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Republic of the Philippines University of Northern Philippines Tamag, Vigan City

College of Nursing

A BEHAVIORAL ANALYSIS ON

BIPOLAR AFFECTIVE DISORDER, current episode MANIC

In partial fulfillment Of the Requirements of the Course, NCM 105 (National Center for Mental Health Duty)

Presented to: Ms. Aiza Ramos, RN, MAN Clinical Instructor

Presented by: Chezka Marie Palola BSN IV Bromeliads

July 18, 2012

INTRODUCTION:
Undifferentiated schizophrenia is a mental disorder which is part of the family of disorders broadly known as schizophrenia. There are a number of subcategories of schizophrenia including paranoid schizophrenia, residual catatonic schizophrenia, and schizoaffective disorganized schizophrenia, schizophrenia,

disorder; undifferentiated schizophrenia is often defined as a form in which enough symptoms for a diagnosis are present, but the patient does not fall into the catatonic, disorganized, or paranoid subcategories. Schizophrenia is characterized by a lack of grounding in reality, known as psychosis. People in a state of psychosis can experience hallucinations, delusions, and other events in which they break from reality. Individuals with schizophrenia experience psychosis and can also develop symptoms such as disorganized speech, lack of interest in social interactions, a flat affect, inappropriate emotional responses to situations, confusion, and disorganized thinking. Patients with undifferentiated schizophrenia do not experience the paranoia associated with paranoid schizophrenia, the catatonic state seen in patients with catatonic schizophrenia, or the disorganized thought and expression observed in patients with disorganized schizophrenia. However, they do experience psychosis and a variety of other symptoms associated with schizophrenia, including behavioral changes which may be noticeable to family and friend. Patient Edgar 25 years old male single patient in Pavilion 1 was born on Noember 14, 1985. He weigh 125 kilogram and height of 53. He lived Barangay Laguio, Ragay, Camarines Sur. He has a Filipino nationality and his religion is Roman Catholic. His educational attainment was till grade 5 only. He was admitted at NCMH on August April 28, 2011, involuntarily and accompanied by his father. His father decided to admit Edgar due to unwanted behavioral changes like restlessness and Sleeping disturbance. He was diagnosed as undifferentiated schizophrenia. .

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

PATIENTs PPROFILE:
A. Patients Data Name: Age: Gender: Address: Nationality: Religion: Date of Birth: Weight: Height: Educational Attainment: Name of Father: Josephine Alog 52 years old Female Laguio, Ragay, Camarines Sur Filipino Roman Catholic November 14, 1985 125 kg 53 Grade 5 Pedro Gaza Contante

B. Clinical Data: Date of Admission: Time of Admission: Admitting Physician: Admitting Diagnosis: Hospital Number: Pavilion: April 28, 2011 10:10 pm Leizl C. Ordonez, M.D Undifferentiated Schizophrenia 27636 Pavilion 1 Ward 8

HISTORY OF PAST AND PRESENT ILLNESS:


A.) Past Illness Patient X is an active individual, who is living normally together with his family. He was the 9 child among the 10 children of Mr. and Mrs. Pedro Gaza Contante. He was then healthy, with sound mind, good physique and well-built body. According to the patient, he was a a construction worker then, and after a year he worked at hardware in their town.. Patient claimed that he was a person which prefers to be alone since he was a student. He was not able to finish schooling because of financial difficulties. Patient had been diagnosed before with sepsis neonatorum and had asthma during childhood. Patient attempted to commit suicide before.
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There were familial history of mental illness on maternal side, with sister who was also confined in the same institution (Nelly Contante, Pavilion 3, with a diagnosis of undifferentiated schizophrenia). There is also history of hypertension among the family particularly on the mother and Pulmonary Tuberculosis on paternal side.

B. Present Illness Patient has been mentally ill since 2004, with several check ups at the psychiatrist in Catlan and 3 previous admissions, last was in 2007, where he was admitted for two weeks and he was discharged improved with unrecalled medications to which he was non compliant except when he was admitted. He was non functional at home. 5 years prior to admission 2 liters of gin was been taken by the patient and then he became violent to his parents and siblings. He was also easily irritated and restless. He would be missing for 3 days to 1 week and would return to their home naked. One time, he punched his father for no apparent reason. He was noted to be sexually abusive to his female siblings. His father tied him and made him a home made jail beside their house, where he would be imprisoned for about 3 months. Patient would eventually escaped and would be missing again. 4 years prior to admission, due to the persistence of the above signs and symptoms, his father brought him to a public hospital in Catlan, where he was admitted. He was given unrecalled medications to which he was non compliant. His symptoms occurred after several days from date of discharge. He then became sexually abusive to other woman, specifically their neighbors. He would suddenly kiss or grab them and touch their private parts. He was marked by people in their community and brought to Barangay hall due to many complaints about his attitude. 4 months prior to admission, patient started to steal appliances inside their home and would throw them outside or some other place. He would laugh and talk to self. He wandered out of the house and would be missing for about 1 week. This happened several times. His father decided to bring him and his sister, who was also distributed with mental illness at that time to this center but patient escaped. 1 month prior to admission, patient raped a girl. He was marked by his community due to this incident but he ran away. 1 week prior to admission, he wandered out again and was missing, until 1 day before admission he returned home and was finally brought to National Center for Mental Health.

