Beruflich Dokumente
Kultur Dokumente
SCHIZOPHRENIA PARANOID
Submitted to:
Aida Bautista RN, MAN
Clinical Instructor
Submitted by:
MENDOZA, STEFANI
OBEDOZA, ESTHER
ODRADA, ELIZABETH
PEROL, MAE
SUNGA, KAREN
TAN, JEANETTE
VALEROS, JAYSON
VICENCIO, DIOSSA
VILLANUEVA, KERSTINE
BSN 3Y2-2D
TABLE OF CONTENTS:
1
Learning Objectives......3
Introduction.....4
Patients Profile......6
Physical Assessment and MSE...7
Psychosocial Theory and Development.9
Gordons Functional Health Pattern..13
Course in the Ward.....15
Psychotherapies...20
Anatomy and Physiology........21
Pathophysiology.......23
Laboratory.....25
Drug Study....27
Nursing Care Plan.........................31
Recommendation............34
General Objectives
This case study aims to identify and determine the general health problems and needs
of the patient with an admitting diagnosis of Paranoid Schizophrenia. This study also
intends to help us promote health and medical understanding of such condition through
the application of the nursing skills.
Specific Objectives
After the completion of this case study, the students will be able to:
INTRODUCTION
Causes
The causes of schizophrenia are not fully known. However, it
appears that schizophrenia usually results from a complex interaction between genetic
and environmental factors.
Epidemiology
Schizophrenia in Southeastern Asia
Country
Number of Cases
East Timor
8,243
Indonesia
1,928,663
Laos
49,080
Malaysia
190,255
Philippines
697,543
Singapore
35,215
Thailand
524,647
Vietnam
668,596
According to the record of Cagayan Valley Medical Center psychiatry department from
Jan. July of 2010, there were 43 patients admitted in female ward, and among those
patients there were 26 cases of schizophrenia. There are 697,543 cases of
schizophrenia in the Philippines, 75% are males and the rest are females. And 51
million people worldwide suffer from schizophrenia in which males have the highest
percentage. (2014, searchcure)
Updates
Research has found a tentative benefit in using minocycline (antibiotic) to treat
schizophrenia. The addition of minocycline to atypical antipsychotic drugs in early
schizophrenia had significant efficacy on negative symptoms but had a slight effect on
the attention domains of patients with schizophrenia. the mechanism of action of
minocycline would include affecting glutamate pathways in the central nervous system,
blocking nitric oxide-induced neurotoxicity, or inhibiting microglial activation in the brain,
5
Chief Complaint:
According to the patient: Pinag-kakaisahan ako ng mga pulis, nakamanman sila sa
akin
The patient came from Bgy. Tabok, Northern Samar who was known to be
frequently involved in fights with the neighbors. She was apprehended by NAPOLCOM
last July 2012. She filed a case against policemen battering her and was then referred
to DOH by a television program of Tulfo and Attorney Persida Acosta. She was then
referred to NCMH to acquire a medical certificate attesting that she is capable to stand
trial against the policemen who allegedly abused her. She came alone and was
irritable, furious, cursing and was physically violent hence admission in NCMH.
ysical Examination
PHYSICAL EXAM ( NO IDENTIFIED PHYSICAL ABNORMALITIES )
normocephalic, symmetrical facial
HEAD
-movements, smooth without
masses or depressions and
symmetrical facial movements
NECK
no abnormal
swelling or masses
no discharge and pink
conjunctiva
EYES
EARS
no lesions or discoloration
nasal flaring
NOSE
MOUTH
dry mouth, cracked lips
Incomplete
TEETH
CHEST
equal chest expansion, clear breath sounds
ABDOMEN
EXTREMITIES
pulses
Neurological Exam
conscious, coherent, hyperproductive speech, oriented to time and place, able to do simple
commands
Cranial Nerves
CN I- smell intact
CN II- pupils equally round and reactive to light
CN III, IV, VI- intact EOM
CN V- can clench teeth
CN VII- no facial asymmetry
CN VIII- intact hearing
CN IX, X- uvula at the midline
CN XI- shrugs shoulders
LIFE STAGE
INDICATIONS
OF POSITIVE
RESOLUTION
INDICATIONS
OF NEGATIVE
RESOLUTION
Learning
how to
trust others
Mistrust,
withdrawal,
enstrangemen
t
ASSESSMENT
JUSTIFICATION
Mistrust
nagtrabaho siya.
