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A Case Study

Presented to the Faculty of


The Ateneo de Davao University
College of Nursing

A Case Study on
Schizophrenia Undifferentiated
Submitted to:
Mrs. Anabel Bauzon, RN, MN
Clinical Instructor – Panelist of the Case Study

Submitted by:
[Group 1]
Abarquez, Eva Rica V.
Ampilanon, Rae Maikko M.
Ausa, Ryan S.
Balboa, Tessa Marie R.
Batuhan, Katherene P.
Beltran, Maribel S.
Bulosan, Von Rainier S.
Cabonita, Kristi Ann J.
Campaner,Marie Allexis I.

BSN-3H

09 February 2010
TABLE OF CONTENTS

Acknowledgement…………………………………………………………………..…..3

Introduction…………...……………………………………………………………….…4

Objectives (General & Specific)……………………………..……………………….….6

Personal Data…………………………………………...……………………………….9

Genogram……………………………………………………………………….………11

Anamnesis………………………………………………………………………….…...12

Theories of Development………………………………………………………….....…24

Etiology and Symptomatology….……………………………………………….……44

Psychodynamics………………………………………………………………..………62

Mental Status Exam……………………………………………………………….…..68

Multi Axial Assessment………………………………………………………………..78

Nurse Patient Interaction ……………………………………………………………..81

Complete Diagnosis…………………………………………………………......…….101

Differential Diagnosis……………………………………………………………....…104

Anatomy and Physiology…………………………………………………….…..……115

Doctor’s Order…………………………………………………………...……………126

Drug Study……………………………………………………………………….……130

Nursing Care plan ……………………………………………………………..………149

Prognosis………………………………………………………………..…….......……176

Recommendations………………………………..………………………...…………180

Significance of the Study……………………………………………………...………182

Appendices……………………………………………………..………………...……183

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References……………………………………………………...………………...……195

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ACKNOWLEDGEMENT

The group wishes to express their deepest gratitude and warmest appreciation to the

following people, who, in any way gave us the possibility making this case study a success:

First of all, to the Almighty God, who never cease in loving us and for the continued

guidance and protection.

To the group’s clinical instructor, Mrs. Apple V. Guiao, R.N,M.N for her guidance and

support in the duration of the study and during the psychiatric nursing exposure , whose help,

stimulating suggestions and encouragement helped us in all the time of making this case study. To

Mrs. Zenaida Lagrosa RN, Mrs. Anabel Bauzon RN and Mr. Richard Cheng,RN for their unlimited

patience, guidance and being with us during our psychiatric nursing exposure . Finally to Ms. Melba

Irene Gabuya RN for imparting knowledge and learning experience during our lectures on

Psychiatric nursing. Without their encouragement and constant guidance, our Psychiatric Nursing

exposure would not have been a very meaningful learning experience.

The group also wishes to acknowledge the invaluable assistance and cooperation of the staff

nurses of the Davao Mental Hospital (DMH), for allowing us to conduct this study, for essential

assistance in reviewing the patient files and giving us the opportunity to care for the mentally-ill

patients.

Special appreciation is extended to the client subjected for this study and other informants

for their selfless cooperation, time and entrusting personal information needed for this study.

To the group, we would like to show our endless gratitude to each other by specifying our

names; Maikz, Eva, Allexis, Kat, Bel, Kitty, Ryan, Tessa and Von; for the understanding, believing

in each other, and teamwork. May we continue working hard for future studies.

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And lastly, to our parents who have always been very understanding and supportive both

financially and emotionally.

INTRODUCTION

Schizophrenia (from the Greek roots skhizein ("to split") and phrēn, phren- ("mind"))

is a severe mental illness characterized by a variety of symptoms including but not limited to loss of

contact with reality. Schizophrenia is not characterized by a changing in personality; it is

characterized by a deteriorating personality. Simply stated, schizophrenia is one of the most

profoundly disabling illnesses, mental or physical, that the nurse will ever encounter (Keltner,

2007). There are 5 subtypes of schizophrenia naming; paranoid, disorganized, catatonic,

undifferentiated, and residual. Schizophrenia undifferentiated is the type of schizophrenia wherein

characteristic symptoms (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.

Schizophrenia is not a terribly common disease but it can be a serious and chronic

one. Worldwide about 1 percent of the population is diagnosed with schizophrenia. About 1.5

million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net).

Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americans

suffer from schizophrenia; fifty percent (50%) experience serious side effects from medications;

and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of

86,241,697 of Filipinos or approximately 0.8% are suffering from schizophrenia

(cureresearch.com). Here in Davao, Dr. Padilla said that the Davao Mental Hospital receives an

average of eight to 10 patients a day suffering from schizophrenia, depression and bi-polar illnesses

(Positivenewsmedia.net).

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Schizophrenia Ranks among the top 10 causes of disability in developed countries

worldwide (World Health Organization, www.who.int) Schizophrenia is a disease that typically

begins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophrenia

slightly earlier than women; whereas most males become ill between 16 and 25 years old, most

females develop symptoms several years later, and the incidence in women is noticeably higher in

women after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onset

is quite rare for people under 10 years of age, or over 40 years of age (schizophrenia.com).

The group 1 of BSN-3H was given opportunity to have a hospital exposure in Davao

Mental Hospital last January 19 – 30, 2010 for their psychiatric exposure. It was on that said dates

that the group found a creditable case sensible to be presented as case presentation as suggested

their Clinical Instructor Apple V. Guiao, R.N. M.N. and was agreed by whole group.

The patient, Bob, not his real name, was one of the patients admitted to the Crisis

Intervention Unit of Davao Mental Hospital due to Schizophrenia Undifferentiated. The group

chose Bob as their subject primarily because his case posed as a very intricate case requiring due

understanding and knowledge. Making this case is a good avenue to broaden the proponents’

knowledge about the mental illness involved.

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OBJECTIVES

General Objective:

The main goal of the group is to be able to present an extensive and comprehensive case

study of our chosen client that would present a comprehensive discussion of Schizophrenia

Undifferentiated to yield important information for the case study.

Specific Objectives:

In order to meet the general objective, the group aims to:

Cognitive:

• interpret the pertinent data gathered from the patient and his significant others;

• present the anamnesis by thorough gathering of the client’s pertinent personal data,

appropriate selection of informants, and familial history tracing;

• evaluate the developmental stage of the patient according to the theories of Erikson, Freud

and Piaget;

• determine the etiology factors (precipitating and predisposing) of the mental disorder;

• evaluate the presence or absence of signs and symptoms seen in the patient in relation to the

mental disorder;

• present the psychodynamics of the client’s diagnosis by recognizing its predisposing and

precipitating factors with appropriate rationales; To track down the significant events

during the client’s developmental stage as shown in the psychodynamics;

• Interpret and analyze nurse-patient interaction taken through spontaneous and effective use

of therapeutic communication;

• thoroughly define the complete diagnosis of the patient;


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• come up with a differential diagnosis with accord to the client’s maladaptive behaviors;

• discuss thoroughly the Anatomy and Physiology of the involved organs and organ systems

in accord to the final diagnosis;

• present the doctor’s order with its rationalization;

• formulate effective, specific, measurable, attainable, realistic and time-bounded nursing

care plans base on identified actual and potential nursing problems;

• arrive to a general realistic prognosis drawn from the information gathered and factors

affecting the patient’s condition;

• provide the significance of the case study;

Psychomotor:

• gather pertinent data about the client through detailed chart taking, and effective therapeutic

communication and interaction with the client and his significant others;

• commence the patient with his personal data and present and past health history;

• trace the health history of the client and family illnesses (past and present) through a

genogram;

• assess client’s mental status thoroughly during the orientation and termination phase as well

as the Multi-Axial diagnosis;

• present the medications given to the client, including their respective modes of action,

indications, contraindications, side effects, adverse reactions, nursing responsibilities, and

importance to the client’s condition;

• render quality nursing care in line with the formulated nursing care plans;

• impart appropriate recommendations to the client, his significant others and community,

medical world, and the group as a part of the nurse’s holistic care.

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Affective:

• establish rapport to the patient and the patient’s significant others; and

• establish a trusting nurse-patient relationship with the client and his significant others

through provision of holistic care toward the client and use of appropriate verbal and non-

verbal therapeutic communication skills with the client and significant others during the

data gathering;

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PATIENT’S DATA

PERSONAL DATA:

CODE NAME: Bob

AGE: 40

SEX: Male

BIRTHDAY: April 9, 1969

BIRTHPLACE: Cagayan de Oro City

ADDRESS: Prk. 1 Rizalian, Bayugan Agusan del Sur

Tulip Drive, Matina, Davao city

ORDINAL RANK: 1st

CIVIL STATUS: Single

NATIONALITY: Filipino

RELIGION: Catholic

EDUCATIONAL ATTAINMENT: 2nd Year College undergraduate

OCCUPATION: None

NUMBER OF CHILDREN: 0

NUMBER OF BROTHERS: 2 NUMBER OF SISTERS: 2

MOTHER: Aina

AGE: 58

EDUCATIONAL ATTAINEMNT: college undergraduate

OCCUPATION: Businesswoman

FATHER: Danni

EDUCAIONAL ATTAINMENT: college undergraduate

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OCCUPATION: Businessman

CLINICAL DATA:

WARD/SERVICE: Crisis Intervention Unit/Psychiatry

ADMITTING PHYSICIAN: GIOIA FE D. DINGLASAN, M.D

ADMITTING DIAGNOSIS: Schizophrenia, undifferentiated

PRINCIPAL DIAGNOSIS: Schizophrenia, undifferentiated

DATE OF AMISSION: January 19, 2010

DATE OF DISCHARGE: January 21, 2010

INSTITUTION: Davao Mental Hospital

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12
GENOGRAM
Super
Apolinario
Danni
Ronan
Jeorgin
Emman
Dennz
59
Gran
Watusi
Lolo
Leo
Fielita
Carmz
Le
Lola Lolo
Angelit
Super
Watus
Ronan
Gran
Angelito
Aina AlΩ†Ωold
years
Al
Pa
Bob
Yose
Legend:
Apolinaria
aaa††
26
39†Ѳyears
o
40 years
31
20
58
Lola

Ma

old
old
†years
years
†years
Ω † - Male
years
as old old
old - Female
∞∞-
schizophrenia
Ω-
hypertension
Ѳ - Diabetes
†-deceased

13
14
ANAMNESIS

A. INTERVIEWS

Informant #1

Name: Aina

Age: 58

Address: Purok 1, Rizalian, Bayugan, Agusan del Sur

Sex: Female

Civil Status: Married

Relationship to Client: Mother

Length of Time Known by the Patient: Since Birth up to Present (40 years)

Apparent Understanding of the Present Illness of the Client:

According to Aina, her son, Bob, started having the condition when he stopped schooling in

late August of 1987 and went back to Agusan because he thought lessons in school are becoming

too difficult for him. Bob also verbalized that something is wrong with him and that he needed a

psychological check-up. Yet, Aina did not pay attention to what he said; until two days after, Bob’s

tongue shrunk, hindering his speech. This event forced Aina to bring Bob to San Pedro Hospital for

a check-up. In San Pedro, no diagnoses indicating any mental illness resulted and they were asked

to come back for a follow-up check up the following month. On November 1987, Aina brought Bob

back to Davao City for a check-up but transferred to Davao Mental Hospital. There, Bob was

diagnosed with Schizophrenia Catatonic Type and was admitted for two weeks; after which, he was

discharged and was asked to go back to the hospital once a month for psychiatric evaluation and for

monthly doses of a depot.

Aina says that Bob at times would show extreme hostility and wild behavior. She believes

that Bob’s wild behavior which is the reason for his second admission in December 2007 and

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current admission this January 2010 is due to Bob’s incompliance with the advices of the doctor to

stop drinking coke, alcoholic beverages and smoking.

The current admission of Bob is already his third admission. Bob and Aina were only at the

Davao Mental Hospital to have Bob’s monthly dose of his depot but Bob shouted at the doctor

without any apparent reason, exhibiting extreme hostility and wild behavior. This action convinced

the doctor that Bob may need a three-day admission at the CIU for observation. After which, he was

then discharged

Characteristics and Attitude of Informant:

Sincerity and concern regarding the condition of the patient is highly evident in the verbal

and non verbal cues of the informant during the interview. She looks straight to the eyes and is very

cooperative all throughout the interview, trying her best to recall all events that took place in

connection to the condition of her son.

Informant #2

Name: Emman

Age: 39

Address: 162 Interior Tulip Drive, Matina, Davao City

Sex: Male

Civil Status: Married

Relationship to Client: Brother

Length of Time Known by the Patient: Since Birth up to Present (39 years)

Apparent Understanding of the Present Illness of the Client:

Emman said that the illness began when Bob went to Bukidnon in August 1987 to fetch him

and go home with him to Agusan. On the night of Bob’s arrival, he started having a convulsion and

was given paracetamol. Hours later, Bob was caught eating his own feces and drinking urine from a

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potty. After the incident, they went home to Agusan. Since then, Bob started to think and talk

illogically, displaying disorganized speech and delusions. Weeks later Bob was brought to Davao

for a check-up, first as San Pedro then at DMH. Since then, Bob has always been visiting Davao

Mental Hospital and was even admitted two times, one in November 1987 then in December 2007,

prior to the recent admission.

Emman sees Bob’s condition rooted from that convulsion which took place in Bukidnon. As

to the reason of the convulsion and the events that took place prior to the convulsion, the brother

does not claim any knowledge.

Characteristics and Attitude of Informant:

Emman was very open and receptive to the group during the interview. He had shown

efforts to recollect all salient points regarding the condition of his brother.

Informant #3

Name: Carmz

Age: 18

Address: 162 Interior Tulip Drive, Matina, Davao City

Sex: Female

Civil Status: Single

Relationship to Client: Sister

Length of Time Known by the Patient: Since Birth up to Present (18)

Apparent Understanding of the Present Illness of the Client:

Mae understands Bob’s condition because she is a student nurse. According to her, Bob’s

manifestations are indeed characteristics of schizophrenia. She believes that Bob’s condition will be

best improved if Bob follows all medication orders of the doctor and strictly avoid everything that

the doctor prohibits him to take.

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Characteristics and Attitude of Informant:

The informant was very responsive in the conversation, showing strong desire to tell the

group everything that she knows about the illness of the patient.

Informant #4

Name: Mimi

Age: 39

Address: 162 Interior Tulip Drive, Matina, Davao City

Sex: Female

Civil Status: Married

Relationship to Client: Sister-in-law

Length of Time Known by the Patient: Since Marriage up to Present (20 years)

Apparent Understanding of the Present Illness of the Client:

According to Mimi , the patient has been isolated and withdrawn since she first met him

when she married his brother, Emman wayback in May of 1990, the patient was 21years old by

then. She noted that Bob is irritating to the family members at times because there are instances

wherein he seems to act like a child. She cited incidents wherein he wakes them up in the midnight

because he was hungry and asks them for something to eat or drink. Bob also occasionally asks his

mother to sleep with him at night. Taking this information to consideration, the sister-in-law

concluded that, somehow, Bob is a burden to their family. She can see that the siblings of Bob have

been exhausted in trying to understand him. Yet, in spite this, the family still show their invaluable

support and love to Bob.

Characteristics of the informant:

The informant was open and hospitable to the group. She made ways for the group to

contact the family and talk to other members of the family in order to gather data that she could not

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provide. The warm and welcoming attitude of the informant made it possible for the group to know

more about the patient.

Informant #5

Name: Boy

Age: 18

Address: 162 Tulip Drive, Matina, Davao City

Sex: Male

Civil Status: Single

Relationship to Client: Nephew

Length of Time Known by the Patient: Since Birth up to Present (18)

Apparent Understanding of the Present Illness of the Client:

Boy says that Bob’s condition was not improving. He said that what Bob’s actions now are

the same as what he does in the past. He was always isolated, self-preserved and indifferent with

others. He could even go for a whole day without talking to anybody and just watch TV. Boy also

says that Bob’s strange actions like talking to the television, flight of ideas and hostile behaviors are

not unusual of Bob anymore.

Characteristics of the informant:

Boy was at the first visit unresponsive to the questions asked by the group. However, on the

next home visit, he volunteered to talk about what he knows about his uncle in a warm manner.

B. FAMILY HISTORY

a. Maternal and Paternal Lineage

Direct bilateral lineage of the patient show no conditions of mental illness. On the

paternal side, prominent family illnesses only concern some members having

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hypertension. Aside from the condition, no other illnesses run the family. On the

maternal line, no illness were reported to run in the family, except one family member

having diabetes mellitus type 2, an illness condition occurring singularly to be

considered familial. Generally, no mental illness can be traced on both sides of the

family.

b. Father

The father is 59 years old; a known small time businessman in their place at

Agusan; owning a small rice mill enough to support the needs of his family. He is a Civil

Engineering Undergraduate and was able to finish only until 3rd year of the above course,

due to his early fatherly obligation. He impregnated the patient’s mother, when he was

only 19 years old, then eloped with her, thwarting him to finish his studies then at the

University of Mindanao.

As a father, he was lenient in his relationship with his children. Most of his time

is spent in their rice mill and would only go home in the afternoon or at night. Moreover,

he is a kind of father who would not spank or scold his children and he seldom

verbalizes what he feels. He would only speak to his children wherever they do

something incorrect.

c. Mother

The mother helps in their small rice mill. Pregnant at the age of 18, she was

unable to finish her college education at the University of Mindanao. She was in her

second year in college when she dropped out of her Chemical Engineering course.

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The mother says that she brought her children up in discipline and love; she said

she doesn’t spank her children because it does them no good. Like the father, she doesn’t

also believe in punishing her children through spanking and the like when they do

something wrong.

However, as she states, she left her children to the care of nannies when they

were young. And put her children in their house in Davao City to pursue their education

from elementary school, leaving them, still with a nanny, and visiting them once a week.

According to her, this is the best way for her to offer the best education and life to her

children and help improve their business in Agusan.

d. Siblings

The family is composed of five siblings; Bob being the eldest, followed by the

second informant, Emman, then by Carmz, Denns and then Yose .

His relationship with his siblings is not so good. As a child, although they were

the only ones that he would play with, he would still isolate himself when with them. He

never shares his thoughts with them. Furthermore, when they grew up and the illness

took place, the siblings gradually got irritated with him because of his hostility towards

others.

III. Personality History

a) Prenatal

Being the result of the early pregnancy of his mother, the patient was an

unexpected child. Only 18 when she was impregnated, the mother was not ready and

did not know what to do, so she eloped with the patient’s father without giving her

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parents the knowledge as to the reason why she ran away. The mother stayed with

the father’s family in Cagayan for the whole duration of her pregnancy.

On course of nine months, the mother has adequate prenatal check-ups at a

nearby health center. Moreover, she was able to eat adequately because the parents

of her husband supported them. They provided her with enough support for her

pregnancy.

b. Birth

Bob was born in the Provincial Hospital in Cagayan de Oro City on the 9th of

April 1969 through Normal Spontaneous Vaginal Delivery. No complications took

place in the delivery. The mother, Aina, described that her labor was very long, she

started having labor pains in the morning and delivered in the afternoon. She did not

also breastfeed the patient because she is having pain breastfeeding him and as

reported, no breast milk would come out; so instead, she bottle fed the patient with a

formula milk in a timed manner. Moreover, she hired a nanny named Nena to look

after the baby because she did not have any experience in taking care of a baby,

considering her age.

c. Infancy and Childhood Characteristics

After the birth, in June of 1969 Aina went back to Agusan to talk to her

parents. She told them that she ran away because she was pregnant and apologized

for everything that she has done. Her parents did accept her apology and welcomed

her back. On the August of 1969, Aina and Danni married each other and decided to

reside in Agusan. Trying their luck in a new business, the couple got busy with their

rice mill that they decided to leave Bob in the care of Nena, Bob’s nanny since birth,

while they attend to their business.

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The nanny was very caring to the child, cuddling him always and looking

after him. However, when Bob was almost five months, Nena went home to her

province and was replaced by another nanny named Ging-ging.

Moreover, Aina instructed her nanny to continue the timed bottle feeding

routine every three hours, a routine which continued until the patient was three years

old. She instructed to feed the baby every three hours, believing that this would help

the nanny attend to other tasks while taking care of the baby. In cases that the baby

would cry Ging-ging would just give him a pacifier for him to stop crying.

Bob was toilet trained when he was 2 years old. Toilet training was mostly

implemented by the nanny Ging-ging, and she is not strict in it. As he had a nanny,

Aina instructed the Ging-ging to teach him to urinate and defecate in a potty because

it irritates her to find urine and stool just anywhere. Aina is very strict in toilet

training. But on instances that Bob would pee or defecate anywhere, Ging-ging

would just clean the mess, not correcting Bob. Bob started talking when he was a

year old and started walking on that certain age more or less as reported.

As to the strategies and the relationship of the nanny to the child, the mother

did not exactly describe because according to her, she changed nannies several times.

According to her, the relationship of the nanny was not so important to her as long as

the needs of her children are met and her children’s safety is not harmed. She

carefully instructed the nannies to give to the children everything they want to keep

them from having tantrums that could hinder the nanny from doing other household

chores.

The mother could not remember whether or not the patient’s immunization is

complete; but what she does remember is that the patient had measles before he was

one year old.

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d. Psychosexual History

The patient’s sexual awareness started when he was 16 years old, on his 4th year

in high school. It was on this time that he started having a crush and actually had a

girlfriend who after sometime broke up with him. This break-up with his only girlfriend

bagged down his self esteem. In addition, his mother also keeps on teasinf him that his

girlfriend’s teeth resembles that of a rat which further decreased his self-confidence and

esteem as he tried to compare himself with the boys of his age.

In his adolescence, he also engages in sexual activities with GROs.

e. Play Life

Bob does not engage so much in cooperative play and prefers solitary play. He

would only sit by himself and play alone in a corner. His playmates were his siblings and

would choose to play only in their yard. As a child, he is not talkative, he is

uncooperative and becomes aggressive when forced to play with other kids.

Furthermore, he likes being a follower in a game rather than a leader.

f. School History

The patient began preschool in June of 1974, when he was five years old where

he was sent to Davao to study at Assumption up to second grade. He stayed in their

residence in Davao which is in 162, Interior Tulip Drive, Matina, Davao City. He stayed

in Davao together with his brother Emman and their nanny. The first days in school were

terrible for Bob, he would cry inside their classroom and would not separate from his

nanny. In his third grade, he was transferred to Our Lady of Fatima School, which he did

not really approve that he cries in between classes just to be sent home. He is withdrawn

from the rest of his classmates and would talk only to a few people. His grades were also

affected by his isolation, he did not perform well in school and was not interested in

studying.

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He spent his high school days still at Fatima. In June of 1982, when he is 13

years old, he entered first year highschool, where he formed new set of friends which he

grew much attached to. These friends of him were not of good influence because when

they started hanging out, he began cutting classes, extorting money from his parents and

having low grades. He started drinking and smoking. Also, he started using marijuana.

His bad school records started worsening when his girlfriend in his fourth year

high school broke up with him, these events pulled his confidence down, that he started

isolating himself and increased his use of marijuana, drinking and smoking. Yet he is

able to graduate from high school in the March of 1986.

Troubles in school were rampant, being evident even when he is already in

college. He was occasionally caught brawling with classmates. Furthermore, his mother

was once called by the Guidance Office because he threw an eraser to his teacher

because the eraser hit him when the teacher threw the eraser at his classmate. He was

also suspected of using marijuana during this time but is persistently denying the

accusations, although it was really true. Peer pressure can be seen as a great contributing

factor in his use of marijuana because his friends would tease him when he refuses to use

marijuana.

