya kay dili jud na siya mangihi sa higdaanan, unya kung kalibangun siya kay manawag na siya nako as verbalized by his mother. Pag-hatagan siya ug kwarta sa iyang mga igsuon kay dili nya dawaton kay wala daw siyay kabayad as verbalized by his mother.

- Stinginess - Rigid thought patterns. - Introvert

Middle Childhood

At this period, the patient was noted to be shy, he didnt interact that much with other people and he cried whenever his mother leaves him at home. He experienced childhood illnesses such as measles, mumps and chicken pox in

Initiative Vs. Guilt

3-6 years (Presch ool)

Beginning development of a conscience; learning to manage conflict and anxiety Wala jud na siya katilaw ug bunal sukad

Phallic

3-5 years

Establishing sexual identity. adtong 5 years old siya, milayas mi uban akong napulo ka mga anak kay wa nako ka-

Childhood

Parents viewed as source of praise and acceptance Shift to parataxic mode (experiences are connected in sequence to

Insecurity

his childhood years, as reported by his mother. His mother claimed that the patient loved going to school but reported that he rarely played with other kids. He didnt have many friends. Both his parents loved him so much so he never experienced any punishment. When he was around 5 years old, his father had an affair with another woman, so his mother, together with her children (including the patient) left his father. Industry Vs. Inferiorit y 6 - 12 years (School Age)

paga-tawo niya, palangga kayo na siya sa iyahang papa

agwanta sa batasan sa iyang papa

each other) Primary zone is anal. Gratification leads to positive selfesteem. Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in selfdefeating patterns of behavior.

Emerging confidence in own abilities; taking pleasure in accomplishmen ts Mahina siya sa math pero maayo siya sa english; wala jud siya kareceive ug awards as claimed by his mother.

Latency

511 or 13 years

Group identification Wala kaayo na siyay kadula, sige ra siya ug puyo sa balay ug tan-aw ug TV as verbalized by his mother.

Juvenile

Shift to the sytaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). Opportunities for approval and acceptance of others. Learn to negotiate own needs Severe anxiety may result in a need to control or restrictive, prejudicial attitudes.

- Inferiority - Poor social skills.

Preadolesc ence

Move to genuine intimacy with friend of the

same sex Move away from family as source of satisfaction in relationships Major shift to syntaxic mode Capacity for attachment, love, and collaboration emerges or fails to develop. Adolescen ce Patient claimed that he had his onset of puberty when he was around 12 years old. His mother claimed that his intellectual capacity was poor. He never received any honors during his school years, but he managed to be promoted to the next level. He liked playing cheese. Listening to music and watching movies were his hobbies. Wala pa jud na siya kauyab, diri ra na siya permanente sa balay , as verbalized by his mother. He never experienced romantic relationships nor he had sexual experiences. He never tried using prohibited drugs, but he drank alcohol occasionally. He had his first job when he was around 16-17 years old. He worked at SM in the maintenance department. It was observed by his mother that he preferred Identity Vs. Role Confusio n 12 - 18 years (Adoles cent) Formulating a sense of self and belonging Burong kaayo na siya as verbalized by his mother. Genital 11 or 15 - adult Developing social control over instincts. Buotan man siya nga bata, pero kung naa siyay problema kay iya rang luom-luomon, mao lagi nga na-ing-ana siya, kay iya rang taguan as verbalized by his mother. Adolescen ce Lust is added to interpersonal equation. Need for special sharing relationship shifts to the opposite sex. New opportunities for social experimentatio n lead to the consolidation of self-esteem or self-ridicule. If the selfsystem is intact, areas of concern expand to include values, ideals, career decisions, and social concerns. - Financially dependent - Low selfesteem

being alone. He seldomly shared his thoughts and feelings, and demonstrated introvert behaviors. He had friends but not of his age, most of his friends are kids from their neighborhood. Young Adulthood The patient had a very strong relationship with his family especially with his mother. His mother reported that he never had any relationship with the opposite sex. But the patient assumed that he has a girlfriend (he was actually referring to his mother). He wanted to be a mechanical engineer, so he enrolled at the University of Cebu, in the department of Mechanical Engineering. But he dropped after the first semester because according to him, he received some invitations from fraternities inside the school and this threatened him. Intimacy Vs. Isolation 18 25/30 years (Young Adult) Forming adult, loving relationships and meaningful attachments to others. Wala pa jud na siya ka-uyab as verbalized by the mother. Naa koy uyab, si Lucilou, naa siya sa Japan, dugay name sa akong uyab, since elementary pa mi as verbalized by the patient. - Persistent isolation and aloneness - Jealousy

GENOGRAM

68

40

38

37

35

33

32

31

30

28

27

LEGEND:

- Female

- Deceased - Patient - Smoker

- Gastritis - PTB - Diarrhea and

- Male - Separated Dehydration - Close relationship

- Schizophrenia Undifferentiated

- Kidney Disease

MINI MENTAL STATUS EXAMINATION

Name of Patient: Mr Schitz

Date: November 29, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single
Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3

Attending Physician: Dr.Jose L. Coruna


Evaluation Activity SN: Unsa man ta nga adlaw karon? Pt: Tuesday. SN: Unsa man ta nga bulan karun? Pt: November. SN: Unsang tuiga karun? Pt: 2011 SN:Aha man ta karun? Pt:Vicente Sotto. SN: Naa koy ipangstorya.. dapat nimu hinumduman ha? Kay ako ipangutana sa imu taod-taod mao kini Ballpen, Manga, Tsinelas balika daw ang ako gepangstorya. Pt: ballpen, mangga. Tsinelas SN: Unsay pasabot nimo anang Honesty is the best Policy Pt: dili mamakak.

Orientation to Place Attention and Immediate Recall

1 3

1 3

Abstract Thinking

Recent Memory

SN: Karon, mangutana kog usab.. unsa tung tulo na gepahinumduman nako sa imo? Pt: Ahh.. katong manga, tsinelas ug ballpen? SN: Unsa ni? pointing on plastic bottle Pt: Sudlanan ug tubig. Mineral.. SN:Kini? pointing on a paper bag Pt: paper bag. SN: Kuhaa daw ning bola dayun e shoot sa ring. Pt: ( gekuha niya ang bola ug ge shoot sa ring ) SN: ( Write a command on a piece of paper. touch your feet and ears and instruct client to do what is written on the paper. Pt: ( the pt. Touch his feet and ears carefully) SN: pagsulat ug bisan unsa basta kay sentence. Pt: ( Write a sentence ) i am happy right now. SN: e reverse daw ang number sugod 10 padulong sa 1. Pt: 10,9,8,7,6,5,4,3,2,1

Naming Objects

Ability to follow simple verbal commands Ability to follow simple written commands

2 2

2 2

Ability to use language correctly Ability to Concentrate

3 4

3 4

Understanding spatial relationships

SN: pag drawing ug orasan, i-label dayon ang mga numbers dayon e-set sa 5:45 (alas singko kwarentay singko) Pt: ( nag draw og circle, iyang ge label ang numbers dayun ge set sa alas singko kwaretay singko) Normal

TOTAL SCORE

31

31

Assessed by:Carolain P. Omar, SN

Date: November 29. 2011 Time: 9:30 am

Name of Patient: Mr Schitz

Date: November 30, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single
Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3

Attending Physician: Dr.Jose L. Coruna


Evaluation Activity SN: Unsa man ta nga adlaw karon? Pt: Miyerkules. SN: unsa nga bulan karon? Pt: November. SN: unsang tuiga? Pt: 2011 SN: Asa man ka karon? Pt: naa ko diri sa vicente sotto hospital. SN: Sun-a daw ni.. 353445 ( repeat these numbers after few minutes ) Pt: 353445 SN: Unsay pasabot nimo sa time is gold Pt: ayaw usiki ang time. SN: Unsay color sa imung sinina ganina sa wala paka nakailis? Pt: Pink. SN:unsa mani? pointing a bag Pt: bag. SN: tungaa ug pilo.a ang papel pagkahuman e labay. Pt: ( gikuha niya ang papel, ge tunga ug gelabay dayon) SN: ( write a command on a piece of paper) touch your nose and give it to the pt. And instruct pt. To do what is written on paper. Pt: ( the pt. Read what is written on the paper and directly touch his nose.

Orientation to Place Attention and Immediate Recall Abstract Thinking Recent Memory

1 3

1 3

3 3

3 3

Naming Objects Ability to follow simple verbal commands

2 2

2 2

Ability to follow simple written commands

Ability to use language correctly

SN: pag sulat ug bisan unsa sa papel basta kay sentance nga naay subject, verb ug naa siyay sakto na meaning. Pt: ( nag sulat ang patient ud i am handsome ug ingon siya gwapo ko SN: e-reverse daw ang bulan sugod december hantod january. Pt: hmm..decenber, november, october, september , august, july, june, may, april, march, february, ug january. SN: pag drawing ug orasan, e-label dayon ang number tapos e set nimu sa alas tres (3:00) Pt: (draw a watch, and label the numbers in sequence and set the clock on 3 oclock) Normal

Ability to Concentrate

Understanding spatial relationships

TOTAL SCORE

31

31

Assessed by: Carolain P. Omar, SN Date:November 30,2011

Time: 10:30 am

Name of Patient: Mr Schitz

Date: December 2, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 26 yo Gender: Male Civil Status: Single Area of Mental Function Evaluated
Orientation to time

Attending Physician: Dr.Jose L. Coruna Evaluation Activity


SN: Mr. Schitz, unsa ta nga adlaw karun? Pt: biyernes man. SN: unsang bulana karon? Pt: December. SN: Ug unsang tuiga? Pt: 2011 SN: Asa man ka karon? Pt: Vicente Sotto Hospital gihapon SN: Sun.a daw ako ge storya. Pt: ku-an 153638. 153638

Maximum Score
3

Actual Score
3

Orientation to Place

Attention and Immediate Recall Abstract Thinking

SN: Unsay pasabot sa Be faithful to God Pt: ku-an, dapat mu simba ka sa Ginoo og motoo ka sa iyaha. SN: Unsay color sa akong bag ug sa akong ge soot gahapon? Pt: ku-an permi man ka naka puti, ga dala ka ug katong bag na itom.