Self-co
ntrol
without loss
of self
esteem;
ability to
cooperate
and
express
oneself
Compulsive
self-discipline
or
compliance;
willfulness and
defiance
Autonomy
Over
restriction of
own desired
activity
Guilt
Bowel control:
1 years old
Daytime
bladder
control:
2 years old
Learning
degree of
assertivene
ss and
purpose
influence
the
environmen
t ; begins to
evaluate
ones own
10
behavior
Di ako
pinapayagan maglaro sa labas,
nagagalit nanay
ko. Pinapasama
ako mangisda
kasama ang tatay
ko kasi doon kami
kumikita.
School Age (7-12 years
old)
Central Task: Industry
vs Inferiority
Developing
sense of
competenc
e and
perseveran
ce
Sense of
being
mediocre;
withdrawal
from peers
and school
Inferiority
Sense of self
and plans to
actualize
ones abilities
Feelings of
confusion,
pressure,
hesitancy
Role
Confusion
Adolescence (12-21
years old)
Central Task: Identity
vs Role Confusion
Concerned with how
they appear to others.
The sense of central
identity appears through
sexual, emotional,
11
Displayed poor
performance in
school due to
absences. She
withdraws herself
with her
classmates. She
only has a few
friends due to lack
of interaction with
them. She dropped
out of school in 4th
grade due to
financial reasons.
Hindi ako
masyadong
nakakapasok sa
eskuwela kasi kapos
at nangingisda kami
ng tatay ko at
tumutulong din magtinda sa palengke.
At the age of 14, her
mother had arranged
marriage for her to be
exchanged for a cow.
Gusto kasi ng nanay
ko ng malaking baka.
Naglalaro pa nga ako
noon nung sinundo
ako sa bahay ng
magulang ng
magiging asawa ko.
educational, ethnic,
cultural and vocational
discovery.
Early Adulthood
(21-35 years old)
Central Task: Intimacy
Vs Isolation
Avoidance of
relationship,
career or
lifestyle
commitments
12
Isolation
Central Task:
Generativity vs
Stagnation
Working
towards the
betterment of
society;
being
productive
Lack of
productivity, not
helping society
to move forward
Contributing to society
and helping to guide
future generations.
When a person makes a
contribution during this
period, perhaps by
raising a family or
working toward the
betterment of society- a
sense of productivity and
accomplishment.
Generativity
She worked as a
house servant for 10
years and saved up
her earnings. She
then started a small
ukay-ukay business
back in the province
which was doing well
for 3 years until she
was apprehended by
policemen and was
detained and
subsequent
admission at NCMH.
Lumuwas ako ng
Manila at namasukan
ng sampung taon.
Nakapag ipon at
umuwi ng probinsya
upang mag-umpisa
ng ukay ukay.
Malakas ang benta
ng mga paninda ko.
Pagkatapos ng
tatlong taon bigla na
lang akong hinuli ng
mga pulis at kinulong
na walang
kadahilanan.
13
NUTRITIONAL-METABOLIC
PRIOR TO ADMISSION
No regular check up
with the doctor
Goes to Albularyo
when sick
Takes otc drugs for
mild fever and colds
and use of herbal
medicines
ELIMINATION
ACTIVITY-EXERCISE
COGNITIVE-PERCEPTUAL
UPON EXAMINATION
Willing to listen to
health teachings
Compliance with
medication regimen
According to patient
Malusog naman ako
kaya lang nag iisip ako
kung kelan ako
makakalabas.