ASSESSMENT:
Mental status examination
A mental status examination (MSE) is an assessment of a patient's level of cognitive (knowledge-related) ability, appearance, emotional mood, and speech and thought patterns at the time of evaluation. It is one part of a full neurologic (nervous system) examination and includes the examiner's observations about the patient's attitude and cooperativeness as well as the patient's answers to specific questions. The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. . A mental status examination can also be given repeatedly to monitor or document changes in a patient's condition. Name: Edgar Mayano Contante Age: 25 years old Birthday: November 14, 1985

General Assessment And Mood behavior

Hygiene and Grooming Patient practice proper hygiene. He takes a bath regularly, can able to brush his teeth, wears clean clothes and slippers and with no untidy matters seen on him. He grooms properly and appropriately. Appropriate Dress Patient was always clad in blue shirt and shorts with NCMH printed on it and sometimes large for him. On the first day of interaction, patient doesnt wear any slippers however, on its following days; he wears slippers all the time. Posture Patient has spoor posture. He often slouches or slumps when sitting. Sometimes, he raises his leg during nurse-patient interactions and activities. Patient also has a leaning forward posture and according to him, he used to lay down every time his inside the cell.

Eye Contact Patient Noel has a poor eye contact when talking, listening and conversing with student-nurses, instructors and other people. He maintains eye contact once in a while and he used to glare at the surroundings when not conversing. Unusual Movements/Mannerisms He has unusual movements or mannerisms, and I noticed that he exhibit involuntary movement by raising his hands simultaneously as if he was writing and solving using his hands. He also seldomly raises his one leg during interviews and activities. He talks or murmurs something when not conversing with him and claims that he is not talking to anyone. Speech Patient speaks in a soft and moderate tone and speed. There are unclear voices that you can hear from him and is needed to verify. Repetition of questions was done to get patients attention because sometimes he doesnt respond to some of the questions.

Mood And affect

Expressed Emotions/Mood Patient is serious most of the time; however he can also throw jokes to the student nurse sometimes which makes us laugh. But he never shows emotion such as anger and aggressiveness and does not show emotions of reproach and morbid ideation. Facial Expression/Affect During the nurse patient interaction, patient seldomly shows facial expressions. He has a flat affect wherein there is no emotions attached to the content of speech and the voice has little modulation.

He smiles when happy and no unusual facial expressions noted.

Thought Process And content

Content Patient communicated unwisely. The content is not productive but some were of sense and it is not the same level of an adequately mentally healthy individual. Thought Process During the nurse-patient interaction, patient was able to answer questions but some responses are not appropriate to it. Sometimes repetition of questions was being done to get his attention. It shows that he has thought disturbances and perceptual distortions. Clarity of Ideas Patient answers questions in an unsure manner wherein there were some instances that the idea of the patient was unclear and not appropriate.

Sensorium And Intellectual process

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

Abnormal Sensory Experiences During the interview, patient denied any neither visual nor auditory hallucinations. In reality, patient murmurs alone as if he was talking to someone and shows hand elevation movements. Concentration Patient has slightly poor concentration. He used to glare at the surroundings so repetition of questions was done in order to catch his attention. One way also of assessing concentration is through calculations wherein it is his strength as a math lover. He can able to recite the alphabet correctly and couned 1-10 straightly and also through backward counting. Abstract Thinking Abilities Patient has poor abstract thinking abilities because his highest educational attainment was in grade 5 only.

Judgment And Insight

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

Self concept

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

Description of Physical Self Patient Edgar practice proper hygiene as evidenced by taking a bath regularly, brushing his teeth and wearing clean and appropriate clothes. He was groomed completely wearing the blue shirt and blue pants with NCMH written on it. The patients height is 53. Has fair complexion and with good body built. His haircut was semi-kalbo with no lice nor lesions seen. His eyes and ears were proportionate and symmetrical. Personal Qualities/Attributes Patient was behaving in a way that he is silent and able to follow rules and regulations on the ward. He was not hard to call on. He eats well and was partly cooperative during activities.

