LICEO DE CAGAYAN UNIVERSITY

R.N Pelaez Blvd. Carmen

Cagayan de Oro City

College of Nursing
NCM 501203

SCHIZOPHRENIA
DISORGANIZED TYPE

April 16, 2009

SUBMITTED BY
GROUP B18:
 TABLE OF CONTENTS

I. INTRODUCTION

A. Overview
B. Objective and Purpose
C. Scope and Limitation
D. Spot Map
E. Patient’s Profile

II. ANAMNESIS

A. Informants
B. Family History
C. Personal History

III. COURSE IN THE HOSPITAL

A. Mental Status Exam

B. Progress Notes

IV. PSYCHODYNAMICS

A. Schematic Presentation

V. LABORATORY RESULTS

VI. DIAGNOSIS

VII. MULTI – AXIAL DIAGNOSIS

VIII. NURSING MANAGEMENT

A. Ideal Nursing Management

B. Actual Nursing Management

IX. MEDICAL MANAGEMENT

X. PROGNOSIS AND RECOMMENDATION

XI. BIBLIOGRAPHY
 I. INTRODUCTION

a. Overview

Over 45 million people worldwide are affected by the so called mental

neurogical or behavioral problems. Defined as an abnormal mental condition
or disorder associated with significant dysfunction which involves cognitive,
emotional, behavioral and interpersonal impairments. Mental illness is vague
that it has different sub classifications and among those is Schizophrenia.

It has been said, it knows no boundaries. In the Philippines alone, there

is an estimated accounted extrapolated statistics of 694,543 as of 2004 and
this was according to the US Census Bureau – International Database.

Schizophrenia is a major mental illness that causes changes in perception,

thoughts and behavior.
It is a complex condition that defies simple description, but a distinction can be
made between two broad types: acute schizophrenia and chronic
schizophrenia.

This is the longer-term state and is characterized by:

• a lack of drive
• under activity
• social withdrawal.

Left to their own devices, schizophrenics may spend long periods of time
doing nothing, or engage in repeated and purposeless activity. Sometimes
they can neglect themselves quite markedly.
 As with the acute state, hallucinations and delusions are common.
Sometimes in chronic schizophrenia the person appears to become used to
these disordered thoughts.
For example, they might harbor the idea that someone is trying to get at them,
but this does not cause any emotional reaction.

b. Objective and purpose of the study

This study generally aims to investigate a mentally ill patient particularly

Schizophrenia. As healthcare providers, we sought to investigate, plan and
implement as we drive to:

 Know the History of the client and the family

 Track down the developmental stages of the client
 Trace the incident that precipitated the mental illness of client
 Describe the symptoms manifested by the client
 Build Nurse-client relationship
 Anticipate the needs pertaining to the client illness
 Provide nursing interventions
 Develop positive coping mechanism
 Provide possible linkages to NGOs
 Encourage verbalization of feelings of the client
 Provide opportunities for the client to practice new behavior
 Promote positive self concept
 Evaluate progress and redefine goals as appropriate
 Provide client relief from presenting problems
 Client social function has improved and his isolation has decreased
 To establish the reality of the separation during the termination phase
 Reorient client and family of the contract
 The purpose of the study is to gather significant data broaden our
understanding and knowledge in psychiatric nursing and to improve our
abilities in determining and/or differentiating the distinct mental disorders.

Moreover, the activity will develop our skills in managing the mentally ill
person.

c. Scope and Limitation

The study focuses mainly on the mental or psychological status of Ms. AJ, the
factors which contributed to her present mental illness, the medical findings
and management of her condition, and the application of appropriate nursing
interventions. Nursing diagnoses were carefully identified with emphasis on
the psychological problem and applicable health teachings. Proper nursing
interventions and health teachings are given to be able to provide quality
nursing care with the utilization of the nursing process.

The care of the patient is good for 5 days, 3 days care and 2 days follow-up
care and visits. Nevertheless, the patient’s Mental Status Examination was
assessed upon initial introduction and succeeding visits. Furthermore, the
limitation of the study lies on providing financial support and short-term
nursing goals were drawn on due to time limitation.

d. Spot map

The residence of our patient isn’t that far, from Liceo de Cagayan University
main campus, it is just a 10 minute ride and 15 minute walk to be able to reach
the patient’s residence, located south bound from the main campus you can ride
on a jeepney which has the route to Carmen CDOC, or just took a walk, when
riding or just walking we start our journey at the main campus of LDCU, then
passing along the Rodolfo Neri Pelaez Blvd. Going southbound we took left when
reaching the intersection between R.N Pelaez Blvd. and Vamenta Blvd, after then
when we reach the Petron gas station at Carmen Cagayan de Oro City we stop
our ride, it is now estimated to be just a few meters away from our patient’s
home, we walk along a small road beside the gasoline station then took a left
turn on the second pathway adjacent to the small road, then passing 7 houses
along the small pathway we could reach the home or residence of our psyche
patient, describing the home, it is made more made of wood panels and which
only has a single floor.
e. Patient’s profile