Eats 3x a day meal
Drinks 4-5 glasses of
water everyday
Could do simple
calculations
Intact memory and has
good fund of
knowledge
Responds
appropriately to
physical and verbal
stimuli
14
SLEEP-REST
SELF-PERCEPTION/
SELF CONCEPT
ROLE-RELATIONSHIP
According to patient
Matanda at mahina na
ako Diyos nalang
nakakaalam sa buhay
ko
SEXUALITYREPRODUCTIVE
COPING/STRESS
TOLERANCE
VALUE-BELIEF
Roman Catholic
Attends Sunday mass
15
Average of 5 hours of
sleep daily
Frequent awakenings
due to noises and
difficulty of going back
to sleep
Separated with
husband for 30 years
Not sexually active
Social isolation
Preoccupation with
unjustified doubts
about trustworthiness
of friends
No restrictions in any
treatments brought by
religion
DAY 1
March 3 2015
8:00am 12:00 noon
Nurses Notes
DAY 2
March 4 2015
8:00am 12:00noon
Nurses Notes
Assisted in administration of medications (Risperidone 2 mg
BID, multivitamins 1 tab OD, biperiden 2mg PRN,)
Received patient in clean hospital gown, fairly groomed, and
wearing slippers
Brought client out from the ward to the activity area
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)
Stated Nakakapagpalakas
DAY 3
March 9 2015
8:00am 12:00noon
Nurses Notes
Games conducted
Participation and cooperation noted
Remotivation therapy provided
Stimulated social skills and interest in their environment
Asked to explain her drawing (Wrote Nakakalungkot ang
kanta and drew a small flower)
Served snack and drink
Awarded game prizes
Assisted with hygiene care
Conducted nurse patient interaction: Working Phase
Maintained relationship and trust
Encouraged client in self-disclosure
Promoted a positive self-concept
Evaluated and redefined goals as appropriate
DAY 4
March 10 2015
8:00am 12:00 noon
Nurses Notes
Games conducted
Participation and cooperation noted
Bibliotherapy provided
Stimulated patient to explore the real world
Asked to reflect on what was read
Served snack and drink
Awarded game prizes
Assisted with hygiene care
DAY 5
March 11 2015
Nurses Notes
Games conducted
Participation and cooperation noted
Bibliotherapy provided
Stimulated patient to explore the real world
Asked to reflect on what was read
Served snack and drink
Awarded game prizes
PSYCHOTHERAPIES
Activity / Goals
Aerobics and Exercise
-To promote physical and
mental health
-To let client dance actively
Student-Nurse
Facilitated Spaghetti morning
exercise dance
Client
Coordinated movements and
stated Nakakabuhay ng
dugo
Recreational Therapy
The brain is one of the most complex and magnificent organs in the human body. Our
brain gives us awareness of ourselves and of our environment, processing a constant
stream of sensory data. It controls our muscle movements, the secretions of our
glands, and even our breathing and internal temperature. Every creative thought,
feeling, and plan is developed by our brain. The brains neurons record the memory of
every event in our lives.The brain controls thoughts, memory and speech, arm and leg
movements, and the function of many organs within the body. It also determines how
people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child,
illness, etc.) by regulating heart and breathing rates. The brain is an organized structure,
divided into many components that serve specific and important functions.
The cerebral hemispheres of the brain are divided into pairs of lobes as follows:
Frontal the largest lobe, located in the front of the brain. The major functions of this
lobe are concentration, abstract thought, information storage or memory, and
motor function. It contains Brocas area which is located in the left hemisphere and is
critical for motor control of speech. The frontal lobe is also responsible in large part
for a persons affect, judgment, personality, and inhibitions.
Parietal a predominantly sensory lobe posterior to the frontal lobe. This lobe analyzes
sensory information and relays the interpretation of this information to other cortical
areas and is essential to a persons awareness of body position in space, size and
shape discrimination, and right-left orientation.
Temporal located inferior to the frontal and parietal lobes, this lobe contains the
auditory receptive areas and plays a role in memory of sound and understanding -
Occipital located posterior to the parietal lobe, this lobe is responsible for visual
interpretation and memory.
Neurotransmitters:
Dopamine- Plays important roles in motor control, motivation, arousal, cognition, and reward.
Serotonin- Responsible for maintaining mood balance, food intake control, sleep and
wakefulness and temperature regulation
Glutamate- Major mediator of excitatory signals in the central nervous system and is involved in
most aspects of normal brain function including cognition, memory and learning.
PSYCHOPATHOLOGY
Etiology
Individual
-Age 57
-(Onset 26)
-Life
experience
s
Interpersonal
Social Factors
-Separation
from
children/spou
se
-Poverty
Migration
-health
beliefs
Stress
Malfunction of
transmission in
electrical impulses
Persecutory delusion
difficulty
concentrating
hostile
suspiciousness
hypervigilant
Actions of:
-dopamine
- serotonin
-glutamate
LABORATORY RESULT
Hematology
Hematology
Result
Normal Values
RBC
4.8
4.6 X 1012 /L
WBC
6.6
5.10 X 109 /L
Hemoglobin
125
120-160 g/L
Hematocrit
0.38
0. 36 -0.42
Neutrophil
0.60
(0.45-0.65)
Lymphocyte
0.25
(0.20-0.35)
Monocyte
0.05
(0.02-0.06)
Eosinophil
0.02
(0.02-0.05)
Platelet Count
333
RDW
0.13
(0.10 -0.18)
MCV
88
80-100
MCH
29.2
27-31 g/L
MCHC
332
330-370 g/L
Differential Count
Urinalysis
Gross Examination
Microscopic findings
Color:
WBC:
25 -28
RBC:
3-6
Yellow
Transparency:
Turbid
Epithelial cells:
Moderate
pH:
Mucus Threads:
Few
Acidic
Protein: Positive(++)
Sugar: negative
Amorphous urates:
Moderate
DRUG STUDY
Drug Name
Generic
Name:
Risperidone
Brand Name:
Risperdal
2 mg BID
Drug Class
Atypical
Antipsycho
tics
Drug
Rationale
is used to
treat certain
mental/mood
disorders
(such as
schizophreni
a, bipolar
disorder,
irritability
associated
with autistic
disorder).