In his college days, he spent his two years of college education at the University

of Mindanao, in the Civil Engineering course. However, he did not have good grades

and still continued cutting classes and indulging in his vices. On his second year, he

finally decided to stop, claiming that he is already having difficulty catching up with the

lessons.

g. Religious and Social Adaptability

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The family is Roman Catholic. However, when he was in college, their family

converted to Seventh-day Adventists. However, the patient still follows the Catholic

Faith and does not go to Seventh-day Adventist religious celebrations.

h. Occupational History

When the patient stopped studying during his second year in college, late in the

August of 1987, he stayed in Agusan and helped in their rice mill business. There, he

would help in the loading and unloading sacks of rice and also in operating the mill. Bob

doesn’t get regular salary because what he gets is ten percent of the day’s income.

i. Marital History

The patient is single. However, he is looking forward to marrying someday.

According to his verbalizations, he wants to be married so badly that he would even

marry their maid at home. According to him, he already told the maid that he wanted to

marry her, but unfortunately, after telling her, the maid ran away.

j. Onset of the present illness

The recent admission is already the third admission of Bob. Recurrence of hostile

behavior is the primary reason why Bob was admitted for three days in the CIU of

Davao Mental Hospital. He suddenly shouted at a doctor in the hospital upon having his

monthly depot injection and check-up.

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THEORIES OF DEVELOPMENT

These are just a few of the fascinating aspects of the field of “human development”: the science

that studies how we learn and develop psychologically, from birth to the end of life. This very

young science not only enables us to understand how each individual develops, it also gives us

profound insights into who we are as adults. Each theory has its own perspective on the

development of man.

ERIK ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

The Psychosocial Stages of Development developed by Erikson enumerates eight stages though

which healthily developing human should pass from infancy to late adulthood. Every stage

describes a task to be accomplished. These development stages can be seen as a series of crisis and

each stage forms on the successful accomplishment of the earlier stages. Successful resolution of

these crises supports a healthy self-development. Failure to resolve the crises damages the ego and

maybe expected to reappear as problems in the future.

LIFE STAGE INDICATORS INDICATORS ASSESSMENT JUSTIFICATION


OF POSITIVE OF NEGATIVE
RESOLUTION RESOLUTION
Infancy (birth to Learning how Mistrust, Mistrust Aina, his mother,
1 year) to trust others withdrawal, did not breastfeed
estrangement Bob because she is
Central task: having pain
Trust vs. breastfeeding him
Mistrust and as reported and
no breast milk
The first stage, would come out; so
centers on the instead, she bottle
infant's basic fed the patient in a
needs being met timed manner. She
27
by the parents. would feed the
The infant baby every three
depends on the hours, believing
parents, that this would train
especially the the baby to be
mother, for food, disciplined.
sustenance, and Moreover, she hired
comfort. If the a Yaya Nena to
parents expose look after the baby
the child to because she did not
warmth and have any
dependable experience in
affection, the taking care of a
infant's view of baby, considering
the world will be her age.
one of trust. After 5 months on

But if the the service, Yaya

caregivers are Nena left and Yaya

neglectful, the Ging-ging took

infant instead over her place in

learns mistrust- taking care of Bob.

that the world is Because Bob was

in an given not enough

unpredictable attention and left

and an unsafe under a care of a

place. nanny he had built


a sense of mistrust
to his parents. He
has not been fed
well since he’s
being fed in a timed
manner, he hasn’t
feel the sense of

28
comfort since his
parents haven’t
been there for him
to cuddle him when
he’s crying or to
play with him when
necessary.
Early Childhood Self- control Compulsive Shame and doubt The patient started
(2 to 3 years) without loss of self-discipline talking when he
Central task: self –esteem; Or compliance; was 1 year old and
Autonomy vs. ability to willfulness and started walking on
Shame & Doubt cooperate and defiance that age as well.

If caregivers express oneself The patient was

encourage self- toilet trained when

sufficient he was 2 years old.

behavior, child As he had a nanny

develops a sense (Yaya Ging-ging),

of autonomy- a the mother

sense of being instructed Yaya

able to handle Ging-ging to teach

many things on him to urinate and

their own. But if defecate in a potty

caregivers because it irritates

demand too his mother to find

much too soon, urine and stool just

refuse to let anywhere, she was

children perform too demanding that

tasks of which the child will learn

they are capable; how to toilet train

children may right away. On the

instead develop other hand, Yaya

shame and doubt Ging-ging doesn’t

about their train him well; she

ability to handle has not disciplined


29
things. the child well if the
child pees
anywhere because
of the unstrict
training Yaya Ging-
ging implemented
on Bob. The child
was unable to
master this kind of
task in this stage,
since he developed
the sense of shame
and doubt in which
he was unable to
handle things
because of the
different
implementation of
the nanny and his
mother.
Late Childhood Learning degree Lack of self Guilt The client does not
(4 to 6 years) of assertiveness confidence; engage much
Central task: and purpose pessimistic and cooperative play
Initiative vs. influence the over restriction and prefers solitary
Guilt environment; of own activity play. He would

During this begins to only sit and play

stage, the child evaluate one’s alone in a corner.

learns to take own behavior. According to his

initiative and get mother and brother,

ready for he’s a silent type of

leadership and person, he’s not

goal achievement talkative. He likes

roles. playing with his


bike and would
30
If adults play only in their

encourage and yard together with

support his siblings.

children’s As verbalized by

efforts, while the mother, when

also helping playing, he was a

them make follower.

realistic and
proper choices,
children develop
initiative-
independence in
planning and
undertaking
activities. But if,
adults discourage
the search of
independent
activities,
children develop
guilt about their
needs and
desires.
School Age (7 to Developing Sense of being Inferiority He attended his
12 years) sense of mediocre; nursery until Grade
Central Task: competence and withdrawal 2 in Holy Cross of
Industry vs. perseverance from peers and Davao College.
Inferiority school. When he was grade

At this stage, 3, he transferred at

children are Our Lady of Fatima

eager to learn School. There, he

and accomplish again developed a

more complex separation anxiety,

31
skills: reading, as he needed to

writing, telling leave his old

time. friends, teachers


and classmates. He
If children are
was a silent type of
encouraged to
person and not very
make and do
cooperative and
things and are
expressive. He
then praised for
withdraws himself
their
with his classmates,
accomplishments
he only have few
, they begin to
friends due to lack
demonstrate
of interaction with
industry by being
them. He also
diligent,
displays poor
persevering at
performance in
tasks until
school and
completed and
uninterested with
putting work
his studies. He has
before pleasure.
not met the
If children are
expectations of his
instead ridiculed
parents from him,
or punished for
which is to do well
their efforts or if
in his studies.
they find they are
incapable of
meeting their
teachers' and
parents'
expectations,
they develop
feelings of
inferiority about
their capabilities.
32
Adolescence (13 Sense of self Feelings of Role Confusion At this stage the
to 19 years) and plans to confusion, client had his first
Central Task: actualize one’s hesitancy, and year high school at
Identity vs. Role abilities possible Holy Cross College
Confusion antisocial of Davao and later
The adolescent is behavior on, they’ve
newly concerned transferred to Cebu,
with how they he enrolled himself
appear to others. to Cebu Avillana
The sense of High School, and
central identity there, due to being
appears through a shy type, he had
sexual, not gained new
emotional, friends. A certain
educational, group of people
ethnic, cultural, make friends with
and vocational him but they were
discovery. The bad influence. He
adolescent started drinking and
person also smoking because of
develops peer pressure. Also,
coherent sense of he started using
self and plans to marijuana, when
actualize one’s they have group
abilities. The sessions he’s
sense of self can cutting his class and
be confused if a because of his vices
core identity he always got low
does not solidify. grades. When he
Feelings of was 4th year high
confusion, school (16 years
hesitancy, and old), he met his first
possible love and became

33
antisocial his girlfriend, but
behavior may when he brought
also emerge. her at home, her
girlfriend was being
criticized by his
mother to have big
front teeth which
are similar to a rat,
this incident bagged
down his self-
esteem. He spent
his two years of
college education at
the University of
Mindanao, in the
Civil Engineering
course. However,
he did not have
good grades and
still continued
cutting classes and
indulging in his
vices and finally
stopped studying
when he was in 2nd
year high school
due to difficulty in
catching up with his
lessons.
Early Adulthood Intimate Avoidance of Isolation After the
(20 to 34 years) relationship relationship, relationship he had,
Central Task: with another career or though crushing
Intimacy vs. person and has lifestyle with other girls, he
Isolation a sense of commitments never developed
34
Once people commitment to another intimate

have established work and relationship with

their identities, relationships another woman. He

they are ready to had not form

make long-term intimate

commitments to relationships with

others. They friends, though he

become capable considers people to

of forming be his friends, he

intimate, didn’t trust them

reciprocal enough. He felt that

relationships and he’s being envied

willingly make by his friends. He

the sacrifices and continues to isolate

compromises himself from

that such others.

relationships
require. If people
cannot form
these intimate
relationships--a
sense of isolation
may result.
Middle Working Lack of Stagnation The patient is not
Adulthood ( 35 towards the productivity; so productive due
to 65 years) betterment of not helping to his illness. He’s
Central task: the society; society to move being dependent to
Generativity vs. being forward his family, though
Stagnation productive generating small
During middle income for helping
age the primary in the Rice Mill, but
developmental still he’s not being
task is one of productive because

35
contributing to the little money he
society and earned is being
helping to guide wasted for buying
future what is being
generations. prohibited for him
When a person to be used, like
makes a marijuana and
contribution cigarettes that
during this contributes in
period, perhaps worsening his
by raising a illness. He has no
family or own family to
working toward support that’s why
the betterment of he wasted his
society, a sense money for his own
of generativity- a wants.
sense of When he
productivity and had free time, he
accomplishment- went to the plazas
results. In or parks to eat or
contrast, a person drink. He also loves
who is self- to watch television
centered and shows. The client
unable or also adapt to his
unwilling to help physical changes in
society move his body and
forward develops accepted this as part
a feeling of of him, about his
stagnation- disease, he hasn’t
dissatisfaction understand this
with the relative fully and needs
lack of further explanation
productivity. for him to

36
A person in this understand. And as
stage should a Filipino citizen,
have time for he has done his part
companionship in becoming a good
and recreation. citizen, he is a
He also knows registered voter and
his planned to vote for
responsibilities Noynoy Aquino in
and knows that the coming election
he is accountable period, in a way
of whatever he’s being
actions he takes. productive because
he has done his
duty for the
betterment of the
country. But still,
he’s not helping the
country to move
forward since he
had violated the
Republic Act 6425
or the Dangerous
Drug Act of 1972,
Article III, Sec. 8
which is regarding
the usage of the
prohibited drugs.

SIGMUND FREUD’S PSYCHOSEXUAL THEORY

37
The concept posits that from birth human have intellectual sexual appetites (libido) which

unfold in a series of stages. Each stage is characterized by erogenous zone that is the source of

libidinal drive during that certain stage.

LIFE STAGE CHARACTERISTICS IMPLICATIONS ASSESSMENT JUSTIFICATION


Oral (Birth to 1 The center of pleasure Feeding NOT Though the
1/2 year) is the mouth; it is the produces ACHIEVED mother, Aina,
major source of pleasure, a sense doesn’t breastfed
pleasure and of comfort or her child because
satisfaction and ease and safety. she felt that it is
exploration. The Feeding should painful, still he
child’s primary need be pleasurable, it feds Bob through
is security or safety. should be bottle-feeding but
Major conflict: provided when in a timed manner
weaning necessary. which is every 3
hours.
ANAL (1 1/2 The sources of Controlling and NOT Toilet training
to 3 years) pleasure are the anus expelling feces ACHIEVED was not strict.
and the bladder give pleasure and Bob was toilet
(sensual satisfaction, sense of comfort. trained by his
self control). Toilet training nanny which was
Major conflict: toilet should be a instructed by his
training. pleasurable mother to instruct
experience. him to defecate in
a potty. Her
nanny, Yaya
Ging-ging was
not able to
implement well
the instructions of
her Ma’am Aina,
the mother of
Bob, Bob was
still urinating and

38
defecating
everywhere. Yaya
Ging-ging was
not able to
discipline Bob
well when it
comes to toilet
training.
PHALLIC (4-6 The genitals are the The child ACHIEVED At this stage, he
years) center of gratification. determines was able to learn
Masturbation offer together with the that a boy is for a
pleasure to the child. parent of the girl, and a girl is
Other actions include opposite sex and for a boy.
fantasy, later takes on a
experimentation with love relationship
peers, and questioning outside the
of adults about sexual family.
issues or sexual
matter.
Major conflicts: the
Oedipus Complex
(refers to the male
child's attraction for
his mother and
unfriendly attitudes
towards his father)
and Electra Complex
(refers to the female's
attraction for her
father and sees her
mother as her rival),
which resolves when
the child identifies
when the child
39
identifies with parent
of same sex.
LATENCY (6 Energy is heading for Encourage child NOT He started to go
years to physical and with physical and ACHIEVED to school by this
puberty) intellectual activities. intellectual time; he had
Sexual impulses tend pursuits. gained few
to be repressed. Encourage sports friends and few
Develop relationships and other playmates
between peers of the activities with because he
same sex. same-sex peers. prefers himself to
be alone. He
isolates himself to
his peers. He had
not been
performing well
to school and
uninterested to
study his lessons.

Genital Energy is directed Encourage NOT He is not


(puberty and toward full sexual separation from ACHIEVED independent, until
after) maturity and function parents, being now , he still
and development of independent and lives with his
skills needed to cope able to make parents and being
with the environment. right and good dependent to
decisions them, especially
when it comes to
his basic needs
and as well as to
meet his personal
needs to gratify
his desires, like
asking money to
have sexual

40
gratification
together with
some GROs and
to buy marijuana
or cigarettes.
He’s not matured
when it comes to
his sexuality.

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT

This theory pertains to the nature and development of human intelligence.

LIFE STAGE CHARACTERISTICS ASSESSMENT JUSTIFICATION


Sensorimotor Thought • In this stage, ACHIEVED The client as an infant
(birth-2years) infants build an was not being
understanding of breastfed by her
the world by mother; he was fed
coordinating with the use of the
sensory bottle, when giving
experiences (such the bottle, the infant
as seeing and Bob grasp it as a
hearing) with response of his
physical, motoric hungriness. The
actions. Infants mother, at times,
gain knowledge of gives him a pacifier
the world from the when the child is
physical actions crying thus fulfilling
they perform on the child’s wants.
it. An infant
progresses from
reflexive,

41
instinctual action
at birth to the
beginning of
symbolic thought
toward the end of
the stage.
• Thought derives
from sensation and
movement.
• The child learns
that he is
separated from his
environment and
that aspects of his
environment
continues to exist
even they may be
outside the reach
of his senses.
Preoperational • Thinking is still ACHIEVED At this age, was fond
Thought (2-7 years) egocentric: has of drawing that
difficulty taking represents his ideas.
the point of view He also draws to show
of others. what is inside of him,
• The children begin to express his feelings
to represent the through images that
world with images he creates.
and words.
Symbolic thought
goes further than
connections of
sensory
information and
physical action.
42
• Objects are
classified in
simple ways,
especially by
significant feature;
the child isn’t able
to conceptualize
abstractly.
Concrete Operational • The child starts to NOT ACHIEVED Bob does not know
Thought (7-12 years) think abstractly how to arrange his
and conceptualize, things systematically
forming logical or in order depending
structures that on its size, shape or
explains his or her any other
physical characteristics; he’s
experiences. disorganized when it
• Children can comes to his things.
execute operations
and logical
reasoning replaces
intuitive thought
as long as
reasoning can be
applied to specific
or concrete
examples.
• Children show
thinking is
decentered -they
consider multiple
aspects of the
problem (e.g.
understanding the
significance of
43
height and width).
They focus on the
dynamic change in
the problem. And,
most importantly,
they show the
reversibility of
true mental
operation.
Formal Operational • The person is ACHIEVED During this stage, the
Thought (12 years and capable of client was able to
above) deductive and understand what love
hypothetical means .He shared
reasoning. about his plans about
• The logical quality getting married in the
of the adolescent's future if given a
thought is when chance; he really
children are more wanted to marry their
likely to solve helper, according to
problems in a him. Though he never
trial-and-error courted the girl, he
fashion. just directly asked her
• During this stage to marry him but the
the young adult is woman refused to
able to understand answer him and went
such things as home to their
love, "shades of hometown.
gray", logical In addition to that,
proofs and values. when asked, “Kung
• During this stage makakita ka ug pitaka
the young adult na punog kwarta,
begins to entertain unsaon man nimo ang
possibilities for pitaka, iuli o gastuhon
the future and is ang kwarta?”; he then
44
fascinated with replied “Iuli nako, kay
what they can be. basig kailangan sa
• At this stage, they tag-iya ang kwarta.”
can also reason He was able to draw
logically and draw conclusion from the
conclusion from given situation
what information available.
is available.

45
ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing
Present/ Absent Rationale Justification
Factors
Family History Absent Individuals with Schizophrenia is not

schizophrenia seem to present in any of the

inherit a predisposition to family members of

the disorder because the patient in both

schizophrenia runs in paternal and maternal

families. The relatives of lineages.

individuals with

schizophrenia have a

greater incidence of the

disorder than chance would

allow. Although an

amazing amount of

resources have been

directed at finding the

genetic cause of

schizophrenia, the results

are far from specific. In

fact, almost every

chromosome has been

46
linked with schizophrenia.

Keltner, N. Psychiatric

Nursing. Chapter 4.
Neurostructural Absent The theorists have The patient’s chart

Anomalies proposed that did not show any

schizophrenia, is a direct laboratory results to

effect of three confirm the existence

nuerostructural defects. of such anomalies if

Ventricular enlargement, such are present in

brain atrophy and the patient.

dysfunctional cerebral

blood flow. These

anatomical anomalies in

the brain play a major role

in the illness.

Keltner, N. Psychiatric

Nursing. Chapter 4.

Precipitating
Present/ Absent Rationale Justification
Factors
Intake of drugs, Present Dopamine is known to be The patient admittedly

substances or the neurotransmitter which takes marijuana since

chemicals which is prominently affecting he was thirteen. All

increase levels of the occurrence of informants also concur

dopamine. schizophrenia. In patients that the patient is

with schizophrenia, indeed using

dopamine levels are marijuana.


47
invariably high. Therefore,

intake or use of drugs,

substances and chemicals

which promote the

elevation of dopamine

levels in the brain would

trigger schizophrenia.

Example of these are

levodopa, ampethamines

and marijuana.

Keltner, N. Psychiatric

Nursing. Chapter 4.
Perinatal Factors Absent Some researchers believe The mother did not

that schizophrenia can be report any

linked to perinatal abnormalities and

exposure to influenza, complications during

birth during winter, her pregnancy and

exposure to lead, minor birth. The mother also

malformations during early verbalized no exposure

gestation, exposure to to any infections

viruses from house cats during her pregnancy.

and complications of

pregnancy, particularly

during labor and delivery.

Keltner, N. Psychiatric

Nursing. Chapter 4.
48
Developmental Present Developmental factors There are some stages

Factors include the internal of development

reaction of an individual to according to Erikson

life stressors or conflicts. that the patient did not

Three theorists could be successfully meet.

considered here: Meyer,

Freud and Erikson. For

Meyer, events in early life

can cause problems that

are as severe as

schizophrenia. For Freud,

developmental factors

include poor ego

boundaries, fragile ego,

inadequate ego

development, superego

dominance, regressed or id

behavior, ambivalent

relationships and arrested

psychosexual

development. Furthermore,

Erikson believed that

eight-stage model of

human development

starting from Trust Vs.

49
Mistrust highly influences

development of the

condition. The

accomplishment or failure

in the levels affect a

person’s developmental

aspect.

Keltner,N. Psychiatric

Nursing. Chapter pp.


Convulsion Present Convulsion, in medicine, The patient had a

series of involuntary convulsion when he

contractions of the was 18 years old.

voluntary muscles. The Informants have

eyeballs frequently roll attested that after the

upward or to one side incident, the patient

during a convulsion; started having odd

breathing appears labored, behavior and

and saliva oozes from the disturbance in thought

mouth. The teeth usually process.

are tightly clenched,

sometimes causing serious

bites to the tongue and the

cheeks.

Convulsions are a common

symptom of epilepsy. They

50
also occur in young

children as a part of the

reaction of the body to

infection. Such

convulsions, called febrile

convulsions, usually last

only a few minutes and are

not dangerous. Other

causes of convulsions are

virus infections; brain

tumors or hemorrhages;

toxemias, such as uremia

or lead or cocaine

poisoning; chemical

disorders, such as

hypoglycemia; and acute

or chronic alcoholism. A

doctor should be notified

whenever a convulsion

occurs. Until the arrival of

a physician, emergency

treatment is directed

toward protection of the

victim from biting or other

forms of self-injury.

51
Anticonvulsant drugs

include diazepam,

phenobarbital, and

phenytoin.

A convulsion may have a

significant effect in an

individual due to

restriction of brain

oxygenation in the

occurrence of the

convulsion. Damage to

brain tissues range from

mild to severe depending

on the type of convulsion

and how long.

Furthermore, brain cell

damage is irreversible.

Microsoft ® Encarta ®
2009. © 1993-2008
Microsoft Corporation. All
rights reserved.

B. SYMPTOMATOLOGY

Symptoms Present/Abse Rationale Justification

nt

52
OBJECTIVE SIGNS

A. Alterations in Personal Relationships


Decreased Present Frequently, patients become less The patient has

attention to concerned with their appearance and troubled relationship

appearance might not bathe without persistent with other people.

and social prodding. Table manners and other

amenities social skills might diminish to the

related to point that the patient becomes

introspection disgusting to others.

and autism. Keltner, N. Psychiatric Nursing.


Inadequate or Present Patients with schizophrenia have Communication skills

inappropriate troubled personal relationships. of the patient show

communicatio Often, these problems develop over a constant incoherent

n long period, well before statements,

schizophrenia is diagnosed, and circumstantiality,

become more pronounced as the tangentiality and the

illness progresses. It is not like which are highly

uncommon to hear that a person was indicative of inadequate

asocial, loner or a social misfit and inappropriate

before being diagnosed. communication.

Keltner, N. Psychiatric Nursing.


Hostility Present Hostility can also be a common As the illness progresses

theme, which distances patient from the hostility became

others. apparent in the patient.

The patient has tantrums,


Keltner, N. Psychiatric Nursing.
confronting people with

53
no apparent reason,

tumbling tables and

chairs and wants to hit

people.

Withdrawal Present Patients with schizophrenia As the informant could

withdraw, which further remember the patient

compromises their ability to engage prefers solitary play in

his childhood. Moreover


in meaningful activities.
in his adolescence he
Keltner, N. Psychiatric Nursing
would hangout with a

few friends. Patient has

diminished or lost

interest in

communicating with

people.

B. Alterations in Activity

Psychomotor Absent Psychomotor retardation, the markedly slow The patient did

retardation speech and body movements which occurs not exhibit this

as a symptom of schizophrenia symptom.

Keltner, N. Psychiatric Nursing


Catatonic Absent Patients with schizophrenia also display The patient did

rigidity alterations of activity. They may be too not exhibit this

active or they may be inactive or catatonic. symptom

Keltner, N. Psychiatric Nursing


SUBJECTIVE SIGNS

A. Altered Perception

54
Hallucinations Present Hallucinations which are false Hallucinations,

sensory perceptions, which can be especially those which

auditory, visual, tactile, gustatory or are auditory in form is

somatic . Hallucinations are highly evident in the

probably caused by verbalizations of the

hyperdopaminergic state in the patient and also in his

limbic areas. actions as described by

Keltner, N. Psychiatric Nursing the informants.


