INTRODUCTION

Being told that you or someone you love has schizophrenia can be frightening or even devastating. Schizophrenia is a severe brain disease that interferes with normal brain and mental functionit can trigger hallucinations, delusions, paranoia, and significant lack of motivation. Without treatment, schizophrenia affects the ability to think clearly, manage emotions, and interact appropriately with other people. It is often disabling and can profoundly affect all areas of your life. There are many theories about the cause of schizophrenia, but none have yet been proven. Schizophrenia may be a genetic disorder, since your chances of developing schizophrenia increase if you have a parent or sibling with the condition, but most people with relatives who have schizophrenia will not develop it. It may also be related to problems experienced during pregnancy (such as malnutrition, or being exposed to a viral infection) that damages the unborn child's developing nervous system. Many arguments have been put forth regarding developmental factors that could cause schizophrenia. The common theme of these theories is the internal reaction to life stressors or conflicts. According to Meyer and Freud, the seeds of mental health and illness are sown in childhood, and that to understand the current functioning of individuals, it is important to understand their upbringing or development. Lack of loving and nurturing primary caregiver, inconsistent family behavior and faulty communication patterns are thought to be responsible for mental problems later in life.

Magnetic resonance imaging (MRI) has revealed that people with schizophrenia often have changes in the structure of their brain such as enlargement of the cerebral ventricles (the fluid-filled spaces in the brain close to the midline). Various brain regions have been found to be smaller in patients with schizophrenia, including the frontal cortex, temporal lobes, and hippocampus. In addition, studies of patients with schizophrenia have found patterns of abnormal activation of the brain while performing tests of memory and problem solving.

Schizophrenia causes two groups of symptoms: negative symptoms and positive symptoms. Negative symptoms generally include apathy or lack of motivation, self-neglect (such as not bathing), and reduced or inappropriate emotion (such as becoming angry with strangers). Negative symptoms usually appear first and may be confused with depression. Positive symptoms, which generally appear later, include symptoms such as hallucinations, delusions, and disorganized or confusing thoughts and speech. Symptoms of schizophrenia usually emerge in adolescence or early adulthood. Symptoms can appear suddenly or may develop gradually, often causing the illness to go unrecognized until it is in an advanced stage when it is more difficult to treat.
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Either a pharmacological or behavioral approach may be used in treating schizophrenia. A variety of antipsychotic medications have been used, and research continues into how to minimize the side effects which are often associated with such drugs. There are several targets for behavioral treatments in schizophrenia Consistent, long-term treatment is critical to the successful management of schizophrenia. Unfortunately, people with schizophrenia often do not seek treatment or they stop treatment due to unpleasant side effects of medicines or lack of support. It is likely that there are various forms of schizophrenia, perhaps with different causes. Schizophrenia is a term given to a complex group of mental disorders. However, different types of schizophrenia may have some of the same symptoms. There are several subtypes of schizophrenia based on symptoms. Paranoid schizophrenia is the most common type of schizophrenia. People with paranoid schizophrenia have frightening thoughts and hear threatening voices. This causes them to act afraid or to argue with other people. Sometimes people with paranoid schizophrenia attack other people or objects in their surroundings because they are afraid of them. This type often develops later in life than other types of schizophrenia. People with paranoid schizophrenia often get better with treatment. Disorganized schizophrenia is rare but is the most serious type of schizophrenia. People who have this type have unpredictable behaviors. They may act silly and giggle for no apparent reason. They often make up words and sentences that make no sense to other people. In addition, they often do not show facial expressions. Disorganized schizophrenia is sometimes called hebephrenic schizophrenia. Catatonic schizophrenia is rare. People with catatonic schizophrenia have episodes in which they sit or stand like a statue for long periods of time (catatonic stupor). In addition, they can have episodes of meaningless and intense activity (catatonic excitement). During these episodes of intense activity, they may injure themselves or other people. Undifferentiated schizophrenia refers to schizophrenia in which the symptoms do not fit the other types of schizophrenia. Residual schizophrenia refers to the continued presence of symptoms of schizophrenia during a remission.

For our patient, he has undifferentiated schizophrenia. This type of schizophrenia is a condition wherein characteristic symptoms (at least two of the following) such as delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms are present, but criteria for paranoid, catatonic, or disorganized subtypes are not met.

Patient Noel Wagas Ching, 48 years of age from Makati City was first admitted to National Center for Mental Health in the year 1987. After this, several admissions were done due to relapse of the signs and symptoms of his illness and last admission was last November 1996. Last February 17, 1998, patient was again admitted to the institution to the performance of violent behavior to his family. Upon admission, his noted chief complaints were irritability,
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difficulty of sleeping, and hitting his mother and nephew. Diagnostic procedures such as drug testing, HIV testing, urinalysis, clinical chemistry and chest x-ray were done for further evaluation of patients condition. His admitting vital signs were as follows: BP-100/70, CR86bpm, RR- 20 cpm, temp- 36.0OC. He was diagnosed with Undifferentiated Schizophrenia and now currently taking in Clozapine 100 mg HS and has been given Fluphenazine decanoate 1cc, IM last April 21, 2012.

objectives
On the completion of this case study, I, the student nurse will be able to: Have more comprehensive understanding about the patients

disease,

UNDIFFERENTIATED SCHIZOPHRENIA Apply nursing care appropriately with proper skills, knowledge and attitude in caring for a patient with UNDIFFERENTIATED SCHIZOPHRENIA

Specifically, the student nurse will be able to: Perform an in depth study about the patients disease, its causes, its signs and symptoms and the disease process. To be able to obtain data about the patient and develop a cooperative relationship between the patient and the student nurse pertaining to the care and treatment. To provide emotional/psychological, spiritual, mental and social support to the patient. Correlate the patients present and past medical and psychosocial history to the disease process. Properly identify and illustrate the pathophysiology of the disease process based on the patients case. Properly assess the patient using the mental status examination. Analyze diagnostic procedures done, relationship of the results to the disease process and implication of the treatment. To study the drugs involve in the treatment of the disease in order to know the interventions needed in case of adverse reactions. Formulate an effective nursing care plan as a framework for the care of the patient and implement it accordingly. Develop an exclusive discharge home care plan and provide health teachings to the patient about the disease, manifestations, way to lessen discomforts and the importance of lifestyle modification, rehabilitation and follow-up.

PATIENTS PROFILE
(According to the Patients Chart)

A.) Personal Data

Name: Noel Wagas Ching Sex: Male Address: 27-A 15th St. West Rembo Fort Bonifacio, Makati City Age: 48 years old Birth Date: November 25, 1963 Birth Place: Pasig Civil Status: Married Nationality: Filipino Religion: Roman Catholic Educational Attainment: College Level (Second Year) Mothers Name: Emiliana Ching

B.) Clinical Data

Date of Admission: February 17, 1998 Time of Admission: 8:30 PM Pavilion: Pavilion 30/Chinese Pavilion Patient Classification: Service Presenting Complaints: Sinuntok ang nanay, binalibag ang pamangkin, irritable, difficulty of sleeping Diagnosis: Undifferentiated Schizophrenia

(According to the Patient: During the Interview)

A.) Personal Data

Name: Noel Ching Sex: Male Address: Guadalupe City Age: 37 years old Birth Date: November 25, 1962 Birth Place: Pasig Civil Status: Single Nationality: Filipino Religion: Roman Catholic Educational Attainment: Second Year College, Engineering Mothers Name: Emiliana Ching

B.) Clinical Data

Date of Admission: Not remembered by the patient Time of Admission: Not remembered by the patient Pavilion: Pavilion 30/Chinese Pavilion Presenting Complaints: Not known by the patient

HISTORY of PAST and PRESENT ILLNESS

A.) History of Past Illness
Patient X is an active individual, who is living normally together with his family. He is married and has two children. He was then healthy, with sound mind, good physique and wellbuilt body. According to the patient, he was a vendor of ice cream then, and sometimes works with his mother in their carinderia. His father has a business of hardware. Patient claimed that he was a person which prefers to be alone since he was a student. He was not able to finish his chosen course which is Engineering to due financial difficulties. The patient did not have any severe or serious illness before his admission to National Center for Mental Health except for common colds, cough and fever that maybe due to weather changes, and management done (the patient cannot remember already what medications he take during those times). There were no familial history of mental illness mentioned, and according to the patient he is the first among their relatives who entered in a Psychiatric Hospital.