Name :
Age :
Gender : Female
Marital status : single (with one child)
Nationality : Filipino
Address :
Birth date :
Birthplace :
Religion :

Educational Attainment

Elementary : Grade 1 – Grade 6, West Elementary School SY- 1987-1992

High School : 1st year, Cagayan de Oro National High School SY- 1992-1993
College : Not Attended

Arrest, Court States Probation : None

Name Age Sex Civil Educational Occupation

Status Attainment
51 yrs. old Male Married Elementary Tinsmith
Graduate
55 yrs. old Female Married Highschool Housewife
Undergraduate
28 yrs. old Female single Highschool Unemployed
(with one Undergraduate
child)
25 yrs. old Male Married Highschool Carpenter
Undergraduate
11 yrs. old Female Single Elementary Student
Level
Vital Signs:
Blood Pressure: 90/70mmhg
Temperature : 36.4 c
Respiratory Rate: 18cpm
Pulse Rate : 70bpm

Food and drug allergy: (-)

Use of street drugs: (-)
Use of street alcohol: (-)

II. ANAMNESIS
A. INFORMANTS

INFORMANT 1:
Name:
Sex: Female
Age: 51 years old
Address:
Relation to the patient: mother
Length of time known to patient: since birth
Apparent understanding of present illness: “na okay nana siya karon
kung ekumpara sa una”
Characteristics and attitude of the informant: nice to talk with and
hospitable

INFORMANT 2:
Name:
Sex: Male
Age: 28 years old
Address:
Relation to the patient: neighbor
Length of time known to patient: more than 12 years
Apparent understanding of present illness: “dugay-dugay napud na
siya na inana unya bago lang siya naulian”
 Characteristics and attitude of the informant: strict type of person but
kind

INFORMANT 3:
Name: M. I.
Sex: Female
Age: 49
Address
Relation to the patient: neighbor
Length of time known to patient: more than 3 years
Apparent understanding of present illness: “na arang-arang na bya na
siya karun gi kaluy-an sa diyos, sa una ga laraw-laraw rana siya dari”
Characteristics and attitude of the informant: talkative

INFORMANT 4:
Name: J. M.
Sex: Female
Age: 24
Address:
Relation to the patient: neighbor
Length of time known to patient: 5 years
Apparent understanding of present illness: “okay naman siya, gaka
atiman na niya iyang kaugalingon karon di pareha atong una”
Characteristics and attitude of the informant: shy type of person

INFORMANT 5:
Name: L. M.
Sex: Male
Age: 51
Address:
 Relation to the patient: neighbor
Length of time known to patient: more than 12 years
Apparent understanding of present illness: “ma storya na namu siya
karon unya maka tubag napud ug tarong, medjo maayu na gyud siya”
Characteristics and attitude of the informant: arrogant type of person

INFORMANT 6:
Name: J. A.
Sex: Female
Age: 35
Address:
Relation to the patient: neighbor
Length of time known to patient: 3-4 years
Apparent understanding of present illness: “katong bago pami dani,
kulang- kulang na gyud na siya, hugaw kayo unya walay atiman sa iyang
kaugalingon, pero karon mga taud-taod napud,na arang-arang na baya
pud, mayo nalang”
Characteristics and attitude of the informant: nice and kind person

INFORMANT 7:
Name: D. P.
Sex: Male
Age: 31
Address:
Relation to the patient: neighbor
Length of time known to patient: 5 years
Apparent understanding of present illness: “sa una gabadlungon namu
na siya kay permi lang ga lakaw-lakaw unya hugaw kayo, pero karun amu
nang gkalingawan ug storya-storya, unya mu tubag naman pud”
 Characteristics and attitude of the informant: nice to talk with and a
humorous person

INFORMANT 8:
Name: L. R.
Sex: Female
Age: 54
Address:
Relation to the patient: neighbor
Length of time known to patient: 10 years
Apparent understanding of present illness: “na mayo na gyud na siya
day, sukad sa pagtul-tol ug inum sa iyang mga tambal unya pag pa check-
up pud, na mayo na iyang pang huna-huna”
Characteristics and attitude of the informant: friendly

INFORMANT 9:
Name: R. T.
Sex: Female
Age: 56 years old
Address:
Relation to the patient: neighbor
Length of time known to patient: more than 15 years
Apparent understanding of present illness: “maayo na siya, ga sige
nalang puyo sa ilang balay din a ga sige ug lakaw-lakaw ”
Characteristics and attitude of the informant: kind and hospitable
INFORMANT 10:
Name: N. S
Sex: Male
Age: 18 years old
Address:
Relation to the patient: neighbor
Length of time known to patient: more than 5 years
Apparent understanding of present illness: “sa akong na bantayan
okay-okay na baya siya, sa una ka puliki na iyang mama ug pangitaay sa
iyaha kay maglakawa man”
Characteristics and attitude of the informant: humorous