This
medication
can help you
to think
clearly and
take part in
everyday life.
Action
Blocks
dopamine
receptors in
the brain.
Side Effects
Nursing Consideration
-Explain the importance and action of the drug
(non observed)
- Monitor patient for 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
stopping drug.
-weight gain
-drowsiness
-dizziness
-drooling
-nausea
-muscle
spasms
-tremors
-insomnia
Generic
Name:
Anticholine
rgic
biperiden
Brand Name:
Prevent EPS
secondary to
neuroleptic
drug therapy
side effects
before they
actually
occur.
Synthetic
anticholinergic
drug, blocks
cholinergic
responses in the
CNS
Dry mouth
-dry mouth
-blurred
vision
-drowsiness
Akineton
-urinary
retention
2 mg PRN
-postural
hypotension
-constipation
-agitation
Drug Name
Generic
Name:
multivitamins
1 tab OD
Drug Class
Multivitamin
s and
minerals
Drug
Rationale
Action
-used to
provide
vitamins that
are not taken
in through
the diet
-also used to
treat vitamin
deficiencies
Promotes
normal
biochemical
reactions,
strengthens
the immune
system,
supports
normal growth
and
development
and helps
Side Effects
Nursing Consideration
(non observed) Avoid taking more than one vitamin/mineral product at the
same time unless your doctor tells you to. Taking similar
vitamin products together can result in a vitamin overdose.
-stomach
upset
-headache
-unpleasant
prevent growth
retardation in
children and
young adult
taste in the
mouth
ASSESSMENT
Subjective:
Pinag-kakaisahan ako
ng mga tao. Tatlong
beses na akong hinuli ng
mga pulis at kinulong.
Wala akong ginawang
masama, minaltrato nila
ako at linagay sa
bartolina as verbalized
by the client.
Objective:
-hypervigilance
-suspiciousness
-easily distracted
-apprehensive (uneasy)
-always on guard
-socially withdrawn
DIAGNOSIS
PLANNING
INTERVENTIONS
RATIONALE
EVALUATION
Disturbed thought
process: persecutory
delusion related to
impaired cognitive
function secondary to
mental illness as
manifested by delusional
thinking and
hypervigilance.
Short term:
Within 1 day of nursing
interventions, the client
will converse about
concrete happenings in
the environment for at
least 15 minutes or more
during nurse patient
interaction.
Avoided laughing,
whispering, or talking
quietly where client can
see but not
hear what is being said
Being sincere when
communicating. Avoided
vague or evasive remarks
Encouraged to participate
in ward activities and
taught client coping skills
that minimize worrying
thoughts. (talking to
someone, singing, reading)
Short term:
After 1 day of
nursing
interventions,
goal was met.
The client
conversed about
concrete
happenings in
the environment
for at least 15
minutes during
nurse patient
interaction.
Long term:
Within 2 weeks of
nursing interventions,
the client will be able to
demonstrate that the
disturbed thoughts are
less intense and less
frequent
Consistent in setting
expectations, enforcing
rules
Recognized the clients
delusions as the clients
perception of the
environment
Did not argue with the
client or try to convince the
client that the delusions are
false or unreal
Interacted with the client on
the basis of real things; did
not dwell on the delusional
thoughts
Recognized and support
clients accomplishments
(projects completed,
interactions initiated)
Showed empathy
regarding clients feelings;
Long term:
After 2 weeks of
nursing
interventions,
goal was partially
met. The client
demonstrated
disturbed
thoughts are less
intense and less
frequent as
evidenced by:
-Delusions were
not observed
during activities
-Participated
more on group
activities
DAY 1
ASSESSMENT
Subjective:
Ayoko makihalubilo
sa iba, pakiramdam ko
kasi sasaktan at
lolokohin lang nila ko.
as verbalized by the
patient.