B.) History of Present Illness

Patient X has been mentally ill since 1987, with several admissions in the same institution (NCMH). His last admission was November, 1996. Follow-ups at Out Patient Service were done, and his last check-up was on February 9, 1998. Medications that were given to him are HPCC+CP2 200 mg BID. However, maybe due to financial incapability, he was not able to take his medications regularly. In between relapses, he is unable to do even usual household chores; he was not able to maintain good and proper hygiene. He became so immature, and cannot do even simple things for himself. He became untidy and undernourished. A week prior to admission, he had a relapse, due to no intake of medications. He became so irritable and was not able to sleep for almost 3 days. He became disoriented to places and persons. Few hours prior to his admission, he became assaultive. He hit his mother and nephew with no apparent reason. Hence, his mother was alarmed and decided to bring him to National Center for Mental Health last February 17, 1998 at 8:30 PM. Upon admission, his noted chief complaints were irritability, difficulty of sleeping, and hitting his mother and nephew. His
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admitting vital signs were as follows: BP-100/70, CR- 86bpm, RR- 20 cpm, temp- 36.0OC and was diagnosed with Undifferentiated Schizophrenia.

Assessment
Mental status examination
A mental status examination (MSE) is an assessment of a patient's level of cognitive (knowledge-related) ability, appearance, emotional mood, and speech and thought patterns at the time of evaluation. It is one part of a full neurologic (nervous system) examination and includes the examiner's observations about the patient's attitude and cooperativeness as well as the patient's answers to specific questions. The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. . A mental status examination can also be given repeatedly to monitor or document changes in a patient's condition. Name: Noel Wagas Ching Age: 48 years old Birthday: November 25, 1963

General
Hygiene and Grooming

Assessment And Mood behavior

Patient practice proper hygiene. He takes a bath regularly, can able to brush his teeth, wears clean clothes and slippers and with no untidy matters seen on him. He grooms properly and appropriately.

Appropriate Dress Patient Noel was always clad in blue shirt and shorts with NCMH printed on it and sometimes large for him. On the first day of interaction, patient doesnt wear any slippers however, on its following days; he wears slippers all the time.

Posture Patient has spoor posture. He often slouches or slumps when sitting. Sometimes, he raises his leg during nurse-patient interactions and activities. Patient also has a leaning forward posture and according to him, he used to lay down every time his inside the cell.
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Eye Contact Patient Noel has a poor eye contact when talking, listening and conversing with student-nurses,

instructors and other people. He maintains eye contact once in a while and he used to glare at the surroundings when not conversing.

Unusual Movements/Mannerisms He has unusual movements or mannerisms, and I noticed that he exhibit involuntary movement by raising his hands simultaneously as if he was writing and solving using his hands. He also seldomly raises his one leg during interviews and activities. He talks or murmurs something when not conversing with him and claims that he is not talking to anyone.

Speech Patient speaks in a soft and moderate tone and speed. There are unclear voices that you can hear from him and is needed to verify. Repetition of questions was done to get patients attention because sometimes he doesnt respond to some of the questions.

Mood
Expressed Emotions/Mood

And affect

Patient is serious most of the time; however he can also throw jokes to the student nurse sometimes which makes us laugh. But he never shows emotion such as anger and aggressiveness and does not show emotions of reproach and morbid ideation.

Facial Expression/Affect During the nurse patient interaction, patient seldomly shows facial expressions. He has a flat affect wherein there is no emotions attached to the content of speech and the voice has little modulation. He smiles when happy and no unusual facial expressions noted.
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Thought Process And content

Content Patient Noel, communicated unwisely. The content

is not productive but some were of sense and it is not the same level of an adequately mentally healthy individual.

Thought Process During the nurse-patient interaction, patient was able to answer questions but some responses are not appropriate to it. Sometimes repetition of questions was being done to get his attention. It shows that he has thought disturbances and perceptual distortions.

Clarity of Ideas Patient answers questions in an unsure manner wherein there were some instances that the idea of the patient was unclear and not appropriate.

Sensorium
Orientation

And Intellectual process

Patient was not oriented to time, place, person and situation. However he was able to state his name correctly including his date of birth and his parents name.

Confusion Patient was confused sometimes.

Memory Patient has a poor remote and recent memory, but has a good immediate memory, so repeated orientation to time, place and person is needed. Remote memory such as what year he has been admitted to the hospital and the name of his wife and children; and recent memory such as recent important events were not answered properly. He cannot exactly remember some of the events in his life and even his significant others.

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Abnormal Sensory Experiences During the interview, patient denied any neither visual nor auditory hallucinations. In reality, patient murmurs alone as if he was talking to someone and shows hand elevation movements.

Concentration Patient has slightly poor concentration. He used to glare at the surroundings so repetition of questions was done in order to catch his attention. One way also of assessing concentration is through calculations wherein it is his strength as a math lover. He can able to recite the alphabet correctly and couned 1-10 straightly and also through backward counting.

Abstract Thinking Abilities Patient was a 2nd year college undergraduate. He has a slightly good abstract thinking ability. He knows similarities and differences of objects.

Judgment And insight

Judgment Patients has a fair judgment as evidenced by his participation on nurse-patient interview, parlor games and activities. He interacts and mingles to other patients seldomly. He can able to recognize his student nurses. During the remotivational therapy, patients judgment was test when the student nurse asked him, ano gagawin mo para mapangalagaan ang kagandahan ng kalikasan? and the patient responded huwag magtapon ng basura kung saansaan.

Insight Patient has a poor insight regarding his condition and oblivious of the reason why he is in NCMH.

Self concept

Personal View of Self Patient views himself as a normal individual. He doesnt usually talk or mingle with other patient.

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Description of Physical Self Patient Noel practice proper hygiene as evidenced by taking a bath regularly, brushing his teeth and wearing clean and appropriate clothes. He was groomed completely wearing the blue shirt and blue pants with NCMH written on it. The patients height is 56. Has fair complexion and with good body built. His haircut was semi-kalbo with no lice nor lesions seen. His eyes and ears were proportionate and symmetrical. He has a pointed nose with light pink lips.

Personal Qualities/Attributes Patient was behaving in a way that he is silent and able to follow rules and regulations on the ward. He was not hard to call on. He eats well and was partly cooperative during activities.

Roles and relationships

Significant Relationships Patient only remembers his parents as his significant others in his life. He claimed that his mother is Emiliana and his father was ----. He was married but was not able to remember it anymore. He also claimed that they were 7 siblings in the family and he was the 5th child.

Support System The first line support system of the patient was his mother. He was excited to see his mother again. The health care team also serves as a support system of the patient.

Physiologic And Self care considerations

Eating Habits Patient eats well. He eats everything that is served by the cooking personnel and those we are serving during break time.

Sleeping Patterns Patient claims that he was having a good sleep despite of the texture of their bed.
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Health Problems Patient was in good health. He doesnt suffer from any illness.

Compliance to Prescribed Medications Patient complies religiously in taking prescribed medications.

Ability to Perform Patient is able to perform activities of daily living. Although sometimes little assistance is needed in some activities.