Roles and relationships

Significant Relationships Patient only remembers his parents as his significant others in his life. He claimed that his father was Pedro and her mother was ----. He can recall his 7 siblings out of 9. He doesnt know about her sister being confined in NCMH. Support System The first line support system of the patient was his father. The health care team also serves as a support system of the patient.

Physiologic And Self care considerations

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

Patient claims that he was having a good sleep despite of the texture of their bed. Health Problems Patient was in good health. He doesnt suffer from any illness. Compliance to Prescribed Medications Patient complies religiously in taking prescribed medications. Ability to Perform Patient is able to perform activities of daily living. Although sometimes little assistance is needed in some activities.

DIAGNOSTIC PROCEDURES
A. Ideal Diagnostic Procedures Name and Purpose of the procedure 1.Mental status test - are used to determine whether a disease or condition is affecting a person's thinking abilities, and whether a person's mental Orientation to person, place, and time Normal attention span Normal judgment Normal recent memory Normal remote Each test can identify different possible problems, as described below. 1.ORIENTATION -Typically, orientation to time is first to be lost, followed by orientation to place, then to person. 2.ATTENTION SPAN Normal Values Significant Values Implication to Disease Condition (interpretation & Significance) If the outcome of the examination is beyond or less than normal it can roll out possible mental problem to the patient such as Emotional dysfunction Mental brain syndrome, Schizophrenia 1. If you know that the person being tested has never been able to read or write, tell the health care provider in advance because Some tests that problems using reading or writing do not account for people who may Nursing Responsibility

retardation, Organic screen for language

condition is improving or getting worse.

memory Normal word comprehensio n, reading, and writing

People who are unable to complete a thought, or are easily distracted, may have an abnormal attention span. This may have a number of causes, including: Attention deficit disorder (ADD), Confusion, Histrionic personality disorder, Manic depressive illness ,Schizophrenia 3.RECENT AND REMOTE MEMORY A medical disorder may cause loss of recent memory but keep remote memory intact. Remote memory is lost when damage to the upper part of the brain occurs in diseases such as Alzheimer's disease. 4.WORD COMPREHENSION, READING, AND WRITING These tests screen for language disorder (aphasia).

never have been able to read or write. 2. If a child is having any of these tests performed, it is important to help him or her understand the reasons for the tests. 3. Always remember that Preparation, especially by a highly intelligent person, could change the results of the test by making it seem that mental function has not declined when it actually has.

5.JUDGEMENT The ability to decide the right course of action is important to survival in many situations. 2. Medical History -During a medical history for schizophrenia, the health professional asks many different questions. This is psychiatrists way of tracing the origin of the disease condition -During also these interviews, the health professional may ask the family member(s) to describe the actions and behaviors of the person who has symptoms that may be caused by schizophrenia. There is no known family member who have diagnosed or experienced schizophrenia 1. History of the presenting complaints -The clinician then attempts to obtain a clear description of these problems. When did they start? How did they start, suddenly, slowly or in fits and starts? Have they fluctuated over time? What does the patient describe as the essential features of the complaints? Having developed a hypothesis of what may be the diagnosis, the clinician next looks at symptoms that might confirm them to consider another possibility. Much of the mental process for the clinician is involved in this process of hypothesis testing to Having collected this information the clinician usually then considers any other factors that might be relevant to the particular patient and enquires about them. Although the gathering of the information may follow the flow of the patient's thoughts rather than those of the clinician, it is not uncommon for the clinician to record the psychiatric history under headings, such as it easier for others who will later read it. Subsequent history taking on reviews concentrates on changes in the levels 2.Provide several ways to answer questions - Some people may be more willing to share health information in a 1. Share your purpose - Explain that you're creating a record to help you determine whether you and your relatives have a family history of certain diseases or health conditions. Offer to make the medical history available to other family members so that they can share the information with their doctors.

this hypothesis or lead those above, to make

arrive at a diagnostic formulation that will form the basis of a management plan. 2. Past history -This is divided into the psychiatric past history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. The medical past history documents significant illnesses, both past and current, and significant medical events such as head injury, surgery and major illnesses. This can also include sexual abuse, (which could have happened when the patient was very young and before the person had a mental knowledge of what was happening) by a family member or close family friend. Leaving the patient with resulting problems.

of symptoms and responses to treatment, including possible side-effects

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

3. Family history -Many psychiatric disorders have a genetic component and the biological family history is thus relevant. Clinical experience also suggests that a response to treatment may have a genetic component as well. Thus a patient who presents with clinical depression whose mother also suffered from the same disorder and responded well to fluoxetine would indicate that this drug would be more likely to help in the patient's disorder. -Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment.

your doctor.