B. FAMILY HISTORY

a. Maternal and Paternal Grand lineage

The grandparents of AJ on both sides had no history of mental illness. Her

grandparents on her paternal side were already both dead just before she was
born. On her maternal side, her grandparents were separated and her
grandfather died when she was still an infant. She did not have the chance to live
with them because her grandmother lived in Medina, Misamis Oriental and they
seldom see each other due to financial problems. Her grandmother was a known
to sell native delicacies. She was a chain smoker and an alcoholic. She died
when AJ was still in her school age.

b. Father
 Mr. AJ Sr. is a superior and strict father. He believes that for every mistake
committed there is a corresponding punishment. He raises his voice whenever
he reprimands them and uses a bamboo stick as punishment when they commit
a big mistake whenever he is the one left in the house to take care of his
children. Mr. AJ Sr. is the one who makes decisions in the family and the wife
would conform to him. He works as a tinsmith or sometimes as a carpenter when
he needs extra income for his family. His work requires him to travel from one
place to another. Because of this, his work cannot suffice the basic needs of his
family. One of his failures was that he was not able to go to College; he was only
an Elementary undergraduate. He drinks alcohol when socializing with friends
and is also a chain smoker. They seldom fight about financial problems but they
were managed to the problem through good communication when they were
calm.

c. Mother
Mrs. LJ is a lenient mother. She is a plain housewife and responsible for
budgeting the money from her husband’s salary. She herself took care of her
children and disciplined them. She only reprimands her children when
mistakes are committed. She had a fair attention given to her children with
love. When it comes to the husband-wife relationship, they seldom fight due to
financial problems but still manage to solve it. She doesn’t have serious
problems with her husband because she says he is a responsible father to his
children.

d. Siblings
AJ has one brother in the family. They were born through a normal
spontaneous vaginal delivery by a midwife. Her brother is now living with his
family in Salay, Misamis Oriental. He works as a bus conductor.

C. PERSONAL HISTORY
a. Prenatal
The conception of AJ was a wanted by her parents for she was their first
born. Mrs. LJ views the coming of their 1st child as a blessing from God. She
stated that she wanted to be pregnant that time because she wants what it feels
like to be pregnant and how amazing she could be as a mother. She had regular
pre-natal check-ups and takes ferrous sulphate only. Her mother could eat the
right nutritious foods that she needs through his husbands hard work even
though they have financial difficulties.
She experiences stress whenever problems arise. The husband was very
supportive during the pregnancy period.

b. Birth
The client was born full term in a normal spontaneous vaginal delivery and
was attended by a midwife. According to the mother, she had a 12- hour labor
and experienced moderate pain but did not have any complications during her
delivery.

c. Infancy and Childhood Characteristics. AJ was bottle-fed during her

infancy and there were lots of cuddling. Her mother tried to breastfed her but
unfortunately; it was only good for one week. The mother did not able to
breastfeed her for a long time because her mother experienced boils on her
left breast. Mrs. LJ was forced to wean her from breastfeeding and started to
give her formula milk. Lugaw with the infant formula was given at 5 months.
Her deciduous teeth erupted when she was six months old and then
introduction of solid food followed. Bottle-feeding was continued until the age
of 2 years old. She learned to mention her first word “mama” at the age of 8
months. She learned to walk at the age of 11 months. During this stage, she
was given enough care because her mother’s attention is focused on her two
children.
At the age of two years old she was toilet trained and proper teaching was
given by her mother.
d. Psychosexual Factors
AJ first noticed her breast changes at the age of 12-13 years old. She started
to have crushes with the opposite sex when she was 13 years old. She had her
first menstruation when she was 14 years old. She has a regular menstruation
that would last for 4 days and she experiences dysmenorrhea during
menstruation.

e. Play life
She plays alone with her toys when she was 6 years old. Sometimes she
plays with other children in both sexes and her playmates are one year older
than her. She doesn’t prefer to lead the play or would act as the mother. She
usually acts as the follower and when they have playhouse, she wants to be the
child. She plays just within the neighbourhood.

f. School History
She entered grade one at the age of 7 years old at West Elementary School.
She is active in school and seldom joins any extracurricular activities. Most of her
teacher comments were that AJ is very silent but participative in class. When her
teacher would call her to answer the question being asked, sometimes she
wouldn’t respond. She enters the class with her assignments done. Math is her
favourite subject. Her grades are satisfactory. She only reached second year
high school level and decided to stop because of financial matters.