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DIAGNOSTIC PROCEDURES
A. Ideal Diagnostic Procedures
Name and Purpose of the procedure Normal Values Implication to Nursing Disease Responsibility Condition (interpretatio n& Significance) Each test can identify If the outcome of the 1. If you know that different possible examination is the person being problems, as described beyond or less than tested has never below. normal it can roll out been able to read or possible mental write, tell the health 1.ORIENTATION problem to the care provider in patient such as advance because -Typically, orientation Emotional Some tests that to time is first to be dysfunction Mental screen for language lost, followed by retardation, Organic problems using orientation to place, brain syndrome, reading or writing then to person. Schizophrenia do not account for people who may 2.ATTENTION never have been SPAN able to read or write. People who are unable to complete a thought, 2. If a child is or are easily having any of these distracted, may have tests performed, it an abnormal attention is important to help span. This may have a him or her number of causes, understand the including: Attention reasons for the deficit disorder tests. (ADD), Confusion, Histrionic personality 3. Always disorder, Manic remember that depressive illness Preparation, ,Schizophrenia especially by a 3.RECENT AND REMOTE MEMORY A medical disorder may cause loss of recent memory but
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Significant Values

1.Mental status test - are used to determine whether a disease or condition is affecting a person's thinking abilities, and whether a person's mental condition is improving or getting worse.

Orientation to person, place, and time Normal attention span Normal judgment Normal recent memory Normal remote memory Normal word comprehension , reading, and writing

highly intelligent person, could change the results of the test by making it seem that mental function has not declined when

keep remote memory intact. Remote memory is lost when damage to the upper part of the brain occurs in diseases such as Alzheimer's disease. 4.WORD COMPREHENSION , READING, AND WRITING These tests screen for language disorder (aphasia). 5.JUDGEMENT The ability to decide the right course of action is important to survival in many situations. 2. Medical History -During a medical history for schizophrenia, the health professional asks many different questions. This is psychiatrists way of tracing the origin of the disease condition -During also these interviews, the health professional may ask the family member(s) to describe the actions and behaviors of the person who has There is no known family member who have diagnosed or experienced schizophrenia Having collected this information the clinician usually then considers any other factors that -The clinician then might be relevant to attempts to obtain a the particular patient clear description of and enquires about these problems. When them. Although the did they start? How gathering of the did they start, information may suddenly, slowly or in follow the flow of fits and starts? Have the patient's thoughts they fluctuated over rather than those of time? What does the patient describe as the the clinician, it is not uncommon for the essential features of clinician to record the complaints? the psychiatric Having developed a history under hypothesis of what headings, such as may be the diagnosis, those above, to make the clinician next it easier for others looks at symptoms that might confirm this who will later read it. hypothesis or lead them to consider 1. History of the presenting complaints
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it actually has.

1. Share your purpose - Explain that you're creating a record to help you determine whether you and your relatives have a family history of certain diseases or health conditions. Offer to make the medical history available to other family members so that they can share the information with their doctors.

2.Provide several ways to answer

symptoms that may be caused by schizophrenia.

another possibility. Much of the mental process for the clinician is involved in this process of hypothesis testing to arrive at a diagnostic formulation that will form the basis of a management plan. 2. Past history -This is divided into the psychiatric past history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. The medical past history documents significant illnesses, both past and current, and significant medical events such as head injury, surgery and major illnesses. This can also include sexual abuse, (which could have happened when the patient was very young and before the person had a mental knowledge of what was happening) by a family member or close family friend. Leaving the patient with resulting problems. 3. Family history -Many psychiatric disorders have a genetic component and the biological family history is thus
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Subsequent history taking on reviews concentrates on changes in the levels of symptoms and responses to treatment, including possible side-effects

questions - Some people may be more willing to share health information in a face-to-face conversation. Others may prefer answering your questions by phone, mail or email. 3.Word questions carefully -Keep your questions short and to the point. 4.Be a good listener -As relatives talk about their health problems, listen without judgment or comment. 5. Respect privacy. -As you collect information about patients relatives, respect their right to confidentiality. Some people may not want to share any health information with you. Or they may not want this information revealed to anyone other than you and your doctor.

relevant. Clinical experience also suggests that a response to treatment may have a genetic component as well. Thus a patient who presents with clinical depression whose mother also suffered from the same disorder and responded well to fluoxetine would indicate that this drug would be more likely to help in the patient's disorder. -Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment. Similar effects are seen with the death of a parent from a protracted illness. 4.Developmental history -This documents the significant events in the patient's life. Ideally it starts with pre-natal factors such as maternal illnesses or complications with the pregnancy, then documents delivery and early childhood illnesses or problems. It then looks at
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significant events in the patient's life such as parental separation, abuse, education, psychosexual development, peer relationships, behavioural aspects and any legal complications. It flows then into adulthood with relationship and occupational histories. The aim is to get an overview of who the patient is and what they have experienced in life, both good and bad. Major stresses and transitions such as marriage, parenthood, retirement, death or loss of a partner, and financial success and failure are all important, as is how the patient has dealt with them. Sexual adjustment and problems can be relevant and are often questioned. 5. Social history -If the information has not already been obtained, the clinician then documents the social circumstances of the patient looking at factors such as finances, housing, relationships, drug and alcohol use, and problems with the law or other authorities. This is also a time to document racial or cultural issues that are
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3. CT scans of the head - is an imaging method that uses x-rays to create cross-sectional pictures of the head, including the skull, brain, eye sockets, and sinuses.

Results are considered normal if the organs and structures being examined are normal in appearance.

relevant to the presenting complaint CT scans of the head and other imaging techniques may find some changes that occur with schizophrenia and may rule out other disorders.

This confirms the diagnosis for schizophrenia

- instruct the patient not to eat or drink anything for 4-6 hours before the test. -Check if the patient is allergic to IV contrast. -ask the patient to remove jewelry and wear a hospital gown during the study. -Though there is no special preparation to the procedure it must be well explained to the patient and to his significant others

4. Scale for the Assessment of Negative Symptoms (SANS) - assesses five symptom complexes to obtain clinical ratings of negative symptoms in patients with schizophrenia.

Result is O over 5 and patient is negative of having the symptoms of schizophrenia

If the result is 5, it means that the patient is having a severe schizophrenia

-Subjectivity SANS assesses behavior based on rater observation and patient interview - Symptomatology while SANS aims to assess specific negative symptoms/symptom clusters associated with schizophrenia, it must be noted that many symptoms covered by SANS are also associated with affective disorders, particularly depression. -use a standard clinical interview in order to evaluate the subject's symptoms. Since positive formal thought disorder is an important positive symptom, it is recommended

5. Scale for the Assessment of Positive Symptoms (SAPS) -This scale is designed to assess positive symptoms, principally those

Result is 0 over 176. Patient is positive in having the symptoms of schizophrenia

If the result is 176, it means the patient is having a severe schizophrenia

-Though there is no special preparation to the procedure it must be well explained to the patient and to his significant others

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that occur in schizophrenia

6. Magnetic resonance imaging (MRI) - scan of the head is a noninvasive method to create detailed pictures of the brain and surrounding nerve tissues.

Results are considered normal if the organs and structures being examined are normal in appearance.

Magnetic resonance imaging of the head and other imaging techniques may find some changes that occur with schizophrenia and may rule out other disorders.

that, in doing this interview, the investigator begin talking with the subject - This helps confirms the diagnosis for schizophrenia

- instruct the patient not to eat or drink anything for 4-6 hours before the test. -Check if the patient is allergic to IV contrast. -ask the patient to remove jewelry and wear a hospital gown during the study.