Similar effects are seen with the death of a parent from a protracted illness. 4.Developmental history -This documents the significant events in the patient's life. Ideally it starts with pre-natal factors such as maternal illnesses or complications with the pregnancy, then documents delivery and early childhood illnesses or problems. It then looks at significant events in the patient's life such as parental separation, abuse, education, psychosexual development, peer relationships, behavioural aspects and any legal complications. It flows then into adulthood with relationship and occupational histories. The aim is to get an overview of who the patient is and what they have experienced in life, both good and

bad. Major stresses and transitions such as marriage, parenthood, retirement, death or loss of a partner, and financial success and failure are all important, as is how the patient has dealt with them. Sexual adjustment and problems can be relevant and are often questioned. 5. Social history -If the information has not already been obtained, the clinician then documents the social circumstances of the patient looking at factors such as finances, housing, relationships, drug and alcohol use, and problems with the law or other authorities. This is also a time to document racial or cultural issues that are relevant to the presenting complaint 3. CT scans of the head - is an imaging Results are considered normal if the CT scans of the head and other imaging techniques may find This confirms the diagnosis for schizophrenia - instruct the patient not to eat or drink anything for

method that uses x-rays to create cross-sectional pictures of the head, including the skull, brain, eye sockets, and sinuses.

organs and structures being examined are normal in appearance.

some changes that occur with schizophrenia and may rule out other disorders.

4-6 hours before the test. -Check if the patient is allergic to IV contrast. -ask the patient to remove jewelry and wear a hospital gown during the study.

Result is O 4. Scale for the Assessment of Negative Symptoms (SANS) - assesses five symptom complexes to obtain clinical ratings of negative symptoms in patients with schizophrenia. over 5 and patient is negative of having the symptoms of schizophrenia

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

-Subjectivity - SANS assesses behavior based on rater observation and patient interview - Symptomatology while SANS aims to assess specific negative symptoms/symptom clusters associated with schizophrenia, it must be noted that many symptoms covered by SANS are also associated with affective disorders, particularly depression.

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

5. Scale for the Assessment of Positive Symptoms (SAPS)

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

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

-use a standard clinical interview in order to evaluate the subject's symptoms.

-Though there is no special preparation to the procedure it must be well explained

-This scale is designed to assess positive symptoms, principally those that occur in schizophrenia

schizophrenia

Since positive formal thought disorder is an important positive symptom, it is recommended that, in doing this interview, the investigator begin talking with the subject

to the patient and to his significant others

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

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

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

- This helps confirms the diagnosis for schizophrenia

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

B. ACTUAL diagnostic procedures Name and Purpose of the procedure 1. HIV Testing Method: Enzyme assay linked immune sorbent Normal Values Significant Values Implication to Disease Condition (interpretation & Significance) Explain purpose and procedure to the client Inform that Nursing Responsibility

blood sample Purpose: check there presence human immune deficiency virus in the patient to further transmission Result 2. Drug Test (Methamphetam ine/Cannabiboid s) Purpose: To check taken if any patient has illegal drugs MET (Methamphetam ine) THC (Tetrahydrocann abinol) 3. Urinalysis Negative Negative Normal Negative Negative Normal Non-reactive Non-reactive Normal Explain purpose and procedure to the client Give patient a specimen bottle to collect urine for analysis. Assist patient in doing the procedure for validity. Send specimen to the laboratory immediately. Attach result to patients chart. Explain the procedure and and prevent To if is of will be taken for further analysis Attach result to patients chart when result is available Inform the physician regarding

Purpose: Analysis of urine using physical, chemical, and microscopical tests to determine the proportions of its normal constituents to other abnormal constituents. Color Varying degrees of Transparency yellow Clear Reaction Specific Gravity Bacteria Protein Sugar RBC Pus Usually acidic 1.000-1.038 Negative Negative Negative Negative Acidic 1.015 Negative Normal Negative Normal Negative Normal Negative Normal Turbid May be due to crystallization of salts Normal Within normal range Yellow Normal

tell its importance to the significant others and to the patient. Give significant others a specimen bottle and instruct them and the patient to discard the flow of urine and catch the midstream flow of urine. Label the specimen bottle before forwarding it to the laboratory.

Negative 4. Hematology Purpose: It is concerned with the study of blood, the blood forming organs and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis and prevention of blood diseases. Hemoglobin

Negative Normal Explain the procedure and tell its importance to the significant others and to the patient. Tell them that blood sample will be taken. Record accurately laboratory result or attach it properly on patients chart and consult the result to the doctor.