g. Occupational history
At the age of 17 years old, she started to work as a helper to their
neighboring house and at the age of 18, she worked as a dishwasher in Carmen
Public Market for 2 years and 3 months with an average salary of Php30.00 per
day. After she delivered her baby, she decided to go to Manila through
recruitment by a friend. She then worked as an all around helper for 1 year and 6
months. Her mother stated that she was not treated nicely by her host family. So
she returned to Cagayan de Oro and came back to her work as a dishwasher.

h. Marital Status
She had her first boyfriend when she was 20 years old. After two years of
their relationship she got pregnant. When she went to her boyfriend’s house and
told her boyfriend her situation, the guy broke her heart through denying that he
is not the father of the unborn child. She then became disappointed and led to
her depression. As she was broken, she tried to get rid of her baby through
taking cortal. Luckily the baby was not aborted. Although she was depressed,
she decided to continue the baby with the support of her parents she delivered a
healthy baby girl through spontaneous vaginal delivery. After the child was born
her boyfriend appeared again and got back with her but he then left her after a
month. Her depression went back so she decided to go to Manila to work. And
from the day the guy left her, she had never seen him again. She did not have
any relationship after her heart was broke by her first love.

i. Religious and Social Adaptability

She had few friends in their place because she prefers to be alone. She was
shy getting involved with any organizations. Most of the time, she prefers to stay
at home. According to her neighbors and family, she is a silent, shy and does not
socialize that much to other people. She easily gets irritated whenever she had
her menstruation. She goes to church with her mother who is religious.

j. Onset of Present illness

As stated by her mother, AJ illness precipitated when his boyfriend denied
that he is the father of the baby she is carrying. She was very disappointed and
did not expect that he would such thing. The worst thing is that the guy accused
her that she had affairs with other men and he is not going to take the
responsibility. She became depressed and tried to abort their child. But
fortunately the baby holds on. When she still pregnant she started to stare
blankly. Maybe because he cannot stand the fact that she was denied by the love
of her life. She was in love with the guy. After she delivered her baby her
boyfriend came back to her but after a month the guy left and never came back.
She can’t stand the things that happening in her life that time so when her friend
recruited her to work in Manila and became a helper for 1 and ½ years but her
host did not treat her nicely so when she had the chance to home to Cagayan
she went back in working in the Carmen market as dishwasher. Her work is very
busy; she cannot eat at the right time and takes almost all her time. She works
from 4 in the morning and ends at 8 in the evening. That’s the time she started
staring blankly again. At first it was ignored by her family until the time that she
claims to be seeing things. She stares at a tree and says he is seeing a black
cat. Even though there is nothing there. She also says that she hears someone
whispering on her ears. She suddenly shouts angrily that you should not touch
her. Sometimes when he sees her daughter she tries to hurt her. She was
observed to be talking and giggling alone. She gets angry for no reason. She
starts to stray. She usually found in the Carmen, Market and does not go home,
unless a guy would convince her to go home. Client was allegedly admitted
before due to unknown cause and date in NMMC.
January 18, 2009, Client was then reported by concerned citizen from Gusa
when they have been noting the patient to be by the sidewalk, homeless,
unkempt, and not on her proper state of mind for about a week. But there were
no noted states of violence. She was also seen in Cugman 2 weeks before. She
was then referred to Northern Mindanao Medical Center. She was examined by
Dr. Eric Borromeo and was given with Haloperidol, Multivitamin and Biperiden.
She then has regular monthly check-up and maintaining her medication.
III. COURSE IN THE HOSPITAL

A. MENTAL STATUS EXAMINATION

ASSESSMENT OF CURRENT STATUS

DAY DAY DAY DAY DAY 5

1 2 3 4
A. GENERAL APPERANCE Good Good Good Good Good
gro- gro- gro- gro- gro-
oming oming oming oming oming
B. GENERAL MOTILITY
Slouch

Slouch
Slouch

Slouch

Slouch
Posture

Activity Purpo Purpo Purpo Purpo Purpo

seful seful seful seful seful
Facial Expression Tense Shy Smilin Smilin Smilin
g g g
C. BEHAVIOR Shy Shy Shy Shy Shy
D. PATIENT NURSE INTERACTION Dista Coop Coop Coop Coop
nt erativ erativ erativ erativ
e e e e
E. SPEECH
Soft / / / / /
Loud
Hesitant /
Slurred
 Superiority
Humor
Frightened
F. Does his style and vocabulary
convey
Coyness / / / / /
Suspiciousness
Arrogance
Secretive
Superiority
Humor
Fear
G. Stream of talk
Spontaneous / / / / /
Pressured
H. Organization of talk
Relevant / / / / /
Irrelevant
Incoherent
Loose Association
Flight of ideas
Tangentiality
Circumstantiality
Perseveration
Clang Association
Neologism
Echolalia
Echopraxia

