Group 4

Alonte, Cathyrine Joy Mendoza, John Michael

Castro, Danna Mae Mendoza, Eldione
Gealone, Alondra Santos, Ma. Trisha Ann
Jacinto, Blair Soldevilla, Elijah
Mariquit, Erica Tulbo, Lirose- Ann
Villanueva, Nicole
 CASE SCENARIO

Ricky was staying with his father for a few weeks on a visit. During the first
week, things had gone pretty well, but Ricky forgot to take his medication for a
few days. His father knew Ricky wasn’t sleeping well at night, and he could hear
Ricky talking to himself in the next room.

One day while his father was at work, Ricky began to hear some voices
outside the apartment. The voices grew louder, saying, “You’re no good; you
can’t do anything right. You can’t take care of yourself or protect your dad.
We’re going to get you both.” Ricky grew more frightened and went to the
closet where his dad kept his tools. He grabbed a hammer and ran outside.
When his father came home from work early,
Ricky wasn’t in the apartment, though his coat and wallet were still there. Ricky’s
father called a neighbor, and they drove around the apartment complex looking for
Ricky. They finally found him crouched behind some bushes. Although it was 45F
(7C), he was wearing only a T-shirt and shorts and no shoes. Ricky’s neighbor
called emergency services. Meanwhile, Ricky’s father tried to coax Ricky into the
car, but Ricky wouldn’t come. The voices had grown louder, and Ricky was
convinced that the devil had kidnapped his father and was coming for him too. He
saw someone else in the car with his dad. The voices said they would crash the car
if he got in., they were laughing at him! He couldn’t get into the car; it was a trap.
His dad had tried his best, but he was trapped too.
The voices told Ricky to use the hammer and to destroy the car to kill the devil.
He began to swing the hammer into the windshield, but someone held him back.

The emergency services arrived and spoke quietly and firmly as they removed the
hammer from Ricky’s hands. They told Ricky they were taking him to the hospital
where he and his father would be safe. They gently put him on a stretcher with
restraints, and his father rode in the emergency van with him to the hospital.
 Schizophrenia

Schizophrenia is a chronic mental disorder

that affects someone’s thoughts, feelings
and behaviour that can result to impairment
of daily functioning. The patient diagnosed
with schizophrenia experiences difficulty in
distinguishing reality from unreal.
 One of the misconceptions about schizophrenia is having a
split personality. The misconception maybe caused by its name
itself because the word schizophrenia originates from the Greek
words “schizo” (split) and “phrene” (mind). but it is meant to
describe the fragmented thinking of people with this disorder.

1.1% of the population above the age of 18 is affected with

schizophrenia and it estimates to be 51 million people
worldwide. This mental disorder can occur to anyone without
regard to class, color and culture. It has higher prevalence and
both genders can be equally affected by the disorder but males
may have earlier onset.
 Types of Schizophrenia

Paranoid
Disorganized
Catatonic
Undifferentiated
Residual
 Paranoid Schizophrenia

Based on the case given, Ricky is experiencing Paranoid

Schizophrenia.
Paranoid schizophrenia is the most common type of
schizophrenia and characterized by unreasonable
suspicion or paranoid behavior. It is exhibited by feelings
of persecution, of being watched.
A person diagnosed with paranoid type schizophrenia may
display anger, anxiety, and hostility. The person usually
has a relatively normal intellectual functioning and
expression of affect.
 Paranoid Schizophrenia

This type shows predominantly positive symptoms of

schizophrenia. The patient may be preoccupied with at
least one delusion or is experiencing frequent auditory
hallucinations.
Both of these experiences can be persecutory or
threatening in nature. A patient may hear a voice or
voices in their head that they do not recognize as their
own thoughts or internal voice. These voices can be
demeaning or hostile, driving a person to do things they
would not do otherwise.
Signs and Symptoms

Divided into 3:
Positive

Negative

Cognitive
 Positive symptoms:

Hallucinations
Delusions
Disorganized behavior and speech
 Negative symptoms:

Apathy
Anhedonia
Blunted affect
Poverty of speech
 Cognitive symptoms:

Thought disorders

Bizarre behavior
Can be Linked to Different Factors:

Genetic factors
Environmental factors
Biochemical factors
 DRUG STUDY

Nursing Consideration
Drug Data Indication

Generic name: • Acute and chronic

Chlorpromazine psychosis,
  particularly when
Brand name: accompanied by
Thorazine increased
 
psychomotor activity.
Classification:
Antipsychotic
• used to control
Antiemetics anxiety or agitation
Dosage: in certain patients
(Adult) • to treat Nausea and
Tablets: 10 mg, 25mg, vomiting
100mg,50 mg,200 mg • used in the
Injectable solution: treatment of
25mg/ML intractable hiccups
 
 
 Continuation…
Nursing Consideration

Before: 2. Keep patient

Route of administration:: 1. Assess the patient’s recumbent for at least 30
PO, IM, IV mental status. minutes following
2. Monitor blood pressure parenteral
3. Assess fluid and bowel 3. Monitoring of blood
function pressure is recommended
4. Monitor patient for during parenteral
onset of akathsia. administration.
4. The drug can be taken
During: with or without food.
5. Do not confuse 5. Observe patient
Chlorpromazine with carefully when
Chlorpropamide . administering medication
Continuation…
Nursing Consideration

After:
1. Advice patient to take medication as directed
2. Encourage to change position slowly
3. Caution to avoid alcohol or other CNS depressants
4. Institute oral hygiene
5. Monitor for tardive dyskinesia
6. Monitor I&O ratios and daily weight and Inform that this may
turn urine into pink to reddish brown color
7. Monitor kidney and liver function of the patient.
8. Monitor cardiovascular status of the patient
9. Monitor for development of neuroleptic malignant syndrome
10. Watch out for somnolence, coma, hypotension and
extrapyramidal symptoms, agitation and restlessness,
convulsion, fever, autonomic reactions.
 DRUG STUDY

Nursing Consideration
Drug Data Indication

Before
Generic name: General
1. Monitor patient’s blood
Fluphenazine Acute and chronic
pressure routinely.
  pyschoses 2. Assess mental status
Brand name:   (mood, behavior,
Prolixin Patient’s Actual orientation).
  Indication 3. Assess weight and BMI.
Classification: N/A 4. Assess positive and
Antipsychotic negative symptoms of
schizophrenia.
5. Assess fluid intake and
bowel function
6. Prepare drug aseptically
and verify the right dose.
Render health teaching as
appropriate.
 Continuation…
During
1. Verify patient’s identity
using the chart and other
patient and nurse’s
confirmation.
2. Administer oral doses
with food, milk, or a full
glass of water.
3. For I.M. and
subcutaneous injection,
use at least a 21G needle.
4. Observe patient carefully
when administering
medication to ensure that
medication is taken not
hoarded or cheeked.
Nursing Consideration
After
1. Document medication
given.
2. Don’t let patient sit or stand
up until
blood pressure and heart rate
have
returned to baseline.
3. Notify prescriber if patient
develops tardive
dyskinesia or urinary
incontinence.
4. Instruct to frequently do
good oral hygiene.
5. Be alert for and
immediately report signs of
neuroleptic malignant
syndrome.
6. Notify prescriber about
worsening psychotic
symptoms: agitation,
catatonic
state, confusion,
depression,
hallucinations, lethargy,
paranoid reactions.
7. Monitor temperature; a
significant, unexplained
rise can indicate
intolerance and a need to
discontinue drug. Notify
prescriber immediately if
this occurs.
 Nursing Assessment

• Assess positive symptoms. Assess for command hallucinations; explore

answers. Assess if the client has fragmented, poorly organized, well-
organized, systematized, or extensive system of beliefs that are not
supported by reality. Assess for pervasive suspiciousness about
everyone and their actions (e.g., vigilant, blames others for
consequences of own behavior, argumentative, threatening).
• Assess negative symptoms. 
• Assess cognitive symptoms.
• Assess medical history. Assess if the client is on medications, what
these are, and adherence to therapy.
• Assess support system. Determine whether the family is well informed
about the disease. Does the family understand the need for medication
adherence?
 Nursing Consideration