Recent Memory

Naming Objects Ability to follow simple verbal commands

2 2

2 2

SN: Unsa mani? Pointing to Glass Pt: Baso nga plastic. SN: kuhaa tong nahulog na baso dayon ibutang sa lababo. Pt: ( ge kuha niya ang baso ug gebutang sa lababo ) SN: ( write on a pice of paper ) clap your hands and instruct the pt. To do what is written on the paper. Pt: ( the patient clap his hands ) SN: Sulat daw diri sa papel ug sentence Pt: ( nag sulat ang patient ) thank you so much SN: e-reverse daw ang number sugod 30 padulong 0. Pt: 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15,14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1. SN: Mag draw napod ka ug orasan, e label napod dayun nimu ang mga numbers. Ug e set sa alas 12:00 ( alas dose ) Pt: ( nag draw ug circle, iyang ge label ang ang numbers pagkahuman ge set sa 12:00 ) Normal

Ability to follow simple written commands

Ability to use language correctly Ability to Concentrate

Understanding spatial relationships

TOTAL SCORE

31

31

Assessed by: Carolain P. Omar, SN

Date:December 2, 2011 Time: 11:30 am

Name of Patient: Mr Schitz

Date: December 6, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single
Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3

Attending Physician: Dr.Jose L. Coruna


Evaluation Activity SN: mr. Schitz, unsa naman sad tang adlawa ron? Pt: Martes. SN: unsang bulana? Pt: December. AN: Unsang tuiga? SN: 2011 SN: Aha ka karon? Pt: Vicente Sotto.

Orientation to Place

Attention and Immediate Recall Abstract Thinking

SN: sun-a daw ni. 09477040 Pt: ku-an 09477040. SN: Unsay pasabot sa Dont talk when your mouth is full Pt: Ayaw storya kung puno imu baba, para dili nimo maluwa imong ge kaon (pt. Smiling) SN: Unsa nga tambal ge inum nimu ganina? Pt: Risperidon og biperiden. SN: Unsa manang ge hawiran ni Greg? pointing on a white gallon Pt: katong puti? Gallon o container. SN: kuhaa ang ballpen nahulog. Pt: ( gekuha niya ang ballpen ug gehatag nako. ) SN: ( write a command on a piece of paper ) Iwagayway ang kamay Pt: ( the pt. Wave his hands ) SN: Mr. Schitz, pag sulat ug sentence. Pt: Im watching TV now. SN: e reverse daw ang 50-0. Pt: 50, 49, 48, 47, 46, 45, 44, 43, 42, 41, 40, 39, 38, 37, 36, 35, 34, 33, 32, 31, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1. SN: Mag draw napop ta ug orasan, e label dayon ang mga numbers ug e set sa 1:45 ( ala una kwarentay singko ) Pt: ( nag draw og circle iyang ge label sa ang mga numbers pagkahuman ge set sa 1:45 (ala una kwarentay singko) Nomal

Recent Memory Naming Objects

3 2

3 2

Ability to follow simple verbal commands Ability to follow simple written commands Ability to use language correctly Ability to Concentrate

Understanding spatial relationships

TOTAL SCORE

31

31

Assessed by:Carolain P. Omar Date: December 6,2011

Time: 11:30 am

Name of Patient: Mr Schitz

Date: December 7, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3 Attending Physician: Dr.Jose L. Coruna Evaluation Activity SN: Unsang petsaha karun Mr. Schitz? Pt: 7. SN: Unsang bulana?

Pt:December. SN: unsang tuiga? Pt: 2011. Orientation to Place Attention and Immediate Recall 1 3 1 3 SN: Aha man ta karon? Pt: naa Vicente Sotto SN: Naa napod ko e-storya ha. Hinumdomi nasad mao kini. sabon, baso, plato unsa gani to? Pt: Sabon, baso ug plato. SN: Unsay pasobot nimo anang be friendly and smile to others Pt: Magbinootan para daghan amiga og mu smile ka sa uban bisan dili nimo amiga/amigo. SN: Unsa gani tong 3 na gepahinumdom nako sa imo? Pt: ku-an sabon, plato ug baso. SN: Unsa ni? Pointing on sink Pt: Lababo or gripo. SN: Ipataas daw imong wala na kamot. Pt: ( raised his left hand) SN: (write a command on a piece of paper) shake your hands with your student nurse Pt: ( pt. Shake his hands with the student nurse ) SN: Unsa man ang masulti nimo ani? ( pointing on a slipper ) Pt: Tsinelas, panlakaw na. SN: e spell daw ang ako ngalan CAROL pabali.. Pt: L-O-R-A-C SN: Pag draw og calendar nga november, ang petsa kay taman 30. Ibutang nimu ang mga adlaw ug sakto pareha ani ( letting him see the sample) Pt: ( draw a november calendar ) Normal

Abstract Thinking

Recent Memory

Naming Objects Ability to follow simple verbal commands Ability to follow simple written commands

2 2

2 2

Ability to use language correctly Ability to Concentrate

Understanding spatial relationships

TOTAL SCORE

31

29

Assessed by: Carolain P. Omar, SN Date: December 7, 2011 Time: 9:30 am

Name of Patient: Mr Schitz

Date: December 8,2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3 Attending Physician: Dr.Jose L. Coruna Evaluation Activity SN: Unsa man ta nga adlaw karon? Pt: Thursday. SN: Unsa mang bulana? Pt: December. SN: Ang tuig unsa man? Pt: 2011. SN: Aha ka karon? Pt: Naa diri vicente Sotto. SN: Usba ako e storya.. T-shirt, relo ug Ballpen. Pt: T-shirt, relo ug ballpen. SN: Unsay pasabot sa health is wealth Pt: Bahandi nato ang maayong lawas. SN: Unsa gani to ang ako gepahinumduman sa imoha? Pt: T-shirt, relo, ug ballpen. SN: Unsa mani? (pointing the crayon box) Pt: Color. SN: e kidhat daw ang inung wala na mata. Pt: ( iyang ge kidhat ang wala na mata. ) SN: Mr. Schitz, naa koy isulat sa notebook.. imung sundon ha. ( esulat imong kompleto na ngalan ) Pt: ( wrote his name ) SN: Mr. Schitz, pag construct og sentence, bisan unsa. Pt: ( he wrote ) Ako si Mr. Schitz. SN: e reverse daw ang number gkan 15 padulong 1. Pt: 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1. SN: Mag pa drawing nasad ko ug orasan ha.. pareha atong una e label nimo ug e set sa alas 11:00 am. Pt: ( nag drawing og orasan, ug ge set niya sa alas onse ( 11:00 ). Normal

Orientation to Place Attention and Immediate Recall Abstract Thinking Recent Memory

1 3

1 3

3 3

3 3

Naming Objects Ability to follow simple verbal commands Ability to follow simple written commands

2 2

2 2

Ability to use language correctly Ability to Concentrate

Understanding spatial relationships

TOTAL SCORE

31

31

Assessed by:

Carolain P. Omar, SN

Date: December 8, 2011 Time: 11:30 am

Name of Patient: Mr Schitz

Date: December 9, 2011

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: 27 yo Gender: Male Civil Status: Single
Area of Mental Function Evaluated Orientation to time Maximum Score 3 Actual Score 3

Attending Physician: Dr.Jose L. Coruna


Evaluation Activity SN: Unsa man tang adlawa ug petsaha karon? Pt: Friday. Og 9 ang petsa karon. SN: ahh.. Unsa mang bulana ug tuig ron? Pt: December, 2011. SN: Aha ka karon? Pt: Vicente Sotto. SN: Naa napod ko ipahinumdom nimo ha.. mao kini ang papel, color, ug lapis. Pt: Papel, color, ug lapis. SN: Hinumdumi na kay pangutan.on taka taodtaod ana. SN: Unsay pasabot nimu anang Always put a smile on your face Pt: dapat permika mu ngisi. SN: Unsa gani to ako gepahinumduman sa imoha? Pt: hmm. Ku-an color,papel og lapis. SN: Unsa to ang gehawidan ni TJ? ( pointing the Bible ) Pt: kana eyage hawidan kay Bible. SN: Isulat daw ang imong ngalan diri sa Bond paper, Dapat dako nga letra tanan. Complete name ha? Pt: ( wrote his complete name ) SN: Basaha og Buhata ang ge Sulat anko sa notebook Mr. Schitz Put the crayon/color inside the box. Pt: ( gekuha ang mga colors og gebutang sa box ) SN: Pag construct og sentence about sa ako-a. Pt: ( he wrote ) kaw ang akong Student Nurse. SN: e reverse daw ang worgd na CRAYON. Pt: N-O-Y-A-R-C SN: Utro nasad tag drawing sa Orasan pareha ra gihapon og e set nimo sa alas noybi traynta (9:30)

Orientation to Place

Attention and Immediate Recall

Abstract Thinking

Recent Memory

Naming Objects

Ability to follow simple verbal commands

Ability to follow simple written commands

Ability to use language correctly Ability to Concentrate Understanding spatial relationships

4 5

4 5

Pt: ( draw a watch and set to 9:30. ) TOTAL SCORE 31 31 Normal

Assessed by:

Carolain P> Omar, SN

Date: December 9, 2011 Time: 9:30 am

COMPREHENSIVE MENTAL STATUS EXAMINATION


WEEK 1 General Appearance Patient wearing white t-shirt and blue short pants with black slippers, well groomed, nails trimmed and clean, combed hair and brushed his teeth daily, take a bath everyday, seems happy while interacting with other patients near the entrance. WEEK 2 Patient wearing dark blue tshirt and dirty red short pants with black slippers, well groomed, nails trimmed and clean, combed hair and brushed his teeth daily, take a bath everyday, sometimes look depressed and sometimes happy, cooperate with his student nurse and interact with other people, take his medications and eat his breakfast, lunch and dinner. PROBLEM IDENTIFIED Social Isolation Self-care Deficit EVALUATION General appearance was assessed objectively.

General Mobility

Patient has a normal gait and posture, can walk and stand normally. Patient is normoactive, friendly, cooperative and warm. Patient has spontaneous character; organization of talk is relevant and has good accessibility.

Patient has a normal gait and posture, can walk and stand normally. Patient is normoactive, friendly, cooperative and warm. Patient has spontaneous character; organization of talk is relevant and has good accessibility.

No problem identified

General mobility was assessed objectively.

Speech Pattern

No problem identified

Speech pattern was assessed objectively.

Emotional State and Reaction

Patient has euthymic mood and Patient has euthymic mood and No problem identified appropriate flat affect with a rate appropriate flat affect with a rate of mood 8/10. Patient looks of mood 8/10. Patient looks friendly because he always friendly because he always smile, looks happy, cooperative, smile, looks happy, cooperative, obeys instructions, interacts withobeys instructions, interacts with his student nurse, easy to talk his student nurse, easy to talk with, shows interest in doing with, shows interest in doing things, loves to talk with things, loves to talk with someone who looks friendly but someone who looks friendly but he chooses sometimes people he chooses sometimes people

NPI was the key tool used to assessed patients emotional state, it was assessed subjectively.

he would like to talk with and to he would like to talk with and to be with. be with.