I. Mood and Affect

1. Mood
Euthymic / / / / /
Depressed
Euphoric
2. Affect
Flat / / / / /
Blunt
Angry
Elated
Anxious
Fearful
3. Range of Affective expression
Consistent / / / /
Labile
 Anhedonic
Appropriate to the
situation and feelings verbalized
J. Perception
Hallucination
Auditory
Visual
Olfactory
Gustatory
Tactile
Delusion
Grandeur
Persecutory
Reference
Others (specify)
Illusion
Derealization
Depersonalization
Identification
Thought Broadcasting
Déjà vu
Jamais Vu
K. Orientation and Memory
Identifies date correctly No Yes Yes Yes Yes
Estimated time of the day No Yes No Yes Yes
Knows where she is No Yes No Yes Yes
Knows the examiner Yes Yes Yes Yes Yes
Recalls activities done within 24 hours Yes Yes Yes Yes Yes
Recalls activities done within 1 week No No No No No

L. Neuro-negative Functioning
Sleep and Rest Pattern
Normal Sleeping / / / / /
Early morning Awakening
Middle night Awakening
Hyper insomnia
Difficulty of falling asleep
Interrupted
Others
M. Elimination
Bowel 1x 1x 0 1x 1x
Bladder 3x 4x 2x 3x 3x
N. Abstract Thinking Ability poor poor poor good good
O. Judgment poor poor good good good

B. PROGRESS NOTES

General Objectives

At the end of 5 days visit, we will be able to interview our client, the mother
and informants, and gather all the needed information, to identify potential
problems of our client and to render assistance.

DAY-1: April 8, 2009

Specific Objectives
At the end of 1 hour, the group will be able to
- meet the patient
- establish agreement
- start to develop trust and establish rapport
- initiate preliminary MSE

On the first day of our visit around 4:00 in the afternoon, the group was able to
meet the patient. We then established the agreement in which the group
emphasized the date, day and time of the first visit down to the last visit. The
group also started to establish rapport and develop trust and preliminary MSE
was initiated. AJ was hesitant and her pattern of speech was soft. She conveyed
coyness as her manner of style and vocabulary. AJ answered questions
spontaneously and was relevant. She was euthymic and expressed flat emotions
consistently. According to AJ, She no longer experience hearing voices and
seeing things. AJ was able to identify date and place correctly on this day but she
wasn’t able to estimate the time. AJ knows the examiner and was able to recall
activities done within 24 hours but not the activities done within 1 week. AJ
experienced normal sleeping. She urinated 3 times and defecated once. The
group tried to ask her to interpret a proverb, but she didn’t respond so we rated-
poor on her abstract thinking ability so with her judgment.

Day 2: April 12, 2009

Specific Objectives
At the end of 1 hour, the group will be able to
- develop trust and establish rapport
- assess and Observe client’s behavior
- gather information
- initiate MSE

On this day, at 10:30 in the morning, the group was able to visit the client at there
residence. The group assessed and observed client’s behavior and initiated
MSE. Upon initiating the MSE, AJ was no longer hesitant and her manner of
speech was soft. AJ was coyness at this time. When we asked her some
questions, she answered spontaneously and is relevant. The group observed
that she was euthymic and expressed emotions flatly and consistent. AJ was
able to identify the date and wasn’t able to estimate the time of the day. She
knows where she is, the examiner and was able to recall the activities done
within 24 hours. According to her she sleeps well. She urinated 4 times and
defecated once. Her abstract thinking ability and judgment were rated-poor.

DAY-3: April 13, 2009

Specific Objectives
At the end of 2 hours, our group will be able to
- conduct home visit
- establish rapport with the family and significant others
- state purpose of visit
- gather relevant information from significant others and family of the
patient
- implement nursing care

On this day at 9:00 in the morning, the group went to the client’s residence for a
visit. The group was able to initiate the interview and state its purpose. The group
were able to gather data from the informants; significant others and neighbors.
The group initiated an assessment for the MSE; her speech was soft, her stream
of talk was spontaneous, and the organization of her talk was relevant. She was
still smiling, with flat affect, and consistent in her range of affective expression.
She was has no auditory hallucination. She can identify the date correctly but
does not know where she is. When we asked her about our names, she was able
to identify. She can recall activities done within 24 hour period but not within the
week. She still experienced normal sleeping. We asked her to give the similarity
between a chair and a table but she was not able to identify it, so, we rated her
poor in abstract thinking ability. During our interview a paper fell on the floor and
she was able to pick it up and returned it to us, this indicates that she has a good
judgment. The group was able to implement nursing care which emphasized
reality orientation, telling her where she is, interacted client in a clear and
consistent manner. Client was encouraged to engage in physical activities such
as exercise and discourage naps during day time to enhance sense of fatigue
and promotes sleep/rest. We presented reality briefly and concisely to correctly
interpret stimuli within the milieu, spending time with the client, listening with
regard and provided with support for changes client was making were the things
provided.
On the afternoon of that day we accompanied her to have her daily check-up in
Northern Mindanao Medical Center. We we’re able to acquire information through
her Neuro-psychologist Dr. Eric Borromeo.