Illusions Absent Illusions are misinterpretations of The patient does not

stimuli. Like hallucinations, exhibit this symptom.

illusions also occur as a result of

hyperdopaminergic state in limbic

areas.

books.google.com.ph/books?

isbn=0471245313
Paranoid Present Suspiciousness of others and their In connection to

thinking actions also occur as a symptom of persecutory delusions

schizophrenia which happens due to of the patient, he is

the alteration of the normal becoming suspicious

perceptual pattern of an individual and distrustful of

affected by the condition. people around him. He

www.asialink.unimelb.edu.au is in deep belief that

people are out there

trying to kill him, thus,

he becomes paranoid.

55
B. Alterations of Thought

Loose Present This is the stringing together of unrelated Loose

associations topics with vague connection. This occurs as associations

a result of the altered thought process in can be traced

individuals with schizophrenia. in many of the

Keltner, N. Psychiatric Nursing. statements

made by the

patient in

conversations.

Details which

do not have

anything to do

with the topic

are being

mentioned by

the patient.
Retardation Absent Retardation is the slowing of mental This symptom

activity, which is also a direct effect of is not exhibited

thought process alterations in individuals by the patient.

affected by schizophrenia.

Keltner, N. Psychiatric Nursing.

56
Blocking Present Blocking is the interruption of a thought and Blocking is

inability to recall it. Blocking may be caused apparent in

by the intrusion of hallucinations, delusions conversations

or emotional factors. with the

Keltner, N. Psychiatric Nursing. patient. There

are several

instances

wherein he

would

suddenly stop

right in the

middle of a

conversation.
Ambivalence Absent Ambivalence is a state in which two This symptom

opposite strong feelings exist is not exhibited

simultaneously. Schizophrenic patients may by the patient.

be immobilized by their ambivalence

regarding a matter as simple as deciding

whether to drink an apple juice or an orange

juice.

Keltner, N. Psychiatric Nursing.

57
Delusions Present Delusions are fixed false beliefs and can Persecutory

take many forms. Delusions are defined as delusions are

false belief firmly held by a person even highly evident

though other people recognize the belief as in the patient’s

obviously untrue. For example, a person verbalizations

who truly believes he is Napoleon Bonaparte and actions

is delusional. Religious beliefs or popular described by

conceptions, such as the belief that people the informants.

have been abducted by aliens, are not

delusions because they are widely held

beliefs. Delusions are a type of psychotic

symptom that indicate a person has lost

contact with reality (see Psychosis).

There are many different types of delusions.

A person with a paranoid delusion believes

that others—such as the FBI, CIA, or the

Mafia—are trying to harm or plot against

him or her. A person with a delusion of

reference believes that events or people refer

specifically to him or her when they do not.

For example, a woman with schizophrenia

may believe that a television news

broadcaster is talking personally to her

rather than to the entire viewing audience. A

grandiose delusion is a belief that one is


58
extremely famous or that one has special

powers, such as the ability to magically heal

people

Keltner, N. Psychiatric Nursing.

en.wikipedia.org/wiki/Delusion

Poverty of Absent Poverty of speech is manifested by the This is not

Speech inability to formulate and articulate thoughts manifested by

that are relevant to the discussion at hand. the patient.

This is also highly connected in the

alterations of thought process taking place in

individuals with schizophrenia.

Keltner, N. Psychiatric Nursing.


Ideas of Absent Ideas of reference and delusions of reference This is not

Reference involve people having a belief or perception exhibited by

that irrelevant, unrelated or innocuous the patient.

phenomena in the world refer to them

directly or have special personal

significance. In psychiatry, delusions of

reference form part of the diagnostic criteria

for psychotic illnesses such as schizophrenia

during the elevated stages of mania.

Keltner, N. Psychiatric Nursing.

59
Autism Absent Autism occurs when patients are so This is not

introspective that they are distracted from manifested by

external events. Patients become the patient

preoccupied with themselves and may be

oblivious to the reality around them.This

results in a personalized view of reality.

Keltner, N. Psychiatric Nursing.


C. Altered Consciousness

Confusion Present Confusion is an anxiety-producing symptom Disorientation

that is associated with psychosis. Keltner, N. to time is

Psychiatric Nursing. evident in the

patient. The

patient is

obviously

confused as to

the time and

chronological

arrangement of

events in his

life.

60
Incoherent Present Like confusion, incoherent speech is also a The patient

Speech direct effect of schizophrenia in the displays

functioning of an affected individual. incoherent

Keltner, N. Psychiatric Nursing. speech as

evidenced by

the

disorganization

of thoughts and

flight of ideas

which are

illogical to

follow.
D. Alterations in Affect

Inappropriate, Absent Affective flattening, inappropriateness, This is not

blunted, lability are affective symptoms sometimes manifested by

flattened or associated with schizophrenia. They often the patient.

labile respond to antipsychotic drug. Flat affect is

a cardinal symptom of negative

schizophrenia and may only respond to an

atypical antipsychotic drug.

Keltner, N. Psychiatric Nursing.

61
Apathy Absent Apathy is another symptom associated with This is not

the affective alterations brought about by manifested by

schizophrenia. It can be defined as a lack of the patient.

concern or interest. It is the inability to

generate a normal response to people,

situations or the environment.

Keltner, N. Psychiatric Nursing.


Overreaction Present Because of emotional limitations, the The patient

schizophrenic patients overreact to normal overreacts to

events to overcome mental and social normal

inertia. Keltner, N. Psychiatric Nursing. situations. The

informants

verbalized that

the patient

overreacts

even in simple

television

shows.
Anhedonia Absent Anhedonia is the inability to experience This is not

pleasure which is highly associated with the manifested by

detrimental effects of schizophrenia in the the patient.

affect of individuals suffering from

schizophrenia. Keltner, N. Psychiatric

Nursing.

62
PSYCHODYNAMICS

63
NARRATIVE PSYCHODYNAMICS

Bob’s parents, Aina and Danni, eloped at the age of 18 and 19 respectively. They ran away

to Cagayan because Aina got pregnant. They lived together with Danni’s parents there while Aina’s

parents did not know about anything. Anxiety, guilt and shame caused emotional distress in both of

them in this stage.

Both undergraduates in their courses, Aina and Danni, stopped studying and were dependent

to Danni’s parents to support them in Aina’s pregnancy. Danni’s parents, supportive of their child,

provided a jeepney for Bob to use as a temporary means of income for them to use in the course of

Aina’s pregnancy. In the course of her pregnancy, Aina had adequate prenatal check-ups at a nearby

heath center. Young for pregnancy and emotionally anxious, Aina’s situation puts her child, Bob at

high risk of fetal abnormalities. In the prenatal stage, the mother’s pregnancy is highly affecting the

baby. According to researches, the mother’s emotional state during pregnancy may bring about long

term effects in the fetus. This is so because stress-induced changes in the endocrine system of a

woman during pregnancy is said to cross the placental barrier, thereby, affecting the fetal

environment. Researches in low income African American populations in 2002 made by Mulder, et.

Al., presented that depressed and anxious mothers during pregnancy were more likely to have

negative consequences to the baby which extend far beyond the events of childbirth. During birth,

the mother may experience complications, premature labor and delivery and even spontaneous

abortion. Depression during pregnancy may also induce immunologic and neurological anomalies

in growing fetus. Cognitive impairment, together with motor retardation may also be possible.

9th of April 1969. Aina felt labor pains early in the morning, unfortunately, Danni was out

making a living, and it was some time before Danni was successfully called by a neighbor that his

wife was already in labor. Aina was rushed to Cagayan de Oro Provincial Hospital. There, she

64
delivered Bob through NSVD without any complication. However, according to her labor was

rather long and extremely painful.

From birth, Bob was left in the care of a nanny named Nena. Aina entrusted Bob to Nena

because she did not have enough skills in tending a child. Furthermore, she also has to go home to

Agusan in order to talk to her parents. Bob was not breastfed because Aina felt pain when she

attempted to breastfeed Bob. So she decided to feed him with formula milk in a timed manner every

three hours.

Bob being left to the care of a nanny and the limited presence of his parents, started building

the sense of mistrust in the part of Bob as a baby. Furthermore, as Bob was not able to be breastfed,

he was unable to absorb significant nutrients from his mother, together with oxytocin and

colustrum, which directly contributes to poor mother-child bonding.

In the August of 1969, Aina and Danni married each other in Agusan and moved there,

starting a rice mill business. Trying their luck on their new business, the couple got busy in their

rice mill and left Bob to the care of Nena. They would only go home at night and has poor bonding

with the child. As a result feelings of Mistrust formed in the child’s psyche.

Moving on, in Bob’s toddlerhood, the core conflict in this stage, according to Erikson is

Autonomy Vs. Shame and Doubt. And in the resolution of this conflict, the child must learn to

imitate. Imitation being the core process involved in the resolution of the conflict in this stage, Bob

is not at all fortunate. His parents’ availability was limited and the attitude of his mother and nanny

were very variable. Thus, Bob developed a sense of confusion and inability to identify to any of his

parents. Bob was unable to master skills such as eliminating and dressing up because everything

was just handed to him readily by the nanny. Although this “spoiling” of the nanny to Bob may

contribute to his sense of autonomy, his lack of figures of attachment bringing about confusion and

inability to master certain tasks further outweighs his derived autonomy. Thus, Bob gained doubt.

65
During his play age, Bob was a loner. He would want to be in solitary play. He would only

play with his siblings and would only play inside their yard. He was not open to other children. In

this stage, the core conflict is Initiative Vs. Guilt. Initiative is the inquiry of the child to the world.

The child begins to explore and uncover the wonders of the world around him and use his senses to

perceive the order of things. In this stage the child learns to adapt and resolve the conflict thru

education. However, Bob was a loner, withdrawing from other people in play. Furthermore, first

signs of hostility were noted on Bob at this stage, because he would become hostile whenever asked

or forced to join other kids in their play. Bob is also a good follower rather than a leader in games.

During this stage, he did not accomplish the developmental task of forming initiative but instead

formed sense of guilt.

In school age, Bob was as withdrawn as he is in his past developmental stage. He has a

difficulty in relating to others and as a result, his school performance is highly affected. He

consistently has separation anxiety and cries inside the classroom every time his nanny would be

out of his sight. Because of this, Bob was unable to form meaningful relationships with others and

thus formed inferiority.

In his adolescence, Bob entered high school at the age of 13 in the June of 1982. Bob

became attached to a certain group of friends who doesn’t seem to be a good influence to him. As a

shy person, Bob didn’t have many friends, so when this small group of people asked him to hang

out with them, Bob was overwhelmed, believing that they could provide belongingness and

acceptance. Bob treasured this small group of friends because this is all that he has. Bob was easily

affected by peer pressure. Fearing rejection if he does not do what his friends would want him to do.

So when his friends asked him to join them in their vices, Bob also joined in. Bob started drinking

alcoholic beverages and smoking. Worse, Bob also began using marijuana.

During his fourth year in high school, Bob was 16 years of age, he met a girl named Rowena

and courted her. Rowena became Bob’s only girlfriend. There was actually a time wherein Bob

66
brought Rowena home, but his mother disapproved of her because she said her teeth looks like rat

teeth. This created anger and insecurity in Bob. Later on, Rowena broke up with him for an

unknown reason. This break up bagged down Bob’s self esteem. He started isolating himself again

and increased his use of marijuana, drinking and smoking. In this stage, Bob is obviously not in

control of his life. His decisions were affected by the people around him. Even his role in the

society and the people that he chooses to be with are dictated by peer pressure and the ideas of his

mother. Bob therefore has role confusion.

Entering college at 17, Bob went to the University of Mindanao for Civil Engineering

course. However, due to his constant to constant absences and tardiness, Bob’s academic

performance trampled. Coupled with his consistent use of marijuana, cigarettes and alcohol, Bob’s

life was greatly affected. Behavioral changes emerged, his hostility grown so large that he already

fights with teachers and brawls with classmates. He was also called in by the Guidance Counselor

regarding his behavior. With this in mind, Bob therefore failed to achieve this stage of development

and formed isolation.

It was also in this stage that the first onset of the illness happened. Bob was 18 back then

when Bob stopped studying, he went back to Agusan with his brother. Prior to going to Agusan, he

had a convulsion in a trip to Bukidnon in the August of 1987, there he ate his own stool and drank

urine from a potty. First persecutory delusion also emerged there. After the incident, Bob was never

the same again. He is already having flight of ideas, disorganized speech, hallucinations and

extreme hostility. Because of this and his verbalization that there is something wrong with him, he

was brought to Davao City for a psychological chec-up. In San Pedro Hospital, no mental illness

was diagnosed, but upon their return the next month and transferred to DMH, Bob was diagnosed

with schizophrenia catatonic type. After then, Bob constantly visits DMH for his depot. At first,

control of symptoms were at its best, but as the years progressed, he was again admitted in the

67
December of 2007 because of the recurrence of symptoms of hostile behavior. The following

admission, which is on the 19th of January 2010 was also due to his hostile behavior.

68
MENTAL STATUS EXAMINATION

INITIAL

Name: Bob Diagnosis: Schizophrenia Undifferentiated

Age: 40 years old Physician: Gioia Fe D, Dinglasan, MD

Ward: Crisis Intervention Unit Date of Examination: January 21, 2009

I. PRESENTATION

A. General Apperance

The patient appears to be younger than his real age which is 40. During the

interview at Crisis Intervention Unit in Davao Mental Hospital, he wore a green

polo shirt, denim shorts, and a pair of slippers and is seated on bed with his

mother and sister-in-law. The patient appears to be untidy. He has dirty clothing,

unkempt hair, long fingernails and toenails with traces of dirt evidently seen on

both. At the time of the interview, the patient was alert and responsive.

B. General Mobility

a. Posture and Gait – The patient slouches when seated but holds himself

erect when standing and walking. His mannerisms include manually

hyper extending his fingers and scratching his head.

b. Activity – The patient’s movement are organized and purposeful during

the interview. He moves in a normal pace and does not show any signs of

over and under activity.

c. Facial Expression – The patient’s facial expressions are very much

appropriate to his verbal responses during the interview. He was

composed and receptive to whatever the group asks him.

69
A. Behavior

The patient was friendly and warm to us during the interview. He was sitting on

bed calmly. He interacts well with the group and as what we had observed; he

has a good relationship with his mother and his sister-in-law who were present at

that time.

B. Attitude towards the Examiner

The patient accepted the group warmly. He entertained our questions and

answered almost all of them. However, his eye contact was poor. He often looks

down.

I. STREAM OF TALK

A. Characteristic of Talk – During our conversation with the patient, we noticed that

he is spontaneous most of the time. However, there are times in which blocking

is evident in between his speech. His articulation words were clear but the

content is slightly vague.

B. Organization of Talk – The patient was eager to talk with the group. He tries to

answer every question the group asks him however, in his answers, we

apparently observe succession of circumstantiality and tangentiality. He provides

an excessive amount of irrelevant detail before finally arriving at the answer, or

at times, he doesn’t arrive at the answer at all.

I. EMOTIONAL STATES AND REACTION

A. Mood – At the course of the interview, the patient’s mood was euthymic. His

feelings were appropriate to the situations as he relays his answers to the group.

His mood was just appropriate and basing from his gestures and other nonverbal

cues, his mood is fitting to the situation.

70
B. Affect – The patient’s affect is appropriate as well. There is a marked harmony

between thought content, emotional response, and expressiveness. When asked,

“Unsa may nabati nimu kadtong nagka-uyab mo?”, he replied, “Lipay kaayo ui.

Alangan. Kaw gud daw magka uyab.” with a smile.

I. THOUGHT CONTROL

A. Perceptions – Throughout the interview, the group observed manifestations of

illusions and hallucinations. When the patient was asked if he experiences any of

the two, he told us that there are times that he hears someone whispering to him.

“Naa may gahong-hong sa ako usahay na mag wild daw ko.”, as claimed by the

patient. He denied that he had any visual hallucinations however, the mother and

the sister-in-law attested that during tantrums, the patient verbalizes that he sees

someone whom they cannot see.

B. Delusion – There are several types of delusions that are present in the patient as

claimed by the patient himself, and confirmed by the mother who witnessed them

all. First, the patient claimed that there is some sort of outside force controlling

his thought, compelling him into the belief that somebody has aa plan to kill him

– which is a clear sign of persecutory delusion. He also has a feeling that others,

especially his friends, hate him because they are jealous of him.

I. NEUROVEGETATIVE STATE

A. Sleep

The patient usually sleeps at 12 in the midnight and usually wakes up at 5am

getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and

instead, he just spends his time watching television until he falls asleep. Five in

the morning for the patient is too early for him to wake up that is why he

71
attempts to go back to sleep, but then, he is unable to do such. This is a

manifestation of late or terminal insomnia.

B. Appetite

The patient has increased appetite. He eats a lot however, he is choosy in his

food. “Ganahan man gud ko mukaon samot na kung lami ang sud-an.”, reported

by the patient. “Kusog kaayo mukaon nang bataa na, pero pili-an lang jud ug

sud-an.”, as verbalized by his mother.

C. Diurnal Variation

The patient’s mood varies during the day. He is usually fine in the morning and

gets, uneasy, restless, and irritable as the day progresses. Other times, his day

starts out worse in the morning and feels better later on.

I. GENERAL SENSORIUM AND INTELLECTUAL STATUS

A. Orientation

The patient is well oriented of the time, place and person. When asked during the

interview if what date and time was it, he answered correctly. However, as the

conversation progressed, we noticed that he is confused and not well oriented

with the time. When asked, when did he last used marijuana, he answered, “Two

months ago. Mga 2008.” The group finds this statement confusing since two

months ago, basing on the date of the interview, is around November of last year

(2009). The patient is also oriented with the situation since he knows that he is

the Davao Mental Hospital for his treatment.

B. Memory

The patient has difficulty recalling remote memories. When asked what his age

when he went to Bukidnon was, he replied; “Ambot lang. Wala ko

72
kahinumdom.” On the other hand, the patient has a good memory when it comes

to remembering recent and immediate memories.

C. Calculation

The patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and the

like. He was able to answer all of them but there we long pauses before he can

finally give the answer.

D. General Information

The patient knows basic general information like the current president of the

Philippines and even of the United States. He know the capital of some

Philippine provinces and he was able to name the national hero of the country.

E. Abstract Thinking, Judgement and Reasoning

The patient was given a maxim translated in Visaya to evaluate his reasoning and

abstract thinking. He was asked to explain the quote Try and try until you

succeed. He was able to explain it but not profoundly. He said, “Maningkamot

gud.” And when asked to elaborate, he refused to. He was also given a situation

wherein someone left her wallet, and he was asked what he should do. He

replied, “Akong i-uli. Di man na akoa so dapat nako i-uli.”

I. INSIGHTS

The patient understands that he needs to go to the hospital for his treatment. Since he

was 18, he knew that there is a problem in him and he even asked his mother to bring

him to the doctor. However, he does not have concrete understanding of what his illness

is. He believes that there is a lube (grasa) in his brain that is why he is acting differently,

thus, he has a fair insight.

73
FINAL

Name: Bob Diagnosis: Schizophrenia Undifferentiated

Age: 40 years old Physician: Gioia Fe D, Dinglasan, MD

Place of Interview: 162, Interior Tulip Drive, D.C. Date of Examination: January 23, 2009

I. PRESENTATION

A. General Apperance

During the home visit the group did, the patient was wearing a blue shirt and

denim pants. Again, Bob looked younger that his age which is 40. He was

properly groomed and looked like he had just taken a bath. He was actually

getting himself ready to go back to Agusan. His fingernails and toenails are still

long and dirty. During the interview, the patient was again warm and yet a little

aloof to us. He looked happy to see us again for the second time.

B. General Mobility

a. Posture and Gait – The patient still slouches when seated but holds

himself erect when standing and walking. His mannerisms are still

present and evident throughout the interview.

b. Activity – During the interview, the patient was able to sit straight and

focus on answering the questions asked to him. There is no overactivity

or underactivity nor impulsiveness noted. He was very calm and

composed along the interview.

c. Facial Expression – The patient was able to exhibit appropriate facial

expression towards a certain topic.

74
A. Behavior/Attitude towards the examiner

The patient was still accommodating to the group but we noticed that he is a little

shy this time. He seated on one corner and has minimal eye contact.

I. STREAM OF TALK

A. Characteristic of Talk – He speaks in a loud tone and his words were very clear

to us. Blocking was still evident especially when we bring in the discussion on

his use of marijuana. He maintains limited eye contact this time and prefers to

look down and do his mannerisms. His attention was still in the conversation

though.

B. Organization of Talk –Most of his statements were not comprehensible this time.

Circumstantiality and Tangentiality still surfaced during the interview. He still

cooperates with the discussion and still, he tries to answer the questions we gave

him.

I. EMOTIONAL STATES AND REACTION

A. Mood – The patient was able to maintain a normal mood all through the home

visit. He was responding well to the conversation and his mood was appropriate

for the discussion.

B. Affect – The patient’s affect was still appropriate as well. His statements jive

very well with his facial expressions and gestures.

I. THOUGHT CONTROL

A. Perceptions – Throughout the interview, the group did not observe any

manifestations of illusions or hallucinations. He was very calm and composed.

B. Delusion –Delusion of paranoia was present. He believes that his friends were

very much jealous of him since his family owns a rice mill. When he was asked

why did he say so, he answered, “Dugay ra ko gaduda ana nila. Maka ingon jud

75
ko na na sina ni sila nako kay din a muduol nako.” This is a manifestation of

delusion of paranoia. He was also asked about his illness. “Naa man koy grasa sa

utok. Murag gud ug makina. Madaot.” This is a manifestation of a somatic

delusion.

I. NEUROVEGETATIVE STATE

A. Sleep

The patient said that he had a good sleep the night before the interview.

According to his sister-in-law, he slept at around 11pm and woke up at around

5am. He said that he did not have any difficulty sleeping at night. “Na

injectionan man gud ko gahapon mao nang maayo akong tulog.”

B. Appetite

The patient had a good appetite. He was eating his breakfast well and was able

to consume a moderate amount of rice and viand.

C. Diurnal Variation

It was around 7:30am when we conducted the home visit and so far, he was

relaxed and comfortable. He did not have any feeling of discomfort or uneasiness

during the interview.

I. GENERAL SENSORIUM AND INTELLECTUAL STATUS

A. Orientation

The patient is well oriented of the time, place and person. He was still able to

recognize our group after two days of not seeing each other. He is aware of the

time and the place as well.

B. Memory

76
Most of our questions to him were about his adolescent life and we can say that

he has difficulty remembering details. Long pauses before answering indicate

that he was trying to retain information for him to come up with the answer. The

nurse asked, “Pila man imong edad gasugod kag gamit ug marijuana?”. He

replied “Ambot lang” and “Dili ko sigurado.”

C. Calculation

The patient was given again given mathematical equations. Still, he was able to

answer all of them correctly and quickly.

D. General Information

The patient was asked to enumerate the presidentiables he knows for this

upcoming election in May 2010. He was able to name Villar, Aquino, Estrada,

and Gordon. He said that he would vote for Aquino since his mother was a good

example to everyone. “Si Noynoy jud akong iboto kay maayo nang tao, liwat sa

iyang mama.”, said with calm emotion by the client.