Thought Content

Patient likes to talk about assembling his motor vehicle and the most important thing for him is his motor and his mother. He viewed himself as a shy person, and dont want to be in a crowded and noisy place, he wanted to live in a peaceful place. He has a delusion type of erotomania in which he thinks that someone is inlove with him. He never attempt commit suicide or homicide. He didnt have preoccupation but at times he ruminates and regrets the things that he had done, like when he broke his components and when he kicked his mother. Patient is paranoid coz he didnt easily trust people like her mother and other student nurse. He chooses those persons hed like to interact with. In terms of perceptual disturbances, patient has negative hallucinations, depersonalization or derealizations nor illusions. Patient has a normal sleep, with good appetite and diurnal variation, weight and libido not assessed.

Patient likes to talk about assembling his motor vehicle and the most important thing for him is his motor and his mother. He viewed himself as a shy person, and dont want to be in a crowded and noisy place, he wanted to live in a peaceful place. He has a delusion type of erotomania in which he thinks that someone is inlove with him. He never attempt commit suicide or homicide. He didnt have preoccupation but at times he ruminates and regrets the things that he had done, like when he broke his components and when he kicked his mother. Patient is paranoid coz he didnt easily trust people like her mother and other student nurse. He chooses those persons hed like to interact with. In terms of perceptual disturbances, patient has negative hallucinations, depersonalization or derealizations nor illusions. Patient has a normal sleep, with good appetite and diurnal variation, weight and libido not assessed.

No problem identified

Questions: SN: unsa mai pinaka importante nga butang par ssa imo sir? PT: motor u gang akong mama SN: Naa ky madunggan nga maka ingun kag wa nadunngan sa uban?makit.an? PT: wala man

Neurovegetative Functions

No problem identified

Pt. sleep is assessed subjectively. SN: kamusta man imong tulog sir? PT: ok ra. SN: kamusta pud imong kaon? PT: ok ra pud. SN: unsa ma oras karun?

General Sensorium and

Patient is well oriented to

Patient is well oriented to

No problem identified

Intellectual Status

time, person and place. He is always alert, can calculate numbers, can count and can solve some mathematical question/abstract, can understands what student nurse wants him to answer and he can response slowly but surely correct, can interpret the information given to him but it takes a time before he can finalize his answers, sometimes he is able to deal with concepts; he can identify things which is not belong to the group and can give meanings when you ask him to say something about certain things, has the ability to understand certain facts and draw conclusions from relationships, can recall immediate, recent and remote memory, has an insight and his ego defense mechanism: acting out.

time, person and place. He is always alert, can calculate numbers, can count and can solve some mathematical question/abstract, can understands what student nurse wants him to answer and he can response slowly but surely correct, can interpret the information given to him but it takes a time before he can finalize his answers, sometimes he is able to deal with concepts; he can identify things which is not belong to the group and can give meanings when you ask him to say something about certain things, has the ability to understand certain facts and draw conclusions from relationships, can recall immediate, recent and remote memory, has an insight and his ego defense mechanism: denial.

PT: alas onse. SN: unsai pangalan nimu? PT: Mr. Schitz SN: naku PT: maam carol SN: aha ka karun? PT: sa VSMMC SN: 54 + 20 = ? PT: 74

PEROS
Subjective General Health Survey

WEEK 1 Objective 27 years old male, weighs 51.3 kgs, no signs of distress. Patient has symmetrical facial features, posture erect, and head midline, both feet point straight ahead all movements coordinated and smooth. Speech is clear but not loud. Patient is in proper dress and grooming. No unusual odors noted. Patient is alert and is oriented to time, place and person. Height is 5 feet 6 inches. Patient cannot recall past weight. Problem Identified Objective 27 years old male, weighs 51.3 kgs

WEEK 2 Problem Identified

okay rako, wala koy gibati. As verbalized by the patient

No Problem Identified

Self- Care Deficit

Conversant and no signs of distress. Patient has symmetrical facial features, posture erect, and head midline, both feet point straight ahead without edema, all movements coordinated and smooth. Responds appropriately. Speech is clear but not loud. Patient is not in proper dress and grooming. Unusual odors noted. Patient is alert and is oriented to time, place and person. Height is 5 feet 6 inches. Patient cannot recall past weight.

Integumentary System SN: Mr. Schitz naa kay mga katol-katol sa imong lawas? Mr. Schitz: wala man SN: Mr. Schitz singtanon ka? Mr. Schitz: Oo sauna. SN: Mr. Schitz aha man gikan ang samad na naa sa imong kilay dapit? Mr. Schitz: Na disgrasya man ko sa bike sauna. Skin color is tan and is uniform with slightly darker exposed areas. Good skin turgor. Hair is evenly distributed to all over the body. Hair in the head is evenly distributed, in black color, thick and nonbrittle, smooth and shiny, with presence of lice and dandruff. Scalp is intact and no lesions or masses as palpated. Nails on fingers and toes are non-brittle. Skin warm to touch. Axilliary temperature is 35.5C. Skin color is tan and is uniform with slightly darker exposed areas. Good skin turgor. Hair is evenly distributed to all over the body. Hair in the head is evenly distributed, in black color, thick and non-brittle, smooth and shiny, with presence of lice and dandruff. Scalp is intact and no lesions or masses as palpated. Nails on fingers and toes are non-brittle. Skin warm to touch. Axilliary temperature is 35.8C.

Self- Care Deficit

Self- Care Deficit

HEENT a. Head and Face

SN: Mr. Schitz ga sakit ang imong ulo? Mr. Schitz: wala

Head is normocephalic, No problem identified symmetrical and facial movements and features are symmetrical, scar noted near the eyebrow on left eye and no lump on scalp noted.

Head is normocephalic, symmetrical and facial movements and features are symmetrical, no lesions and pigmentations, scaliness and lump

No Problem identified

b. Eyes

SN: Mr. Schitz halap ang imong panan-aw? Mr. Schitz: dili Eyes clear and bright, in proper alignment, eye lashes are present, evenly distributed and curving outward, sclera is white and pinkish conjunctiva. Not able to assess visual acuity due to lack of equipments (Snellen Eye Chart). Parallel movements of eyes in all directions. No presence of redness, swelling and discharges noted. No periorbital edema. No problem identified

on scalp. Eyes clear and bright, No problem identified in proper alignment, eye lashes are present, evenly distributed and curving outward, sclera is white. Not able to assess visual acuity due to lack of equipments (Snellen Eye Chart). Peripheral vision intact in left eye in all fields except in the right eye. Light is symmetrical on each cornea when assessed corneal light reflex. Gaze is steady when eye is covered and uncovered. No drifting noted. Parallel movements of eyes in all directions. No presence of redness, swelling and No problem identified discharges noted. No periorbital edema. Helix of ear is level with inner and outer canthus of eye. Ears are intact, no lesions and discharges

c. Ears

SN: Ga sakit ang imong dungan Mr. Schitz? Mr. Schitz: wala may sakit. SN: makadungog ka og tarong? Helix of ear is level with inner and outer canthus of eye. Ears are intact, cerumen is noted in both ears, no lesions and discharges noted. Consistent with skin color. Ears are soft

No problem identified

and pliable. Mr. Schitz: Oo. d. Nose SN: Mr. Schitz naa kay problema sa imong pagsimhot? Mr. Schitz: wala man. e. Oral Cavity SN: Mr. Schitz nag sakit ang imong ngipon karon og naa kay luas? Mr. Schitz: wala raman Lips midline, symmetrical with pinkish color of gums. There is no presence of carries and decays. Oral mucosa and gums pink no bleeding noted. Tongue is midline and can move up, down and in both sides.

noted. Consistent with skin color. Ears are soft and pliable.

Shape is symmetrical, midline. No presence of masses and displacement of bone and cartilage. Can distinguish scent.

No problem identified

No problem identified

No problem identified

Shape is symmetrical, midline. No presence of masses and displacement of bone and cartilage. Can distinguish scent. Lips midline, symmetrical, dry and intact. Gums pinkish in color as well as the tonsils and uvula. There is no presence of carries and decays. Oral mucosa and gums pink no bleeding noted. Tongue is midline and can move up, down and in both sides.

No problem identified

Neck SN: Mr.Schitz naai kai sakit na gibati sa imong li-og? Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No distended No problem identified Neck erect, midline, no lumps, bulges, or masses. Thyroid not visible. No distended No problem identified

Mr. Schitz: wala rapod

veins. Trachea is midline. Head can move in all directions. Lymph nodes not palpable. Chest is symmetrical in appearance with symmetrical rise and fall when breathing, skin is intact. No sternal and intercostals retraction or bulging. Equal chest expansion, upon auscultation. Clear breath sounds, no crackles, wheezes or rubs. Respiratory rate is 16.

veins. Trachea is midline. Head can move in all directions. Lymph nodes not palpable. Chest is symmetrical in appearance with symmetrical rise and fall when breathing, skin is intact. No sternal and intercostals retraction or bulging. Equal chest expansion, upon auscultation. Clear breath sounds, no crackles, wheezes or rubs. Respiratory rate is 18.

Respiratory System

SN: Mr. Schitz mag lisod kag ginhawa? Mr. Schitz: Dili man.

No problem identified

No problem identified

Cardiovascular System

SN: Mr. Schitz magsakit imong dughan? Mr. Schitz: Dili man

Edema not present on other parts of body. No jugular vein distention Pulses on upper extremities are strong and bounding with 82 bpm. No adventitious and extra heart sounds, regular rhythm, no bruit and thrills. BP- 100/80 P- 82bpm

No Problem Identified.

Breast and Axilla

SN: Mr. Schitz naay ga burot-burot sa imong dughan o dapit sa imong totoy? Mr. Schitz: wala may gaburot SN: Mr. Schitz nag sakit ang imong tiyan? Mr. Schitz: wala SN: Ika pila ka maka libang sa isa ka simana? Mr. Schitz: Depende man gud. Sa isa ka week kay ka 6 kasagara. SN: naka sulay naka og sakit pad libang Mr. Schitz? Mr. Schitz: gialmuranas raman ko sauna.

Breast symmetrical, consistent with color, nipples pointing on direction, no lesions and discharges and is midclavicular line. Areola and nipple darker than breast tissue. Patient can swallow properly with no pain felt, umbilicus in midline, inward and no herniation noted. No abdominal movements, no bruit sounds, normoactive bowel sounds. RUQ- 13 LUO- 12 RLQ- 11 LLQ- 12.

No problem identified

Gastointestinal System/ Abdomen

No Problem Identified.

Edema not present on other parts of body. No jugular vein distention, Capillary refill time is less than 2 sec. Pulses on upper extremities are strong and bounding with 84bpm.. No adventitious and extra heart sounds, regular rhythm, no bruit and thrills. BP100/70 P- 84bpm

No problem identified

Genitourinary System

SN: Mr. Schitz walay magsakit kung mangihi ka? Mr. Schitz: Dili man

Input: 3 glasses/day Output: 180cc/day Genitalia dark brown in color and has long pubic hair and thick. No lesion and edema is noted. No problem identified

Breast symmetrical, consistent with color, nipples pointing on direction, no lesions and discharges and is midclavicular line. Areola and nipple darker than breast tissue. Posture erect, head midline with ectomorph nody. Patient can move legs up and down. Can perform pronation and supination of hand, finger to thumb and is able to identify sharp and dull objects.