140-180g/L

120g/L

Low hemoglobin may be due to anemia and malnutrition Low hemoglobin

Hematocrit

0.40-0.54 g/L RBC

0.37g/L

may be due to anemia and malnutrition

WBC 4-6x1012/L Neutrophil 5-10x10^9/L Lymphocytes 0.40-0.75 Monocytes 0.20-0.45 0.36 0.02-.06 0.06 Within normal range Within normal range 0.58 5 x10^9/L Within normal range 3.89 x1012/L Within normal range

Within normal range 5. Clinical Chemistry Purpose: A test that yields about the cellular component of the blood. Glucose/RBS Electrolytes: Sodium 135150mmol/L 134mmol/L Slightly decreased, may still be accepted as normal Potassium 3.4-5.5mmol/L 3.3 mmol/L Slightly decreased, may still be accepted as normal 4.9-7.0mmol/L 8.65mmol/L High, may be due to hyperglycemia Explain the procedure and tell its importance to the significant others and to the patient. Tell them that blood sample will be taken. Record accurately laboratory result or attach it properly on patients chart and consult the result to the doctor.

Lithium

Below 0.2 mm/L

Negative

Normal

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

Psychodynamics

IDEAL
Numerous studies have found that psychosocial treatments can help patients who are already stabilized on antipsychotic medications deal with certain aspects of schizophrenia, such as difficulty with communication, motivation, self-care, work, and establishing and maintaining relationships with others. Learning and using coping mechanisms to address these problems allows people with schizophrenia to attend school, work, and socialize. A positive relationship with a therapist or a case manager gives the patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for managing the disease. People with schizophrenia can take an active role in managing their own illness. Once they learn basic facts about schizophrenia and the principles of schizophrenia treatment, they can make informed decisions

Illness Management Skills

about their care. If they are taught how to monitor the early warning signs of relapse and make a plan to respond to these signs, they can learn to prevent relapses. Patients can also be taught more effective coping skills to deal with persistent symptoms.

Substance abuse is the most common co-occurring


Integrated Treatment for Co-occurring Substance Abuse

disorder in people with schizophrenia, but ordinary substance abuse treatment programs usually do not address treatment programs produces better outcomes.

this population's special needs. Integrating schizophrenia treatment programs and drug

Rehabilitation

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

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

Patients with schizophrenia are often discharged hospital into the care of their families, so it is important that family members know as much as
Family Education

from the possible about

the disease to prevent relapses. Family members should be able to use different kinds of treatment adherence programs and have an arsenal of coping strategies and problem-solving skills to manage their ill relative effectively. Knowing where to find outpatient and family services that support people with schizophrenia and their caregivers is also valuable.

Cognitive behavioral therapy is useful for patients with symptoms that


Cognitive Behavioral Therapy

persist even when they take medication. The cognitive therapist teaches people with schizophrenia how to test the reality of their perceptions, how to "not listen" to their voices, and how to shake off

thoughts

and

the apathy that often immobilizes them. This treatment appears to be effective in reducing the severity of symptoms and decreasing the risk of relapse.

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

Self-Help Groups

source

of mutual support and comfort for each other, which is also therapeutic. People in self-help groups know that others are facing the same problems they face and no longer feel isolated by their illness or the illness of their loved one. The networking that takes place in self-help groups can also generate social action. Families working together can advocate for research and more hospital and community treatment programs, and patients acting as a group may be

able to draw public attention to the discriminations many people with mental illnesses still face in today's world.

Crisis and Stress Management Education

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

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

Various forms of group therapy may be used as a

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

patient is seen problems. certain negative from attempts to

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

The goal of this student-nurses.

Community Dancing

activity is to build trust between patients and begins by having a formation then self- introduction.

This

Inform the patients of the activity for the day and sing the song with actions and visual aids. Involves injection of short- acting general anesthetic
Electroconvulsive Therapy

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

minute or slightly longer. It temporarily alters some of the brains electrochemical processes.

Actual:

MUSIC AND ART THERAPY: May 9, 2011


The therapys main goal is to let the patient express and vent out. This lets the patient express the problems and his state of mind through dawning and illustrations with the aid of music accompaniment. After the patient draw the feeling in the paper he then interprets it. Its like breaking the shell of a turtle or like opening Pandoras Box. Last May 9, 2012, music and art therapy was done wherein the patient listens to a soft and fast music then crayons and bond papers were given for him to draw what he feels. After the patient illustrates and expresses his state of mind through drawing, he then interprets it to the group.

BIBLIOTHERAPY: May 10, 2012


It is the use of printed materials as a means of modifying and stimulating patients emotion and at the same time providing information to the patient. It is used to improve the attention span of individual with limited power of concentration, to divert the attention and lift the spirit of a depressed patient, and to help relieve insomnia, stimulate the imagination and foster desirable attitudes and ideas. Bibliotherapy was done at the entrance lobby of the said Pavillion wherein patients where able to watch the role play of the Legend of Pineapple. Visual aids which contains the summary of the legend was also used for the patients to read for further understanding of the said story. Patient Noel actively participates and was able to read and summarize the story for the group.