E. Abstract Thinking, Judgement and Reasoning

The patient was given another set of situations and questions to evaluate him. He

was asked to tell the group the meaning of certain idiomatic expressions like

parang basing sisiw. He was them each correctly but with limited words. When

asked if he would cheat on a quiz if the teacher is not around, he insistently

answered NO. “Dili mana maayo nang manikas ka. Maski wala pa gatan-aw ang

teacher, gatan-aw man ang Ginoo.” He explained.

I. INSIGHTS

77
The patient still had the same understanding of his illness. Manifestation This time, he

insists his false belief that marijuana is not harmful to him and even claimed that it is

therapeutic for him. Delusions were more evident this time. He also insists that his vices

especially smoking and drinking Coke, which the doctor prohibited, are helpful to him.

With these statements, we can say that he has a poor insight.

78
MULTIAXIAL ASSESSMENT

Axis I- Schizophrenia Undifferentiated

This type of schizophrenia is manifested by pronounced delusions, hallucinations,

and disorganized thought processes and behavior, but criteria for other types of

schizophrenia are not met (Antai-Otong, 2003).

Axis II

Schizotypal Personality Disorder

Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder

that is characterized by a need for social isolation, odd behavior and thinking, and often

unconventional beliefs. These people tend to turn inward rather than interact with others, and

experience extreme anxiety in social situations. People with schizotypal personality disorder often

have trouble engaging with others and appear emotionally distant. They find their social isolation

painful, and eventually develop distorted perceptions about how interpersonal relationships form.

(Psychiatric Nursing: contemporary practice. Mary Ann Boyd. 2007)

Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions,

and beliefs.

Diagnostic criteria fort 301.22 Schizotypal Personality Disorder


A. A pervasive pattern of social and interpersonal deficits marked by acute

discomfort with, and reduced capacity for, close relationships as well as by

cognitive or perceptual distortions and eccentricities of behavior, by beginning by

early adulthood and present in a variety of contexts, as indicated by five or more of

the following:

1. Ideas of reference (excluding delusions of reference)


2. odd beliefs or magical thinking that influences behavior and is

inconsistent with subcultural norms (e.g., superstitiousness, belief

79
in clairvoyance, telepathy, or “sixth sense in children and

adolescents, bizarre fantasies or preoccupations)


3. unusual perceptual experiences, including bodily illusions ✔
4. odd thinking and speech (e.g., vague, circumstantial, ✔

metaphorical, overelaborate, or stereotyped)


5. suspiciousness or paranoid ideation ✔
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric or peculiar ✔
8. lack of close friends or confidants other than first-degree ✔

relatives
9. excessive social anxiety that does not diminish with familiarity ✔

and tends to be associated with paranoid fears rather than

negative judgments about self


B. Does not occur exclusively during the course of Schizophrenia, a Mood

Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive

Developmental Disorder

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,

“Schizotypal Personality Disorder (Premorbid)


6÷10

×100

=60%

Axis III- Axis 3 is not applicable to the client.

Axis IV- inability to go back to school, unemployment

Napoleon was unable to finish his schooling. He was a 2nd-year undergraduate at the

University of Mindanao with a course of Civil Engineering. The reason for stopping school

was due o the onset of his illness. As a result of the patient’s mental illness, he has not

landed a permanent job and is currently unemployed. The patient’s educational attainment

80
also made him unable to land a job. The patient is currently living with his parents and

depends on them for his basic needs.

Axis V- Global Assessment of Functioning

a) Initial Assessment (51-60)

Moderate symptoms or moderate difficulty in social, occupational, or school

functioning. According to the patient, he finds it hard to sleep at night. He usually

sleeps at around 12am and wakes around 5am. Circumstantial and tangential speech

is also noted since he provides an excessive amount of irrelevant detail before finally

arriving at the answer, or at times, he doesn’t arrive at the answer at all. According to

Bob, he has very few friends. Also, he is quite withdrawn to people around him like

the workers of his parents’ business.

b) Final Assessment (51-60)

Moderate symptoms or moderate difficulty in social, occupational, or school

functioning. During the final assessment, circumstantiality and tangentiality is still noted

in his speech. He was also quite aloof to the group, when the interview and assessment

was being conducted.

81
NURSE-PATIENT INTERACTION
Name: Bob Diagnosis: Schizophrenia Undifferentiated
Age: 40 years old Physician: Gioia Fe D. Dinglasan, MD
Ward: Crisis Intervention Unit Date: January 21, 2009 – 1:40 pm
FIRST NURSE-PATIENT INTERACTION

NURSE PATIENT
INTERPRETATION ANALYSIS
Verbal Nonverbal Verbal Nonverbal
Maayong Greets the Maayong buntag Looks at the Nurse: Gives the patient and his Greetings acknowledge client’s
buntag! Kami patient pud. Unsa diay student nurses family a warm greeting to create presence as well as creating a good
diay mga with a inyong and smiles a positive atmosphere and start and knowing client’s
estudyanteng smile and pangutana? Looks curious establish a good rapport disposition.
nars sa Ateneo uses hand upon asking Patient: Greets back
de Davao gestures to the purpose of acknowledges the nurses with a Fundamentals of Nursing by
University. Naa introduce the interview smile and shows interest and Kozier, B. p. 430
lang miy pipila the group curiosity
ka pangutana sa members
imo. Ok ra ba
nimu?
Kumusta man Looks at Ok ra man. Laay Scratches head N: Tries to open up a Broad openings make explicit that
ka? Unsa man the patient lang kaayo akong and looks conversation by using questions the client has the lead in the
imong pamati and smiles paminaw dire. down that encourages patient to talk interaction. For the client who is
karong adlawa? Starts to Gusto na ko and share hesitant about talking, broad
establish a muuli. P: Exhibits boredom over his openings may stimulate him or her

82
good hospital stay and expresses wish to take the initiative.
rapport to go home Psychiatric Mental Health Nursing
by Frisch p 185

Kanus-a pa man Looks at Tulo na kaadlaw. Changes into a N: Asks a question to seek viable Seeking information is used to
diay ka diri? the patient Pero pirmi man comfortable information know more about client’s feelings,
mi dire sige balik sitting position P: His change of position thoughts and ideas. It is also used
balik. communicates his interest to to make clear that which is not
participate in the conversation meaningful or vague.
Psychiatric Mental Health Nursing
by Frisch p 185
Ah. Kabalo pd Continues Kabalo ui. Naa Makes an eye N: Attempt to evaluate patient’s Exploring is delving further into a
ka nganong naa to may gahong- contact with understanding and perception of subject or idea. This can help
ka diri karon ug maintain hong sa ako the nurse his own illness patient examine the issue
kung ngano eye usahay na mag N: Reports understanding that he morefully. Any problem or concern
gabalik balik mo contact wild daw ko. needs to be treated and evaluated can be better understood if
dire? Magpatambal once in a while by a doctor explored. If patient expresses

man ko. Pa unwillingness to share, the nurse

injection ba. must respect his or her wishes.

Tapos naa na pud Mental Health and Psychiatric

nang mga Nursing by Ann Isaacs p.197

pangutana sa Auditory hallucinations are false

doctor nga balik sensory impression heard by the

balik. patient, usually, commanding in


nature.
Mental Health and Psychiatric

83
Nursing by Ann Isaacs p.197

Magpatambal Moves O. Magpatambal Scratches head N: Repeats the statement made Clarification is putting into words
ka? Ngano? closer to ko. Kani man gud and looks by the client to seek clarification. vague ideas or unclear thoughts of
Unsa diay sakit the patient akong utok, naa down again Asks further questions to delve in the client. Purpose is to help nurse
nimu? niy grasa. Murag to what the patient has said. understand, or invite the client to
gud ug makina. P: Explains his understanding of explain.
Kunga maguba, his illness. Patient has a false idea Mental Health and Psychiatric
kaylangan that his brain had some sort of a Nursing by Ann Isaacs p.197
ayuhon. lubricant. His belief that there is a lube
(grasa) in his brain is a
manifestation of Somatic delusion.
This type of delusion is a false
notion or belief concerning body
image or body function.
Psychiatric Nursing by Keltner, N
Chap 9 pp.112-113
Ngano naka Looks at Mailhan man Manually N: Attempts to focus and bring in Focusing is concentrating on a
ingon man ka na the patient nako. Basta hyperextending the discussion into a single topic single point; Picking up on central
naay grasa mulain na akong his fingers in a P: Verbalizes his thought about topics or cues given by the client.
imong utok? paminaw. repetitive what he believes towards his The nurse encourages the client to
manner illness. Starts to show his concentrate his energies on a sing
mannerisms. le point, which may prevent a
multitude of factors or problems
from overwhelming the client.
Mental Health and Psychiatric

84
Nursing by Ann Isaacs p.197

Unsa diay imung Looks at Naay mag hung Manually N: Asks question to open and Encouraging description of
mga gipangbati? the patient hung sa ako nga hyperextending explore a certain topic. perceptions is asking the client to
mag wild daw ko his fingers in a P: Retells what he experiences verbalize what he or she perceives.
ug maglagot. repetitive whenever his illness recurs. The To understand the client, the nurse
Usahay (pause) manner pause in between his lines is a must see things from client’s
pud kay mu ana manifestation of blocking speech. perspective. Encouraging the client
nga patyon daw to describe fully may relieve the
ko sa usa ka tao. tension the client is feeling, and he
might be less likely to take action
on ideas that are harmful or
frightening.
Psychiatric Nursing by Keltner, N
Chap 9 p 233
Unya, unsa pud Looks at Usahay kay Looks down N: Evaluates how the patient Exploring is delving further into a
imung buhaton the patient tuohan man nako and scratches reacts to such stimulus subject or idea. This can help
anang ga hung and uses kay mura pud head P: Patient has the tendency to patient examine the issue more
hung nimo? hand bitaw ug tinuod. heed to whatever this stimulus is fully. Any problem or concern can
gestures to saying. Scratching his head is be better understood if explored. If
convey another mannerism evident in the patient expresses unwillingness to
message patient. share, the nurse must respect his or
her wishes.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.197
Panan-aw nimu, Continues Wala man. Nikalit Looks at the N: Tries to stimulate the patient Seeking information is used to
nganong nasakit eye cotact ra man ni. Pero nurse to recall past events of his life know more about client’s feelings,
85
man ka? Naay ba kabalo ko na naay that could have contributed to his thoughts and ideas. It is also used
kay jud lain mao to present illness. to make clear that which is not
mahinumduman gusto pd ko P: Patient cannot remember any meaningful or vague.
ngano nagka padoktor. significant event which he thinks Psychiatric Mental Health Nursing
ingon ana ka? is a contributing factor. by Frisch p 185
Ah… Kumusta Maintains Okay ra man. Looks at his N: Assesses patients relationship Focusing is concentrating on a
man relasyon eye Palangga man ko mother and towards his family single point; Picking up on central
nimo sa imong contact nila. Samot na ni smiles then P: Expresses seriousness in his topics or cues given by the client.
mama ug papa? and mama. looks at the tone of voice The nurse encourages the client to
Imung mga presents a Suod pud mi sa nurse again Tells the nurse how close he is to concentrate his energies on a sing
igsuon? conveying akong mga his family le point, which may prevent a
hand manghud. The pause in between his multitude of factors or problems
gesture Kamaguwangan statement is again, a from overwhelming the client.
(pause) man ko. manifestation of blocking speech. Mental Health and Psychiatric
Suod ming Nursing by Ann Isaacs p.197
Emman. Kadtong Blocking is usually caused by
nagsunod sa ako. affectively charged topics,
delusional thoughts or
preoccupations.
Psychiatric Nursing by Keltner, N
Chap 9 p 233
Ah! Kung mag Looks at Wala uy! Okay Looks at the N: Asks question to look at the General leads indicate that the
away mo sa the patient kaayo among nurse with a current topic being discussed for nurse is listening and following
imung mga pamilya. I-agi ra face that tries further assessment what the client is saying without
isgsuon ug sa gud sa storya. Di to convince P: Strongly denies any presence taking away the initiative for the
imong mga man kinhanglan of domestic violence. Seeks interaction. They also encourage

86
ginikanan, naka magsinakitay affirmation from the nurse by the client to continue if he is
sinakitay mo? diba? asking “Diba”. hesitant or uncomfortable about the
topic.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.191
Tama pud no. Maintains Naa gud. Dula Scratches head N: Commends the patient for the Giving recognition is
Maayo nang eye dula. Pero di man good insight given. acknowledging and indicating
ingon ana. contact ko malingaw sa Assess the patient’s childhood to appraisal to the client’s actions.
Kadtong bata pa ilang mga (pause) get viable information This helps elevate client’s self
ba ka, daghan ba dulay usahay mao P: Expresses gloom through fall esteem.
kag kadula? nang ako na lang of voice tone. Blocking of speech Mental Health and Psychiatric
isa madula sulod is evident. Nursing by Ann Isaacs p.197
sa balay.
Nganong di man Sits on bed Dagan dagan. Manually N: Uses open-ended questions to Questioning is a therapeutic
pud ka and Lami kaayo hyperextending allow patient to explain communication technique using
malingaw? maintains magdagan dagan. his fingers in a P: Restricted facial expression open-ended questions to achieve
eye Dili ko ganahan repetitive and inconsistency of eye contact relevance and depth discussion.
contact sa ilang mga dula. manner show that the patient is not Psychiatric Nursing by Keltner, N
Daghan kaayo interested on the topic. Chap 9 p 93
sila. Samukan ko. Circumstantiality is evident on If in response to a direct question,
his speech as he provides the patient provides and excessive
irrelevant data before answering amount of irrelevant details before
the question. finally answering the question, the
condition is called
circumstantiality.
Psychiatric Nursing by Keltner, N

87
Chap 9 p 113

Kadtong Looks the Ok ra gud. Uses hand N: Changes the topic since the Questioning is a therapeutic
elementary ug patient Barkada barkada. gestures as he patient started to exhibit communication technique using
high school ka, Bugoy bugoy talks disinterest in the conversation open-ended questions to achieve
kumusta man kadali. Bisyo P: Is interested again in the relevance and depth discussion.
imong pag bisyo. Mura ra conversation as his vocal tone Psychiatric Nursing by Keltner, N
skwela? gud ug rises and as he gestured while Chap 9 p 93
ordinaryong talking
studyante.
Bisyo? Unsa pud Maintains Sigarilyo ug Coke Does his finger N: Tries to explore and Exploring is delving further into a
na nga bisyo? eye jud ako (pause) mannerisms encourage the patient to recall his subject or idea. This can help
contact ganahan, inom- again vices patient examine the issue more
inom, chiks chiks. P: Blocking is evident in his fully. Any problem or concern can
Ana lang gud. speech as he enumerates his vices be better understood if explored. If
patient expresses unwillingness to
share, the nurse must respect his or
her wishes.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.197
Ah. Ganahan Looks at Ganahan mo lang. Looks up at the N: Focuses the topic on a Focusing is concentrating on a
diay kag Coke? patient Kadtong New ceiling particular subject single point; Picking up on central
Year, halos isa ka P: Retells a particular event topics or cues given by the client.
case ako nahurot. where his craving for Coke was The nurse encourages the client to
Boring man gud evident. concentrate his energies on a sing
maghulat ug alas le point, which may prevent a
dose. multitude of factors or problems
88
from overwhelming the client.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.197
Wala pud ka Maintains Droga??? Shabu? Looks down N: Explores for further Seeking information is used to
nitisting anang eye Wala ui. and scratches significant details know more about client’s feelings,
droga droga? contact Marijuana nuon. head P: has a delusion marijuana is not thoughts and ideas. It is also used
Pero di mana an prohibited and dangerous drug to make clear that which is not
droga. meaningful or vague.
Psychiatric Mental Health Nursing
by Frisch p 185
Nagagamit kag Conveys Oo ui. Kadtong Smirks N: Uses restatement to verify The nurse repeats what the client
marijuana? curious high school pa ko. acquired information has said in approximately or nearly
Sukad kanus-a facial Uso mana didto sa P: Smiked when the topic on his the same words the client has used.
pa? expression agro. Kami tanan peers and their marijuana use was This restatement lets the client
while sa among barkada brought in know that he or she communicated
keeping an gagamit ana. the idea effectively.
eye Ganahan man gud Mental Health and Psychiatric
contact ko sa feeling ba. Nursing by Ann Isaacs p.197
with
patient
Unsa diay Looks at Lami kaayo sa Smiles and N: Seeks significant information Exploring is delving further into a
mabati-an nimu the patient paminaw ui. Mura looks at the on the effect of marijuana to the subject or idea. This can help
kung mugamit ka kag galutaw sa nurse patient patient examine the issue more
ana? hangin pero. P: Shows elated response as he fully. Any problem or concern can
Walay problema. smiles and verbalized how he be better understood if explored.
Mag sige lang kag enjoys marijuana Mental Health and Psychiatric

89
katawa. Tistingi Nursing by Ann Isaacs p.197
ra gud,
maganahan ka.
Kabalo ba kang Looks at Dili mana Shakes head N: Gives information and When it is obvious that the client is
makadaot ng the patient makadaot. and frowns presents reality to patient that misinterpreting reality, the nurse
marijuana sa Makatambal pa marijuana use is not good neither can indicate what is real. The
imo? man gani na. Si beneficial nurse does this by calmly and
mama, sige ko P: Shows disagreement as he quietly expressing the nurse’s
kasab-an bahin shook his head and frowned perceptions or the facts not by way
ana kay di lage of arguing with the client or
daw maayo. belittling h is experience.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.199
Unsa pud imu Looks at Muhilom lang. Scratches head N: Explores on the topic Exploring is delving further into a
ginabuhat kung the patient Pero di man ko and looks discussed to get more information subject or idea. This can help
kasab-an ka sa mutuo niya. Wa down P: Insists his belief that marijuana patient examine the issue more
imong mama. man ko nadaot. is not harmful fully. Any problem or concern can
be better understood if explored.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.197
Panan-aw nimu? Stands up Ang babae Shakes head N: Assesses patient’s perception To understand the client, the nurse
Dili kaha mao from ganina, wala and looks on how marijuana affected his must see things from client’s
nang rason sitting nikaon. Sayang down illness perspective. Encouraging the client
nganong nasakit position ang pagkaon ba. P: Provided irrelevant answers to describe fully may relieve the
ka? Continues and never arrived to the real tension the client is feeling, and he
to answer – a manifestation of might be less likely to take action

90
maintain tangentiality. on ideas that are harmful or
eye frightening.
contact Mental Health and Psychiatric
Nursing by Ann Isaacs p.192
Tangentiality is when patient gets
lost in unnecessary and irrelevant
details and never answers the
question.
Psychiatric Nursing by Keltner, N
Chap 9 p 93
Bob, naa koy ipa Smiles Dapat dili Looks down N: Evaluates the abstract thinking Questioning is a therapeutic
explain nimu. muundang ug of the patient of the client communication technique using
Unsa imo skwela. Sige P: Uses self as example. Looking open-ended questions to achieve
pagsabot sa try dapat ka ug down could indicate relevance and depth discussion.
and try until you skwela para disappointment. Psychiatric Nursing by Keltner, N
succeed? maabot ang Has concrete understanding of Chap 9 p 93
pangarap ba. the the quotation given. Testing the abstract thinking ability
Dapat dili is a test to note the congruence
musundog nako. between the patient’s economic
status and his abstracting abilities.
Mental Health and Psychiatric
Nursing by Ann Isaacs p.194
Diay ba? Dire Taps Aw. Sige sige. Smiles and N: Terminates the conversation The nurse gives recognition in a
lang sa mi kutob patient’s Okay ra kaayo ui. waves hand and orients patient on the nonjudgmental way. The nurse
sa among back Adto mog balay scheduled meeting then terminates the interaction by
pagpangutana. ha? Kita kita ta Recognizes effort of the patient thanking the client for his

91
Bisitahun ra ka didto karong who was accommodating to the participation and cooperation
namu unya sa Sabado. Salamat group throughout the during the whole interview.
inyong balay sa inyong conversation Fundamentals of Nursing by
karong Sabado panahon. Shows gratitude to patient for the Kozier, B. p 470
para magstorya time he and his family spared for
na pd ta. Ayos ba us.
na? Salamat sa P: Shows understanding and
imung panahon. cooperation by responding
positively to nurse’s statement

SECOND NURSE-PATIENT INTERACTION


Place of Interview: 162, Interior Tulip Drive, Davao City (Patient’s City Address) Date: January 23, 2009 – 7:30 pm

NURSE PATIENT
INTERPRETATION ANALYSIS
Verbal Nonverbal Verbal Nonverbal
Maayong buntag Smiles and Nindot kaayo ang Stares blankly Nurse: Greets the patient to The nurse greets the patient
Bob! Kumusta man looks at the adlaw. Lami and looks create a positive environment and upon seeing each other and
ang imong tulog patient manglaba karon kay down establish rapport. Starts uses broad openings to start
kagabii? init. conversation using a broad their conversation. Broad
Ok lang man. opening. openings lead or invite the
Nakatulog man kog Patient: Able to answer the client to explore thoughts or
tarong. Sayo sayo question but circumstantiality is feelings. Open-ended
gani ko kamata. evident and poor eye contact was questions specify only the
noted. topic to be discussed and
invite answers that are longer
92
than one or two words.
Circumstantiality is when in a
response to a direct question,
the patient provides an
excessive amount of
irrelevant detail before finally
answering the question.
Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 469.