No problem identified

Musculoskeletal SN: Mr. Schitz System magsakit imong kalawasan? Mr. Schitz: Dili man pod

Posture erect, head midline with ectomorph nody.No edema noted. Patient can move legs up and down. Can perform pronation and supination of hand, finger to thumb and is able to identify sharp and dull objects.

No problem identified

No problem identified

Neurologic System

SN: Mr. Schitz kapoy ang paminaw sa imong lawas? Mr. Schitz: okay raman.

A. Balance Patient can perform accurately touching examiners finger and his nose, can alternately touch his own fingers.

A. Balance Patient can perform the heel-to-toe walking, tandem walking, Rombergs test, hop in one foot and heel tracing. Patient can perform accurately touching examiners finger and his nose, can alternately touch his own fingers but cant perform rapidly.

B. Strength Left arm muscle strength is 5/5 in active motion with some resistance, right arm muscle strength 5/5. Left leg muscle strength 5/5, right leg muscle strength is 4/5 due to edema, active motion with some resistance.

B. Strength Left arm muscle strength is 5/5 in active motion with some resistance, right arm muscle strength 5/5. Left leg muscle strength 5/5, right leg muscle strength is 4/5 due to edema, active motion with some resistance. C. Sensory

No problem identified

No problem identified

C. Sensory Can detect dull and sharp sensation. Patient can detect number of hands holding him; can identify objects such as coin or ballpen.

Patient can feel soft brush from the forehead towards the whole extremities. Can detect dull and sharp sensation. Patient can detect number of hands holding him; can identify objects such as coin or ballpen. D. Cranial Nerves Cranial Nerve I.Olfactory

D. Cranial Nerves Cranial Nerve I.Olfactory Can identify scents such as alcohol and perfume.

Can identify scents such as alcohol and perfume. Cranial Nerve II.Optic Not able to assess visual acuity due to

Cranial Nerve II.Optic Not able to assess visual acuity due to lack of equipment (Snellen Eye Chart). Peripheral vision intact in left eye in all fields except in the right eye. Cranial Nerve IIIOcculoSchitz, IVTrochlear and VIAbducens Can move eyes up, down and both sides, equally round, reactive to light Cranial Nerve VTrigeminal Can sense brush on face using sharp and dull objects. Cranial Nerve VIIFacial Smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VIIIAcoustic Can hear examiner upon whisper test. Cranial Nerve IX-

No problem identified

lack of equipment (Snellen Eye Chart). Peripheral vision intact in both eyes and all fields. Cranial Nerve IIIOcculoSchitz, IVTrochlear and VIAbducens Can move eyes up, down and both sides, equally round, reactive to light Cranial Nerve VTrigeminal Can sense brush on face using sharp and dull objects. Cranial Nerve VIIFacial Smiles coordinately, constructively and facial grimace appropriate, in coordinated facial structures. Cranial Nerve VIIIAcoustic Can hear examiner upon whisper test. Cranial Nerve IXGlossopharyngeal and X- Vagus Intact gag reflex, taste buds can taste

No problem identified

Glossopharyngeal and X- Vagus Intact gag reflex, taste buds can taste sweet and bitter. Cranial Nerve XISpinal Accessory Muscle Ca move shoulder up but with resistance. Cranial Nerve XIIhyposglossal Tongue is midline and can move up, down and in both sides

sweet and bitter. Cranial Nerve XISpinal Accessory Muscle Ca move shoulder up but with resistance. Cranial Nerve XIIhyposglossal Tongue is midline and can move up, down and in both sides.

Lymphatic / Hematologic System

No limb enlargement, not pale nor flushed, no active bleeding noted No problem identified on oral mucusa, No lymph nodes palpated.

No limb enlargement, not pale nor flushed, no active bleeding noted on oral mucusa, nose and rectum as observed. No lymph nodes palpated. Hemoglobin - 133 (decreased) Hematocrit - 0.40 (decreased) RBC - 4.2 (decreased)

No problem identified

Endocrine System

No buffalo hump, no abnormal pigmentation, does not sweat a lot or No problem identified flushed. No edema noted.

No buffalo hump, no abnormal pigmentation, does not sweat a lot or flushed. No edema noted.

No problem identified

Spiritual Assessment Mr. Schitz views religion as an important aspect to his life because he believes that being faithful to God means praising and following his words. Before he was admitted, he often goes to church with his mother to ask guidance. He also believes that God can heal his illness if you just pray. God and his mother has been his source of inspiration and hope that he can go through all this trials in life.

Cultural Assessment Mr. Schitz belongs to Bisayan culture. He consults doctor immediately whenever Mr. Schitz feels any unusualities such as fever, cough and colds. He never went to a quack doctor before and never uses any herbal medications as claimed by his mother.

DIAGNOSTIC TEST
Complete Blood Count Examination White blood cell Hemoglobin Results 6.6 133 Normal Values 4.8-10.8 140-180 Interpretations Normal Decreased Macrocytic anemia (liver disease, hypothyroidism, vitamin B12 deficiency, folate deficiency), normocytic anemia (early iron deficiency, anemia of chronic disease, hemolytic anemia, acute hemorrhage), and microcytic anemia (iron deficiency, thalassemia). Macrocytic anemia (liver disease, hypothyroidism, vitamin B12 deficiency, folate deficiency), normocytic anemia (early iron deficiency, anemia of chronic disease, hemolytic anemia, acute hemorrhage) and microcytic anemia (iron deficiency, thalassemia). Liver disease, megaloblastic anemia (folate, B12 deficiencies), reticulocytosis, newborns. Spurious increase in autoagglutination, high white blood cell count. Drugs: methotrexate, phenytoin, zidovudine Alcohol abuse; Chronic liver disease; Folic acid deficiency; Hypothyroidism; Myelodysplasia ;Spherocytosis ;Vitamin B12 deficiency Addisons disease; Alcohol abuse; Anemias; Bone marrow suppression; Chronic infection; Date: December 05, 2011 Significance results

Hematocrit

0.40

0.42-0.52

Decreased

MCV(Mean corpuscular volume)

95.0

80-94

Increased

MCH(mean corpuscular hemoglobin)

31.6

27-31

Increased

Red blood count

4.2

4.7-6.1

Decreased

Chronic renal failure; Hemodilution; Hemolysis; Hemorrhage; Hodgkins disease; Hypothyroidism; Leukemia; Multiple myeloma; Myelodysplasia; Rheumatic fever; Subacute bacterial endocarditis; Systemic lupus erythematosus; Vitamin deficiency (B6, B12, folic acid) MCHC RDW MPV Platelet count 332 12.4 7.3 335 330-370 11-16 7.2-11.1 150-400 Normal Normal Normal Normal

DIFFERENTIAL COUNT Examination Neutrophils Lymphocytes Monocytes Eosinophils Basophils Stab Atypical Lymphocytes Metamyelocytes Myelocytes Blast Results 65.3 24.3 6.5 3.7 0.2 0 0 0 0 0 Normal Values 40-75 19-48 3-9 0-7 0-2 Interpretations Normal Normal Normal Normal Normal Significance results

CHEMISTRY Creatinine SGPT SGOT 1.22 28.2 22.1 0.9-1.3 0.0-41.0 0.0-35.0 Normal Normal Normal

NURSE PROGRESS NOTES


DAY 1 (Tuesday, Nov. 29, 2011) Patient sitting on a chair; awake, alert and coherent, wearing pink t-shirt with white print and red short and black slippers. Nails not trimmed and dirty with hair combed. Seemed happy, not interacting with other patients. Not so cooperative but responded to his SN. Demonstrate d shyness. Oriented to time person and place. DAY 2 (Wednesda y, Nov. 30, 2011) Patient standing, eating unripe mango. Wearing red t-shirt, pink short and black slippers. In good grooming. Nails trimmed and clean. Seemed happy and cooperate well with his SN . Oriented to time and place. DAY 3 (Thursday, Dec. 1, 2011) Patient sitting under a tree, wearing a plain white tshirt, blue short with yellow and white print and black slippers. Wellgroomed. Looks newly bathed. Seemed happy. Verbalized interest to play basketball with the SN. DAY 4 (Friday, Dec 2, 2011) DAY 5 (Monday, Dec. 05, 2011) Patient was wearing white t-shirt and blue short with black slippers. Newly bathed and wellgroomed. Sitting near the wall while watching TV. Seems bored and not interacting well with his SN. DAY 6 (Tuesday, Dec. 06, 2011) Patient was wearing plain dark blue t- shirt, and red short pant with black slippers. Newly bathed and properly groomed. Sitting on a long bench inside male ward while watching TV. Seemed happy and interact well with the SN and interacting cooperativel y during conversation s.But when other SN from other school joined the conversation s he suddenly stopped DAY 7 (Wednesda y, Dec. 07, 2011) Patient was wearing dark blue T-shirt, and red short pant with black slippers. Not yet taking a bath verbalized unya na ko maligo pag human nako og inom sa tambal. Sitting alone near the window while watching TV verbalized di ko kailis kay way sanina basa pa daw tanan piro maligo ko. Seems happy ineracting with SN. DAY 8 (Thursday, Dec. 08, 2011) Patient was wearing dark blue t- shirt, and dirty red short pant with black slippers. Trimmed fingernails and clean. Seems interested in interacting with the SN. Sitting on a long bench near the wall while watching TV. Interacts with other patients especially his bestfriend which he called Mr. White man. Oriented to time and place. DAY 9 (Friday, Dec. 09, 2011) Patient was wearing dark blue t-shirt, and red short with black slippers. Newly bathed. Combed hair. Standing behind the gate verbalized gihulat nako akong mama . Seems happy ineracting with the Student nurses and other patients.Orie nted to time and place. Seemed worried about the day of his discharge verbalized nagguol ko

D A T A

Patient standing near window, wearing a black t-shirt, red short with black slippers. Wellgroomed. Seemed happy while interacting with his SN and selected patients.

talking and seemed irritated.

kong makagawas ra ba ko karong adlaw. Encouraged patient to observe proper personal hygiene such as handwashin g.Reinforced to take his medications. Encouraged to cooperate in assessing Mini Mental Status Examination. Encouraged to join art therapy,and encouraged to eat his lunch. Trimmed fingernails. Kept watched for any unusualities and any changes in his behavior. Encouraged to brush teeth and to participate others activities. Encouraged to join morning stretch. Instructed and assisted client in cleaning/wipi ng his face with used of wet tissue. Encouraged to cooperate in assessing Physical Examination. Vital signs taken. Encouraged to maintain proper hygiene. Maintained eye to eye contact, always smiling during interaction with the SN and other patients. Participated in the morning stretch

A C T I O N

Encouraged proper hygiene. Encouraged cooperation with SN during interviews and nurse patient interactions and encourage client not to be shy to his SN.