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ACTUAL diagnostic procedures

Name and Purpose of the procedure Normal Values Significant Values Implication to Disease Condition (interpretatio n& Significance) Nursing Responsibility

1. HIV Testing Method: Enzyme linked immune sorbent assay Purpose: To check if there is presence of human immune deficiency virus in the patient and to prevent further transmission Result Non-reactive Non-reactive Normal

Explain purpose and procedure to the client Inform that blood sample will be taken for further analysis Attach result to patients chart when result is available Inform the physician regarding

2. Drug Test (Methampheta mine/Cannabib oids) Purpose: To check if patient has taken any illegal drugs MET (Methamphetami ne) THC (Tetrahydrocann abinol) Negative Negative Normal

Explain purpose and procedure to the client Give patient a specimen bottle to collect urine for analysis. Assist patient Negative Negative Normal in doing the procedure for validity. Send specimen to the laboratory
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immediately. Attach result to patients chart. 3. Urinalysis Purpose: Analysis of urine using physical, chemical, and microscopical tests to determine the proportions of its normal constituents to other abnormal constituents. Color Varying degrees of yellow Clear Yellow Normal Explain the procedure and tell its importance to the significant others and to the patient. Give significant others a specimen bottle and instruct them and the patient to discard the flow of urine and catch the midstream flow of urine. Label the specimen bottle before forwarding it to the laboratory.

Transparency

Turbid

May be due to crystallization of salts Normal Within normal range Normal Normal Normal Normal Normal

Reaction Specific Gravity Bacteria Protein Sugar RBC Pus 4. Hematology Purpose: It is concerned with the study of blood, the blood forming organs and blood

Usually acidic 1.000-1.038 Negative Negative Negative Negative Negative

Acidic 1.015 Negative Negative Negative Negative Negative

Explain the procedure and tell its importance to the significant others and to the patient. Tell them that blood sample will be taken. Record
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diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis and prevention of blood diseases. Hemoglobin 140-180g/L 120g/L Low hemoglobin may be due to anemia and malnutrition Low hemoglobin may be due to anemia and malnutrition

accurately laboratory result or attach it properly on patients chart and consult the result to the doctor.

Hematocrit

0.40-0.54 g/L

0.37g/L

RBC WBC Neutrophil Lymphocytes Monocytes 5. Clinical Chemistry Purpose: A test that yields about the cellular component of the blood. Glucose/RBS Electrolytes: Sodium

4-6x1012/L 5-10x10^9/L 0.40-0.75

3.89 x1012/L 5 x10^9/L 0.58 0.36

Within normal range Within normal range Within normal range Within normal range

0.20-0.45 0.02-.06 0.06 Within normal range Explain the procedure and tell its importance to the significant others and to the patient. Tell them that blood sample will be taken. Record accurately laboratory result or attach it properly on patients chart and consult the result to the

4.9-7.0mmol/L

8.65mmol/L

High, may be due to hyperglycemia Slightly decreased, may still be accepted as normal Slightly decreased, may still be accepted as normal Normal

135150mmol/L

134mmol/L

Potassium

3.4-5.5mmol/L

3.3 mmol/L

Lithium

Below 0.2

Negative
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mm/L

doctor.

6. Chest X-ray Purpose: A chest x-ray can determine the size of the heart and lungs. It can also show any extra blood or fluid in the lungs. Result: The chest is slightly enlarged with few fibrotic densities on the right lower lung fields. Impression: Slightly cardiomegaly Fibrotic scarring Nursing Responsibility: Explain the procedure to the patient. Inform that several images may be taken from different angles Instruct to remove any metals in the body or necklace which may alter the result of the procedure. Have the patient practice holding still and holding a breath in preparation for the test. Attach result to patient chart and inform the doctor.

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PATHOPHYSIOLOGY
Noels Risk Factors
Psychosocial stressors and interpersonal events: He prefers to be alone during his school years Unable to finished his chosen course which is Engineering Unknown problem

Demographic: Age (34 years old; first occurrence of illness)

Frustration

n Depression

Ineffective coping

Alteration of persons physical, psychological, environmental, emotional, physiological and environmental aspects

Diagnosis: Medical history Mental health assessment Drug Test Urinalysis HIV Testing Chest X-ray Clinical Chemistry

Brain affectation

Dysfunctional anatomic and functional system

Failure in development or a subsequent loss of brain tissue Enlarge ventricles and cortical atrophy

Disorganized thinking and behavior

Occurrence of signs and symptoms 26

Impaired functioning: Self care deficit Altered thought process Interpersonal relationship Social isolation Disorganized Behavior

Self neglect Inappropriate emotion

Disorganized thoughts, behavior and speech Difficulty of sleeping Irritability

Diminished of glucose metabolism and O2 in frontal cortical structure of the brain

Decreased brain volume and abnormal brain function in frontal and temporal lobe

Undifferentiated Schizophrenia

Malfunctioning of transmission of electrical impulses

Discontinue medications Poor family support Do not seek prompt treatment Low socio- economic support

Relapse and reoccurrence of psychotic signs

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and symptoms

Explanation:
Undifferentiated schizophrenia is a condition wherein characteristic symptoms (at least two of the following) such as delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior and negative symptoms are present, but criteria for paranoid, catatonic, or disorganized subtypes are not met. Patients risk factors include his age wherein during this developmental stage people where now on their own family life carrying the responsibilities needed for their everyday needs. Patient was an undergraduate of Engineering wherein he only finish till 2nd year of his course due to financial problems claimed by the patient. He is also a person who preferred to be alone. Unknown factor or problem which is not told may also be a great influence of the development of the illness. This risk factors leads to development of frustration, depression and ineffective coping. As a result, alteration of persons physical, psychological, environmental, emotional, physiological and environmental aspects happen leading to brain affectation. Failure in development or a subsequent loss of brain tissue results to enlarge ventricles and cortical atrophy. Then diminished of glucose metabolism and oxygen in frontal cortical structure of the brain will happen and there will b a decreased brain volume and abnormal brain function in frontal and temporal lobe. As a result, malfunctioning of transmission of electrical impulses especially an increase in dopamine receptors happen. Increase in dopamine receptors leads to impaired functioning such self care deficit, altered thought process, altered interpersonal relationship, social isolation and disorganized or violent behavior. Patient also manifests irritability, selfneglect, inappropriate emotion and difficulty of sleeping. The relapse and reoccurrence of psychotic signs and symptoms of undifferentiated schizophrenia was due to discontinue medications or poor medication compliance, poor family support, does not seek prompt treatment and low socio- economic support.

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Psychodynamics
IDEAL
Numerous studies have found that psychosocial treatments can help patients who are already stabilized on antipsychotic medications deal with certain aspects of schizophrenia, such as difficulty with communication, motivation, self-care, work, and establishing and maintaining relationships with others. Learning and using coping mechanisms to address these problems allows people with schizophrenia to attend school, work, and socialize. A positive relationship with a therapist or a case manager gives the patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for managing the disease. People with schizophrenia can take an active role in managing their own Illness illness. Once they learn basic facts about schizophrenia and the principles of Management schizophrenia treatment, they can make informed decisions about their care. If Skills they are taught how to monitor the early warning signs of relapse and make a plan to respond to these signs, they can learn to prevent relapses. Patients can also be taught more effective coping skills to deal with persistent symptoms. . Substance abuse is the most common co-occurring disorder

Integrated Treatment for Co-occurring Substance treatment programs usually do not address this population's special Abuse needs. Integrating schizophrenia treatment programs and drug treatment programs produces better in people with schizophrenia, but ordinary substance abuse outcomes.

Rehabilitation emphasizes social and vocational training to help people with Rehabilitation schizophrenia function more effectively in their communities. Because people with

schizophrenia frequently become ill during the critical career-forming years of life (ages 18 to 35) and because the disease often interferes with normal cognitive functioning, most patients do not receive the training required for skilled work. Rehabilitation programs can include vocational counseling, job training, money management counseling, assistance in learning to use public transportation, and opportunities to practice social and workplace communication skills.

Patients with schizophrenia are often discharged from the into the care of their families, so it is important that family know as much as possible about the disease to prevent Family Education

hospital members relapses.

Family members should be able to use different kinds of treatment adherence programs and have an

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arsenal of coping strategies and problem-solving skills to manage their ill relative effectively. Knowing where to find outpatient and family services that support people with schizophrenia and their caregivers is also valuable.

Cognitive behavioral therapy is useful for patients with symptoms that persist Cognitive Behavioral Therapy "not listen" even when they take medication. The cognitive therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to to their voices, and how to shake off the apathy that often immobilizes them.