Objective:
- Social Withdrawal
- Prefers to be alone
- Reluctance to
involve in group
activities
- Poor eye contact
during interaction
- Uncommunicative
with others
- Pre-occupation with
own thoughts
- Sense of discomfort
with others.
DIAGNOSIS
PLANNING
Social Isolation
related to disturbed
thought process as
manifested by evident
discomfort in social
situation
Short Term:
Within 8 hours of
nursing interventions,
the patient will
understand causes
and techniques to
correct isolation.
Long Term:
Within 2 weeks of
nursing interventions,
the patient will
participate willingly in
therapeutic activities
and involve self in
social interaction.
INTERVENTIONS
RATIONALE
Develop a therapeutic
nurse-patient
relationship through
frequent brief
contacts and an
accepting attitude.
Acceptance and
conveyance
enhances feelings of
self-worth and
facilitates trust.
Encourage patient to
express feelings and
perceptions of
problems.
Defense
mechanisms used to
protect the individual
that may contribute
to feelings of
isolation.
Show unconditional
positive regard.
Provide positive
reinforcement for
patients voluntary
Positive
reinforcement
EVALUATION
Short Term:
After 8 hours of
nursing
interventions,
the patient was
able to
understand
causes and
techniques that
corrects isolation
as evidenced by
absence of
discomfort in
social situation.
Long Term:
After 2 weeks of
nursing
interventions,
the patient was
able to
participate
willingly in
therapeutic
activities and
involved self in
social
interaction.
ASSESSMENT
Subjective:
Uupakan na kita
dyan eh! Porket
matanda na ako
pinagkakaisahan
niyo
DAY 1
ako! as verbalized by
the patient in
response to another
client's statement.
Objective:
DIAGNOSIS
Risk for violence:
directed to others
related to disturbed
thought process and
rage reactions to
threatening situation
as delivered by
patient.
PLANNING
Short:
Within 30 minutes of
performing nursing
interventions, the
patient will learn to
assess situation
realistically before
taking action
Long term:
Within 2 weeks of
performing nursing
interventions, the
patient will
1.) Develop strategies
to control impulse.
2.) Refrain from
hurting others.
INTERVENTIONS
RATIONALE
EVALUATION
Short term: After
Anxietyenhances
level risesselfin a
esteem
and
it
stimulating environment 30 minutes of
encourages
thus increases
violent
nursing
repetition of desirable
behavior
interventions,
Provides
information
behaviors.
goal was met.
interactions
Maintained
low level of with
others.
stimuli in clients
environment.
-Assisted in identifying
situation
stimuli that
needed for problem
and
Encourage
the
The client learned
initiated angry outburst and
solving.
client can
ToThe
minimize
stimulito assess
patient in realitythe means of dealing with
alternative
oriented activities that then identify
that will
trigger
situation
stimuli, such as walking
responses.
involved human
symptoms of the realistically before
away or taking deep
contact
with
her
cocondition.
taking action as
breaths
patient.
-Provided safe
Removal of dangerous evidenced by
-Leaving the
environment by removing
objects prevents client
stimulus and
all dangerous objects from
in an agitated,
clients environment.
composed herself
confused state from
DAY 2
Discussed impact of
behavior on others and
consequences of action.
-Then explained
her feelings in a
nonconfronting
manner
Close observation is
important , because
appropriate
interventions can be
provided immediately
To determine violent
intent.
Longterm:
After 2 weeks of
performing
nursing
interventions, the
patient has
developed
strategies to
control impulse
and refrained
from hurting
others.
To provide opportunity
for client to understand
reason and techniques
to prevent violent
behavior.
To assist client to
accept responsibility for
impulsive behavior.
RECOMMENDATIONS
Medications:
Explain the indication and side effects of the drug (lack of knowledge may result
to noncompliace of the drug)
Inform client to secure disability card from the local government and present card
at the pharmacy to avail discounted or free medications when discharged
Environment:
Treatment:
Family therapy (support group available for families relatives wherein they gather
once a month to help them deal with living with a family member with mental
illness)
Encouraged to ask questions (preparation of discharge)
Health Teaching:
Outpatient:
Return if problems with sleep and eating pattern will be observed and have
questions or concerns about condition of care.