REMOTIVATION THERAPY: May 14, 2012

It is a socialized group therapy, usually 10-12 participants that trigger patients focus and alertness and intellectual functioning by enhancing the clients ability to rationalize and think deeply. This technique is one way of letting the patient vent-out and be attached to reality. Last May 14, 2012, this therapy was done and the patients were able to figure out the topic of the said activity which is Dagat. Picture of the sea was presented and patient responded that he view people there swimming and the sea was blue. Patient was able to answer the questions correctly. He also read the poem presented to them.

PLAY THERAPY: May 15, 2012


Play therapy is a form of therapy wherein the therapist engages the client in play for the therapeutic opportunity to discharge strong emotions in the atmosphere with a trusted therapist. Its objective is to discover the cause of the clients conflicts through observation of his play and or interpret it to the clients language which he understands. Play therapy was done last May 15, 2012 wherein patient actively participates to the said games as evidenced by raising his hand to join the said games and to answer the needed questions. First game was BASKETBALL wherein he performed well and was belong to the top Next game was PINOY HENYO wherein he actively said oo, hindi, pwede as part of the game.

OCCUPATIONAL THERAPY: May 16, 2012


This is the use of resources to make handicrafts in order to earn income. This therapy encompasses the expression of inner feelings. This also establishes to divert the patients conflicts. This will rehabilitate the patient and to develop self-esteem and confidence. Hotdog on Bun Making halo halo was the focus of the said activity. Introduction of the said topic and explanation of its procedures was done. Next was the turn of the patients to read the visual aid presented and respond to the questions being asked. After this, hand washing technique was taught wherein patient was able to perform it correctly. Patient performed the said activity well wherein he made a halo - halo with little assistance from the student nurse. This focuses on the clients specific needs and promoting an effective exchange of ideas through interpersonal interaction. This will let the patient have the trust to the health care
Therapeutic Communication

provider is sharing his problems and thoughts.

DRUG STUDY
NAME OF THE DRUG 1. Clozapine DOSE, FREQUECY, and ROUTE 100 mg HS, PO Binds selectively to dopaminergic receptors in the CNS and may interfere with adrenergic, cholinergic, histaminergic, and serotonergic receptors. For patients who Contraindicated who of toxic are history to CNS: Neuroleptic Malignant has Syndrome, or dizziness, sedation EENT: visual disturbances CV: hypotension, myocarditis, tachycardia, Seizures, 1)Observe and Apply the 10 rights of administration Right drug Right patient Right dose Right Route Right Time Right Approach Right drug preparation and administration. Right of patient to know the reason for the drug Right of patient to refuse Right documentation 2)Monitor patients mental status (delusions, and dry mouth, drug SCHIZOPHRENIA, in patients MECAHNISM OF ACTION INDICATION CONTRAINDICATIONS SIDE EFFECTS/ ADVERSE REACTION NURSING RESPONSIBILITIES

non-responsive to or idiosyncratic intolerant to classical granulocytopenia/ antipsychotics. agranulocytosis,

impaired bone marrow hypertension function, uncontrolled GI; constipation, abdominal epilepsy, alcoholic and discomfort, drug intoxication, vomiting other toxic psychoses, increased salivation, nausea, severe cardiac or renal DERM: rash, sweating disorders, chronic liver ENDO: hyperglycemia diseases. HEMA: leucopenia MISC: fever, weight gain agranulocytosis,

behavior). 3)Monitor blood pressure and pulse rate before and administration. 4)Observe patient carefully when that administering medication is medication to ensure actually taken and not hoarded after

. 5)Monitor for signs and symptoms adverse/ mentioned. 6) Monitor patient for onset of akathisia and EPE of side the effects

(Parkinsonism difficulty speaking/swallowing, loss of balance control, pill-rolling motion, mask like face, shuffling gait, rigidity, tremors and dystonic muscle spasm. Notify physician of other health care professional if these symptoms occurs.

2. Fluphenazine decanoate

1 cc IM now

Possess anticholinergic and alphaadrenergic blocking activity.

For treatment of acute and chronic psychoses. To diminished signs and symptoms of psychoses. Contraindicated to hypersensitivity to the drug. Contraindicated to patients with severe liver or cardiovascular diseases, respiratory

CNS:EPE- sedation, tardive dyskinesia EENT: blurred vision, dry eyes, lens opacities CV: Hypotension,tachycardia

1) Observe and Apply the 10 rights of drug administration Right drug Right patient Right dose Right Route Right Time

GI: anorexia, constipation, drug-induced hepatitis, dry

disease.

mouth GU: urinary retention DERM: photosensitivity, pigment changes, rashes ENDO: galactorrhea HEMA: AGRANULOCYTOSIS, leucopenia MISC: allergic reactions, hyperthermia

Right Approach Right drug preparation and administration. Right of patient to know the reason for the drug Right of patient to refuse Right documentation 2) Monitor patients mental status (delusions, and behavior). 3) before 4) Monitor and Observe blood after patient when pressure and pulse rate administration. carefully

administering medication to ensure that medication is actually taken and not hoarded. 5) Monitor for signs and symptoms of the adverse/

side effects mentioned. 6) Monitor patient for onset of akathisia and EPE (Parkinsonism difficulty speaking/swallowing, loss of balance control, pillrolling motion, mask like face, rigidity, shuffling tremors gait, and

dystonic muscle spasm. Notify physician of other health care professional if these symptoms occurs.