Day-4: April 14, 2009

Specific Objectives
At the end of 1 hour, the group will be able to
- gather additional information from the client
- Provide nursing care
- Implement health teachings

The group went to there house to visit our client and gathered additional
information. AJ at this time was not secretive, her answers were relevant and that
her talk was spontaneous. She was still smiling and she had a flat affect. She still
identifies date correctly but does not know the estimated time of the day. She
identifies her examiner and she recalls activities done within the day but does not
recall activities done within a week. Client was encouraged verbalization of
feelings to ease tension, provided reality orientation-telling her the time of the
day, encouraged participation in the discussion of life review and present day
event and interacted client in a clear and consistent manner was being done by
the group.

Day-5: April 15, 2009

Specific Objectives
At the end of 1 hour, the group will be able to
- Conduct the last visit to the client
- terminate agreement

On this day, the group was able to visit the client and initiated termination of
agreement that emphasized the end of contract. The group was able to
expressed gratitude to the client, hence the group was able to say goodbye.
V. LABORATORY TEST

Patient AJ did not undergone any Laboratory Exams

VI. DIAGNOSIS

CHRONIC SCHIZOPHRENIA, DISORGANIZED TYPE

VII. MULTI – AXIAL DIAGNOSIS

Unfortunately, there is no laboratory test for schizophrenia. Its complex spectrum

of symptoms cannot be gauged with methods like the mental status examination.
Diagnosis is made by clinically examining the following:
• Person's family history
• Emotional history
• Current symptoms
• Presence of other disorders (differential diagnosis)

It may be difficult to diagnose acute (quick, severe, and brief) schizophrenia

during its first episode. Often, physicians must wait to establish recurrence,
chronicity, and intensity, especially with regard to negative symptoms. For these
reasons, a physician's main goal in early diagnosis is to distinguish a person's
disturbance from other conditions, including other psychotic disorders, organic
disorders, and drug-related conditions.
Differential diagnosis for schizophrenia involves distinguishing it from bipolar
disorder, schizoaffective disorder, and brief psychotic disorder. Schizophrenia-
related changes in mood can include mania and depression. However, these
changes in mood typically do not meet the criteria for full-blown mania or
depression, which occur in bipolar disorder.
However, diagnosing schizophrenia is complicated by the fact that changes in
mood occur in its early, active, and late phases. Schizoaffective disorder features
depression or mania along with schizophrenic symptoms. The following three
diagnostic criteria are used to diagnose it:
• Change in mood corresponds to active phase symptoms
• Changes in mood must be present for a significant time during psychotic
episode
• Delusions and hallucinations must be present for 2 weeks without
changes in mood
The prognosis for schizoaffective disorder is typically better than that for
schizophrenia, but worse than that for mood disorder.
Brief psychotic disorder features one or many schizophrenic symptoms, including
delusions, hallucinations, disorganized speech and behavior, and flattened affect.
There is usually a clear trigger, and symptoms last less than 1 month. So the
duration criterion for diagnosis of schizophrenia is not met.
Organic medical conditions may also produce schizophrenia-like symptoms.
Certain frontal brain disorders, encephalitis (swelling of the brain due to viral
infection), and delirium must be ruled out. Delirium is a serious type of confusion
that may involve hallucination, incoherent speech, and disorientation. It is caused
by a number of things, including illness, shock, drug abuse, and anxiety and may
closely resemble schizophrenia.
Drugs of abuse, including amphetamines and PCP, or phencyclidine ("angel
dust"), may cause delusions, hallucinations, wild behavior, and babbling.
Phencyclidine can even cause what appear as schizophrenic negative
symptoms, like emotionless stupor. A physician will determine whether the drug is
causing and sustaining symptoms that resemble schizophrenia, or aggravating
the preexisting symptoms of the disease. This usually requires that he or she
observe the person during drug abstinence.
Finally, other psychiatric disorders, like obsessive-compulsive disorder (OCD),
posttraumatic stress disorder (PTSD), and schizoid personality may resemble
schizophrenia.
Obsessive thoughts, hallucinations, disorganized behavior, paranoia, and
delusional thinking are common in one or more of these diseases and may
appear as symptoms of schizophrenia. The severity and duration of these
symptoms, in addition to the person's age and psychological history, differentiate
these disorders from schizophrenia. Also, schizophrenia is often diagnosed as
one of several subtypes.

In addition to investigating a person's family history of mental illness, a physician

will use the American Psychiatric Association's criteria for diagnosis to assess
their emotional past and current symptoms.
The American Psychiatric Association (APA) specifies the criteria for diagnosis of
schizophrenia in the DSM-IV, the Diagnostic and Statistical Manual of Mental
Disorders. Included here are the definitive symptoms, duration, and severity.
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):
• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment, incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms (e.g., affective flattening, alogia, avolition)
Note: 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.