Encouraged to join music activity, and encouraged to eat his lunch. Trimmed his fingernails. Encouraged not to be shy with his SN. Reinforced medicine regimen.

Encouraged and assisted client in shaving his mustache and beard. Played basketball with the patient. Encouraged to verbalized feelings and thoughts and always smiling. Encouraged interaction with other patients in the ground.

Encouraged and assisted client in cleaning his ears with used of cotton buds. Encouraged to brush teeth before and after eating and before going and waking up in bed.

Kept watched for any unusualities, vital signs taken, reinforced medicine regimen, ensured safety environment.

Encouraged to join dance therapy. Encouraged verbalization of feelings and thoughts. Ensure safety environment and accompanie d patient the whole shift.

R E S P O N S

Always smiling during interactions ,maintained eye to eye contact and demonstrate d shyness when interacting with his SN.

Participated in the activity and obeyed instructions given, but did not shared his feelings towards the said activity (Music Activity). Shown interest in

Always smiling during interactions, maintained eye to eye contact and verbalized that enjoyed playing basketball.

Maintained eye to eye contact, shown interests in every activities, verbalized feelings of relief after cleaning of ears and brushing of teeth.

Seems bored and fair eye to eye contact, with low tone of voice when interacting with SN. Dont participate other activities wa ko sa mood

Participated in the dance therapy and obeyed the instructions given, enjoyed joining the group. Shown positive changes in self (taking a bath

Maintained eye to eye contact, always smiling during interaction with the SN. Showed concerned with his SN verbalizing lingkod sa kay gikapoi

Participated other activities, maintained eye to eye contact, always smiling during interaction with the SN and other patients.

every interaction and always smiling.

Seemed excited and happy to go home as evidenced by verbalization ayaw mo kaulaw adto sa amua. Smiles while saying byebye.

mu apil. Naulaw na ko sa inyu kay niingon ko na mkagawas ko atong FRIDAY unya hantud karon wa pa ko kagawas, verbalized by the pt. with low tone of voice and avoid eye to eye contact.

everyday,bru shing teeth after eating).

na ka og tindog.

activity and cooperated during assessment in his physical examination and interact well with the student nurses.

PSYCHODYNAMICS Biologic factors include age and gender, as well as the hereditary problems present in their family. He was only breastfeed for a month and was bottle feed since 2 months. It is also the period for developing and seeks emancipation from parents. This makes the person at risk for developing the signs and symptoms of schizophrenia. Separation of his parents at his childhood also adds in the factors that precipitates Mr. Schitz to schizophrenia. His parents separated at age 5. His father is described as an authoritative type of person during the pregnancy of Mr. Schitz mother. The incidence of trauma and injury during the second trimester and birth has also known considered in the development of schizophrenia (Shives, 2008). He was then raised by his mother in Cebu with his siblings. After the separation of his parents, Mr. Schitz didnt receive any financial support from his father, as well as losing his father figure which results in overly dependence to his mother. Mr. Schitz grew up being an introvert, secretive and silent type of person. Social factors include the type of friends he hangs up and his relationship with his family. Mr. Schitz is close to his mother and older sister. He doesnt have any close friends and keeps all his problems by himself. In addition, stressors that have been thought to contribute to the onset of schizophrenia include deeply disturbed family interpersonal relationships, disturbed body image, and rigid concept of reality, frustrations and poor intimate relationships (Shives, 2008). He usually mingles with children, watches movies and read magazines. This makes Mr. Schitz didnt develop close and sharing relationships with other people. Environmental factors can also predispose Mr. Schitz in developing schizophrenia. The current situation of his environment can have a depressive effect on him. Theorists also believe that persons who come from low socioeconomic areas or single-parent homes in deprived areas are not exposed to situations in which they can achieve or become successful in life. Thus, they are risk for developing schizophrenia (Shives, 2008)

CONCEPT MAP: Schizophrenia Undifferentiated

Head Trauma

Intrauterine Influences: STRESS

Poverty

Stressful Life Situation: Separation of Parents

Brain physiology alteration

Distubance in brain development Failure of coping mechanisms: Acting Out Denial

LEGEND:
Predisposing Factors Pathogenesis Medications Nursing Diagnoses Precipitating Factors Signs & Symptoms

Decreased brain volume

Continued disequilibrium
Diagnostic Tool

Functional Deficit

Temporal Deficit Biperiden 2mg/tab, 1 tab per day Positive Symptoms

Frontal Deficit

Detachment to reality

Ineffective coping r/t inabitlity to trust/ low self-esteem/ inadequate support systems/ possible hereditary factors.

Risperidone 2mg, 1 tab BID Labile Mood

Negative Symptoms

Schizophrenia Undifferentiated

Disturbed thought process r/t delusional thinking /possible hereditary factors

Delusions: Erotomania Paranoia Risk for self-directed or otherdirected violence r/t false fixed beliefs, lack of trust and history of violence. interactions with others

Anhedonia

DSM-IV-TR

Social Isolation r/t lack of trust/delusional thinking/past experiences of difficulty in interactions with others

Self-care deficit r/t withdrawal into the self

Symptoms: Delusions + Anhedonia Social/occupational dysfunction Duration: signs of the disturbance persist for at least six months

LIFE CHART

1983 1997-1999

Nov. 24, 1984

December 1989

1996

1997-1999

Patients mother was pregnant. Her husband was irrationaly suspicious and sometimes locked her in a room

Patient was born at their house in Hinondayan, with the help of a manghihilot via NSVD.

At age 5, his father had an affair with another woman this caused his parents separation

At Grade 6, patient met a bicycle accident and got a head injury.

He enrolled at Consolacion National High School

Being the youngest, his parents loved him dearly, specially his father.

His mother together with her children left Leyte and went to Cebu.

He was a very silent and rarely interacts with people; he made no friends during his High School. He preferred to be alone

Patient became more quiet and introvert

His mother claimed that he never had a girlfriend

2000

2002

2006

2008-2009

2010

He enrolled at University of Cebu in the department of Mechanical Engineering.

He worked as maintenance personnel in SM

He worked at Happyherbs as a sales-man.

Spent time at home, occasionaly went out, very poor social interaction, talked to self

Stopped medications due to financial instability

Dropped ou t after the first semester because he was fearful of the people who urged him to join fraternities at school

He quitted after two months.

He quitted after a month.

He Had check-up at the Community Hospital, prescribed with medications.

Since then, he lost his interest in studying, his mother claimed.

Aug.-Sept. 2011

Oct 2011

Oct 27, 2011

Nov. 24, 2011

Dec. 10, 2011

Patients condition worsen.

Patient was admitted at VSMMC with the diagnosis of Schizophrenia Undifferentiated.

Discharged with improved condition, complied well with prescribed medications

Patient hit a child; punched and kick his mother and this prompted readmission in VSMMC

Discharged with improved condition.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER


According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met: 1. Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment). Delusions Hallucinations Disorganized speech, which is a manifestation of formal thought disorder Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior Negative symptoms - affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation) If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication. 2. 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. 3. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). Subtypes The DSM-IV-TR contains five sub-classifications of schizophrenia.

Paranoid type: Where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code F20.0)

Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1) Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code 295.2/ICD code F20.2) Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)

Residual type: Where positive symptoms are present at a low intensity only. (DSM code 295.6/ICD code F20.5)

Mindanao Sanitarium and Hospital College Department of Nursing

PSYCHIATRIC-MENTAL HEALTH NURSING CARE PLAN

Name of patient: Mr. Schitz DSM IV TR Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Nov. 04, 2011 Implementation Date: Nov. 29, 2011

Shift: 6:00AM - 10:00 AM Ward: Male Ward (XII)

Nursing Diagnosis: Social Isolation r/t lack of trust/delusional thinking/past experiences of difficulty in interactions with others Cause Analysis: Clients with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase of the illness. A common characteristic of schizophrenic delusions is the direct, immediate, and total certainty with which the client holds these beliefs. Because the client believes the delusion, he or she will therefore act accordingly. For example, the client with delusions of persecution will probably be suspicious, mistrustful, and guarded about disclosing personal information; he or she may examine the room periodically or speak in hushed, secretive tones. Cues Subjective: Magpundo ra siya permi sa kwarto, dili gyud mugawas; wala gyud siyay mga barkada diri as verbalized by his mother. Objective: -Preoccupation with own thoughts (thoughts of assembling his own bicycle) - Lack of trust: paranoid (poor eye to eye contact, answered questions with Nursing Outcomes STO: Within 4 hours of nurseclient interactions, the client will willingly attend therapy activities accompanied. Intervention Nurse Patients Relationship: - Convey an accepting attitude by making brief, frequent contacts. - An accepting attitude increases feelings of self-worth and facilitates trust. - This conveys your belief in the client as a worthwhile human being. - The presence of a trusted individual provides emotional security for the client. Honesty and dependability promote a trusting relationship. - Honesty and dependability promote a trusting relationship. Rationale STOE:

References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 309

Evaluation

Short term goals were met. After 4 hours of nurse-client interactions, the client demonstrated willingness and desire to socialize with others. LTOE: Long term goals were met. After 4 days of nurse-client interactions, the client voluntarily attended group activities; and approached others in appropriate manner for one-to-one

- Show unconditional positive regard.

LTO: Within 4 days of nurseclient interactions, the client will voluntarily spend time with other clients, student nurses and staff members in group activities.

- Be with the client to offer support during group activities that may be frightening or difficult for him or her.

- Be honest and keep all promises.

hesitations.)

- Be cautious with touch. Allow client extra space and an avenue for exit if he or she becomes too anxious. - Orient client to time, person, and place, as necessary. - Give recognition and positive re inforcement for clients voluntary interactions with others. - Discuss with client the signs of increasing anxiety and techniques to interrupt the responses (e.g., relaxation exercises, thought stopping). Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.
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- A suspicious client may perceive touch as a threatening gesture.

interaction.

- Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors. - Maladaptive behaviors such as withdrawal and suspiciousness are manifested during times of increased anxiety.

- Antipsychotic medications help to reduce psychotic symptoms in some individuals, thereby facilitating interactions with others.