Ah. Maayo. Mao Smiles Aw. Kani? Mubalik Touches shirt N: Acknowledges patient’s effort Giving recognition, in a
pud diay sayo ka na man gud ming and smiles to groom self and look nonjudgmental way, of a
nakaligo no? Asa mama sa Agusan. presentable during the interview. change in behavior, an effort
diay ka muadto Excited na gani ko. P: Shows excitement and the client has made, or a
ron? Nindot man Gikapoy na man enthusiasm while conversing contribution to a
lage kag suot? gud ko didto sa with the nurse and expresses his communication.
hospital ba. feelings regarding his stay in the Acknowledgment may be
hospital. with or without
understanding, verbal or
nonverbal.
Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 470.
Diay ba? Abi nako Smiles and Ang among bugasan Looks at the N: Asks a question to explore a Questioning uses open-ended
naay kay pormahan establishes sa Agusan kusog nurse and certain topic. questions to achieve
karong adlawa? eye contact kaayo ug kita. smiles P: Shares his experiences and relevance and depth in
Nagkauyab ba ka? Oo. Ka-usa ra. opinions about his previous discussion (not closed/yes-no

93
Kadtong high relationship in a comical manner. questions). The nurse ask
school pa ko. Pero Irrelevant details are provided questions to explore and gain
dili naman mi uyab before arriving to answer – a information from a new topic.
karon. Pangit na manifestation of Circumstantiality is when in a
man gud siya. circumstantiality. response to a direct question,
Ngipon niya murag the patient provides an
ngipon sa ilaga. excessive amount of
irrelevant detail before finally
answering the question.
Keltner, et. al, Psychiatric
Nursing, 5th Edition. Chapter
7, p. 93.
Unsa may pangalan Maintains Ah. Kadto siya? Si Points finger at N: Focuses on the topic to gather Focusing is helping the client
ato? Nagdugay pud eye contact Rowena. Taga dinha the specified more information and look into expand on and develop a
mo ato? ra man to sa una oh! direction his past experiences. topic of importance. It is
Namalhin na man P: Shares information about his important for the nurse to
siguro to sila. experience with a former wait until the client finishes
Dugay dugay pud. girlfriend. Patient is trying to stating the main concerns
Mga pipila ka bulan. remember how long their before attempting to focus.
Pero wa ni abot ug relationship lasted. The focus may be an idea or
tuig. feeling.
Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 470.
Ah! Gi unsa nimu Smiles Wala na uy! Ning Giggles and N: Inquires about the history on Questioning uses open-ended
pagka uyab sa iya? ngisi ra man to siya scratches head how the relationship with her questions to achieve
Gi ligawan pa ba nako. Naka crush former girlfriend started. relevance and depth in

94
nimu siya? siguro ba. Ni ngisi P: Narrates their story in an discussion (not closed/yes-no
ra pud kog balik. amusing manner as he questions). The nurse
Mao to. Uyab na remembered what happened questions or inquires about
dayon mi. between them. the client’s past history.
Keltner, et. al, Psychiatric
Nursing, 5th Edition. Chapter
7, p. 93.
Kuyawa ba.Gwapo Laughs and Wala na. Wala na Laughs and N: Actively listens to client and Active listening pays close
diay kaayo ka no continues to man koy continues to compliments on his physical attention to verbal and
ka yang babae man look at the nagustuhan. Mga scratch head attributes by giving recognition. nonverbal communications,
ni-una. patient pangit na man ang The nurse then resumes focusing patterns of thinking, feelings
Pagkahuman sa uban uy. Bati ug on the previous topic by asking and behaviors and the nurse
iya? Wala na kay nawong. questions. gives a positive recognition
na uyab? P: Shares to the nurse his lack of as a response to the patient’s
interest in having a relationship statement.
and his perceptions about Keltner, et. al, Psychiatric
women. Nursing, 5th Edition. Chapter
7, p. 93.
Pero sa edad nimu Conveys a Gusto uy! Gusto Manually N: Explores on patient’s The nurse assists the client to
ron, gusto pa ka more man gani nako hyperextending perceptions and thoughts about explore thoughts and feelings
magminyo? serious minyoon among his fingers in a getting married at his age. and acquires understanding
facial katabang bahalag repetitive P: States his interest in getting from the client. The nurse
expression pangit. Pero kataw- manner married and his intention of tries to assess the client’s
an ra man ko nila marrying their helper. Patient perceptions to the questions
man pag ako silang tells the nurse the reaction of his asked.
ingnon. family about his decision of Kozier, B. Fundamentals of

95
marrying their helper. Nursing. Chapter 26, p. 473.
Ngano gusto man Maintains Wala namay lain. Smiles and N: Clarifies the patient’s Clarification is a method o
pud nimu minyoon eye contact Kadto na lang. Wala looks down statement on his objective of making the client’s broad
inyo katabang nga na may lain. Pero di marrying their helper, even if, overall meaning of the
pangitan man diay man musugot si according to him is unattractive. message more
ka? mama. Di na jud P: Replies to question with understandable. To clarify the
siguro ko maminyo noticeable desperation. Shows message, the nurse can restate
ani. that he is no longer interested the basic message or confess
with the topic. confusion and ask the client
to repeat or restate the
message.
Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 470.
Unya Bob, karong Looks at the Ambot ato nila ui. Looks at the N: Shifts topic to explore on The nurse assists the client to
pag-uli nimu, patient Nasina man to sila nurse another subject that may have explore thoughts and feelings
magkita na pud mo nako kay ako tig significance with his mental and acquires understanding
sa imong mga operate sa rice mill illness. from the client. The nurse still
barkada? unya sila kay driver P: Shares insights about his tries to explore on the
lang. Di na lang ko friends back in his hometown and patient’s perceptions on the
muduol nila kay lain his views about them. question asked.
naman sila. Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 473.
Giunsa nimu Maintains Mabati-an gyud Looks at the N: Focuses on the topic and seeks Focusing is helping the client
pagkabalo nga eye contact nako. Sige silag tan- nurse and an understanding from the expand on and develop a
nasina sila nimu? aw nako. Sigeg scratches head patient’s feelings towards his topic of importance. The
panabis. Di na ko friends. focus may be an idea or

96
ganahan mustorya P: Relates his thoughts and feeling. The nurse then seeks
nila. feelings about his friends and understanding after focusing
how they respond to him, on the topic.
according to his observations. Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 470.
Wala pud ka Maintains Wala na uy! Klaro Looks away N: Seeks more information, by The nurse seeks informing by
nitisting ug duol eye contact na kaayo sa TB TB from the nurse asking questions regarding the asking questions about the
nila unya na lain jud ilang and shakes topic, from the patient to further topic. Questioning uses open-
mangutana? buot sa ako. Bahala head understand his situation with his ended questions to achieve
gud sila. friends. relevance and depth in
P: Responded according to what discussion (not closed/yes-no
he felt and from his viewpoint questions).
about his friends. Lack of interest Keltner, et. al, Psychiatric
was observed when asked to Nursing, 5th Edition. Chapter
approach his friends. 7, p. 93.
Bob, kung kita ka Looks at the Daghan pitaka Looks at the N: Evaluates patient’s judgment Encouraging evaluation asks
ug pitaka, unya patient baligya sa gawas ba. nurse from the given situation. for patient’s views of the
nabilin sa tag-iya. Akong I-uli. P: Answers accordingly from the meaning or importance of
Unsa man imu Alangan. Dili man given situation that showed something. Circumstantiality
buhaton? na ako. appropriate behavior. is when in a response to a
direct question, the patient
provides an excessive amount
of irrelevant detail before
finally answering the
question.
Keltner, et. al, Psychiatric

97
Nursing, 5th Edition. Chapter
7, p. 93.
Dili pud kaha nimu Maintains Dili uy. Dili man na Shakes head N: Further evaluates patient’s The nurse is trying to
kuhaon? Kwarta na eye contact ako. Kung wala koy and looks at judgment from the given evaluate on the client’s
gud na. kwarta, magayo ra the nurse situation and how he would judgment further.
Makatabang na gud ko. Dili jud respond from it. Encouraging evaluation asks
nimu. nako na hilabtan. P: Explained his intention of for patient’s views of the
returning the money that showed meaning or importance of
a correct behavior from the given something. Keltner, et. al,
situation. Psychiatric Nursing, 5th
Edition. Chapter 7, p. 93.
Wow! Maayo no Smiles and Daghan kaayo ug Looks at the N: Provides affirmative The nurse gives recognition
kay i-uli jud nimu maintains kawatan dira sa nurse reinforcement to the patient’s on the client’s behavior and
ang pitaka eye contact silingan. Samot na positive behavior in the given an effort the client has made,
magkina-unsa man. kung gabii. situation. or a contribution to a
Masakpan pa gani P: Responded to the nurse communication.
nako usahay irrelevant from their topic. Acknowledgment may be
Tangentiality was noted. with or without
understanding, verbal or
nonverbal. Tangentiality
differs from circumstantiality
in that the patient gets lost in
unnecessary and irrelevant
detail and never directly
answers the question.
Kozier, B. Fundamentals of

98
Nursing. Chapter 26, p. 470.
Bob, unsa ba Looks at the Math. Mao ganing Looks at the N: Asks a question to explore on The nurse asks a new
paborito nimu nga patient nag Civil nurse and a new topic. question to the client to delve
subject? Engineering ko. smiles P: Answered appropriately to the in a new topic. Questioning
question asked. Relates it to his uses open-ended questions to
reason of taking up his course. achieve relevance and depth
in discussion (not closed/yes-
no questions).
Keltner, et. al, Psychiatric
Nursing, 5th Edition. Chapter
7, p. 93.
Sige daw bi. Moves Laughs and N: Evaluates the client’s skill in The nurse is evaluating as
1+1? closer to the 2 uy. looks at the calculation. well as exploring on the
7+2? patient 9. ceiling P: Answered most of the client’s ability to solve
40-7? 33. Grabe pud. calculations asked to him to solve mathematical solutions.
6x8? Ahmm.. 48! on his own. Took time answering Videbeck. Psychiatric-Mental
25/5? 5 questions that were quite hard to Health Nursing. Chapter 6.
100-7? (pause) 97? solve. p.107.
Tama! Paborito Smiles and Sige. Kay excited na Smiles N: Provides a positive feedback The nurse gives recognition
nimu siguro ang maintains pud ko muuli. Si to the client’s skill in calculation in a nonjudgmental way. The
math. Sige Bob. eye contact papa lang man gud and shows acknowledgment by nurse then terminates the
Murag mulakaw na isa sa balay. giving recognition. Establishes interaction by thanking the
jud mo kay Gikapoy na pud ko information that the nurse is client for his participation and
naghulat na si dire. Salamat pud sa leaving and wishes him well cooperation during the whole
Mama nimu. pag storya storya upon their next encounter. interview.
Mulakaw na lang nako. Terminates nurse-client Kozier, B. Fundamentals of

99
pud mi ug una. relationship. Nursing. Chapter 26, p. 470.
Salamat! Hangtod P: Responds appropriately and
sa atong sunod na shows an eagerness to go back
pagkita. Pamansin home and see his father.
ha?

100
101
DEFINITION OF COMPLETE DIAGNOSIS

SCHIZOPHRENIA UNDIFFERENTIATED

SCHIZOPHRENIA

Schizophrenia is one of the most common causes of psychosis. It is not characterized by a

changing personality; it is characterized by a deteriorating personality. Simply, schizophrenia is one

of the most profoundly disabling illnesses, mental or physical. It is a diagnostic term used by mental

health professional to describe a major psychotic disorder. It is characterized by disturbances in

thought and sensory perception (hallucinations, delusions), thought disorders, and by deterioration

in psychosocial functioning.

Keltner, et. al, Psychiatric Nursing (p. 351).3rd Edition (1999)

Philippines: C&E Publishing Inc.

Schizophrenia is a disorder associated with a variety of a complex combination of

symptoms, including hallucinations, delusions, disorganized speech, disorganization, flat affect,

alogia, and avolition (APA, 2000; Bleuler, 1950). Persons experiencing an earlier onset of

schizophrenia usually have more problems with movement from adolescence into adulthood and

development of inappropriate social relationships and interactions.The course of the disease may be

different for each person, depending on when the disorder manifests itself and if symptoms of the

schizophrenia are compounded by a person’s use of alcohol or other substance (Brunette and Drake,

1998).

Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 347).

Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).

Refers to a group of psychotic disorders in which there are certain characteristic disorders

like disturbances in reality testing, hallucinations, delusions, withdrawal from society, etc.

102
Schizophrenia is a major mental disorder having a characteristic set of symptoms. It is most closely

approximate what most of us think as “craziness.” Schizophrenia ranges from mild to intense.

It is the label given to a group of psychoses in which deterioration of functioning is marked

by severe distortion of thought, perception and mood, by bizarre behaviour and by social

withdrawal.

Jafar Mahmud. Abnormal Psychology (p. 186).

APH Publishing Corp. (2002)

Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the

world. People with schizophrenia have an altered perception of reality, often a significantloss of

contact with reality. They may see or hear things that don’t exist, speak in strange or confusing

ways, believe that others are trying to harm them, or feel like they’re being constantly watched.

With such a blurred line between the real and the imaginary, schizophrenia makes it difficult—even

frightening—to negotiate the activities of daily life. In response, people with schizophrenia may

withdraw from the outside world or act out in confusion and fear.

Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231).

RMSIA Publishing, Quezon City, Phils. (2004)

UNDIFFERENTIATED TYPE

Undifferentiated schizophrenia is manifested by pronounced delusions, hallucinations, and

disorganized thought processes and behavior.

Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 348).

Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).

Subtype in which the clients clearly meet the general criteria of schizophrenia, yet do not fit

into any of the other three subtypes.

103
James Hansen & Lisa Damour. Abnormal Psychology (p. 406).

Hobeken, N.J.: Wiley (2005).

Clients with diagnosis of undifferentiated schizophrenia display forbid psychotic symptoms

(delusions, hallucinations, incoherence, disorganized behavior) that do not clearly fit under any

other category.

Forti Nash & Holoday Worret. Psychiatric Nursing Care Plans (p. 113).

4th Edition. Mosby Inc., St. Louis, Missouri.

The essential feature of undifferentiated schizophrenia is that it cannot be classified in any

category listed or that meet the criteria for more than one of the other mentioned schizophrenic

disorders.

Jafar Mahmud. Abnormal Psychology (p. 188).

APH Publishing Corp. (2002)

This type is characterized by some symptoms seen in all of the other types but not enough of

any one of them to define it a particular type of schizophrenia.

Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231).

RMSIA Publishing, Quezon City, Phils. (2004)

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DIFFERENTIAL DIAGNOSIS

SCHIZOPHRENIA

Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination

of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and

impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the

clinical picture that occasioned the most recent evaluation or admission to clinical care and may

therefore change over time. They are defined by their symptomatology. The disorder lasts for at

least 6 months and includes at least one month of the active phase symptoms namely two or more of

the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The

subtypes are:

295.30 Paranoid Type

295.10 Disorganized Type

295.20 Catatonic Type

295.90 Undifferentiated Type

295.60 Residual Type

Diagnostic Criteria for Schizophrenia


A. Characteristic symptoms. Two or more of the following, each present for a
significant portion of time during a 1-month period (or less if successfully
treated): ✔
(1) delusions ✔
(2) hallucinations ✔
(3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms (i.e. affective flattening, alogia or avolition)

Only one Criterion A symptom is required if delusions are bizarre or


105
hallucinations consist of a voice keeping up a running commentary on the
person’s behavior or thoughts, or two or more voices conversing with each other.
A. Social/occupational dysfunction.
For a significant portion of the time since the onset of the disturbance, one or ✔
more major areas of functioning such as work, interpersonal relations, or self-
care are markedly below the level achieved prior to the onset (or when the
onset is in childhood or adolescence, failure to achieve expected level of
interpersonal, academic, or occupational achievement)
A. Duration ✔
Continuous signs of the disturbance persist for at least 6 months. This 6-
month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e. active-phase symptoms) and
may include periods of prodromal or residual symptoms. During these
prodromal or residual periods the signs of the disturbance may be manifested
by only negative symptoms or two or more symptoms listed in Criterion A
present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.)
A. Schizoaffective and Mood Disorder exclusion: ✔
Schizoaffective Disorder and Mood Disorder with Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, Or Mixed
Episodes have occurred concurrently with the active-phase symptoms; or (2)
if mood episodes have occurred during active-phase symptoms, their total
duration has been brief relative to the duration of the active and residual
periods.
A. Substance/general medical condition exclusion:
The disturbance is not due to the direct physiological effects of a substance ✔
(e.g. a drug of abuse, a medication) or a general medical condition
A. Relationship to a Pervasive Developmental Disorder:
If there is a history of Autistic Disorder or another Pervasive Developmental
Disorder, the additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a month (or less if
successfully treated.
Total 7÷10×100=
70%

295.30 Schizophrenia Paranoid Type

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The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent

delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning

and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized

speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent.

Delusions are typically persecutory or grandiose or both but delusions with other themes may also

occur. Hallucinations are also typically related to the content of the delusional theme.

Diagnostic criteria for 295.30 Paranoid Type


A. Preoccupation with one or more delusions or frequent auditory hallucinations ✔
B. None of the following is prominent: disorganized speech, disorganized or
catatonic behavior, or flat or inappropriate affect.
TOTAL 1÷2×100
= 50%

295.10 Schizophrenia Disorganized Type

The essential features of the Disorganized Type of Schizophrenia are disorganized speech,

disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of

Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not

organized into a coherent theme.

Diagnostic criteria for 295.10 Disorganized Type


A. All of the following are prominent
1. disorganized speech ✔
2. disorganized behavior
3. flat or inappropriate affect
B. The criteria are not met for catatonic type ✔

TOTAL 1÷4×100
= 50%

295.20 Schizophrenia Catatonic Type

The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor

disturbance that may involve motoric immobility, excessive motor activity, extreme negativism,

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mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include

stereotypes, mannerisms, and automatic obedience or mimicry.

Diagnostic criteria for 295.20 Catatonic Type


A type of Schizophrenia in which the clinical picture is dominated by at least two
of the following

TOTAL 1÷5×100
=20%

295. 90 Schizophrenia Undifferentiated Type

Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic

symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly

fit under any category.

Diagnostic criteria for 295.90 Undifferentiated Type


A type of Schizophrenia in which symptoms that meet Criterion A are present, but ✔
the criteria are not met for the Paranoid, Disorganized, or Catatonic Type
TOTAL 1÷1×100
= 100%

295.60 Schizophrenia Residual Type

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The Residual Type of Schizophrenia should be used when there has been at least one

episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic

symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing

evidence of the disturbance as indicated by the presence of negative symptoms or two or more

attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and

are not accompanied by strong affect.

Diagnostic criteria for 295.60 Residual Type


A. Absence of prominent delusions, hallucinations, disorganized speech and
grossly disorganized or catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by the presence of ✔
negative symptoms or two or more symptoms listed in Criterion A for
Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual
experience)
TOTAL 1÷2×100
= 50%

301.22 Schizotypal Personality Disorder

Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions,

and beliefs.

Diagnostic criteria fort 301.22 Schizotypal Personality Disorder


A. A pervasive pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as well as by
cognitive or perceptual distortions and eccentricities of behavior, by beginning by
early adulthood and present in a variety of contexts, as indicated by five or more of
the following:
1. Ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e.g., superstitiousness, belief
in clairvoyance, telepathy, or “sixth sense in children and
adolescents, bizarre fantasies or preoccupations)
3. unusual perceptual experiences, including bodily illusions ✔
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4. odd thinking and speech (e.g., vague, circumstantial, ✔
metaphorical, overelaborate, or stereotyped)
5. suspiciousness or paranoid ideation ✔
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric or peculiar ✔
8. lack of close friends or confidants other than first-degree ✔
relatives
9. excessive social anxiety that does not diminish with familiarity ✔
and tends to be associated with paranoid fears rather than
negative judgments about self
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,
“Schizotypal Personality Disorder (Premorbid)
6÷10
×100
=60%

Schizoid Personality Disorder

Individuals with schizoid personality disorder are emotionally detached and prefer to be left

alone.

Diagnostic criteria for 301.20 Schizoid Personality Disorder


A. A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
Criteria Present
1. neither desires nor enjoys close relationship, including being a
part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with ✔
another person
4. takes pleasure in few, if any , activities ✔
5. lacks close friends or confidants other than first degree ✔

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relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened activity ✔
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder and is not due to the direct physiological effects of a
general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,
“Schizoid Personality Disorder (Premorbid)”
TOTAL 4÷8 ×100
=50%

297.1 Delusional Disorder

The essential feature of Delusional Disorder is the presence of one or more nonbizarre

delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not

prominent. Tactile or olfactory hallucinations may be present if they are related to delusional

themes.

Diagnostic Criteria for 297.1 Delusional Disorder


A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as
being followed, poisoned, infected, loved at a distance, or deceived by spouse or
lover, or having a disease) of at least 1 month’s duration.
B. Criterion A for Schizophrenia has never been met.
Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if
they are related to the delusional theme.
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not ✔
markedly impaired and behavior is not obviously odd or bizarre.
D. If mood episodes have occurred concurrently with delusions, their total duration
has been brief relative to the duration of the delusional periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g., ✔
a drug of abuse, a medication) or a general medical condition.
TOTAL 2÷5×100
=40%

Substance-Induced Psychotic Disorder


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The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations

or delusions that are judged to be due to the direct physiological effects of a substance.

Hallucinations that the individual realizes are substance induced are not included here and instead

would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying

specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a

Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic

symptoms occur only during the course of delirium.

Diagnostic criteria for Substance-Induced Psychotic Disorder


A. Prominent hallucinations or delusions. ✔
Note: Do not include hallucinations if the person has insight that they are substance
induced
B. There is evidence from the history, physical examination, or laboratory findings
of either (1) or (2):
1. the symptoms of Criterion A developed during or within a month of,
Substance intoxication or Withdrawal
2. Medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by a Psychotic disorder that is not
substance induced. Evidence that the symptoms are better accounted for by a
Psychotic Disorder that is not a substance induced might include the following: the
symptoms precede the onset of the substance use (or medication use); the symptoms
persist for a substantial period of time (e.g., about a month) after the cessation of
acute withdrawal or severe intoxication, or are substantially in excess of what would
be expected given the type or amount of the substance used or the duration of use; or
there is other evidence that suggests the existence of an independent non-substance
–induced Psychotic Disorder (e.g., a history of recurrent non-substance related
episodes.
D. The disturbance does not occur exclusively during the course of delirium.

Note: This diagnosis should be made instead of a diagnosis of Substance


intoxication or Substance Withdrawal only when the symptoms are in excess of
those usually associated with the intoxication or withdrawal syndrome and when the
symptoms are sufficiently severe to warrant independent clinical attention.

112
1÷5×100
TOTAL = 20%

295.70b Schizoaffective Disorder

Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia

but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some

time in the absence of any mood syndrome.

Diagnostic criteria for 295.70b Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a


Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with
symptoms that meet criterion A for Schizophrenia.
Note: The Major Depressive Episode must include criterion A1: depressed mood.
B. During the same period of illness, there have been delusions or hallucinations for
at least 2 weeks in the absence of prominent mood symptoms.
C. Symptoms that meet criteria for a mood episode are present for a substantial
portion of the total duration of the active and residual periods of the illness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., ✔
a drug of abuse, a medication) or a general medication.
1÷4×100
= 25%

Substance Intoxication Delirium

Diagnostic criteria for Substance Intoxication Delirium


A. Disturbance in consciousness(i.e., reduced clarity of awareness of the ✔
environment) with reduced ability to focus, sustain or shift attention
B. A change in cognition (such as memory deficit, disorientation, language
disturbance) or the development of a perceptual disturbance that is not better
accounted for by a preexisting, established, or evolving dementia
C. The disturbance develops over a short period of time (usually hours to days) and ✔
tends to fluctuate during the course of the day.
D. There is evidence from the history, physical examination, or laboratory findings
of either (1) or (2)

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Criteria Present
1. the symptoms in Criteria A and B developed during Substance
Intoxication
2. medication use is etiologically related to the disturbance*

2÷5×100
=40%

INITIAL SUMMARY

Schizophrenia 70%

Paranoid Type 50%

Disorganized Type 50%

Catatonic Type 20%

Undifferentiated Type 100%

Residual Type 0%

Schizotypal Personality Disorder 60%

Schizoid Personality Disorder 50%

Delusional Disorder 40%

Schizophreniform Disorder 50%

Substance-Induced Psychotic Disorder 20%

Schizoaffective Disorder 25%

Substance Intoxication Delirium 40%

ANATOMY AND PHYSIOLOGY

The nervous system is an intricate, highly organized network of billions of neurons and

neuroglia. The structures that make up the nervous system include the brain, cranial nerves, spinal

nerves, ganglia, enteric plexuses and sensory receptors. The two main subdivisions of the nervous

system are the central nervous system and the peripheral nervous system.

114
The central nervous system consists of the brain and spinal cord. The brain is the center for

registering sensations, correlating them with one another and with stored information, making

decisions and taking actions. It also is the center for the intellect, emotions, behavior, and memory.

The major parts of the brain include: the brain stem, cerebellum, diencephalon, and cerebrum. The

spinal cord is connected to a section of the brain called the brainstem and runs through the spinal

canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both sides of the body.

The spinal cord carries signals (messages) back and forth between the brain and the peripheral

nerves.

The brain stem is continuous with the spinal cord and consists of the medulla oblongata,

pons, and midbrain. The medulla oblongata forms the inferior part of the brain stem. The medulla

contains the cardiac, respiratory, vomiting and vasomotor centers and deals with breathing, heart

rate and blood pressure. The pons is a bridge that connects parts of the brain with one another. The

midbrain extends from the pons to the diencephalon. The midbrain is a short section of the brain

stem between the diencephalon and the pons.