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).

C. 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 an
attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. 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.

E. 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.
F. Relationship to a Pervasive Developmental Disorder (PDD): 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).

VIII. NURSING MANAGEMENT

NURSING CARE PLAN

A. Ideal Nursing Management

Nursing Diagnosis: Disturbed thought processes related to physiologic

changes

INTERVENTION RATIONALE

• Be sincere and honest when Delusional client are extremely

communicating with the client. sensitive about others and can
Avoid vague or evasive remarks. recognize insincerity. Evasive
comments or hesitation reinforces
mistrust or delusions.

• Do not make promises that you Broken promises reinforce client’s

cannot keep. mistrust to others.

• Encourage client to talk with you Probing increases the client suspicion
but do not pry for information. and interferes with the therapeutic
relationship.
 • Recognize the client delusion as Recognizing the client perceptions can
the client’s perception of the help you understand the feelings she’s
environment. experiencing.

• Initially, do not argue with the Logical argument does not dispel
client or try to convince the client delusional ideas and can interfere with
that delusions are false or the development of trust.
unreal.

• Interact with the client on the Interacting about reality is healthy for
basis of real things; Do not dwell the client.
on the delusional materials.

Nursing Diagnosis: Health maintenance altered related to lower socioeconomic

group with limited resources

INTERVENTION: RATIONALE

• Compare present/pre-illness Dysfunction in family (diminished

level of Home/health problem solving, poor financial
maintenance. Consider deficit in management/inadequate resources,
communication, knowledge, and ineffective support system;
decision making, developmental emotional improvement and lack of
task and support system and motivation to participate in treatment
their effect on clients’ basis can impair functioning.
health practices.
• Assist client/ family to identify Poor organization capacity for ADL’s
appropriate healthcare/ and socialization as well as personnel
practices (e.g., dental physician,involvement can lead to neglect of
clinic, regular hygiene practices,these areas and provides opportunity
as some social contacts). for nurse to assess capacity for/
compliance with home/ health
management needs.
• Involve client in the development Involvement increases the potential for
of a long term plan for optimal cooperation with plan
home/ health management,
encouraging indentification/ use
of resources.
 Nursing Diagnosis: Low self-esteem related to feelings of
worthlessness.

INTERVENTION RATIONALE

• Provide for a specific amount of This gives patient time for self-
uninterrupted non-care related exploration.
time to engage patient in
conversation

• Listen to patient with This expands patient’s self-awareness

understanding, responding with and reduces the element of threat.
nonjudgmental acceptance,
genuine interest, and sincerity.

• Assess patient’s mental status High anxiety from self-rejection may

through interview and cause cognitive, sensory, and
observation at least once perceptual disturbances.
weekly.
• Arrange situations to encourage Disturbed interpersonal relationships
social interaction between are direct expression of self-hate.
patient and others.

• Help patient mobilize resources To help patient replace maladaptive

for assistance when discharged. coping behaviors with more adaptive
ones.

• Refer patient to a mental health Severity of symptoms accompanying

professional as indicated. chronic low self-esteem may require
long-term psychotherapy.

B. Actual Nursing Management

SOAPIE

S “Ako may ga ligo sa iya kay dili man kayo siya kabalo nga siya ra”, as
verbalized by the informant

o • dirty nails
• unruly hair
• bad breath

A Self-care deficit related to poor personal hygiene

P Long term: At the end of one week, the patient will be able to observe
proper personal hygiene
Short term: At the end of two hours, we will be able to demonstrate to
the patient on what’s the proper way of taking care of herself.
I Independent:
• try to show to the patient the proper way of combing her hair
and as well as explain to the patient why she needs to do so, to
make her look good
• clean the nails of the patient and show to her the proper way on
how to use the nail cutter with the supervision of her mother to
prevent accidents like improper using of the nail cutter
• remind the patient to brush her teeth twice a day and show her
the proper way of brushing the teeth and the purposes should
also be emphasized to minimize having bad breath
• explain well to the patient the purposes of taking a bath once a
day to maintain the cleanliness
• teach not only the patient but also the mother, this is to facilitate
her daughter very well on performing any personal hygiene

E At the end of two hours, we were able to demonstrate to the patient, the
proper way of taking care of herself.

S ““Kana si mama? Usahay mag.self-pity na sya,” as verbalized by her

daughter.

o • Expression of self-negating thoughts

• Need for excessive reassurance
• Repeated experience of failure
A Chronic low self-esteem related to feelings of worthlessness.

P At the end of therapy, Ms. AJ, will be able to express feelings about self,
doesn’t feel threatened by facility environment, and converses with
others on daily basis.