• Recognize schizophrenia. Note characteristic signs and

symptoms of schizophrenia (e.g., speech abnormalities,
thought distortions, poor social interactions).
• Establish trust and rapport. Don’t tease or joke with
patients. Expect that patient is going to put you through
rigorous testing periods. Introduce yourself and explain
your purpose.
• Maximize level of functioning. Assess patient’s ability
to carry out activities of daily living (ADLs).
 NURSING DIAGNOSIS
Disturbed sensory perception: Auditory related to
psychological stress as evidenced by auditory hallucinations,
talking to self and persecutory delusions.
 Nursing Care Plan
Name: Ricky Age: 40 Gender: Male
Nursing Diagnosis: Disturbed sensory perception: Auditory related to
psychological stress as evidenced by auditory hallucinations, talking to self
and persecutory delusions.
Short Term Goal: After 4 hours of nursing intervention, the nurse will be able to
present reality to the patient.
Long Term Goal: After 3 days of nursing intervention, the patient will be able
to verbalize understanding that the voices are result of his illness,
demonstrate ways to interrupt hallucinations and increased ability to
concentrate.
Medical Diagnosis: Schizophrenia (Paranoid subtype)
Cues Problem Scientific Reason
Subjective: Hallucinations It is change in the amount or
“May sinasabi sa akin yung patterning of incoming
demonyo na papatayin niya ako at stimuli accompanied by a
ang tatay ko. Kikidnapin nila ang diminished, exaggerated,
tatay ko.” as verbalized by the distorted, or impaired
patient. response to such stimuli.
Objective:  
 Talking to self  
 Auditory hallucinations Annotation:
 Tilting the head as if listening  
to someone Schultz, M.J.;Videback, S.L.;
 Looks fearful Lippincott’s Manual of
 Agitated Psychiatric Nursing Care
 Restlessness Plans 7th edition
 Inaccurate interpretation of
the environment
 Persecutory delusion
 Extreme suspiciousness
Nursing Intervention
Independent:
1. Acknowledge that the voices and
sightings are real to the client but
clearly state that you do not hear or
see them.
2. Make conversations simple, basic
and reality-based. Avoid
bombarding the client with multiple
ideas. Instead, help the client to
focus on one idea at a time.
3. Involve the client in reality-based
activities such as drawing or
listening to music.
Rationale
Independent:
1. Stating to the client that you do not sense or
perceive the voices and sightings will help the
client become uncertain of the validity of what
they see or hear.
2. The client’s thought process might be
disorganized. A basic and reality-based
conversation will help the client to focus.
3. Being engaged in reality-based activity provides
a healthy diversion and prevents the client from
acting out his/her hallucinations.
Nursing Intervention Rationale
6. Stay with the client when he/she starts to 6. There are instances when clients can learn to push away or
hallucinate. Guide him/her to tell the “voices” to disregard the voices when they are given repeated instructions.
go away. Repeat this often and in a tone that is 7. Might herald hallucinatory activity, which can be very
matter-of-fact. frightening to client, and client might act upon command
7. Be alert for signs of increasing fear, anxiety or hallucinations.
agitation. 8. People often obey hallucinatory commands to kill self or
8. If voices are telling the client to harm self or others. Early assessment and intervention might save lives.
others, take necessary environmental 9. Suspicious clients may perceive touch as a threatening
precautions. gesture.
9. Avoid physical contact, use gestures carefully. 10. To verify that client is swallowing the tablets or capsules.
10. Mouth checks may be necessary after Suspicious clients may believe they are being poisoned with their
medication administration. medication and attempt to discard the pills.
   
Dependent: Dependent:
11. Intervene with one-on-one, seclusion, or PRN 11. Intervene before anxiety begins to escalate. If the client is
medication (As ordered) when appropriate. already out of control, use chemical or physical restraints
   following unit protocols.
8.During acute phase, client’s delusional thinking might dictate
to them that they might have to hurt others or self in order to be
safe. External controls might be needed.
 EVALUATION
SHORT TERM GOAL:
After 4 hours of nursing intervention
the nurse was able to present reality
to the patient as evidenced by
continuous learning ways to refrain
from responding to hallucinations.
LONG TERM GOAL:
After 3 days of nursing intervention,
the patient was able to verbalize
understanding that the voices are
result of his illness, demonstrated
ways to interrupt hallucinations and
increased ability to concentrate as
evidenced by techniques that
decrease the frequency of
hallucinations.