This treatment appears to be effective in reducing the severity of symptoms and decreasing the risk of relapse.

Self-help groups for people with schizophrenia and their families are becoming increasingly common. Although professional therapists are not involved, the group members are a continuing source of mutual support and

Self-Help Groups

comfort for each other, which is also therapeutic. People in self-help groups know that others are facing the same problems they face and no longer feel isolated by their illness or the illness of their loved one. The networking that takes place in self-help groups can also generate social action. Families working together can advocate for research and more hospital and community treatment programs, and patients acting as a group may be able to draw public attention to the discriminations many people with mental illnesses still face in today's world.

Crisis and Stress Management Education

In every illness, exacerbation of symptoms may occur. And another form of stress may occur. And stress is one of the risk

factors for schizophrenia. Education on stress management must ne established with the client. The important commonalities in different psychotherapies may in fact be therapist attitude and attributes rather than their theoretical beliefs at present, there is little support for the use of insight-oriented or exploration- based psychotherapy with schizophrenic client.

Various forms of group therapy may be used as a

Group Therapy

psychosocial form of treatment for psychotic clients in mental health facilitates. Communication with the psychotic person, in group and other kinds of therapies, may be concrete, brief and direct, or may be psychoanalytically oriented; depending on he therapist is theoretical framework. In the behaviorist approach, the schizophrenic patient is seen with specific and measurable problems. These problems, it is are treated by certain behavioral interventions, such as 30 Behavior Therapy as a n individual believed, positive

and negative reinforcement. Recent years have seen a shift in focus from attempts to alleviate schizophrenic disorder itself with different forms of psychotherapy to programs designed to improve the clients social adaption, vocational functioning and subjective well-being. It is a team effort with a therapeutic effect for schizophrenic clients related to the teams abilities to communicate and work together. The psychiatric-mental health staff must feel free to talk about clients, families, events, and their own feelings to prevent a dangerous buildup of anger and frustration. The overall miles attitude reflects the therapeutic effectiveness of the environment that has been designed for clients.

Mileu Therapy

The goal of this

Community Dancing

activity is to build trust between patients and studenthaving a formation then self- introduction. Inform the

nurses. This begins by

patients of the activity for the day and sing the song with actions and visual aids.

Involves injection of short- acting general anesthetic

Electroconvulsive Therapy

along with succinylcholine and passage of small electric current to brain for 5 seconds or less through electrode placed above the producing a seizure which last 30 seconds to 1 minute or slightly

longer. It temporarily alters some of the brains electrochemical processes.

Actual:
The therapys main goal is to let the patient express and vent out. This lets the patient express the problems and his state of mind through dawning and illustrations with the aid of music interprets it.
Music and Arts Therapy (May 11, 2012)

accompaniment. After the patient draw the feeling in the paper he then Its like breaking the shell of a turtle or like opening Pandoras Box.

Last May 11, 2012, music and art therapy was done wherein the patient listens to a soft and fast music then crayons and bond papers were given for him to draw what he feels. After the patient illustrates and expresses his state of mind through drawing, he then interprets it to the group.

Dance Therapy (May 11, 2012)

Dance is the most fundamental of the arts, involving direct expression through the body. Dance /movement therapy effects changes in feelings, cognition, physical functioning, and behavior.

Its goal is to encourage release/ express clients emotions, to let the client learn on how to dance
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in simple steps and to let the client dance freely and actively. Through the tune of Nobody, the facilitators are in the front, dancing different steps, in able for the client to follow easily the steps.

Play Therapy (May 11, 2012)

Play therapy is a form of therapy wherein the therapist engages the client in play for the therapeutic opportunity to discharge strong emotions

in the atmosphere with a trusted therapist. Its objective is to discover the cause of the clients conflicts through observation of his play and or interpret it to the clients language which he understands. Play therapy was done last May 11, 2012 wherein patient actively participates to the said games as evidenced by raising his Song therapy (May 14, 2012) hand to join the said games and to answer the needed questions. First game was Hep-hep-hooray wherein he performed well and was belong to the top 3. Next game was Every breath you take which requires a prolonged utterance of the word Gwapo Ako. He uttered the word for 10 seconds. The last game was Calamansi Sweetest Smile wherein patient sips the juice of calamansi and was able to show his sweetest smile to the group. Song therapy is a kind of recreational therapy under the music category, which connects us with our creativity, innate wisdom and our vast inner resources for growth and well-being. It has a soothing and pleasing effect and provides for emotion and release. Its goal is develop patients ability to read and reflect, to develop patients listening skill, to encourage them to participate and cooperate and patients will learn to express emotions and feelings. Using visual aids that has the written lyrics, patients first read the its lines then the nurses together with the patients sing the song entitled Salamat.

It is the use of printed materials as a means of modifying and stimulating patients emotion and at the same time providing information to the patient. It is used to improve the attention span of

Bibliotherapy
(May 14, 2012)

individual with limited power of concentration, to divert the attention and lift the spirit of a depressed patient, and to help relieve insomnia, stimulate the imagination and foster desirable attitudes and ideas. Bibliotherapy was done at the entrance lobby of the said Pavillion wherein patients where able to watch the role play of the Legend of Pineapple. Visual aids which contains the summary of the legend was also used for the patients to read for further

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understanding of the said story. Patient Noel actively participates and was able to read and summarize the story for the group.

Remotivation Technique (May

15, 2012)

It is a socialized group therapy, usually 10-12 participants that trigger patients focus and alertness and intellectual functioning by enhancing the clients ability to rationalize and think

deeply. This technique is one way of letting the patient vent-out and be attached to reality. Last May 15, 2012, this therapy was done and the patients were able to figure out the topic of the said activity which is Dagat. Picture of the sea was presented and patient responded that he view people there swimming and the sea was blue. Patient was able to answer the questions correctly. He also read the poem presented to them.

Occupational Therapy (May 16,

2012)

This is the use of resources to make handicrafts in order to earn income. This therapy encompasses the expression of inner

feelings. This also establishes to divert the patients conflicts. This will rehabilitate the patient and to develop self-esteem and confidence. Hotdog on Bun was the focus of the said activity. Introduction of the said topic and explanation of its procedures was done. Next was the turn of the patients to read the visual aid presented and respond to the questions being asked. After this, hand washing technique was taught wherein patient was able to perform it correctly. Patient performed the said activity well wherein he made a hotdog on bun with little assistance from the student nurse.

This focuses on the clients specific needs and promoting an effective exchange of ideas through interpersonal interaction. This will let the patient have the trust to the health care provider is sharing his problems and thoughts.

Therapeutic Communication

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DRUG STUDY
NAME OF THE DRUG 1. Clozapine DOSE, FREQUECY, and ROUTE 100 mg HS, PO MECAHNISM OF ACTION Binds selectively to dopaminergic receptors in the CNS and may interfere with adrenergic, cholinergic, histaminergic, and serotonergic receptors. INDICATION CONTRAINDICATIONS SIDE EFFECTS/ ADVERSE REACTION CNS: Neuroleptic Malignant Syndrome, Seizures, dizziness, sedation EENT: visual disturbances CV: myocarditis, hypotension, tachycardia, hypertension GI; constipation, abdominal discomfort, dry mouth, increased salivation, nausea, vomiting DERM: rash, sweating ENDO: hyperglycemia HEMA: agranulocytosis, leucopenia MISC: fever, weight gain NURSING RESPONSIBILITIES 1) Observe and Apply the 10 rights of drug administration Right drug Right patient Right dose Right Route Right Time Right Approach Right drug preparation and administration. Right of patient to know the reason for the drug Right of patient to refuse Right documentation 2) Monitor patients mental status (delusions, and behavior). 3) Monitor blood pressure and pulse rate before and after administration. 4) Observe patient carefully

For SCHIZOPHRENIA, in patients who are non-responsive to or intolerant to classical antipsychotics.