PSYCHIATRIC NURSING CARE PLAN


CUES DIAGNOSIS
P: Coping anak, Ineffective

NURSING

ANALYSIS

OBJECTIVES
May 10 ,2012 7:00 an

NURSING

INTERVENTIONS
INDEPENDENT Determine the or of of

NURSING

RATIONALE

EVALUATION
May 18, 2012 8:00 am

SUBJECTIVE: at mga

Stressors

Wala akong asawa Individual; Walang bumibisita personal Schizophrenia After 7, days of intervention, will Altered emotional state behavior display pt.

Provides information about perceived and GOAL actual coping ability, MET life change unit, anxiety level, AEB: the pt. was able to do the PARTIALLY

presence degree clients impairment abilities

saken as verbalized E: maybe r/t by the patient vulnerability, OBJECTIVES: Patient thin a is system and a inadequate coping Poor deference mechanism

inadequate support

congruent verbalization feeling, demonstrate understanding appropriate constructive

with of

coping

stressors, functioning, defense

developmental level of activities done but mechanisms concept and poor use of still with poor self -

male, tall and methods. in

of

and problem solving judgment. ability.

appearance, in S: as evidence by uniform He mingle cognition, doesnt self-concept. with perception, poor

hospital impaired judgment, Ineffective individual coping

effective of coping.

methods Assist client to identify thoughts, perceptions and Client is able to view how perception/thinking/a

usually talk or other patient.

ffect is processed and to strengthen reality

feeling.

orientation coping skills.

and

In Encourage patient express areas of formation realistic to

relationship, the client skills without fear of judgment.

trusting

can begin to learn

concern support goals Knowledge stressors that have of of

and learning of appropriate techniques. Encourage client to precipitating to identify problem solving

precipitated deteriorated ability client to enables coping the

recognize

and deals with it.

factors that lead coping ineffective when With support, client learn to has the ooputunity to perceptions validate before

possible.

selecting appropriate coping methods. Explore clients perception validated to prior drawing how Increased flexible solving behaviors or problemcoping prevent more

conclusions.

decomposition.

SUBJECTIVE: alam, hindi ko na matandaan, verbalized patient. by

P: Altered Thought

Stressors

May 10,2012 8:00 am Assist client to recognize After 7, days of performing develop appropriate effective coping must in the skills. and Identification symbolic nature of of primitive

May 18, 2012 8:00 am

Wala. Hindi ko na Process as E: may be r/t the impaired judgment, psychosocial conflicts, OBJECTIVES: Passive to ambivalence, and concomitant and dependence. some S: as evidence by inaccurate interpretation, Altered Thought Process Anatomic and function system altered Schizophrenia

communications promotes

thinking GOAL MET

PARTIALLY

nursing intervention, client recognized changes thinking behavior, maintains, orientation reality and

understanding of the AEB: individual

clients readily oriented but

the

pt.

is

thought process and he cannot perform enables planning\g of decision making. appropriate Provides interventions.

unresponsive questions

an

Patient has a impaired ability to poor but remote make decision, poor good judgment and

establish interpersonal relationship.

INDEPENDENT Determine altered from the

emotionally interpersonal interaction. Therapeutic communications and consistent

safe

milieu that enables

recent memory unresponsiveness and has a good immediate memory Has a slightly poor concentration Sometimes copies the patients

severity of clients process, concrete thought noting or

are and

loose

clear, concise, open, require use of self.

associations, content and flow.

Lack of considerations of these factors can case inaccurate misdiagnosis/

what Establish nurse-client therapeutic relationship. a

interpretation.

other

answer during activities. He has flight of ideas looseness only or of

Client s often unable to recognize thoughts and flow of thoughts is often characterized

Use to

therapeutic intervene

as maundering retarded.

racing, or

association. He close answers ended

communications effectively.

questions and does not pay attention ended or Structure to clients communications reflect Provide for control behavior. the opportunity client aggressive to consideration of socioeconomic, educational and cultural history/ values. Express desire to understand by clients thinking clarifying what is unclear, focusing on the feeling rather to Helps the attainment of best plan of care. Enhances self-esteem and promote safety others. for the client and

gets rid to open questions.

than the content, endeavoring understand, listening carefully of regulate the flow needed. thinking and as

Used

psychotic symptoms.

to

reduce

SUBJECTIVE: Hindi masyadong mga

P: Social ako Interaction; Impaired

Stressors

May 10, 2012 8:00 am

Reinforce congruent thinking; refuse to argue with and

Presence nay help improve as a clients worthwhile perception of self of person.