- To prevent occurrence of new problems

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 103-105

Name of patient: Mr. Schitz DSM IV TR Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Nov. 04, 2011 Implementation Date: Nov. 30, 2011

Shift: 10:00AM - 2:00 PM Ward: Male Ward (XII)

Nursing Diagnosis: Risk for self-directed or other-directed violence r/t false fixed beliefs, lack of trust and history of violence. Cause Analysis: Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The client may be paranoid and suspicious of the nurse and the environment and may feel threatened and intimidated. Although the clients behavior may be threatening to the nurse, the client also is feeling unsafe & may believe his or her well-being to be in jeopardy. Cues Subjective: Nabuhat ra man tu nako (referring to his act of violence) kay gigutom ko as verbalized by the client. Naa koy uyab since elementary, iyang ngalan kay Lucilou, naa siya sa Japan as verbalized by theclient Objective: - History of violence (nikalit ra siyag pandapat sa bata, iya kong gisumbag ug gisipa as verbalized by his mother) - Lack of trust: paranoid (poor eye to eye contact, answered questions with hesitations.) - Delusions of Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will recognize signs of increasing anxiety and agitation and report to staff for assistance with intervention. Intervention Nurse Patients Relationship: - Maintain and convey a calm attitude toward client. - Observe clients behavior frequently (every 15 minutes). Do this while carrying out routine activities. - Anxiety is contagious and can be transmitted from staff to client. - So as to avoid creating suspiciousness in the individual. Close observation is necessary so that intervention can occur if required to ensure client (and others) safety. - Physical exercise is a safe and effective way of relieving pent-up tension. Rationale STOE:

References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 313

Evaluation

Short term goals were met. After 4 hours of nurse-client interactions, was able to recognize signs of increasing anxiety and agitation and verbalized to report to staff for assistance with intervention. LTOE: Long term goals were met. After 3 days of nurse-client interactions, the client caused no harm to self or others. He also demonstrated trust of others in his environment.

LTO: Within 3 days of nurseclient interactions, the client will not harm self or others.

- Try to redirect the violent behavior with physical outlets for the clients anxiety.

Milieu Management: - Maintain low level of stimuli in clients environment (low lighting, few people, simple decor, low noise level). - Remove all dangerous objects from clients environment - Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening. - So that in his or her agitated, confused state client may not use them to harm self or others. - This shows the client evidence of control over the situation and

- Have sufficient staff available to indicate a show of strength to client if

Erotomania

it becomes necessary.

provides some physical security for staff. - The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client.

Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.
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- To prevent occurrence of new problems.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 102-103

Name of patient: Mr. Schitz DSM IV TR Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Nov. 04, 2011 Implementation Date: Nov. 30, 2011

Shift: 10:00AM - 2:00 AM Ward: Male Ward (XII)

Nursing Diagnosis: Ineffective coping r/t inabitlity to trust/ low self-esteem/ inadequate support systems/ possible hereditary factors. Cause Analysis: Identifying and managing ones own health needs are primary concerns for everyone, but this is a particular challenge for clients with schizophrenia because their health needs can be complex and their ability to manage them may be impaired. The nurse helps the client to manage his or her illness and health needs as independently as possible. This can be accomplished only through education and ongoing support. Cues Subjective: Wala siyay barkada; iyang mga magulang nagminyo, kami nalang duha nabilin sa balay as Nursing Outcomes STO: Within 4 hours of nurseclient interactions, the client will develop trust in the SN or at least one Intervention Nurse Patients Relationship: - Encourage same staff to work with client as much as possible. - In order to promote development of trusting relationship. Rationale

References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 318

Evaluation STOE: Short term goals were met. After 4 hours of nurse-client interactions, the client was able to eats food from tray

- Suspicious clients may perceive

verbalized by hjs mother. Igihan aayo iyang amahan; adtong nagburos ko niya (referring to the client), lakan ko niya sa kwarto Objective: - Suspiciousness of others, resulting in: Alteration in societal participation Inability to meet basic needs Inappropriate use of defense mechanisms

staff member. LTO: Within 3 days of nurseclient interactions, the will demonstrate use of more adaptive coping skills as evidenced by appropriateness of interactions and willingness to participate in the therapeutic community.

- Avoid physical contact.

touch as a threatening gesture. - Suspicious clients often believe others are discussing them, and secretive behaviors reinforce the paranoid feelings.

and takes medications without evidence of mistrust. LTOE: Long term goals were met. After 3 days of nurse-client interactions, the client appropriately interacted and cooperated with staff and SN in therapeutic community setting.

- Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said.

-Be honest and keep all promises.

- Honesty and dependability promote a trusting relationship.

- Activities should never include anything competitive.

- Activities that encourage a oneto-one relationship with the nurse or therapist are best. Competitive activities are very threatening to suspicious clients.

- Encourage client to verbalize true feelings. The nurse should avoid becoming defensive when angry feelings are directed at him or her.

- Verbalization of feelings in a non-threatening environment may help client come to terms with long-unresolved issues.

- An assertive, matter-of-fact, yet genuine approach is least threatening and most therapeutic.

- A suspicious person does not have the capacity to relate to an overly friendly, overly cheerful attitude.

Psychoparmacology: - Mouth checks may be necessary following medication administration to verify whether client is swallowing the tablets or capsules.
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-Suspicious clients may believe they are being poisoned with their medication and attempt to discard the pills.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 105-106

Name of patient: Mr. Schitz DSM IV TR Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Nov. 04, 2011 Implementation Date: December 06, 2011

Shift: 10:00AM - 2:00 PM Ward: Male Ward (XII)

Nursing Diagnosis: Self-care deficit r/t withdrawal into the self Cause Analysis: Because of apathy or lack of energy over the course of the illness, poor personal hygiene can be a problem for clients who are experiencing psychotic symptoms as well as for all clients with schizophrenia. Cues Subjective: Naulaw nako ninyo kay nag-ingon ko adtong Friday nga makagawas nako pero wala pa diay, as verbalized by the client. Dili ko gusto maligo kay hinay ang agas as verbalized by the client Objective: - Refusal to take a bath - lack of interest in maintaining appearance at a satisfactory level Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will verbalize a desire to perform ADLs. LTO: Within 4 days of nurseclient interactions, the client will be able to perform ADLs in an independent manner and demonstrate a willingness to do so by time of discharge from treatment. Intervention Nurse Patients Relationship: - Encourage client to perform normal ADLs to his or her level of ability. - Encourage independence, but intervene when client is unable to perform. - Offer recognition and positive reinforcement for independent accomplishments. - Show client, on concrete level, how to perform activities with which he or she is having difficulty. - Keep strict records of food and fluid intake. Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects. Rationale - Successful performance of independent activities enhances self-esteem. - Client comfort and safety are nursing priorities. - Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. - Because concrete thinking prevails, explanations must be provided at the clients concrete level of comprehension. - This information is necessary to acquire an accurate nutritional assessment. - The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client. STOE:

References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 319

Evaluation

Short term goals were met. After 4 hours of nurse-client interaction, the client was able to take a bath, change clothing and brush teeth. LTOE: Long term goals were met. After 4 days of nurse-client interactions, the client maintained optimal level of personal hygiene by bathing daily and carrying out essential toileting procedures without assistance.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 111-112

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Name of patient: Mr. Schitz DSM IV TR Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Nov. 04, 2011 Implementation Date: December 06, 2011

Shift: 10:00AM - 2:00 PM Ward: Male Ward (XII)

Nursing Diagnosis: Disturbed thought process r/t delusional thinking /possible hereditary factors Cause Analysis: The client (with schizophrenia) experiencing delusions utterly believes them and cannot be convinced that they are false or untrue. Such delusions powerfully influence the clients behavior. Cues Subjective: kada adlaw mubisita akong papa sa balay, as verbalized by the client. Objective:
- Inappropriate non-

References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 314 Evaluation STOE:

Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will verbalize that false ideas occur at times of increased anxiety. LTO: By time of discharge from treatment, client will experience (verbalize evidence of) no delusional thoughts and will be able to differentiate between delusional thinking and reality.

Intervention Nurse Patients Relationship: - Convey your acceptance of clients need for the false belief, while letting him or her know that you do not share the belief. - Do not argue or deny the belief. Use reasonable doubt as a therapeutic technique: I find that hard to believe.

Rationale

- It is important to communicate to the client that you do not accept the delusion as reality.

Short term goals were met. After 4 hours of nurse-client interaction, the verbalized reflect thinking processes oriented in reality. LTOE: Long term goals were met. On the day of the discharge, was able to maintain activities of daily living (ADLs) to his maximal ability and refrained from responding to delusional thoughts.

reality-based thinking - Delusional thinking (false ideas) - Short attention span distractibility

- Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded. - If the client can learn to interrupt escalating anxiety, delusional thinking may be prevented.

- Help client try to connect the false beliefs to times of increased anxiety. Discuss techniques that could be used to control anxiety (e.g., deep breathing exercises, other relaxation exercises, thought stopping techniques). - Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people.

- Discussions that focus on the false ideas are purposeless and useless, and may even aggravate the psychosis.

- Assist and support client in his or her attempt to verbalize feelings of anxiety, fear, or insecurity. Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.

- Verbalization of feelings in a nonthreatening environment may help client come to terms with long unresolved issues. The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 108-109

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PSYCHOTHERAPIES
DEFINITION Music therapy Forms of music therapy generally are based around cognitive/behavioral, humanistic or psychoanalytic frameworks or a mixture of approaches. There are usually both active and receptive parts of the therapy, meaning that at times music is listened to and at other times there is the use of musical improvisation or creation. INDICATION Is the most frequently used to help the mentally or physical disabled. It can help people to express feelings by making musical sounds and music . NURSING RESPONSIBILITIES -Stimulate patient to think about something and talk about himself. -Gives him reason to value himself and increase his selfrespect. -music is selected which evoke the clients long term memory processes and stimulates reminiscence. MECHANICS Use of music as an addition to relaxation therapy in psychotherapy to elicit expression of suppressed emotion by promoting patients to dance, out, laugh or crazy in response.

Dance therapy A method of psychological treatment in which movement and dance are used to express and deal with feelings and experiences, both positive and negative. Also called movement therapy

is based on the premise that the body and mind are interrelated. Dance therapist believes that mental and emotional problems are often held in the body in the form of muscle tension and constrained movement patterns. Conversely, they believe that the state in the body can affect attitudes and feelings, both positively and negatively.

-Remain calm and state limits on behavior in a firm manner. Be truthful but not judgmental. -provide protection in the environment by constant observation and removal of objects that could harm self/ others.

Promote healing in a number of ways. Moving in a group brings people out of isolation, creates powerful social and emotional bonds. And generates those good feelings that come from being others. Moving rhythmically eases muscle rigidity, diminishes anxiety, and increases energy

Art therapy

Promote healing in a number of ways. Moving in a group brings people out of isolation, creates powerful social and emotional bonds. And generates those good feelings that come from being others. Moving rhythmically eases

Practice is based on knowledge of human developmental and psychological theories which are implemented in the full spectrum of models of assessment and treatment including

-Ensures that appropriate materials and space are available for the client-artist, as well as an adequate amount of time for the session.

As human service profession that uses art media, images, the creative process, and patient/client responses to the created products as reflections of individuals development, abilities, personality, interest, concerns and conflicts.