Contraindicated to patients who has history of toxic or idiosyncratic granulocytopenia/ agranulocytosis, impaired bone marrow function, uncontrolled epilepsy, alcoholic and other toxic psychoses, drug intoxication, severe cardiac or renal disorders, chronic liver diseases.

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when administering medication to ensure that medication is actually taken and not hoarded

. 5) Monitor for signs and symptoms of the adverse/ side effects mentioned. 6) Monitor patient for onset of akathisia and EPE (Parkinsonism difficulty speaking/swallowing, loss of balance control, pill-rolling motion, mask like face, shuffling gait, rigidity, tremors and dystonic muscle spasm. Notify physician of other health care professional if these symptoms occurs.

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2. Fluphenazine decanoate 1 cc IM now

Possess anticholinergic and alphaadrenergic blocking activity.

For treatment of acute and chronic psychoses. To diminished signs and symptoms of psychoses.

Contraindicated to hypersensitivity to the drug. Contraindicated to patients with severe liver or cardiovascular diseases, respiratory disease.

CNS:EPE- sedation, tardive dyskinesia EENT: blurred vision, dry eyes, lens opacities CV: Hypotension,tachycardia GI: anorexia, constipation, drug-induced hepatitis, dry mouth GU: urinary retention DERM: photosensitivity, pigment changes, rashes ENDO: galactorrhea HEMA: AGRANULOCYTOSIS, leucopenia MISC: allergic reactions, hyperthermia

1) Observe and Apply the 10 rights of drug administration Right drug Right patient Right dose Right Route Right Time Right Approach Right drug preparation and administration. Right of patient to know the reason for the drug Right of patient to refuse Right documentation 2) Monitor patients mental status (delusions, and behavior). 3) Monitor blood pressure and pulse rate before and after administration. 4) Observe patient carefully when administering medication to ensure that medication is actually taken and not

36

hoarded. 5) Monitor for signs and symptoms of the adverse/ side effects mentioned. 6) Monitor patient for onset of akathisia and EPE (Parkinsonism difficulty speaking/swallowing, loss of balance control, pill-rolling motion, mask like face, shuffling gait, rigidity, tremors and dystonic muscle spasm. Notify physician of other health care professional if these symptoms occurs.

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PSYCHIATRIC NURSING CARE PLAN

CUES
SUBJECTIVE: Wala akong asawa at mga anak, si nanay lang ang bumibisita sa akin dito as verbalized by the patient

NURSING DIAGNOSIS
P: Coping Individual; Ineffective

ANALYSIS
Stressors

NURSING OBJECTIVES
May 10 ,2012 7:00 an

NURSING INTERVENTIONS
INDEPENDENT Determine the presence or degree of impairment of clients coping abilities

RATIONALE

EVALUATION
May 18, 2012 8:00 am

Schizophrenia

E: maybe r/t personal vulnerability, inadequate support system and inadequate coping OBJECTIVES: Patient is a methods. male, tall and thin in S: as evidence by appearance, in impaired a hospital judgment, uniform cognition, perception, poor He doesnt self-concept. usually talk or mingle with other patient.

Altered emotional state

Poor deference mechanism

Ineffective individual coping

After 7, days of intervention, pt. will display behavior congruent with verbalization of feeling, demonstrate understanding of appropriate constructive effective methods of coping.

Provides information about perceived and actual coping ability, life change unit, anxiety level, stressors, developmental level of functioning, use of defense mechanisms and problem solving ability.

GOAL PARTIALLY MET AEB: the pt. was able to do the activities done but still with poor self concept and poor judgment.

Assist client to identify thoughts, perceptions and feeling.

Client is able to view how perception/thinking/af fect is processed and to strengthen reality orientation and coping skills.

Encourage patient to express areas of concern support

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In a trusting relationship, the client can begin to

formation of realistic goals and learning of appropriate problem solving techniques. Encourage client to identify precipitating factors that lead to ineffective coping when possible.

learn skills without fear of judgment.

Knowledge of stressors that have precipitated deteriorated coping ability enables the client to recognize and deals with it.

Explore how clients perception validated prior to drawing conclusions.

With support, client has the ooputunity to learn to validate perceptions before selecting appropriate coping methods.

Assist client to recognize and develop appropriate effective coping skills.

Increased more flexible problemsolving or coping behaviors prevent decomposition.

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SUBJECTIVE: Wala. Hindi ko na alam, hindi ko na matandaan, as verbalized by the patient.

P: Altered Thought Process

Stressors

May 10,2012 8:00 am

INDEPENDENT Determine the severity of clients altered thought process, noting from loose or concrete associations, content and flow. Identification of symbolic primitive nature of thinking communications promotes understanding of the individual clients thought process and enables planning\g of appropriate interventions. Provides an emotionally safe milieu that enables interpersonal interaction. Therapeutic communications are clear, concise, open, and consistent and require use of self. Lack of considerations of these factors can case misdiagnosis/ inaccurate interpretation.

May 18, 2012 8:00 am

E: may be r/t impaired judgment, psychosocial OBJECTIVES: conflicts, ambivalence, and Passive and concomitant unresponsive dependence. to some questions S: as evidence by inaccurate Patient has a interpretation, poor remote impaired ability to but good recent make decision, memory and poor judgment and has a good unresponsiveness immediate memory Has a slightly poor concentration Sometimes copies what the other patients answer during activities. He has flight of

Schizophrenia After 7, days of performing nursing the Anatomic and intervention, client must function system recognized changes altered in thinking behavior, Altered Thought maintains, reality orientation and Process establish interpersonal relationship.

GOAL PARTIALLY MET AEB: the pt. is readily oriented but he cannot perform decision making.

Establish a nurseclient therapeutic relationship.

Use therapeutic communications to intervene effectively.

Structure communications to reflect consideration of clients socioeconomic, educational and cultural history/ values. Express desire to understand clients
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Client s often unable to recognize thoughts

ideas or looseness of association. He only answers close ended questions and does not pay attention or gets rid to open ended questions.

thinking by clarifying what is unclear, focusing on the feeling rather than the content, endeavoring to understand, listening carefully and regulate the flow of thinking as needed. Reinforce congruent thinking; refuse to argue with disintegrated thought and present reality. Share appropriate thinking and set limits if the patient tries to respond unwillingly. Asses present degree of factors affecting clients capacity for divertional activities. COLLABORATIVE Administer antipsychotics indicted.

and flow of thoughts is often characterized as racing, maundering or retarded.

Provide opportunity for the client to control aggressive behavior.

Enhances self-esteem and promote safety for the client and others.

Helps the attainment of best plan of care.

as

Used to reduce psychotic symptoms.

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SUBJECTIVE: Hindi ako masyadong nakikipag-usap sa mga kasama ko dito, as verbalized by the patient.

P: Social Interaction; Impaired E: may be r/t absence of available significant others or peers S: as evidence by dysfunctional interaction with others.

Stressors

May 10, 2012 8:00 am

INDEPENDENT Spend time with client, this may just mean sitting in silence for a while.

May 18, 2012 8:00 am Presence nay help improve clients perception of self of GOAL MET as a worthwhile person. AEB: the pt. willingness and Presence, desire to socialize acceptance, and with other and conveyance of voluntarily attend positive regard group activities. enhance the clients feeling of self-worth.

Schizophrenia After 7 days of interventions the patient will be able to gain trusting relationship with others.

Confinement in the institution

OBJECTIVES: Seen all alone by himself Patient is not talking or interacting with other patients Patients is seen talking by himself Patient looks shy

Absence of available significant others or peers

Develop a therapeutic nurse client relationship through frequent brief contacts and accepting attitude, show unconditional positive reward. Provide positive reinforcement for clients voluntary interactions with others. Teach assertiveness techniques. Interaction with others may be negatively affected by clients used of passive or aggressive behavior.