115
Posterior to the brain stem is the cerebellum. Traditionally, the cerebellum has been known

to control equilibrium and coordination and contributes to the generation of muscle tone. It has

more recently become evident, however, that the cerebellum plays more diverse roles such as

participating in some types of memory and exerting a complex influence on musical and

mathematical skills.

Superior to the brain stem is the diencephalon, which consists of the thalamus,

hypothalamus, and epithalamus. The thalamus acts a relay center for all sensory impulses, except

smell, to the cerebral cortex. The hypothalamus is involved in the acceleration or deceleration of the

heart. Impulses from the posterior hypothalamus produce a rise in arterial blood pressure and an

increase of the heart rate. Impulses from the anterior portion have the opposite effect. The

hypothalamus is also involved in body-temperature regulation. If the arterial blood flowing through

the anterior portion of the hypothalamus is above normal level, the hypothalamus initiates impulses

that cause heat loss through sweating and vasodilation of cutaneous vessels of the skin. A below-

normal blood temperature causes the hypothalamus to relay impulses that result in heat production

and retention through the initiation of shivering, the contraction of cutaneous blood vessels. The

hypothalamus is also involved in the regulation of hunger and control of gastrointestinal activity.

Low levels of blood glucose, fatty acids and amino acids are partially responsible for the sensation

of hunger elicited from the hypothalamus. When sufficient amounts of food have been ingested, the

hypothalamus inhibits the feeding center. It also regulates sleeping and wakefulness. A specialized

sexual center in the hypothalamus responds to sexual stimulation of the tactile receptors within the

genital organs. Also, the hypothalamus is associated with specific emotional responses, such as

anger, fear, pain and pleasure. The hypothalamus produces neurosecretory chemicals that stimulate

the anterior pituitary gland to release various hormones. The epithalamus is the posterior portion of

the diencephalon.

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Supported on the diencephalon and brain stem is the cerebrum, which is the largest part of

the brain. The cerebrum is the largest part of the brain and controls voluntary actions, speech,

senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called

sulci), the largest of which are termed fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance. Each convolution is delimited

by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves,

known as the right and left hemispheres. A mass of fibers called the corpus callosum links the

hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body,

and the left hemisphere controls voluntary limb movements on the right side of the body. Almost

every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas,

which are interconnected.

The frontal lobes are located in the front of the brain and are responsible for voluntary

movement and, via their connections with other lobes, participate in the execution of sequential

tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.

The parietal lobes are located behind the frontal lobes and in front of the occipital lobes.

They process sensory information such as temperature, pain, taste, and touch. In addition, the
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processing includes information about numbers, attentiveness to the position of one’s body parts,

the space around one’s body, and one's relationship to this space.

The temporal lobes are located on each side of the brain. They process memory and auditory

(hearing) information and speech and language functions.

The occipital lobes are located at the back of the brain. They receive and process visual

information.

Neurotransmitters are chemicals which relay, amplify, and modulate signals between a neuron

and another cell. Some neurotransmitters are commonly described as "excitatory" or "inhibitory".

The only direct effect of a neurotransmitter is to activate one or more types of receptors. Examples

of neurotransmitters are acetylcholine, dopamine, gamma-aminobutyric acid, dopamine, glutamate,

aspartate, and serotonin. The chemical compound acetylcholine (often abbreviated ACh) is a

neurotransmitter in both the peripheral nervous system (PNS) and central nervous system (CNS) in

many organisms including humans. In the peripheral nervous system, acetylcholine activates

muscles, and is a major neurotransmitter in the autonomic nervous system. In the central nervous

system, acetylcholine and the associated neurons form a neurotransmitter system, the cholinergic

system, which tends to cause excitatory actions. Gamma-Aminobutyric acid (GABA) is the chief

inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating

neuronal excitability throughout the nervous system. In humans, GABA is also directly responsible

for the regulation of muscle tone.

Dopamine has many functions in the brain, including important roles in behavior and

cognition, voluntary movement, motivation, punishment and reward, inhibition of prolactin

production (involved in lactation and sexual gratification), sleep, mood, attention, working memory,

and learning. In the frontal lobes, dopamine controls the flow of information from other areas of the

brain. Dopamine disorders in this region of the brain can cause a decline in neurocognitive

functions, especially memory, attention, and problem-solving. Reduced dopamine concentrations in

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the prefrontal cortex are thought to contribute to attention deficit disorder. Dopamine is commonly

associated with the pleasure system of the brain, providing feelings of enjoyment and reinforcement

to motivate a person proactively to perform certain activities. Dopamine is released (particularly in

areas such as the nucleus accumbens and prefrontal cortex) by naturally rewarding experiences such

as food, sex, drugs, and neutral stimuli that become associated with them. Recent studies indicate

that aggression may also stimulate the release of dopamine in this way. This theory is often

discussed in terms of drugs such as cocaine, nicotine, and amphetamines, which directly or

indirectly lead to an increase of dopamine in the mesolimbic reward pathway of the brain, and in

relation to neurobiological theories of chemical addiction (not to be confused with psychological

dependence), arguing that this dopamine pathway is pathologically altered in addicted persons.

Projection neurons that produce dopamine are found in the diencephalon and the brainstem. In the

diencephalon, dopamine cell bodies give rise to tuberopophysial dopamine projections, e which

inhibit the release of prolactin and melanocyte-stimulating hormone from the anterior and

intermediate lobes of the pituitary, respectively, and the incertohypothalamic projections, which

connect the zona incerta in the posterodorsal diencephalon with the anterior hypothalamus and

septal area. A third dopamine projection system arises from neurons scattered along the ventricular

system in the periaqueductal gray, the dorsal motor of the nucleus of the vagus, and the nucleus

solitarius. The preventricular system provides terminals in the gray matter along the course of the

ventricles.

Longer dopamine projection systems arise from the substantia nigra and the ventral tegmental

area (VTA) of the midbrain. The former, the nigrostriatal dopamine system, is particularly

important in the control of motor function. The function of the VTA’s dopamine projections to the

forebrain, called the mesolimbic and mesocortical systems, has been linked to the complex group of

disease we refer to as schizophrenia. Sociability is also closely tied to dopamine neurotransmission.

Low D2 receptor-binding is found in people with social anxiety. Traits common to negative

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schizophrenia (social withdrawal, apathy, anhedonia) are thought to be related to a

hypodopaminergic state in certain areas of the brain. In instances of bipolar disorder, manic subjects

can become hypersocial, as well as hypersexual. This is credited to an increase in dopamine,

because mania can be reduced by dopamine-blocking anti-psychotics.

The locus ceruleus at the rostal end of the floor of the fourth ventricle on each side marks the

position of a nucleus with a rich vascular supply and consisting of neurons containing melanin

pigment. The nucleus (also known as nucleus pigmentosus) is partly in the pons and partly in the

midbrain, lying dorsolateral to the oral pontine reticular nucleus. The locus ceruleus is the largest of

about a dozen nuclei I the brainstem that produce cathecolamines. Most produce norepinephrine,

but some of those in the medulla produce epinephrine. A third catecholamine is dopamine, a

transmitter used by the large neurons of the substantia nigra and ventral tegmental area, and by

certain nuclei of the hypothalamus.

Serotonin or 5-Hydroxytryptamine (5-HT) is a monoamine neurotransmitter that is primarily

found in the gastrointestinal (GI) tract and central nervous system (CNS) of humans and animals.

Approximately 80 percent of the human body's total serotonin is located in the enterochromaffin

cells in the gut, where it is used to regulate intestinal movements.[1][2] The remainder is

synthesized in serotonergic neurons in the CNS where it has various functions, including the

regulation of mood, appetite, sleep, muscle contraction, and some cognitive functions including

memory and learning. Modulation of serotonin at synapses is a thought to be a major action of

several classes of pharmacological antidepressants.

Serotonin secreted from the enterochromaffin cells eventually finds its way out of tissues into

the blood. There, it is actively taken up by blood platelets, which store it. When the platelets bind to

a clot, they disgorge serotonin, where it serves as a vasoconstrictor and helps to regulate hemostasis

and blood clotting. Serotonin also is a growth factor for some types of cells, which may give it a

role in wound healing.


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Serotonin is eventually metabolized to 5-HIAA by the liver, and excreted by the kidneys. One

type of tumor, called carcinoid, sometimes secretes large amounts of serotonin into the blood, which

causes various forms of the carcinoid syndrome of flushing, diarrhea, and heart problems. Due to

serotonin's growth promoting effect on cardiac myocytes, persons with serotinin-secreting carcinoid

may suffer a right heart (tricuspid) valve disease syndrome, caused by proliferation of myocytes

onto the valve.

Glutamate is the most abundant excitatory neurotransmitter in the vertebrate nervous system.

At chemical synapses, glutamate is stored in vesicles. Nerve impulses trigger release of glutamate

from the pre-synaptic cell. In the opposing post-synaptic cell, glutamate receptors, such as the

NMDA receptor, bind glutamate and are activated. Because of its role in synaptic plasticity,

glutamate is involved in cognitive functions like learning and memory in the brain.

CRANIAL NERVES

Cranial nerves are nerves that emerge directly from the brain stem, in contrast to spinal

nerves which emerge from segments of the spinal cord. There are 12 pairs cranial nerves emerging

from the brain, and these are:

Cranial Sensory,
nerve Name Motor Function
number or Both

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Transmits the sense of smell; Located in olfactory
I Olfactory nerve Purely Sensory
foramina of ethmoid
Transmits visual information to the brain; Located
II Optic nerve Purely Sensory
in optic canal
Innervates levator palpebrae superioris, superior
rectus, medial rectus,inferior rectus, and inferior
III Oculomotor nerve Mainly Motor
oblique, which collectively perform most eye
movements; Located in superior orbital fissure
Innervates the superior oblique muscle, which
depresses, rotates laterally (around the optic axis),
IV Trochlear nerve Mainly Motor
and intorts the eyeball; Located insuperior orbital
fissure
Both Sensory Receives sensation from the face and innervates
V Trigeminal nerve
and Motor the muscles of mastication
Innervates the lateral rectus, which abducts the
VI Abducens nerve Mainly Motor
eye; Located insuperior orbital fissure
Provides motor innervation to the muscles of facial
expression, posterior belly of the digastric muscle,
and stapedius muscle, receives the special sense of
taste from the anterior 2/3 of the tongue, and
Both Sensory
VII Facial nerve provides secretomotor innervation to the salivary
and Motor
glands (except parotid) and the lacrimal gland;
Located and runs through internal acoustic
canal to facial canal and exits at stylomastoid
foramen
Vestibulocochlear Senses sound, rotation and gravity (essential for
nerve (or auditory- balance & movement). More specifically. the
VIII vestibular Mostly sensory vestibular branch carries impulses for equilibrium
nerveor statoacousti and the cochlear branch carries impulses for
c nerve) hearing.; Located in internal acoustic canal
IX Glossopharyngeal Both Sensory Receives taste from the posterior 1/3 of the tongue,
nerve and Motor provides secretomotor innervation to the parotid
gland, and provides motor innervation to
the stylopharyngeus (essential for tactile, pain, and
122
thermal sensation. Some sensation is also relayed to
the brain from the palatine tonsils. Sensation is
relayed to opposite thalamus and some
hypothalamic nuclei. Located in jugular foramen
Supplies branchiomotor innervations to most
laryngeal and all pharyngeal muscles (except
the stylopharyngeus, which is innervated by the
glossopharyngeal);
provides parasympathetic fibers to nearly all
Both Sensory thoracic and abdominal viscera down to the splenic
X Vagus nerve
and Motor flexure; and receives the special sense of taste from
the epiglottis. A major function: controls muscles
for voice and resonance and the soft palate.
Symptoms of damage: dysphagia (swallowing
problems),velopharyngeal insufficiency. Located
in jugular foramen
Accessory nerve Controls sternocleidomastoid and trapezius
(or cranial muscles, overlaps with functions of the vagus.
XI accessory nerve Mainly Motor Examples of symptoms of damage: inability to
or spinal accessory shrug, weak head movement; Located in jugular
nerve) foramen
Provides motor innervation to the muscles of the
tongue and other glossal muscles. Important for
XII Hypoglossal nerve Mainly Motor
swallowing (bolus formation) and speech
articulation. Located in hypoglossal canal

123
DOCTOR’S ORDER

Date Order Rationale Remarks


01/19/10 Please admit to CIU. For close monitoring of the patient Admitted
2:40pm and proper management of his
condition.
The crisis intervention unit is a
special unit operating on a 24-hour
basis, which serves as a receiving
and action center for walk-in
referred, and rescued individuals
and families in crisis situation.
Secure consent to This is done to ensure that the Secured.
care. client or significant others has
been adequately informed of
significant information concerning
treatment processes and
procedures. When persons, due to
age or mental status, are legally
incapable of giving informed
consent, doctors obtain informed
permission from a legally
authorized person, if such
substitute consent is legally
permissible. To secure the consent
of the client is important for legal
purposes.
DAT with aspiration This is done to give appropriate Done
precaution. and adequate nourishment with the
prevention or minimization of risk
factors in the patient at risk for
aspiration.

124
Monitor vsq6 and Vital signs are important for Taken and
record please baseline assessment and to recorded.
monitor patients condition which
evaluates the whole treatment
course, especially the medications
he receives that could be a
contributing factor in the variation
results of the vital signs.
Meds: Given
Haloperidol 5mg Haloperidol is an older
1amp IM now then antipsychotic used in the treatment
q12 of schizophrenia.

Flupentixol is a long acting


Flupentixol dec 20mg
injection given two or three
1ampule now then q
weekly to people with
monthly
schizophrenia who have a poor
compliance with medication and
suffer frequent relapses of illness.

Biperiden Hcl Biperiden is commonly used to


2mg/tab 1 tab BID improve parkinsonian signs and
PRN for EPS symptoms related to antipsychotic
drug therapy.
Homicidal and This is ordered so that the patient Done
suicidal tendencies will be monitored closely and to
escape precaution avoid the harming of patient's life
please or others.
Restrain patient when Psychiatric facilities often use Done
necessary. medical interventions in the form
of restraints to reduce safety risks
posed by violent patients and to
prevent patients from harming
themselves and others.

125
Refer accordingly This may create a collaborative Referred
treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.
01/20/10 11:40am

Hold Haloperidol IM To change to chlorpromazine. Done


Start Chlorpromazine This is given as a substitute for Given
decanoate 200 mg/tab Haloperidol. This is an atypical
½ tab in am, 1 tab at drug and is considered to have less
HS. EPS side effects.
01/21/10 07:40 AM
CONTINUE MEDS To promote the patient's well Done
For possible discharge being.

MGH: The patient’s psychotic episodes Done


have diminished. The patient is
advised to go home so the patient
may go back to his normal life..
Home meds: This is ordered as patient's
1. Chlorpromazine maintenance medications for his
200mg 1tab, ½ in AM condition.
2. Biperiden HCL
2g/tab 1tab BID
3. Flupentixol dec
20mg/1amp IM
qmonthly (last dose
1/1910)
>Follow up at OPD This is ordered for patient's
after 1 month. reassessment and constant
monitoring.

126
DRUG STUDY

Generic Name: Haloperidol

Brand Name:

Aloperidin, Bioperidolo, Brotopon, Dozic, Duraperidol (Germany), Einalon S, Eukystol,

Haldol, Halosten, Keselan, Linton, Peluces, Serenace, Serenase, and Sigaperidol

Classification(s): Typical Antipsychotic

Suggested Dose:

Individualized dose depends on indication and response.

AVAILABLE FORMS:

Haloperidol: Tablets – 0.5 mg, 1 mg, 2 mg, 5mg, 10 mg, 20 mg.

Haloperidol decanoate: Injection – 50mg/ml, 100 mg/ml

Haloperidol lactate: Injection – 5mg/ml. Oral concentration: 2 mg/ml.

Ordered dose: Haloperidol 5 mg 1 amp IM now then q 12 (January 19, 2010)

Mode of Action: Unknown. A butyrophenone that probably exerts antipsychotic effects by

blocking postsynaptic dopamine receptors in the brain.

ROUTE ONSET PEAK DURATION

P.O. Unknown 3-6 hr Unknown

I.V. Unknown Unknown Unknown

127
I.M. Unknown 3-9 days Unknown

(decanoate)

I.M. (lactate) Unknown 10-20 min Unknown

Indications:

♂ Psychotic disorders (Adults and children older than age 12: Dosage varies for

each patient. Initially, 0.5 to 5 mg P.O. b.i.d. or t.i.d. Or, 2 to 5 mg I.M. haldol

lactate q 4 to 8 hours, although hourly administration may be needed until

control is obtained.)

♂ Chronic psychosis requiring prolong therapy (Adults: 50 to 100 mg I.M.

haloperidol decanoate q 4 weeks.)

♂ Tourette Syndrome (Adults: 0.5 to 5 mg P.O. b.i.d., t.i.d., or p.r.n.)

Contraindications:

♂ In patients hypersensitive to drug and in those with parkinsonism, coma, CNS

depression.

♂ Use cautiously in elderly and deliberated patients; in patients with history of

seizures or EEG abnormalities, severe CV disorders, allergies, glaucoma, or

urine retention; and in those and those taking anticonvulsants anticoagulants,

antiparkinsonians, or lithium.

Drug Interaction:

Drug – Drug

♂ Anticholinergics: May increase anticholinergic effect and glaucoma. Azole antifungals,

buspirone, macrolides: May increase haloperidol level. Carbamazepine: May increase

haloperidol level. CNS depressants: May increase CNS depression. Lithium: May cause

lethargy and confusion after high doses. Methyldopa: May cause dementia. Rifampin: May

decrease haloperidol level.

128
Drug – Lifestyle

♂ Alcohol use: May increase CNS depression.

Side Effects:

♂ CNS: severe extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, lethargy,

headache, insomnia, confusion, vertigo.

♂ CV: tachycardia, hypotension, hypertension, ECG changes

♂ EENT: blurred vision.

♂ GI: dry mouth, anorexia, constipation, diarrhea, nausea, vomiting, dyspepsia.

♂ GU: urine retention, menstrual irregularities, priapism.

♂ Hematologic: leukocytosis.

♂ Hepatic: Jaundice.

♂ Skin: rash, other skin reactions, diaphoresis.

♂ Other: gynecomastia.

Adverse Effects:

♂ CNS: seizures and neuroleptic malignant syndrome.

♂ CV: torsades de pointes, with I.V. use.

♂ Hematologic: Leukopenia

Nursing Responsibilities:

♂ Although drug is least sedating of the antipsychotics, warn patient to avoid activities that

require alertness and good coordination until effects of the drugs are known.

♂ Educate patient that drowsiness and dizziness usually subside after a few weeks.

♂ Inform patient to avoid alcohol while taking this drug.

♂ Tell patient to relieve dry mouth with sugarless gum or hard candy.

♂ Always remember, don’t give deconate form IV.

129
♂ Monitor the client for signs of tardive dyskinesia which may occur after prolonged use. It

may not appear until months or years later and may disappear spontaneously or persist for

life, despite ending drug.

♂ Watch out for signs and symptoms of neuroleptic malignant syndrome, which is rare but

fatal.

♂ Inform patient to do not withdraw the drug abruptly unless required by severe adverse

reactions.

♂ Remind patient to always protect the drug from light. Slight yellowing injection or

concentrate is common and doesn’t affect potency. Discard the drug if there is a markedly

discolorations in the solutions.

♂ Stop taking haloperidol and check the patient with their doctor right away if they have any

of the following symptoms while using haloperidol: convulsions (seizures); difficulty with

breathing; a fast heartbeat; a high fever; high or low blood pressure; increased sweating; loss

of bladder control; severe muscle stiffness; unusually pale skin; or tiredness. These could be

symptoms of a serious condition called neuroleptic malignant syndrome (NMS).

BIBLIOGRAPHY: 26th Edition Nursing 2006 Drug Handbook by Lippincott Williams and

Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.

130
Generic Name: Flupentixol

Brand Name: Fluanxol; Depixol; Depixol Low Volume; Depixol-Conc

Classification(s): Typical Antipsychotics

Ordered dose: Flupentixol decanoate 20 mg 1 amp now then q monthly (January 19,

2010)

Mode of Action: Flupenthixol is a type of thioxanthene drug and acts by antagonism of D1 and

D2 dopamine receptors (as well as serotonin). Side effects are similar to

many other typical antipsychotics, namely extrapyramidal symptoms

of akathisia, parkinsonian tremor and rigidity. However, anticholinergic

adverse effects are low.

The typical antipsychotics are less commonly used now that

the atypical antipsychotics are available (with less side effects).

Indications:

131
♂ Schizophrenia and other psychoses

Dose: oral (rarely used) - initially 3-9mg twice daily, max. dose 18mg/day

Depot antipsychotic (Depixol) (brand name: Fluanxol Depot in Australia)

○ test dose of 20mg IM,

○ if tolerated, further dose of 20-40mg after 7 days,

○ usual interval 2-4 weeks between doses,

○ usual maintenance dose between 50mg every 4 weeks and 300mg every 2 weeks,

○ max. 400mg IM weekly.

♂ Depression

Dose:

○ initially 1mg/day, increased after 1 week to 2mg/day,

○ use half above doses in the elderly,

○ max 3mg/day (2mg in the elderly),

○ doses above 2mg (1mg in the elderly) should be gived as divided doses.

Contraindications:

♂ If patient is allergic to flupentixol or any other medicine of this class.

♂ If patient is allergic to any other medicine including preservative and dyes.

♂ Elderly people should be prescribed flupentixol with caution.

♂ If patient has history of kidney problem, liver problem or epilepsy.

♂ If patient has a problem of heart disease, high blood pressure or diabetes.

132
♂ If patient has a problem of enlarged prostate, thyroid problem or Parkinson’s disease.

♂ If two drugs are taken together, they may interact with each other. If patient is taking

any prescribed or non-prescribed, food supplements or herbal medicine.

♂ If patient is pregnant, or plan to become pregnant.

Drug Interaction:

♂ Prescription and nonprescription medications, especially those that may cause

drowsiness such as: sedatives, narcotic pain relievers (e.g., codeine), anti-anxiety agents

(e.g., diazepam), antidepressants or other psychiatric medicine, dopamine-type drugs

(e.g., cabergoline, pergolide, bromocriptine, pramipexole), muscle relaxants (e.g.,

cyclobenzaprine), drowsiness-causing antihistamines (e.g., diphenhydramine), atropine-

like drugs, anti- seizure drugs.

♂ Many cough-and-cold products contain ingredients that may add a drowsiness effect.

Side Effects:

• Nausea, drowsiness, dizziness, diarrhea, constipation, blurred vision, insomnia, urine

problem, tremor, weakness, vomiting, and difficulty in breathing, slow heart rate,

irregular blood pressure and convulsions.

• Less common side effects of flupentixol include skin rashes, muscle problem, dizziness

while rising from bed, sore throat, dark urine, increased sweating, yellowness of skin and

eyes, decreased sex drive and painful erection, chest pain and muscle spasms.

Nursing Responsibilities:

♂ Educate patient that Flupentixol can cause drowsiness, dizziness and blurred vision.

♂ Remind client that alcohol will increase feelings of drowsiness.

133
♂ Remind patient that before having any surgery, including dental or emergency treatment,

tell the surgeon, doctor or dentist that you are taking flupentixol.

♂ Inform client that Flupentixol can occasionally cause a dry mouth. If patient experiences

this, try chewing sugar-free gum, sucking sugar-free sweets or pieces of ice.

♂ Flupentixol can cause some people's skin to become more sensitive to sunlight than it

usually is. Avoid strong sunlight and sunbeds until you know how your skin reacts and

use a suncream higher than factor 15.