-provide

protection

in

the

muscle rigidity, diminishes anxiety, and increases energy

educational, psychodynamic, cognitive, transpersonal, and other therapeutic means of reconciling emotional conflicts, foster selfawareness, developing social skills, managing behavior, solving problems , reducing anxiety, and increasing self esteem.

environment by constant observation and removal of objects that could harm self/ others.

Exercise therapy

Prescription of bodily movement to correct impairment, improves musculoskeletal function, or maintains a state of wellbeing.

Improve muscle strength and maintain maximal voluntary contractile force. Improve exercise performance and functional capacity (endurance). Improve circulation and respiratory capacity.

-Accept the client manipulative behaviorism such as anger without reacting an emotional basis. -Remain calm and state limits on behavior in a firm manner. Be truthful but not judgmental. -provide protection in the environment by constant observation and removal of objects that could harm self/ others.

A climate or warm friendliness and acceptance are essential, reading, poetry and current events from bridge to reality, props are used to promote discussion of topics.

NURSE PROCESS RECORDING Name: Mr. Schitz 9, 2011 Age: 27 years old Date: Nov 29-Dec

Diagnosis: Schizophrenia Undifferentiated Coruna, Jose Jr. Lima Time and Setting:

Attending Physician: Dr.

Time of Interaction: between 6-10 am and 10am to 2pm Setting of Interaction: on the male grounds and near the entrance Objectives: Short Term Objectives: 1. Within 4 hours of effective nursing care the patient will exhibit compliance with medication. 2. Within 4 hours of effective nursing care the patient will demonstrate the ability to perform personal hygiene on a daily basis with minimal assistance. 3. Within 4 hours of effective nursing care the patient will be able to verbalize his physical needs. 4. Within 4 hours of effective nursing care the patient will exhibit accurate perception of reality. 5. Within 4 hours of effective nursing care the patient will exhibit an increase the ability to socialize. Long Term Objectives: Within two weeks of exposure ot Vicente Sotto Memorial Medical Center, Center of Behavioral Sciences, the patient will show positive change in self (build Self-esteem), improve social interaction (talk with other patients), maintain hygiene and good grooming, and verbalize feelings and thoughts without hesitations. Description of Patient: November 29, 2011 Mr. Schitz, 27 years old was wearing white t-shirt and blue short pants with slippers, fairly groomed; nails are not trimmed, seem to be silent but interact with close friends only.

November 30, 2011 Mr. Schitz, 27 years old was wearing white t-shirt and blue short pants with slippers, fairly groomed; nails are trimmed, seem to be happy during the music therapy with other patients on the male ground. December 01, 2011 Mr. Schitz, 26 years old was wearing white t-shirt and blue shorts, well groomed, nails are clean, confidently interacting with student nurse and maintaining eye to eye contact during interaction seems happy when student nurse help him in shaving his moustache and beard, participate in activities spear-headed by the student nurse and maintain improvement. December 02, 2011 Mr. Schitz, 27 years old was wearing a white t-shirt and blue short with white and yellow print, well groomed, nails trimmed and combed hair, seems happy while interacting with other patients near the entrance. December 03, 2011 Mr. Schitz, 27 years old was wearing blue t-shirt and red short pants with black slippers, well groomed, combed hair, seem to be happy while interacting with his SN, participated in the dance therapy but did not share his feelings towards the activities, sometimes moody. December 04, 2011 Mr. Schitz, 27 years old was wearing blue t-shirt and red shorts with black slippers, fairly groomed, seem lazy and not in the mood, looks sleepy. Nurse-Patient Interactions (important details) Conversation SN: Unsa man imo masultui sa iyang pagbisiota? (pertaining to her mother) Analysis Seeking Information Interpretation seeking to make clear that which is not meaningful or that which is vague. (Videbeck, 2nd ed., p.118) concentrating on a single point. (Videbeck, 2nd ed., p.118)

Focusing

Comprehension Patient: Nalipay ko. Mingawon man ko sa akong mama og sa among balay, ganahan man ko muoli unya dili man mu sugot akong mama. Not looking at his SN with low tone voice

ability to understand which is asked during the communication (MHPN compilation by Al Madale, p.72) Appropriate affect is displaying a facial expression that is congruent with mood and situation. (Videbeck, 3rd ed., p.154 Tone can indicate whether sometimes is relaxed, agitated or bored (Videbeck, 3rd ed., p. 118) Seeking to make clear that which is not meaningful or that which is vague. (Videbeck, 2nd ed., p.118) Concentrating on a single point. (Videbeck, 2nd ed., p.118)

Appropriate Affect

Low Tone of Voice

Seeking Information SN: Unsa diay nahitabo sa imo saw ala paka naka sulod diri? looking at his patient Focusing

Soft Tune of Voice Patient looking outside the window and nodded, and said Dili man ko makasulod diri kung wa nakistorya og lain akong mama, ambot di ko kasabot sa akong gi-bati ato nga oraqsa, mauto

Giving Information

Speaking softly may indicate a concern for another, whereas speaking loudly may be the result of feelings of anger or hostility (Shives, 7th ed., p. 138) Making available

nisulod ko sa CR gisumbag-sumbag og gi-sipa-sipa ang dingding, mauto gidala ko sa akong mama diri, gi-mingaw na gali ko sa Exploring among balay og katong motor nako na gip alit sa akong papa, Yamaha man to, (Patient paused for Comprehension awhile breathed-deeply and leaned on the table.)

the facts that the client needs. (Videbeck, 2nd ed., p.117) Delving further into a subject or idea. (Videbeck, 2nd ed., p.116) ability to understand which is asked during the communication (MHPN compilation by Al Madale, p.72) Recent memory is the ability to recall events in the immediate past and for up 2 weeks previously. (MHPN compilation by Al Madale, p.72) Failure to accept the reality (Shives, 7th ed., p. 138)

Recent memory: Good

Denial

Seeking Information SN: Unsa imong na-feel katong pag-admit diri? Nga diri ka gi-dala sa imong mama. Focusing -

Seeking to make clear that which is not meaningful or that which is vague. (Videbeck, 2nd ed., p.118) concentrating on a single point. (Videbeck, 2nd ed., p.118)

Mr. Schitz remained silent and leaned on the table, after awhile he went to other chair and told me that he wanted to watch TV (Cartoon Series) and SN let him watched the cartoon series.

PSYCHOPHARMACOLOGY
Indications Generic Name: risperidone Trade Names: Risperdal Classification: Therapeutic: Antipsychotics, mood stabilizers Pharmacologic: Benzisoxazoles Schizophrenia in adults and adolescents age. Antagonizes serotonin2 and dopamine2 receptors in CNS. Also binds to alpha1and alpha2 adrenergic receptors and histamine H1 receptors. Oral: 2mg/tab, 1 tab BID CNS: aggressive behavior, dizziness, drowsiness, extrapyramidal reactions, headache, increased dreams, longer sleep periods, insomnia, sedation, fatigue, nervousness, agitation, anxiety, tardive dyskinesia, hyperkinesia, akathisia, transient ischemic attack (TIA), cerebrovascular accident (CVA), neuroleptic malignant syndrome CV: orthostatic hypotension, chest pain, tachycardia, arrhythmias EENT: vision disturbances, rhinitis, sinusitis, pharyngitis GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, dry mouth, increased salivation, anorexia GU: difficulty urinating, polyuria, galactorrhea, dysmenorrhea, menorrhagia, decreased libido Musculoskeletal: joint or back pain Respiratory: cough, Drug-drug Antihistamines, opioids, sedative hypnotics: additive CNS depression Carbamazepine: increased metabolism and decreased efficacy of risperidone Clozapine: decreased metabolism and increased effects of risperidone Levodopa, other dopamine agonists: decreased antiparkinsonian effects of these drugs Drug-behaviors Alcohol use: increased CNS depression Sun exposure: increased risk of photosensitivity Patient Monitoring
Closely monitor

Mechanism of Action

Route, Frequency, Dosage

Adverse Reactions, Side Effects

Interactions

Nursing Implications

neurologic status, especially for neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscle rigidity, and autonomic dysfunction), extrapyramidal reactions, TIA, CVA, and tardive dyskinesia. Monitor blood pressure, particularly for orthostatic hypotension. Assess body temperature. Check for fever and other signs and symptoms of infection. Patient Teaching
Instruct patient to

remove orally disintegrating tablet from blister pack, place on tongue immediately, and swallow as tablet dissolves. Tell patient to mix oral solution with water, coffee, orange juice, or low-fat milk. Tell him solution isnt compatible with cola or tea. Advise patient to use effective bedtime routine to avoid sleep disorders. Teach patient to

dyspnea, upper respiratory tract infection Skin: pruritus, diaphoresis, rash, dry skin, seborrhea, increased pigmentation, photosensitivity Other: toothache, fever, impaired temperature regulation, weight changes

recognize and immediately report signs and symptoms of serious adverse reactions, including tardive dyskinesia and neuroleptic malignant syndrome. Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease. Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of lightheadedness (especially in hot weather). Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Advise female patient to tell prescriber if she is or plans to become pregnant. Caution her not to breastfeed during therapy. Advise patient not to drink alcohol. As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above. Interactions: Drug- drug : Paralytic ileus, sometimes fatal, with other NURSING INTERVENTIONS:
Decrease dosage or

Generic Name: Biperiden

Relief of symptoms of extrapyramidal

Blocks acetylcholines action at

Oral: 2m/tab 1 tab/day

CNS: Disorientation, confusion, psychoses, agitation, nervousness,

Trade Name: Akineton Classifications: Anticholinergic, Antidyskenitic Pharmachologic: Anti-parkinsonian

disorders that accompany phenothiazine therapy.

cholinergic receptor sites. This action restores the brains normal dopamine and acetylcholine balance, which relaxes muscle movement and decreases rigidity and tremors. Biperidenalso may inhibit dopamine reuptake and storage, which prolongs dopamines action.

delusions, delirium, paranoia, euphoria, excitement, lightheadedness,dizziness, depression, drowsiness, weakness, giddiness, paresthesia, heaviness of the limbs (centrally acting anticholinergic effects). CV: tachycardia, palpitations, hypotension, orthostatic hypotension (peripheral anticholinergic effects). Dermatologic: Rash, urticaria, other dermatoses. EENT: Blurred vision, mydriasis, diplopia, increased intraocular tension, angle closure glaucoma GI: Dry mouth, constipation, dilation of the colon,paralytic ileus, acute suppurative parotitis, nausea, vomiting, epigastric distress GU: Urinary retention, urinary hesitancy,dysuria, difficulty achieving or maintatining an erction. OTHER: flushing, deacreased sweating, elevated temperature, muscular weakness, muscular cramping.

anticholinergics,with drugs that have anticholinergic properties (phenothiazines, TCAs) Additive adverse CNS effects (toxic psychosis) with drugs that have CNS anticholinergic properties (phenothiazines, TCAs). Possible masking of extrapyramidal symptoms , tardive dyskinesia, in long term therapy with antipsychotics (phenothiazines, haloperidol), possibly due to central antagonism.

discontinue temporarily if dry mouth makes swallowing or speaking difficult. WARNING:


Give with caution, and

reduce dosage in hot weather. Drug inerferes with sweating and ability of body to maintain heat equilibrium; anhidrosis and fatal hyperthermia have occurred. Give with meals ig GI upset occurs; give before meals to patients with dry mouth; give after meals if drooling or nausea occurs. Ensure that patient voids just before receiving each dose of drug if urinary retention is a problem. Patient Teaching:
Take this drug exactly as

prescribed.
Avoid the use of alcohol,

sedative, and over the counter drugs (can cause dangerous effects) You may experience these side effects;drowsiness, dizziness, confusion, blurred vision (avoid driving or engaging in activities that require alertness and visual acuity);nausea (eat frequent small meals); dry mouth (suck sugarless lozenges or ice chips ); painful or difficult urination (empty the bladder immediately before each

those);constipation (maintain adequate fluid intake and exercise regularly); use caution in hot weather (you are susciptible to heat prostration). Report difficult or painful urination;constipation; rapid or pounding heartbeat; confusion,eye pain, or rash.