Impaired Social Interaction

Positive reinforcement enhances self esteem and encourages repetition of desirable behaviors. Knowledge of assertive techniques could improve clients relationships with others

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SUBJECTIVE: Nawala yong tsinelas ko kaya palakad-lakad na lang ako na nakapaa, as verbalized by the patient. OBJECTIVES: Patient is seen barefooted inside and outside the ward. He puts up his foot when sitting and eating He placed his food even on dirty areas The patient has a poor hygiene and looks untidy

P: Self Care Deficit E: may be r/t perceptional and cognitive impairment; decreased psychomotor activity. S: as evidence by dysfunctional interaction with others.

Stressors

May 10, 2012 8:00 am

INDEPENDENT Asses presence/ severity of factors that affect clients capacity for self care. Discuss personal appearance/ grooming and encourage patient for self care. Give positive feedback for efforts. Increase daily activity and as client progresses. Impairment can alter clients ability for self care.

May 18, 2012 8:00 am

Schizophrenia After 7 days of performing nursing interventions pt. will be able to perform self- care appropriately.

GOAL MET

anatomic and function system altered

Self Care Deficit

AEB: the pt. can Appearance affects willingness to how the client sees perform self care self. like taking a bath, shaving and the likes but still needs guidance Adequate exercise increase muscle tone and consistency in daily routine stimulates bowel elimination.

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Discharge plan
Patient Noel is not yet discharged:

medication

Follow strict medication compliance. Follow proper ordered dose of drugs to achieve drug reactions Medications being taken:

Exercise

Instruct patient to perform exercise every morning such as stretching extremities or applying the steps being taught to them for maintenance of the bodys flexibility.

Treatment

Strict medication compliance Treatment of Schizophrenia includes daily dose of prescribed medication Avoid taking over the counter drugs that is not prescribed

Health teachings

Encourage patient to sleep early and have adequate time for rest and sleep. Emphasize the importance of proper hygiene such as taking a bath, brushing teeth and wearing clean and appropriate clothes. Encourage patient to do hand washing before and after eating to prevent acquiring infection Instruct patient to eat nutritious foods such as green leafy vegetables and fruits to meet nutritional demands. Advise patient to avoid stressful events so as not to trigger illness. Emphasize the importance of mingling or socializing with other people to overcome or combat loneliness.
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Opd

Encourage patient to attend check-ups regularly Inform patient/SOs to seek for health care provider when symptoms such as depression, wandering, inability to sleep/insomnia, poor personal hygiene, weight loss, poor appetite and self isolation occurs.

Diet spiritual

Instruct patient to eat nutritious foods such as green leafy vegetables and fruits to meet nutritional demands. Encourage patient to pray all the time and instill in his mind that God is always there to guide and light our path towards hardships and there is always hope and solutions for all the problems.

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Bibliography
Books
Smeltzer, Suzanne C. & Brenda G. Bare. Brunner & Suddarths Textbook of MedicalSurgical Nursing, Vol 2, 10th Ed. Philadelphia: Lippincott Williams & Wilkins, 2004. Doenges and Moorhouse, Nurses Pocket Guide: Nursing Diagnoss with Interventions 4th Edition, 1993 by Merriam & Webster Booksotre, Inc. Manila Videbeck, Psychiatric Mental Health Nursing, Third Edition Shives, Isaacs, Basic Concepts of Psychiatric-Mental Health Nursing Nurses Dictionary, Second Edition Emmanuel Latin et.al, PDDs Nursing Drug Guide,2007, Malan Press Inc., City Jacques Wallach, M.D., Interpretation of Diagnostic Tests 7th Edition, 2000 Lippincott Williams & Wilkins Spratto and Woods, Delmar Nurses Drug Handbook 2010 Edition, 2010 by Cengage Learning Delmar, by Pasig

Website:
http://www.sciencedaily.com/releases/2012/01/120102180842.htm http://www.sciencedaily.com/releases/2012/03/120327124235.htm http://www.sciencedaily.com/releases/2011/05/110517105148.htm http://www.sciencedaily.com/releases/2011/07/110720121900.htm http://www.sciencedaily.com/releases/2012/03/120326160827.htm http://www.psychpage.com/learning/library/assess/msciense.htm

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Updates
Schizophrenia Diagnosis Associated With Progressive Brain Changes among Adolescents
ScienceDaily (Jan. 2, 2012) Adolescents diagnosed with schizophrenia and other psychoses appear to show greater decreases in gray matter volume and increases in cerebrospinal fluid in the frontal lobe compared to healthy adolescents without a diagnosis of psychosis, according to a report in the January issue of Archives of General Psychiatry, one of the JAMA/Archives journals. "Progressive loss of brain gray matter (GM) has been reported in childhood-onset schizophrenia; however, it is uncertain whether these changes are shared by pediatric patients with different psychoses," the authors write as background information in the study. Celso Arango, M.D., Ph.D., of the Hospital General Universitario Gregorio Maran, Madrid, Spain, and colleagues, examined the progression of brain changes in first-episode earlyonset psychosis and the relationship to diagnosis and prognosis at two-year follow-up among patients at six child and adolescent psychiatric units in Spain. The authors performed magnetic resonance imaging (MRI) of the brain for 61 patients (25 diagnosed with schizophrenia, 16 with bipolar disorder and 20 with other psychoses) and 70 healthy control participants. MRI scans were conducted at study baseline and after two years of follow-up. Compared with control patients, those diagnosed with schizophrenia showed greater gray matter volume loss in the frontal lobe during the two-year follow-up. Patients with schizophrenia also showed cerebrospinal fluid increase in the left frontal lobe. Additionally, changes for total brain gray matter and left parietal gray matter were significantly different in patients with schizophrenia compared with patients in the control group. Among patients with schizophrenia, progressive brain volume changes in certain areas were related to markers of poorer prognosis, such as more weeks of hospitalization during follow-up and less improvement in negative symptoms. Greater left frontal gray matter volume loss was related to more weeks of hospitalization whereas severity of negative symptoms correlated with cerebrospinal fluid increase in patients with schizophrenia. The authors did not find any significant changes in patients with bipolar disorder compared to control patients, and longitudinal brain changes in the control group were consistent with the expected pattern described for healthy adolescents. "In conclusion, we found progression of gray matter volume loss after a two-year followup in patients who ended up with a diagnosis of schizophrenia but not bipolar disease compared with healthy controls," the authors write. "Some of these pathophysiologic processes seem to be markers of poorer prognosis. To develop therapeutic strategies to counteract these pathologic progressive brain changes, future studies should focus on their neurobiological underpinnings.
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Epigenetic Changes in Blood Samples May Point to Schizophrenia

ScienceDaily (Mar. 27, 2012) In a new study, researchers at Karolinska Institutet have identified epigenetic changes -- known as DNA methylation -- in the blood of patients with schizophrenia. The researchers were also able to detect differences depending on how old the patients were when they developed the disease and whether they had been treated with various drugs. In the future this new knowledge may be used to develop a simple test to diagnose patients with schizophrenia. Schizophrenia is one of our most common chronic psychiatric diseases and affects 1% of the population. It is already known that the risk of developing schizophrenia increases if one has close family members who have had the disease. At the same time, studies on identical twins, who therefore have the same genetic make-up, show that 50% of the disease risk can be explained by genetic factors. This in turn suggests that environmental factors, which include epigenetic changes to the genome, account for the remaining 50% of the cause of the disease. "Epigenetics involves small reversible chemical changes, for instance in the form of methyl groups that bind to certain DNA sequences in the genome, that can consequently modifythe function of the DNA," says Professor Tomas Ekstrm, who has directed the study at the Center for Molecular Medicine (CMM). "The research results we are now presenting suggest that epigenetic mechanisms are of great importance in mental illness. It is particularly interesting that these changes can also be linked to age at disease onset." The current study, which is published in the scientific journalFASEB Journal, shows that the methylation levels in DNA in the white blood cells from individuals who suffer from schizophrenia are substantially lower than normal and that the degree of methylation is related to age of disease onset and the severity of the disease. The researchers also compared the degree of methylation in samples from patients who had been treated with various types of drugs. It emerged that treatment with one type of antipsychotic drug could influence the levels of DNA methylation in the blood cells towards more normal levels. In their article in FASEB Journal, the researchers at CMM note that at present there is no biomarker for schizophrenia that is suitable for clinical sampling. An interesting area of application for the new knowledge may therefore be to develop a simple test of this kind to diagnose schizophrenia, and to monitor how patients respond to the treatment they receive. "The fact that DNA methylation in an ordinary blood sample can be used as a marker of the severity of schizophrenia opens up completely new opportunities," says Professor Martin Schalling, one of the researchers behind the study. "But follow-up studies are needed to clarify, for example, whether choice of treatment can be linked to this type of test."