♂ If client experience 'flu like' symptoms such as stiffness, high temperature, abnormal

paleness, leaking bladder and a racing heartbeat contact their doctor or go to the accident

and emergency department of your local hospital immediately.

♂ Educate the patient that the symptoms of overdose may include seizers, muscle spasms,

weakness, fast heartbeat, fever, difficult breathing, severe dizziness, drowsiness,

convulsions, irregular heartbeat, disturbed concentration, constipation and coma.

♂ Inform patient to take the medicine with a full glass of water.

♂ Remind the patient that the medicine can be taken with or without food.

♂ Instruct to the patient that he can swallow the medicine as whole. Don’t cut or chew the

medicine.

BIBLIOGRAPHY: 26th Edition Nursing 2006 Drug Handbook by Lippincott Williams and

Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.

134
Generic Name: Biperiden

Brand Name: Akineton, Benzum 2, Berofin, Biperen, Bipiden, Desiperiden

Classification(s): Anti-Parkinson's Agent, Anticholinergic

Suggested Dose:

Adults:

Parkinsonism: 2 mg 3-4 times/day

Extrapyramidal: 2 mg 1-3 times/day

Elderly: Initial: 2 mg 1-2 times/day

Ordered dose: Biperiden Hcl 2 mg / tab 1 tab B.I.D. prn for EPS (January 19, 2010)

Mode of Action: Biperiden is a weak peripheral anticholinergic agent with nicotinolytic

activity. The beneficial effects in Parkinson's disease and neuroleptic-induced

extrapyramidal symptoms are believed to be due to the inhibition of striatal

cholinergic receptors.

Indications:
135
♂ Adjunctive treatment of all forms of Parkinson's disease (postencephalitic, idiopathic, and

arteriosclerotic).

♂ Improve parkinsonian signs and symptoms related to antipsychotic drug therapy.

♂ Relieves muscle rigidity, reduces abnormal sweating and salivation, improves abnormal gait,

and to lesser extent, tremor.

Contraindications:

♂ Hypersensitivity to biperiden or any component of the formulation

♂ Narrow-angle glaucoma

♂ Bowel obstruction, megacolon

♂ Myasthenia gravis

♂ Caution in patients with obstructive diseases of the urogenital tract, patients with a known

history of seizures and those with potentially dangerous tachycardia.

Drug Interaction:

Drug – Drug

♂ Amantadine, rimantadine: Central and/or peripheral anticholinergic syndrome can occur

when administered with amantadine or rimantadine.

♂ Anticholinergic agents: Central and/or peripheral anticholinergic syndrome can occur when

administered with opioid analgesics, phenothiazines and other antipsychotics (especially

with high anticholinergic activity), tricyclic antidepressants, quinidine and some other

antiarrhythmics, and antihistamines.

136
♂ Atenolol: Anticholinergics may increase the bioavailability of atenolol (and possibly other

beta-blockers); monitor for increased effect.

♂ Cholinergic agents: Anticholinergics may antagonize the therapeutic effect of cholinergic

agents; includes tacrine and donepezil.

♂ Digoxin: Anticholinergics may decrease gastric degradation and increase the amount of

digoxin absorbed by delaying gastric emptying.

♂ Levodopa: Anticholinergics may increase gastric degradation and decrease the amount of

levodopa absorbed by delaying gastric emptying.

♂ Neuroleptics: Anticholinergics may antagonize the therapeutic effects of

neuroleptics.

Side Effects:

♂ CNS : Drowsiness, vertigo, headache, and dizziness are frequent. With high doses

nervousness, agitation, anxiety, delirium, and confusion. Biperiden may lower the seizure-

threshold.

♂ Peripheral side effects : Blurred vision, dry mouth, impaired sweating, abdominal

discomfort, and obstipation are frequent. Tachycardia may be noted. Allergic skin reactions

may occur.

♂ Eyes : Biperiden causes mydriasis with or without photophobia. It may precipitate narrow

angle glaucoma.

Adverse Effects:

♂ Cardiovascular: Orthostatic hypotension, bradycardia

137
♂ Central nervous system: Drowsiness, euphoria, disorientation, agitation, sleep disorder

(decreased REM sleep and increased REM latency)

♂ Gastrointestinal: Constipation, xerostomia, dry throat, nasal dryness

♂ Genitourinary: Urinary retention

♂ Neuromuscular & skeletal: Choreic movements

♂ Ocular: Blurred vision

Nursing Responsibilities:

♂ Instruct patient to use caution when driving, operating machinery, or performing other

hazardous activities. Biperiden may cause dizziness or blurred vision. If patient

experience dizziness or blurred vision, avoid these activities.

♂ Remind patient to use alcohol cautiously. Alcohol may increase drowsiness and

dizziness while client is taking biperiden.

♂ Remind client to avoid becoming overheated. Biperiden may cause decreased sweating.

This could lead to heat stroke in hot weather or with vigorous exercise.

♂ Educate client to take each dose with a full glass of water.

♂ Educate patient to take biperiden after a meal if it upsets his stomach.

♂ Remind the patient to store biperiden at room temperature away from moisture and heat.

♂ This medication decreases saliva production, an effect that can increase gum and tooth

problems (e.g., cavities, gum disease). Instruct client to take special care with their

dental hygiene (e.g., brushing, flossing) and have regular dental check-ups.

138
♂ If client experiences signs of hyperthermia such as mental/mood changes, headache, or

dizziness, promptly seek cool or air-conditioned shelter and/or stop exercising, and seek

immediate medical attention.

♂ Remind patient to not share the medication to others.

♂ If patient misses a dose, remind them to take it as soon as they remember. If it is near the

time of the next dose, skip the missed dose and resume their usual dosing schedule. Do

not double the dose to catch up.

BIBLIOGRAPHY: 26th Edition Nursing 2006 Drug Handbook by Lippincott Williams and

Wilkins; Phil. Pharmaceutical Directory Review, 7th edition

Generic Name: Chlorpromazine Hydrochloride

Brand Name: Chlorpromanyl, Largactil, Novo-Chlorpromazin, Thorazine

Classification(s): Typical Antipsychotic

Suggested Dose:

Individualized dose depends on indication and response.

AVAILABLE FORMS:

Capsules (extended release): 200 mg, 300 mg.

Injections: 25 mg/ml

Oral concentrate: 30 mg/ml, 100 mg/ml

139
Suppositories: 25 mg, 100 mg

Syrup: 10 mg/5ml

Tablets: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg

Ordered dose: Chlorpromazine 200g/tab (January 20, 2010)

Mode of Action: Unknown. A piperidine phenothiazine that probably blocks postsynaptic

dopamine receptors in the brain.

ROUTE ONSET PEAK DURATION

P.O. 30-60min Unknown 4-6hr

I.M., I.V. Unknown Unknown Unknown

P.R. >1hr Unknown 3-4 hr

Indications:

♂ Psychosis, mania (Adults: for hospitalized patients with acute disease, 25 mg

I.M.)

♂ Nausea and vomiting (Adults: 10 to 25 mg PO q 4 to 6 hours, p.r.n. Or, 25 mg

IM initially.)

♂ Acute intermittent porphyria, intractable hiccups (Adults: 25 to 50 mg PO t.i.d.

or q.i.d.)

♂ Tetanus (Adults: 25 to 50 mg IV or IM t.i.d. or q.i.d.)

Contraindications:

♂ In patients hypersensitive to drug; in those with CNS depression, bone marrow

suppression, or subcortical damage, and in those in coma.

♂ Use cautiously in elderly and deliberated patients and in patients with hepatic or

renal disease, severe CV disease, respiratory disorders, hypocalcemia, glaucoma,

pr prostatic hyperplasia.

140
♂ Use cautiously in acutely ill or dehydrated children.

Drug Interaction:

Drug – Drug

♂ Antacids: May inhibit absorption of oral phenothiazines. Anticholinergics such

as tricyclic antidepressants, antiparkinsonians: May increase anticholinergic activity,

aggravated parkinsonian symptoms. Anticonvulsants: May lower seizure threshold.

Barbiturates, lithium: May decrease phenothiazine effect. Centrally acting

anthypertensives: May decrease antihypertensive effect. CSN depressants: May increase

CNS depression. Electroconvulsive therapy, insulin: may cause severe reactions. Lithium:

May increase neurologic effects. Meperidine: May cause excessive sedation and

hypotension. Propanolol: May increase levels of both propanolol and chlorpromazine.

Warfarin: May decrease effect of oral anticoagulants.

Drug – Lifestyle

♂ Alcohol use: May increase CNS depression, particularly psychomotor skills.

Side Effects:

♂ CNS: extra pyramidal reactions, sedation, tardive dyskinesia, pseudoparkinsonism.

♂ CV: orthostatic hypotension

♂ GI: dry mouth, constipation

♂ GU: urine retention

♂ Skin: mild photosensitivity reactions, pain at IM injection site

Adverse Effects:

♂ CNS: Seizures and neuroleptic malignant syndrome.

♂ Hematologic: Leukopenia, agranulocytosis, aplastic anemia, thrombocytopenia

Nursing Responsibilities:

141
♂ Obtain baseline blood pressure measurements before starting therapy, and monitor regularly.

Watch client for orthostatic hypotension.

♂ Monitor client for tardive dyskinesia, which may occur after prolonged use.

♂ Warn patient to avoid activities that require alertness or good coordination until effects of

drug are known.

♂ Remind client that drowsiness and dizziness usually subside after a few weeks.

♂ Advise patient not to crush, chew, or break extended release capsule form before

swallowing.

♂ Educate patient to avoid alcohol while taking the drug.

♂ Have the patient to report signs of urine retention or constipation.

♂ Remind patient to use sunblock and to wear protective clothing to avoid oversensitivity to

the sun.

♂ Advise client to relieve dry mouth with sugarless gum or hard candy.

♂ Withhold dose and notify prescriber if jaundice, symptoms of blood dyscrasia, or persistent

extrapyramidal reactions develop.

BIBLIOGRAPHY: 26th Edition Nursing 2006 Drug Handbook by Lippincott Williams and

Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.

SCIENTIFIC NAME: Cannabis sativa L.

BRAND/STREET NAME: Marijuana, Marihuana, Hemp, Hashish

142
CLASSIFICATION: Psychoactive drug; stimulant; depressant; hallucinogen

ROUTE OF ADMINISTRATION:

Inhaled smoke, screened bowls, bubblers (small pipes with water chambers),

bongs, one-hitters, chillums, paper-wrapped joints and tobacco-leaf-wrapped blunts,

tea, and orally.

CHEMICAL CONSTITUENTS:

Cannabis chemical constituents including about 100 compounds responsible

for its characteristic aroma. These are mainly volatile terpenes and sesquiterpenes.

INDICATIONS:

• Amelioration of nausea and vomiting

• Stimulation of hunger in chemotherapy and AIDS patients

• Lowers intraocular eye pressure (shown to be effective for treating glaucoma)

• General analgesic effects (pain reliever)

CONTRAINDICATIONS:

• Hypersensitivity to cannabis

• Pregnant women, or planning to get pregnant

DRUG INTERACTIONS:

• Alcohol: Make both drugs stronger.

• Amphetamines

• Cocaine: (Uppers and downers)

• Ecstasy: Extends and expands the experience of ecstasy.

• Heroin: Complimentary effects.

• Ketamine: Increases cannabis effects.

SIDE EFFECTS:

• General sense of well being and relaxation, giggliness and euphoria

143
• Eyes: Reddening, decreased intraocular pressure.

• Dreaminess, increased appreciation of music, sleepiness and time distortion

• Dryness of the mouth

• Increase heart rate

• Muscle relaxation

• Low blood pressure

• Impairment of short-term episodic memory, working memory, psychomotor coordination,

and concentration

• Anxiety, panic, paranoia and feelings of impending doom

ADVERSE EFFECTS:

• Lung cancer

• Chronic fungal infections

• Paranoia

• Confusion

• Long-lasting toxic psychosis

NURSING RESPONSIBILITIES:

• Reassure client that anxiety attacks are common side effects of the drug and will disappear

within hours.

• Provide a supportive environment for the client when experiencing feelings of paranoia and

anxiety.

• Remind client to avoid strenuous activities like driving or operating machinery until the

effects of the drug diminishes.

• Educate client that effects at first can be subtle, first time users usually detect little or no

effect at all.

144
• Inform the client that if he is possibly experiencing marijuana OD symptoms, it is

recommended that he calls the local emergency line.

• Educate client that if he is a regular cannabis smoker (every day) and stopped smoking, he

will experience some of the following withdrawal symptoms: restlessness, irritability, mild

agitation, insomnia, nausea, sleep disturbance, sweats, and intense dreams.

145
146
NURSING CARE PLAN
TIME CUES NEED NURSING GOAL OF CARE INTERVENTIONS EVALUATION
AND DIAGNOSIS
DATE
Januar SUBJECTIVE: C Disturbed sensory At the end of 2 1. Establish rapport and January 21, 2009
y 21, “Naay nagahung- O perception related hours of nursing build trust with the @ 2:30 PM
2009 hung sa akoa usahay G to alteration in care, the patient client
@ nga mag-wild daw ko N function of brain will be able to ® The client must trust GOAL
12:30 ug maglagot” as I tissue • maintain the nurse before talking UNMET
P.M. verbalized by the T orientation about hallucinations and
patient I ®It is the change to time, other sensory-perceptual • T
V in the amount or place, alterations he
OBJECTIVE E patterning of person, and 2. Continuously orient patient
• Disoriented - incoming stimuli circumstanc the client to actual was
to time P accompanied by a es for environmental events able to
• Auditory and E diminished, specified or activities in a maintai
visual R exaggerated, period of nonchallenging way. n
hallucination C distorted, or time; ®Brief, frequent orientati
s E impaired • demonstrate orientation helps to on to
• Misinterprets P response to such accurate present reality to the time,
actions of T stimuli. perception client with sensory- place,
others U of the perception disturbance person
• Inability to A Schultz, environmen 3. Reinforce and focus and
make simple L M.J.;Videback, t by on reality. Talk about situatio
decisions S.L.; Lippincott’s responding real events and real n.
• Inappropriate P Manual of appropriatel people. Use real “Huweb
147
responses A Psychiatric y to stimuli situations and events es
T Nursing Care in the to divert client from karon.
T Plans 7th edition surrounding long, tedious, Mga
E s; and repetitive udto na
R • lessen verbalizations of false man
N visual and ideas siguro.
auditory ® Working with Naa ko
hallucinatio reality lessens sa
ns patient’s initiation of Mental
his hallucinations. hospital
4. Correct client's para
description of magpac
inaccurate perception, heck-
and describe the up”
situation as it exists in • H
reality owever,
® Explanation of, the
and participation in, client
real situations and real was not
activities interferes able to
with the ability to demonst
respond to rate
hallucinations. accurate
5. Observe for verbal percepti
and nonverbal on of
behaviors associated the
148
with hallucinations environ
® Early recognition of ment as
sensory-perceptual evidenc
disturbance promotes ed by
timely interventions the
and alleviation of the presenc
client’s symptoms. e of
6. Describe the delusion
hallucinatory and
behaviors to the hallucin
client. ation
® The client may be • Pr
unable to disclose esence
perceptions and the of
nurse can openly auditory
facilitate disclosure by hallucin
reflecting on ation is
observations of the still
client’s behaviors, evident.
which helps the client
engage in more open
discussion with the
nurse, which in itself
brings relief.
7. Explore the content of
hallucinations to
149
determine the
possibility to harm
self, others or the
environment
® Exploring the
content of the
hallucination helps the
nurse identify if the
sensory-perceptual
disturbance is
threatening or
dangerous to the
client, such as a
command type of
hallucination that may
be telling the client to
harm or kill the client
or others. The nurse
can then reinforce
treatment and safety
precautions.
8. Use clear, direct,
verbal communication
rather than unclear or
nonverbal gestures
®Unclear directions
150
or instructions can
confuse the client and
promote distorted
perceptions or
misinterpretations of
reality.
9. Modify the client’s
environment to
decrease situations
that provoke anxiety
®Decreased anxiety
can reduce the
occurrence of
hallucinations
10. Reassure the client
(frequently if
necessary) that the
client is safe and will
not be harmed
®Alleviation of fear is
necessary for the
client to begin to trust
the environment and
to feel safe.

151
152
TIME CUES NEED NURSING GOAL OF CARE INTERVENTIONS EVALUATION
AND DIAGNOSIS
DATE
Januar SUBJECTIVE C Disturbed At the end of 2 1. Be sincere and January 21, 2009
y 21, “Magpatambal ko. Kani O thought process hours of nursing honest when @ 12:30 PM
2009 man gud akong utok, naa G related to care, the patient communicating
@ niy grasa.” as verbalized N disintegration will be able to with the client. GOAL
7:00 by the patient I thinking. • Maintain PARTIALLY
A.M T reality ®Clients are MET
I ®It is the orientation; extremely sensitive • The client
OBJECTIVE V disruption in • Demonstrat about others and was able to
• Delusion of E cognitive e reality can recognize maintain
persecution - operations and based insincerity. Evasive reality
• Delusion of P activities. thinking in remarks reinforce orientation.
paranoia E Cognitive verbal and mistrust. He is
• Thought insertion R processes nonverbal oriented to
• Incoherent speech C include those behavior; 2. Assess client’s time when
• Demonstrates a E mental and nonverbal behavior, asked what
disturbance in P processes by • Demonstrat such as gestures, day it is.
sleep pattern T which e the ability facial expression But he is
• Presence of U knowledge is to abstract, and posture. still
auditory A acquired. These conceptuali preoccupie
hallucinations L mental ze, reason ®This assessment d with his
processes and may help to meet delusions
P include reality calculate the client’s needs about his
153
A orientation, consistent that cannot be being
T comprehension, with ability conveyed through jealous to
T awareness, and to speech. him
E judgment. A
R disruption in 3. Encourage the • The client
N these mental client to express was not
processes may feelings and do not able to
lead to pry cross examine demonstrat
inaccurate for information e reality-
interpretations based
of the ®Probing increases thinking in
environment client’s suspicion verbal and
and may result and interferes with nonverbal
in an inability to the therapeutic responses.
evaluate reality relationship His
accurately. mannerism
Alterations in 4. Show empathy to is largely
thought the client’s observed
processes are feelings, reassure and he
not limited to the client of your wasn’t able
any one age presence and to establish
group, gender, acceptance eye contact
or clinical with any of
problem. ®The client’s the
(http://www1.us experiences can be interviewer
.elsevierhealth.c distressing. .
om/MERLIN/G Empathy conveys • However, 154
155
TIME CUES NEED NURSING GOAL OF CARE INTERVENTIONS EVALUATION
AND DIAGNOSIS
DATE
. SUBJECTIVE: S Situational low At the end of 2 1. Encourage client to January 21, 2010
Januar “Maulaw man gyud ko E self-esteem hours of nursing express honest @ 2:30 PM
y 21, basta ing-ana” L related to care, the patient feelings in relation
2010 F cognitive will: to loss of prior level GOAL UNMET
@ 12 OBJECTIVE: - impairment of functioning.
:30 • Lacking eye P • Verbalize Acknowledge pain • The
PM contact E It is the state in understandi of loss. Support patient
• Lack social R which an ng of things client through was
interaction C individual who that process of grieving. unable to
• Has little interest E previously had precipitate verbalize
® Client may be
in activities P positive self- current understa
fixed in anger stage
• Talks only when T esteem situation; nding of
of grieving process,
asked I experience a and things
which is turned
O negative feeling • Demonstrat that lead
inward on the self,
N towards self due e behaviors to
resulting in
to a certain that show current
diminished self-
situation positive situation
esteem.
self-esteem • The
Handbook of 2. Devise methods for patient
Nursing assisting client to was
Diagnosis by express feelings unable to
Lynda Juall demonstr
156
Carpenito- properly.. ate
Muyet behavior
® To explore the
s that
feelings of the
show
client thereby
positive
allowing him to
self-
acknowledge his
esteem
own strength and
as
weakness.
evidence
3. Encourage client's d by
attempts to inability
communicate. If to have
verbalizations are an eye-
not understandable, contact
express to client as well
what you think he as
or she intended to looking
say. It may be down at
necessary to during
reorient client the
frequently. intervie
® The ability to w.
communicate
effectively with
others may enhance

157
self-esteem.

4. Encourage
reminiscence and
discussion of life
review. Also
discuss present-day
events. Sharing
picture albums, if
possible, is
especially good. ®
Reminiscence and
life review help the
client resume
progression through
the grief process
associated with
disappointing life
events and increase
self-esteem as
successes are
reviewed.

5. Encourage
participation in
group activities.
Caregiver may need
158
to accompany client
at first, until he or
she feels secure that
the group members
will be accepting,
regardless of
limitations in verbal
communication.

® Positive
feedback from
group members will
increase self-
esteem.

6. Offer support and


empathy when
client expresses
embarrassment at
inability to
remember people,
events, and places.
® Focus on
accomplishments to
lift self-esteem.

7. Encourage client to

159
be as independent
as possible in self-
care activities.

® The ability to
perform
independently
preserves self-
esteem.