DISCHARGE PLAN Name of the patient: Mr. Schitz Age: 26 years old Gender: Male Room Number: XII Date: Dec 09, 2011 Time: 10:00AM Chief Complaints: Gidala namo siya sa ospital kay nikalit ra siyag pandapat sa bata, iyang pag-umangkon, iya dayon kong gisumbag ug gisipa as verbalized by the clients mother. Diagnosis/Impression: DSM-IV-TR: Schizophrenia Undifferentiated Type Attending Physician: Dr. Jose Lim Coruna, Psychiatrist MEDICATIONS Medications
Biperiden

Dosage/Frequency
2mg/tab, once a day

Nursing Instructions
Take this drug exactly prescribed. Avoid the use of alcoholism ,sedative and over the counter drugs(can cause dangerous effect) You may experience these side effects: drowsiness, dizziness, confusion, blurred vision, nausea, dry mouth, difficulty urination, constipation. Report difficult Or painful urination, constipation, rapid or pounding heartbeat, confusion, eye pain, rashes

risperidone

2mg/tab,once a day

Instruct patient to remove orally disintegrating tablet from blister pack, place on tongue immediately, and swallow as tablet dissolves. Tell patient to mix oral solution with water, coffee, orange juice, or low-fat milk. Tell him solution isnt compatible with cola or tea. Advise patient to use effective bedtime routine to avoid sleep disorders. Teach patient to recognize and immediately report signs and symptoms of serious adverse reactions, including tardive dyskinesia and neuroleptic malignant syndrome. Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood

pressure decrease. Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of lightheadedness (especially in hot weather). Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Advise patient not to drink alcohol. As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above.

EXERCISE -Stretching exercise -Deep breathing exercises involves inhaling slowly and deeply through the nose, holding the breath for a few seconds, then exhaling slowly through the mouth pursing the lips. THERAPY -Group Therapy A form of psychological treatment in which a number of clients meet together with a therapist for purposes of sharing gaining personal insight and improving interpersonal coping strategies. HEALTH TEACHINGS -Avoid smoking and drinking alcoholic beverages. -Do not skip doses of medications. -Be aware of the common side effect that may because by your medications. -Do not stop prescription medications without taking to your doctor. -Encourage client to perform independently as many activities as possible. (independent accomplishment and positive reinforcement enhance self-esteem and promote repetition of desirable behaviors). -Ensuring that client continues to get treatment after hospitalizations.

-Encourage client to regain his/her activities, abilities. It is important that goals be attainable, since the patient feels paranoid and/ repeatedly criticized by others will probably experience irritation that may worsen the symptoms. OPD VISITS/REFERRALS -Follow check-up after one to two weeks of discharge, especially for medication relapse cases and when patient is combative. DIET 1 cup rice 3 ounce of salmon 1 boiled egg serving of bas-uy 1 glass of milk and water SPIRITUAL CARE -Encourage the patient to pray and ask for help to our heavenly father to give him more strength, in order to cope with his problems as well as for faster recovery from his condition. Encourage to participate in bible studies.

PROGNOSIS
Prognosis Onset of Illness Acute - Good Document Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, and loss of interest in school or work, and neglected hygiene. (videbeck rd 3 ed., p. 277) Coping with schizophrenia is a major adjustment for both clients and their families. Understanding the illness, the need for continuing medication and follow-up, issues. Clients and families need help to cope with the emotional upheaval that schizophrenia causes. rd (videbeck 3 ed., p. 296) Pattern of depressive cognitions and behaviors in a variety of contexts is absent. rd (videbeck 3 ed., p. 351) Clients with schizophrenia report and demonstrate wide variances in mood and affect. They often are described as having flat affect (no facial expression) or blunted affect (few observable facial rd expressions). (videbeck 3 ed., p. 286) Maintaining the medication regimen is vital to a successful outcome for clients with schizophrenia. Failing to take medications as prescribed is one of the most frequent reasons for recurrence of psychotic symptoms and hospital admission. (Kane and Marder, 2005)

Family Support

Strong - Good

Depression Feature

Absent - Good

Mood and Affect Appropriate

Good

Willingness to take medication

Schizophrenia Treatment Recommendations Medication advice Since the last PORT review, two large clinical trials have compared efficacy of first- and second-generation antipsychotics: the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS). Based on the findings of these studies, the PORT reviewers noted that in many cases, first- and secondgeneration antipsychotics are equally effective for treating schizophrenia. First-episode of Psychosis. The PORT review recommends using any antipsychotic except clozapine (Clozaril) and olanzapine (Zyprexa), because these drugs are most likely to cause significant weight gain and other metabolic side effects. Because patients experiencing psychosis for the first time are both more responsive to medications and more likely to have side effects, antipsychotics should be prescribed at doses that are lower generally about half compared with those recommended for patients with chronic schizophrenia. Relapse. Patients who initially responded to medication but suffer a relapse of symptoms have several options. The PORT team recommends any first- or second-generation antipsychotic other than clozapine, and stipulates that medication be prescribed at the lowest effective doses to reduce side effects. Choice of which antipsychotic to use depends on patient preference, past medication response, side effects, and medical history. Maintenance therapy. Studies that have followed patients with first-episode or chronic schizophrenia for one to two years have concluded that continuous maintenance antipsychotic treatment reduces risk of relapse. The PORT review recommends that intermittent maintenance therapy a strategy of stopping antipsychotics until symptoms reappear or worsen be reserved only for patients who refuse to continue taking an antipsychotic or for those who cannot tolerate the side effects.

For patients with chronic schizophrenia, both first- and second-generation antipsychotics are equally effective at preventing relapse. During maintenance therapy, first-generation drugs may be used at lower doses than those required to treat the initial (acute) episode, while second-generation drugs can be prescribed at whatever dose was effective in the initial phase. Long-acting injectable antipsychotics provide another option in maintenance therapy, especially for patients who have trouble taking medication. The PORT review concluded that it is unclear whether injectable medications are any more effective than pills at preventing relapse, mainly because of a lack of randomized controlled studies. Treatment resistance. The PORT review recommends that patients who have not responded adequately to two previous antipsychotics try clozapine for at least eight weeks. If this does not alleviate a patient's symptoms, a blood test may be useful to determine whether the medication has reached a therapeutic level (defined as blood levels above 350 nanograms per milliliter). Some patients require higher doses of clozapine to achieve this blood level. Smoking cessation. As many as nine in 10 patients with schizophrenia smoke cigarettes. The PORT team recommends that patients who want to stop smoking take bupropion (Wellbutrin) twice a day for 10 to 12 weeks, either with or without nicotine replacement therapy, and supplement it with a support group or some type of psychosocial intervention. The report notes that this approach may help patients to quit at least temporarily, but long-term success remains unclear. Other challenges. The PORT review also offers advice about clinical situations that are less common. For example, clozapine is an option for patients with schizophrenia who are hostile or persistently violent, as well as for patients who are at risk for suicide. Patients who become agitated may respond to oral or injectable antipsychotics, alone or combined with a rapid-acting benzodiazepine. Patients who continue to experience auditory hallucinations in spite of antipsychotic treatment may respond to low-frequency transcranial magnetic stimulation.

GLOSSARY
Ambivalence holding seemingly contraindicating beliefs of feelings about the same persons or event or situation. Anergia lack of energy; inactivity. Anhedonia feeling of no joy or pleasure from life or any activities or relationships. Antipsychotic are used primarily to treat most dorms of psychosis such as schizophrenia, schizoaafective disorder and others. Apathy lack of emotion. Delusion a false fixed belief or opinion. Dementia deterioration of intellectual faculties, such as memory, concentration, and judgment, resulting from an organic disease or a disorder of the brain. Denial failure to admit the reality. Echolalia the immediate and voluntary repetition of words or phrases just spoken by others, often a symptom of autism or some types of schizophrenia. Echopraxia imitation of posture of others. Flat affect absence or near absence of any signs of affective responses. Hallucinations perception of visual, auditory, tactile, olfactory, or gustatory experiences without an external stimulus and with a compelling sense of their reality, usually resulting from a mental disorder or as response to a drug. Illusions the condition of being deceived by a false perception or belief. Paranoia in psychology, a term denoting persistent, unalterable, systematized, logically reasoned delusions, or false beliefs, usually of persecution or grandeur. Schizophernia a severe mental disorder characterized by delusion, hallucinations, incoherence and physical agitations. Schizoparanoid is the presence of auditory hallucinations or prominent delusional thoughts about persecution agitations. Schizodisorganized there is impairment of the emotional processes of the individual. Social isolation persons spends most of the day alone or only with close friend. Thought blocking sudden stop in train of thought. Thought content - is the specific meaning expressed in the patients communication. It refers to the what of the patients thinking.

BIBLIOGRAPHY
BOOKS Videbeck, Sheila L. (2004) Psychitric Mental Health Nursing, 2rd Edition Shives, Louise R. (2008) Psychiatric-Mental Health Nursin, 7th edition Townsend, Mary C. (2008) Nursing Diagnoses in Psychiatric Nursing, 7th Edition Schull, P. D. (2010) Nursing Spectrum Drug Handbook, 5th Edition. Deglin, J. H. (2008) Davis Drug Guide, 11th Edition Nicoll, Diana et. al. (2001) Pocket Guide to Diagnostic Test, 3rd Edition Wilson, Denise D. (2008) Manual of Laboratory & Diagnostic Tests

ELECTRONIC SOURCES www.search.ebscohost.com www.mentalhelp.net/poc/view_doc.php?type=doc&id=8806