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A 'Brain Wave' Test for Schizophrenia Risk?

ScienceDaily (May 17, 2011) There is a significant need for objective tests that could improve clinical prediction of future psychosis. In this new study, the researchers followed a group of people clinically at high risk for developing psychosis. They found that the individuals who went on to develop schizophrenia had smaller MMN than the subgroup who did not. This finding suggests that MMN might be useful in predicting the later development of schizophrenia. One strategy has been to determine whether physiologic measures that are abnormal in people diagnosed with schizophrenia might also be useful in estimating the risk for developing this illness. This is the strategy taken by German and Swiss researchers in the current issue ofBiological Psychiatry. They used electroencephalography (EEG), which measures the brain's electrical activity or "brain waves," to study the brain's response to commonly and rarely presented tones that differed in length. When these rare "deviant" tones are presented to healthy people, the brain automatically generates a particular electrical wave called mismatch negativity, or MMN. People diagnosed with schizophrenia have reduced MMN. In this new study, the researchers followed a group of people clinically at high risk for developing psychosis. They found that the individuals who went on to develop schizophrenia had smaller MMN than the subgroup who did not. This finding suggests that MMN might be useful in predicting the later development of schizophrenia. "With this type of study, the devil is always in the details. How sensitive is MMN as a risk predictor? How reliable is it? How many people are mistakenly classified? How long of a follow-up period is necessary to make this test useful? Are there subgroups of individuals for whom this test is or is not reliable?" mused Dr. John Krystal, Editor of Biological Psychiatry. "If we hope to use this type of measure to guide research and even clinical interventions, then it has to be an extremely robust measure with respect to the issues that I just mentioned, among others. Yet, this is exactly the type of initial step that we need to move toward clinically meaningful biological tests." First author Dr. Mitja Bodatsch agreed, adding that "integration of both biological and clinical measures into multidimensional models might be the crucial next step forward to improve risk staging in psychiatry."

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Cancer Drugs May Help Treatment of Schizophrenia

ScienceDaily (July 20, 2011) Researchers have revealed the molecular pathway that is affected during the onset of schizophrenia and successfully alleviated symptoms of the illness in mice, using a commonly used cancer drug. The research, published online in the journal Brain, is from a group led by Professor Peter Giese at King's College London, and offers new avenues for drug discovery. Schizophrenia is one of the most common serious mental health conditions in the UK, and affects about 24 million people worldwide. The illness is a long-term mental health condition that causes a number of psychological symptoms, including hallucinations and delusions as well as behaviour changes. The exact cause of the illness is unknown, although it is generally believed to be a combination of genetic and environmental factors. According to the World Health Organization, 90% of people with untreated schizophrenia are in developing countries. Current treatments for schizophrenia include both psychological treatments such as psychotherapy, counselling or cognitive behaviour therapy and/or medication. However, many of the antipsychotic drugs or major tranquillisers used to treat or manage the illness have very bad side-effects. Professor Giese, based at the Institute of Psychiatry at King's, said: 'For the first time we have found that an enzyme activator called p35 is reduced in patients with schizophrenia and moreover, modelling this reduction in mice led to cognitive impairment typical for this disease. This gives us a better understanding of the changes that occur in the brain during the onset of schizophrenia.' Proper brain development is ensured, in part, by the activation of a protein in the brain called Cdk5. The activation of Cdk5 requires the presence of an enzyme in the brain, called p35. The research found that in human post-mortem brains, there was approximately 50% less p35 in the brains of patients who had suffered from schizophrenia. These molecular changes were then modelled and monitored in mice that had been modified to contain a comparable reduction in the p35 enzyme. As a result of this reduction in p35, the mice showed a reduction in synaptic proteins -- important in maintaining neural connections -- and displayed symptoms associated with schizophrenia, including learning impairments and inability to react to sensory stimuli. Understanding this signalling pathway and the impact of low levels of p35, is important in finding potential future treatments for the disease. Professor Giese continues: 'We noted that the reduction in p35 affects the same molecular changes targeted by a cancer drug called MS-275, so we administered this drug to the mice. We were excited to find that MS-275 not only addressed the molecular changes but also alleviated the symptoms associated with schizophrenia.'

50

He concludes: 'Our findings encourage the future exploration of these types of drugs for treating impaired cognition in schizophrenia.' The research was funded by the Medical Research Council UK (MRC), the National Institutes of Health (USA), the Boehringer Ingelheim Fonds, Germany and the Deutsche

Forschungsgemeinshaft

Smokers Could Be More Prone to Schizophrenia

ScienceDaily (Mar. 26, 2012) Smoking alters the impact of a schizophrenia risk gene. Scientists from the universities of Zurich and Cologne demonstrate that healthy people who carry this risk gene and smoke process acoustic stimuli in a similarly deficient way as patients with schizophrenia. Furthermore, the impact is all the stronger the more the person smokes. Schizophrenia has long been known to be hereditary. However, as a melting pot of disorders with different genetic causes is concealed behind manifestations of schizophrenia, research has still not been able to identify the main gene responsible to this day. In order to study the genetic background of schizophrenia, the frequency of particular risk genes between healthy and ill people has mostly been compared until now.

Pharmacopyschologist Professor Boris Quednow from University Hospital of Psychiatry, Zurich, and Professor Georg Winterer's workgroup at the University of Cologne have now adopted a novel approach. Using electroencephalography (EEG), the scientists studied the processing of simple acoustic stimuli (a sequence of similar clicks). When processing a particular stimulus, healthy people suppress the processing of other stimuli that are irrelevant to the task at hand. Patients with schizophrenia exhibit deficits in this kind of stimulus filtering and thus their brains are probably inundated with too much information. As psychiatrically healthy people also filter stimuli with varying degrees of efficiency, individual stimulus processing can be associated with particular genes. Smokers process stimuli less effectively In a large-scale study involving over 1,800 healthy participants from the general population, Boris Quednow and Georg Winterer examined how far acoustic stimulus filtering is connected with a known risk gene for schizophrenia: the so-called "transcription factor 4" gene (TCF4). TCF4 is a protein that plays a key role in early brain development. As patients with schizophrenia often smoke, the scientists also studied the smoking habits of the test subjects. The data collected shows that psychiatrically healthy carriers of the TCF4 gene also filter stimuli less effectively -- like people who suffer from schizophrenia. It turned out that primarily smokers who carry the risk gene display a less effective filtering of acoustic impressions. This effect was all the more pronounced the more the people smoked. Non-smoking carriers of the risk gene, however, did not process stimuli much worse. "Smoking alters the impact of the TCF4 gene on acoustic stimulus filtering," says Boris Quednow, explaining this kind of gene51

environment interaction. "Therefore, smoking might also increase the impact of particular genes on the risk of schizophrenia." The results could also be significant for predicting schizophrenic disorders and for new treatment approaches, says Quednow and concludes: "Smoking should also be considered as an important cofactor for the risk of schizophrenia in future studies." A combination of genetic (e.g. TCF4), electrophysiological (stimulus filtering) and demographic (smoking) factors could help diagnose the disorder more rapidly or also define new, genetically more uniform patient subgroups.

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