8. Listen to patient’s
concerns and
verbalizations
without comment
or judgment.

®It enables the


client to develop
trust and thereby
establish
communication

9. Provide feedback to
client’s negative
feelings.

®To allow the


client experience a
different view.
160
161
TIME CUES NEED NURSING GOAL OF CARE INTERVENTIONS EVALUATION
AND DIAGNOSIS
DATE
January SUBJECTIVE: C Impaired At the end of 3 day 1. Provide January 21, 2010
21, The clarified when O memory related nursing care, the opportunities for @ 2:30 PM
2010 exactly was the 2 G to neurological patient will be able reminiscence or
@12:30 months he was referring N disturbances to: recall past events GOAL MET
PM about his last used of I ®Impaired • Verbalize ®Long-term • The patient
marijuana, he verbalized T memory is awareness memory may was able to
“Kadtong 2007 man to, I directly related of memory persist after loss of verbalize
aw 2008 diay” V to effects of problems; recent memory. awareness
E general medical and Reminiscence is of memory
OBHECTIVE: - condition or • Accept usually an problems
• Disorientation to P ongoing effects limitations enjoyable activity as he
time E of substance. of current for the client. verbalized
• Observed R Depending o n condition “Usahay
experience of C the areas of the 2. Encourage the gyud
forgetting E brain, the client client to use written makalimot
• Scratches his P are unable to cues such as na ko”
head when he is T recall calendars or • The patient
unable to recall U information, notebooks was able to
information A either remote or ®Written cues verbalize
• Inability to L recent. The decrease the acceptance
determine if a client may client’s need to of his
behavior is confabulate to recall activities, limitations
162
performe fill in those lost plans and so on due to his
memories. from memory. conditions
3. Encourage
ventilation of
feelings of
frustration,
helplessness, and so
forth. Refocus
attention to areas of
focus and progress.
®To lessen feelings
of
powerlessness/hope
lessness
4. Provide for proper
pacing of activities
and having
appropriate rest
®To avoid fatigue
5. Allow the client to
do tasks on his
own, but do not
rush him to do it.
Make the client feel
that he can still do
things
163
independently.
®It is important to
maximize
independent
function, assist the
client when
memory has
deteriorated further.
6. Assist the client
deal with functional
limitations and
identify resources.
®To meet
individual needs,
maximizing
independence.
7. Provide single step
instructions when
instructions are
needed.
®Client with
memory
impairment cannot
remember multistep
instructions
8. Do not contradict
164
the client who
experiences an
illusion. Instead,
simply explain
reality, and find
some practical
solutions to the
problem
®Therapeutic
responses promote
reality while
offering solutions
that help enhances
the client’s sense
and may reduce
fear, anxiety, and
confusion.
9. Monitor client’s
behavior and assist
in use of stress-
management
techniques
®To reduce
frustration
10. Determine client’s
response to
165
medication
medications
prescribe to
improve attention,
concentration,
memory process
and to lift spirits
and modify
emotional
responses.
®Helpful in
deciding whether
quality of life is
improved when
using the
medications
prescribed.
TIME CUES NEED NURSING GOAL OF CARE INTERVENTIONS EVALUATION
AND DIAGNOSIS
DATE

166
JanuarySUBJECTIVE: A Self care deficit: After 2 hours of 1. Establish rapport. January 21, 2009
“Makatamad usahay nursing care, the
21, C bathing / R: to gain client’s trust @ 2:30 PM
maligo. Wala pa gani ko client will be able
2010 @ ligo ron. Kapoy pud T hygiene related to: and facilitate a
manlimpyo ug kuko”, as a) verbaliz good working
12:30 I to lack of relationship. GOAL
verbalized by the
e self
P.M. patient. V motivation PARTIALLY
care 2. Identify reason for
I ® The patient MET
OBJECTIVE: difficulty in self-care.
need
Unkempt hair noted T has an impaired
food stains visible on b) Demon R: underlying cause
Y ability to After 2 hours of
clothing affects choice of
strate
untrimmed fingernails - provide self care interventions/ nursing care, the
and toenails with visible techniq strategies.
E requisites due to client was able to:
dirt noted
ues to
X environmental 3. Determine hygienic a) ver
meet
E and needs and provide bali
self-
R psychological assistance as needed ze
care
C factors. with activities like self
needs
I care of nails and car
S brushing teeth. e
E R: basic hygienic needs nee
may be forgotten. d
P 4. Discuss on importance b) but
A of hygiene. was
T R: makes client aware una
T of how hygiene is ble
E vital in caring for to
oneself.
R de
N 5. Orient client to mo
different equipment nstr
167
for self-care like ate
various toiletries. tec
R: increases the client’s hni
awareness of que
different materials
for self-care. s to
6. Let the patient me
enumerate his ideas on et
the importance of self
hygiene. -
R: Encourages the car
patient to e
understand the need
nee
for hygiene.
7. Discuss the possible ds.
negative implications
of not taking a bath
such as infections and
odor.
R: Broadens the
patient’s idea about
the problem and
encourages him to
meet the need.
8. Encourage client to
perform self-care to
the maximum of

168
ability as defined by
the client. Do not rush
client.
R: promotes
independence and
sense of control,
may decrease
feelings of
helplessness.

9. Allot plenty of time to


perform tasks.
R: cognitive
impairment may
interfere with
ability to manage
even simple
activities.

10. Assist with dressing


neatly or provide
colorful clothes.
R: Enhances esteem
and convey
aliveness.

169
170
PROGNOSIS

GOOD FAIR POOR JUSTIFICATION


Onset of the ☻ Bob first experiences the signs and symptoms of
illness schizophrenia when he was 18 years old and now he
is 40 years old. The first signs that Bob showed was
when he ate feces and since then people who are
close to him noticed that he has illogical speech and
flight of ideas. It was until after two months,
November 1987 that they decided to bring Bob to
the hospital for check-up when Bob’s tongue
shrunk. The onset of illness was poor since the
family waited that the situation of Bob worsened
and did not immediately seek medical advice
immediately when there was changes in his
behavior like when he ate stool and showed illogical
speech and flight of ideas.
Duration of ☻ The client has been diagnosed with schizophrenia
illness catatonic 22 years ago. The patient went to the
Davao Medical Hospital for his third admission last
January 19, 2010 and was diagnosed with
schizophrenia undifferentiated. As we can see, the
duration of illness has been very long since it was
years ago since he was mentally sick thus rating him
with poor prognosis.
Precipitating ☻ Intake of drugs, substances or chemicals which
factors increase levels of dopamine and developmental
factors are the present precipitating factors seen in
Bob. The proponents rated this area as poor since
Bob is abusing substances like marijuana, alcohol,
cigarette and soft drinks. In his development, Bob
developed mistrust, shame and doubt, guilt,
inferiority, role confusion, and isolation which rated
him poor.

171
Mood and Affect ☻ During the interview, Bob has appropriate mood
and affect therefore rating him with good prognosis.

Family Support ☻ During the interview the mother and the sister-in-
law was with the patient. As the interview
progresses the student nurses observed that the
family is supporting the patient. The patient is
receiving appropriate family support since his
family is doing all they can to help him recover.
They are helping him financially as well as
emotionally. The family understood what he is
undergoing and giving him the support he need for
his recovery.
Willingness to ☻ Bob was brought to the hospital for check-up
take medications because he demanded to his parents saying that
and treatment something is wrong with him. Bob submits himself
properly to the medication without missing any
single dose. He may be taking the proper regimen,
however, he is not listening to the advice of the
doctor to stop alcohol, smoking, taking marijuana
and even drinking soft drinks. For a person to be
treated he must not only take the drugs prescribed
but also to stop things that are contraindicated for
him for his treatment. Because of this, Bob was
rated with prognosis with the willingness to take the
medication and treatment.
Depressive ☻ During the interview, the patient does not show any
features depressive features. Bob knew that something is
wrong with him and he need medical attention.
Even though he is aware that something is wrong
with him, he is still not depressed with this fact. He
didn’t finish college but he is not depressed with
this fact. Not getting the things he wants won’t
make him depress but instead, Bob goes wild and

172
becomes hostile.
Computation:
➢ Poor: (3*1)/7 = 3/7
➢ Fair: (1*2)/7 = 2/7
➢ Good: (3*3)/7 = 9/7
Total 3 1 3 Total: 2.00
General Prognosis:
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD

Rationale for Fair Prognosis:

Bob has a fair prognosis therefore he has small chance, according to the calculation, of

recovering from his illness. The onset of illness was 22 years ago. He was not immediately brought

to the hospital but they waited 2 months and decided to bring him to the hospital because of

shrinking of his tongue and he demanded so. The duration of illness is long since it was last

November 1987 that he was first diagnosed of Catatonic Schizophrenia and just this last January 19,

2010 that he was diagnosed of Schizophrenia undifferentiated. He also abused many substances like

marijuana, alcohol, cigarette and soft drinks. And during his development, he developed mistrust,

shame and doubt, guilt, inferiority, role confusion, and isolation which rated him poor.

In addition to that, he didn’t listen to the advice of the doctor to stop alcohol, smoking,

taking marijuana and drinking soft drinks. However, he submits himself to the regimen, taking the

medications promptly even going to the hospital every month for his medication.

Furthermore, during the interview, Bob has appropriate mood and affect therefore rating

him with good prognosis. He has good family support as evidenced by the support of his mother

and sister-in-law while he is in the hospital. His father is supporting him financially but is not able

to go with him because of his work back in Agusan. The family understood what he is undergoing

and giving him the support he need for his recovery. Lastly, the patient does not show any

173
depressive features. Bob knew that something is wrong with him and he need medical attention.

Even though he is aware that something is wrong with him, he is still not depressed with this fact.

He didn’t finish college but he is not depressed with this fact. Not getting the things he wants won’t

make him depress but instead, Bob goes wild and becomes hostile.

174
RECOMMENDATION

The group 1 of section 3H would like to recommend the following:

To the patient:

He is advised to take part in complying with the treatment; the medication and therapeutic

regimen designed for his rehabilitation. He should realize the importance of complying with his

medication and the benefits this practice would bring to the improvement of his well-being.

To the patient’s family:

The patient’s family plays an important role in the patient’s mental illness and recovery. The

family should make themselves physically present so that the patient would feel their support and

concern. They are encouraged to continue interacting with the patient so that ideas of violence

towards self and others will be diverted. In addition, it is of prime importance that they are oriented

and educated regarding the patient’s mental illness so that they will understand him even better and

assist him in his daily activities.

To the Ateneo de Davao University- College of Nursing:

The faculty and staff are encouraged to continue improving the standards of the Ateneo

Nursing Curriculum by providing quality education to students. Also they, themselves, must be

equipped with the knowledge and skill that they may impart to student nurses. They are challenged

to not just teach but impart to us as well nursing experiences that we may apply in the course of

caring for our future patients.

175
To the Davao Mental Hospital:

The group recommends that they should improve their facilities in treating the mentally-ill

patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and

have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the

patients and staff. Address the needs of each patient by first assessing the level of severity of the

patient’s condition; let every patient be submitted for history and physical examination and be

evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend

that the psychiatric team would work together in order to provide mental health care service that

promotes rehabilitation of the patient. Also they are recommended to know the latest trends in

improving therapeutic communication between them and the patients.

To the student nurses:

Even if nursing students find it difficult to establish therapeutic relationships with mentally-

ill patients because of the relatively short time spent in the clinical area, still we have to render

amounts of effort, time and trust to our patients; and improve our therapeutic technique in caring for

our patients; that we may play a part in the rehabilitation of our mentally-ill patients.

176
SIGNIFICANCE OF THE STUDY

This study will be a significant undertaking in depth understanding the reason behind our

subject’s mental illness. This study will also be beneficial to the students and clinical instructors in

College of Nursing in making use of different concepts taught inside the classroom related to

psychiatric nursing.

This case study will give us better understanding regarding mentally-ill patients; provide

recommendations on how to deal with them in the future. It will give us better grasp why certain

people experience being mentally unstable by looking deeper into the history, physiology, brain

chemistry; development of physical, emotional and cognitive; and social relations of the patient.

Some of the mentally ill patients remain undiagnosed and untreated because they never

sought medical attention due to old stigmas and societal attitudes towards mental illness. Stigmas

results in the social exclusion of people with a mental illness and is detrimental to the part of the

family. Moreover, this study will be helpful to aid the family in caring their mentally-ill member;

giving them more understanding, acceptance, and how to deal with the illness and issues concerning

it.

177
APPENDICES

DIAGNOSTIC STATISTICAL MANUAL


CRITERIA FOR DIFFRENTIAL DIAGNOSIS

Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination


of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and
impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the
clinical picture that occasioned the most recent evaluation or admission to clinical care and may
therefore change over time. They are defined by their symptomatology. The disorder lasts for at
least 6 months and includes at least one month of the active phase symptoms namely two or more of
the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The
subtypes are:

295.30 Paranoid Type


295.10 Disorganized Type
295.20 Catatonic Type
295.90 Undifferentiated Type
295.60 Residual Type

Diagnostic Criteria for Schizophrenia


A. Characteristic symptoms. Two or more of the following, each present for
a significant portion of time during a 1-month period (or less if
successfully treated):
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms (i.e. affective flattening, alogia or avolition)

Only one Criterion A symptom is required if delusions are bizarre or


hallucinations consist of a voice keeping up a running commentary on the
person’s behavior or thoughts, or two or more voices conversing with each other.
178
A. Social/occupational dysfunction.
For a significant portion of the time since the onset of the disturbance, one or
more major areas of functioning such as work, interpersonal relations, or self-
care are markedly below the level achieved prior to the onset (or when the
onset is in childhood or adolescence, failure to achieve expected level of
interpersonal, academic, or occupational achievement)
B. Duration
Continuous signs of the disturbance persist for at least 6 months. This 6-
month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e. active-phase symptoms) and
may include periods of prodromal or residual symptoms. During these
prodromal or residual periods the signs of the disturbance may be manifested
by only negative symptoms or two or more symptoms listed in Criterion A
present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.)
C. Schizoaffective and Mood Disorder exclusion:
Schizoaffective Disorder and Mood Disorder with Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic, Or Mixed
Episodes have occurred concurrently with the active-phase symptoms; or (2)
if mood episodes have occurred during active-phase symptoms, their total
duration has been brief relative to the duration of the active and residual
periods.
D. Substance/general medical condition exclusion:
The disturbance is not due to the direct physiological effects of a substance
(e.g. a drug of abuse, a medication) or a general medical condition
E. Relationship to a Pervasive Developmental Disorder:
If there is a history of Autistic Disorder or another Pervasive Developmental
Disorder, the additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a month (or less if
successfully treated.
Total

295.30 Schizophrenia Paranoid Type


The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent
delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning

179
and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized
speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent.
Delusions are typically persecutory or grandiose or both but delusions with other themes may also
occur. Hallucinations are also typically related to the content of the delusional theme.
Diagnostic criteria for 295.30 Paranoid Type
A. Preoccupation with one or more delusions or frequent auditory hallucinations
B. None of the following is prominent: disorganized speech, disorganized or
catatonic behavior, or flat or inappropriate affect.
TOTAL

295.10 Schizophrenia Disorganized Type


The essential features of the Disorganized Type of Schizophrenia are disorganized speech,
disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of
Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not
organized into a coherent theme.
Diagnostic criteria for 295.10 Disorganized Type
A. All of the following are prominent
1. disorganized speech
2. disorganized behavior
3. flat or inappropriate affect
B. The criteria are not met for catatonic type

TOTAL

295.20 Schizophrenia Catatonic Type


The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor
disturbance that may involve motoric immobility, excessive motor activity, extreme negativism,
mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include
stereotypes, mannerisms, and automatic obedience or mimicry.

180
Diagnostic criteria for 295.20 Catatonic Type
A type of Schizophrenia in which the clinical picture is dominated by at least two
of the following

TOTAL

295. 90 Schizophrenia Undifferentiated Type


Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic
symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly
fit under any category.
Diagnostic criteria for 295.90 Undifferentiated Type
A type of Schizophrenia in which symptoms that meet Criterion A are present, but
the criteria are not met for the Paranoid, Disorganized, or Catatonic Type
TOTAL

295.60 Schizophrenia Residual Type


The Residual Type of Schizophrenia should be used when there has been at least one
episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic
symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing
evidence of the disturbance as indicated by the presence of negative symptoms or two or more
attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and
are not accompanied by strong affect.
Diagnostic criteria for 295.60 Residual Type
A. Absence of prominent delusions, hallucinations, disorganized speech and
grossly disorganized or catatonic behavior.
B. There is continuing evidence of the disturbance, as indicated by the presence of

181
negative symptoms or two or more symptoms listed in Criterion A for
Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual
experience)
TOTAL

301.22 Schizotypal Personality Disorder


Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions,
and beliefs.
Diagnostic criteria fort 301.22 Schizotypal Personality Disorder
A. A pervasive pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as well as by
cognitive or perceptual distortions and eccentricities of behavior, by beginning by
early adulthood and present in a variety of contexts, as indicated by five or more of
the following:
1. Ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms (e.g., superstitiousness, belief
in clairvoyance, telepathy, or “sixth sense in children and
adolescents, bizarre fantasies or preoccupations)
3. unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g., vague, circumstantial,
metaphorical, overelaborate, or stereotyped)
5. suspiciousness or paranoid ideation
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric or peculiar
8. lack of close friends or confidants other than first-degree
relatives
9. excessive social anxiety that does not diminish with familiarity
and tends to be associated with paranoid fears rather than
negative judgments about self
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,
“Schizotypal Personality Disorder (Premorbid)

182
Schizoid Personality Disorder
Individuals with schizoid personality disorder are emotionally detached and prefer to be left
alone.
Diagnostic criteria for 301.20 Schizoid Personality Disorder
A. A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of
the following:
Criteria Present
1. neither desires nor enjoys close relationship, including being a
part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with
another person
4. takes pleasure in few, if any , activities
5. lacks close friends or confidants other than first degree
relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened activity
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder and is not due to the direct physiological effects of a
general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,
“Schizoid Personality Disorder (Premorbid)”
TOTAL

301.0 Paranoid Personality Disorder


People with paranoid personality disorder are distrustful and suspicious and anticipate harm
and betrayal.
Diagnostic Criteria for 301.0 Paranoid Personality Disorder
A. A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in variety of
contexts, as indicated by four (or more) of the following:
Criteria Present

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1. suspects, without sufficient basis, that others are exploiting,
harming or deceiving him or her
2. is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates
3. is reluctant to confide in others because of unwarranted fear that the
information will be used maliciously against him or her
4. reads hidden demeaning or threatening meanings into benign
remarks or events
5. persistently bear grudges , i.e., is unforgiving of insults, injuries, or
slights
6. perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack
7. has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner
B. Does not occur exclusively during the course of Schizophrenia, a Mood
Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive
Developmental Disorder and is not due to the direct physiological effects of a
general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g.,
“Paranoid Personality Disorder (Premorbid)”
TOTAL

298.8 Brief Psychotic Disorder


The essential feature of Brief Psychotic Disorder is a disturbance that involves the sudden
onset at least one of the following positive psychotic symptoms: delusions, hallucinations,
disorganized speech or grossly disorganized or catatonic behavior
Diagnostic Criteria for 298.8 Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms
1. delusion
2. hallucination
3. disorganized speech
4. grossly disorganized catatonic behavior

Note: Do not include a symptom if it is a culturally sanctioned response pattern


B. Duration of an episode of the disturbance is at least 1 day but less than 1 month,
with eventual full return to premorbid level of functioning
C. The disturbance is not better accounted for by a Mood Disorder With Psychotic

184
Features , Schizoaffective Disorder, or Schizophrenia and is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a
general medical condition
TOTAL

297.1 Delusional Disorder


The essential feature of Delusional Disorder is the presence of one or more nonbizarre
delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not
prominent. Tactile or olfactory hallucinations may be present if they are related to delusional
themes.
Diagnostic Criteria for 297.1 Delusional Disorder
A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as
being followed, poisoned, infected, loved at a distance, or deceived by spouse or
lover, or having a disease) of at least 1 month’s duration.
B. Criterion A for Schizophrenia has never been met.
Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if
they are related to the delusional theme.
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not
markedly impaired and behavior is not obviously odd or bizarre.
D. If mood episodes have occurred concurrently with delusions, their total duration
has been brief relative to the duration of the delusional periods.
E. The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition.
TOTAL

295.40 Schizophreniform Disorder


The essential features of Schizophreniform Disorder are identical to those of Schizophrenia
(Criteria A) except for two differences: the total duration of the illness (including prodromal, active,
and residual phases) is at least 1 month but less than 6 months and impaired social or occupational
functioning during some part of the illnesses not require although it may occur.
Diagnostic Criteria for 295.40 Schizophreniform Disorder
A. Criteria A, D, and E of Schizophrenia are met
B. An episode of the disorder (including prodromal, active, and residual phases)
lasts at least 1 month but less than 6 months. (When the diagnosis must be made
without waiting for recovery, it should be qualified as “Provisional.”)
TOTAL

185
Substance-Induced Psychotic Disorder
The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations
or delusions that are judged to be due to the direct physiological effects of a substance.
Hallucinations that the individual realizes are substance induced are not included here and instead
would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying
specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a
Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic
symptoms occur only during the course of delirium.
Diagnostic criteria for Substance-Induced Psychotic Disorder
A. Prominent hallucinations or delusions.
Note: Do not include hallucinations if the person has insight that they are substance
induced
B. There is evidence from the history, physical examination, or laboratory findings
of either (1) or (2):
1. the symptoms of Criterion A developed during or within a month of,
Substance intoxication or Withdrawal
2. Medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by a Psychotic disorder that is not
substance induced. Evidence that the symptoms are better accounted for by a
Psychotic Disorder that is not a substance induced might include the following: the
symptoms precede the onset of the substance use (or medication use); the symptoms
persist for a substantial period of time (e.g., about a month) after the cessation of
acute withdrawal or severe intoxication, or are substantially in excess of what would
be expected given the type or amount of the substance used or the duration of use; or
there is other evidence that suggests the existence of an independent non-substance
–induced Psychotic Disorder (e.g., a history of recurrent non-substance related
episodes.
D. The disturbance does not occur exclusively during the course of delirium.

Note: This diagnosis should be made instead of a diagnosis of Substance


intoxication or Substance Withdrawal only when the symptoms are in excess of
those usually associated with the intoxication or withdrawal syndrome and when the
symptoms are sufficiently severe to warrant independent clinical attention.

TOTAL

186
293.xx Psychotic Disorder Due to General Medical Condition
Diagnostic criteria for 293.xx Psychotic Disorder Due to General Medical Condition
A. Prominent hallucination or delusions
B. There is evidence from the history, physical examination, or laboratory findings
that the disturbance is the direct physiological consequence of a general medical
condition
C. The disturbance is not better accounted for by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
TOTAL

295.70b Schizoaffective Disorder


Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia
but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some
time in the absence of any mood syndrome.

Diagnostic criteria for 295.70b Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a


Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with
symptoms that meet criterion A for Schizophrenia.
Note: The Major Depressive Episode must include criterion A1: depressed mood.
B. During the same period of illness, there have been delusions or hallucinations for
at least 2 weeks in the absence of prominent mood symptoms.
C. Symptoms that meet criteria for a mood episode are present for a substantial
portion of the total duration of the active and residual periods of the illness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medication.

Substance Intoxication Delirium


Diagnostic criteria for Substance Intoxication Delirium
A. Disturbance in consciousness(i.e., reduced clarity of awareness of the
environment) with reduced ability to focus, sustain or shift attention
B. A change in cognition (such as memory deficit, disorientation, language
disturbance) or the development of a perceptual disturbance that is not better
accounted for by a preexisting, established, or evolving dementia
C. The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day.

187
D. There is evidence from the history, physical examination, or laboratory findings
of either (1) or (2)
Criteria Present
1. the symptoms in Criteria A and B developed during Substance
Intoxication
2. medication use is etiologically related to the disturbance*

188
REFERENCES

1. DSM-IV-TR.4th edition. American Psychiatric Association. Book promotion and services

Ltd.

2. Handbook of Psychodiagnostic Testing by Kellerman and Burry

3. Kozier. Fundamentals of Nursing 6th edition.

4. Keltner, Psychiatric Nursing 5th Edition.

5. Drug & Drug Abuse. 2nd edition. Addiction research oundation by Cox et. Al

6. Lippincott’s Manual of Psychiatric Nursing care Plans. 7th edition by Schultz and Videbeck

7. Human Anatomy & Physiology 11th edition by Tortora and Derrickson

8. Clinical Handbook of Schizophrenia. Edited by Mueser and Jeste

9. Concepts of Anatomy and Physiology 4th edition. By Graaft & Fox

10. Psychiatric Nursing: a textbook and reviewer.maria Evangelista –Sia c2004;p.234

11. Psychiatric nursng care plans. Fortinash & Holoday Norret.4th edition..p113.mosby inc. St

Louis,Missouri

12. Psychiatric Nursing. Norma.Keltner,et.al.pte Ltd. C2007

13. Abnormal Psychology. P.186 by Jefnar Mahmud. APH. Pulishing corp. New delhi c2002

14. Abnormal psychology: current perspective. Larren Alloy,et.al c1996. McGraw-hill inc.

15. Psychia nursing:biological &behavioural concepts (Deborah Antai-

Drong)p.351.thomson/Delmar learning;c2003

16. Abnormal psychology. James Hansen; Lisa Damour. Hobeken, NJ: Willey c2005

17. Scizizophrenia:chemistry,metabolism & Treatment. J.R. Smythies. Illinois, Thomson c1963

18. http://positivenewsmedia.net/am2/publish/Health_21/P4-M_Davao_mental_hospital_multi-

purpose_building_to_rise_next_year.shtml)

19. http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=8805&cn=7
189
20. (http://www.cureresearch.com/s/schizophrenia/stats-country.htm).

21. http://www.schizophrenia.com/szfacts.htm

22. http://www.ppa.ph/files/PPA%20Research%20Abstracts.pdf

190