May 18, 2012 8:00 am

nakikipag-usap sa kasama

Schizophrenia After 7 days of interventions Confinement in the to institution gain patient will be able relationship others. the

ko E: may be r/t significant others or peers

disintegrated thought present reality. Share

GOAL MET the pt. and and

dito, as verbalized absence of available by the patient.

Presence, acceptance, AEB: positive

trusting with appropriate thinking and set limits if the patient tries to respond unwillingly. Asses present

and conveyance of willingness enhance the clients with feeling of self-worth. other

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

S: as evidence by all dysfunctional others. by interaction with

regard desire to socialize voluntarily

Absence of available significant others or peers

group activities.

attend

Positive

reinforcement enhances self esteem and encourages of

Impaired Social Interaction

degree of factors affecting clients capacity divertional activities. for

repetition

desirable behaviors. Knowledge could of improve

Patient looks

assertive techniques

shy

COLLABORATIVE Administer antipsychotics as indicted.

clients relationships with others

SUBJECTIVE: Nawala tsinelas lang ko ako

yong

P: Self Care Deficit

Stressors

May 10, 2012 8:00 am

INDEPENDENT Spend time with Impairment can alter clients ability for self care. May 18, 2012 8:00 am

kaya E: may be r/t na cognitive na perceptional and as impairment; psychomotor activity. is S: as evidence by dysfunctional interaction with Self Care Deficit Schizophrenia After 7 days of performing nursing interventions will be able pt. to

palakad-lakad nakapaa, patient. OBJECTIVES: Patient seen

client, this may just mean sitting in silence for a while.

verbalized by the decreased

anatomic and function system altered

GOAL MET Appearance affects willingness to how the client sees AEB: the pt. can self. perform self care like taking a bath, shaving Adequate and and the

perform self- care appropriately.

Develop client

therapeutic nurse relationship through frequent brief contacts and accepting attitude, show increase muscle tone daily consistency in

barefooted inside outside ward. his the

and others.

likes but still needs exercise guidance

He puts up

foot

unconditional

routine

when sitting and eating He his even placed food on

positive reward. Provide positive

stimulates elimination.

bowel

reinforcement for clients voluntary interactions with others. Teach assertiveness techniques. Interaction others negatively may with be

dirty areas

The patient has a poor looks untidy hygiene and

affected by clients used of passive or aggressive behavior.

INDEPENDENT Asses presence/

severity of factors

that affect clients capacity for self care.

Discuss personal appearance/ grooming and

encourage patient positive feedback for efforts. Increase daily

for self care. Give

activity and as client progresses.

Discharge plan

Patient Edgar is not yet discharged:

Medication

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

Exercise

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

Treatment

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

Health teachings

Encourage patient to sleep early and have adequate time for rest and sleep. Emphasize the importance of proper hygiene such as taking a bath, brushing teeth and wearing clean and appropriate clothes. Encourage patient to do hand washing before and after eating to prevent acquiring infection

Instruct patient to eat nutritious foods such as green leafy vegetables and fruits to meet nutritional demands. Advise patient to avoid stressful events so as not to trigger illness. Emphasize the importance of mingling or socializing with other people to overcome or combat loneliness.

Opd

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

Diet

Instruct patient to eat nutritious foods such as green leafy vegetables and fruits to meet nutritional demands.

Bibliography
Books
Smeltzer, Suzanne C. & Brenda G. Bare. Brunner & Suddarths Textbook of MedicalSurgical Nursing, Vol 2, 10th Ed. Philadelphia: Lippincott Williams & Wilkins, 2004. Doenges and Moorhouse, Nurses Pocket Guide: Nursing Diagnoss with Interventions 4th Edition, 1993 by Merriam & Webster Booksotre, Inc. Manila

Videbeck, Psychiatric Mental Health Nursing, Third Edition Shives, Isaacs, Basic Concepts of Psychiatric-Mental Health Nursing Nurses Dictionary, Second Edition Emmanuel Latin et.al, PDDs Nursing Drug Guide,2007, Malan Press Inc., City Jacques Wallach, M.D., Interpretation of Diagnostic Tests 7th Edition, 2000 Lippincott Williams & Wilkins Spratto and Woods, Delmar Nurses Drug Handbook 2010 Edition, 2010 by Cengage Learning Delmar, by Pasig

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

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