I Independent:
• Provide for a specific amount of uninterrupted non-care related
time to engage patient in conversation.
 • Listen to patient with understanding, responding with
nonjudgmental acceptance, genuine interest, and sincerity.
• Assess patient’s mental status through interview and
observation at least once weekly
Arrange situations to encourage social interaction between patient and
others.
• Help patient mobilize resources for assistance when discharged.
E Ms. AJ, was able to express feelings about self, doesn’t feel threatened
by facility environment, and converses with others on daily basis since
she is eager to share her feelings with us

S “mau gyud na dugay-dugay iyang pagka ulian kay ga problema gyud

mi sa kwarta para pang palit sa iyang mga tambal”,

o • Financial constraints

A Ineffective compliance of therapeutic regimen related to financial

problem

P At the end of 2 hours, the family will display interest to follow prescribed
regimen and find ways to comply with the medication prescribed
 I Independent:
• Determined the barriers to compliance with the medication to
know reasons why client cannot maintain medication regimen.

• Teach and informed the family members about the biologic

causes and clinical course of schizophrenia and the need for
ongoing support, this is to remind them that, maintaining the
medication regimen is vital to a successful outcome for clients
with schizophrenia

• Instructed the mother to keep the client from drinking cola drinks
and candies to ease the anticholinergic effects of dry mouth.

• Arranged a scheduled check-up visit to Northern Mindanao

Medical Center to know the patient’s current mental status.

E At the end of 2 hours, the family was able to display interest in following
medication regimen.

X. PROGNOSIS AND RECOMMENDATION

The prognosis of our client is POOR based on the following criteria:
CRITERIA RESULT GOOD POOR PROGNOSIS
PROGNOSIS
A. Onset of The onset of illness (-) (+)
illness started during her
adolescence stage.
B. Duration of She suffered from (-) (+)
illness mental illness / disorder
for about ten years.

C. Precipitating Precipitating factors (-) (+)

factors/ were clearly identified
Predisposing and possible
factors Predisposing factors
also surfaced during the
interview with the
mother.

D. Status Single (-) (+)

E. Mood & Observed (-) (+)
affect manifestations of
thoughts and verbal
inconsistencies
F. Attitude and Patient was able to take (+) (-)
willingness to medications on time.
take
medications and
treatment.
G. Family Only the parents (+) (-)
Support supports financially .

“Ms. AJ” has no concrete evidence of having a mental disorder in the family
lineage. Her disorder was probably brought about by, not eating her meals and
depression due to public humiliation.
According to her mother “Ms. AJ” started being hostile during the onset of

her illness, she started having auditory and visual hallucinations, blunt affect and

became anhedonic. She suffered with the illness for almost ten years now. She

was found straying at the streets by the DSWD health workers and she stayed

there for about three days and was referred to NMMC. Her neighbors stated that
“Ms. AJ” is now responding to the antipsychotic drugs given, but symptoms may

appear if there is failure in maintenance of medication. Based on the gathered

data, “Ms. AJ” has a chance to become a productive member of the society if she

continues taking her medication and receives full support from her family and

relatives.

As student nurses for the psychiatric patient, we suggested that “Ms. AJ”

must continue her monthly check-ups to her Psychiatrist, get other prescriptions

if there are any and must follow treatments recommended by the doctor such as;

proper medications and coping mechanisms. The group also recommended that

she must eat regularly and orient her about reality; the time, place and let her

recall the activities she had done within 24 hours or within 1 week. These are all

the important things to be done to prevent reoccurrence of her illness.

XI. BIBLIOGRAPHY

Doenges, M.E.; Moornous, M.F.; Geislerr-Murr, A.C. (2004), Nurse’s Pocket

Guide. Diagnoses, Interventions, and Rationales(9th ed). F.A. Davis
Company. Pp 143-150.
Kaplan, H.I.; Sadock, B.J. (2000). Synopsis of Psychiatry.Behavioral Sciences
Clinical Psychiatry (6th ed). Lippincott William and Wilkins. Pp 334-
336.
Kneisl, C.R.; Wilson, H.S.; Rodriguez, M.R. (1990). Psychiatric Nursing. Pp. 252-
256, 355-361, 401-421.
Kozier, Barbara, Erb, and Blais: Fundamentals of Nursing, 5th edition, Reprinted

2001, 1998 by Addition Wesley Longman, Inc. pp. 570-586

Merriam, Webster (1995). Merriam-Webster’s Medical Dictionary. Merriam-

Webster Incoporated, Springfield, Massachusetts, U.S.A. pp 278.
Murray, Beckman, R.; Skoetter, H. Wilson, M. Psychiatric/ Mental Health Nursing.
Giving Emotional Care (3rd ed). C and E Publishing Co., pp 538-548
Pelliteri, Adelle: Maternal and Child Nursing Care; The Lippincott Company, 4th
Edition, 2001. pp 793-826.
Townsend, M.C.(2000). Nursing Diagnoses in Psychiatric Nursing. A Pocket
Guide for Care Plan Construction(2nd ed). Pp 143-144
Videbeck, S.L.(2004). Psychiatric Mental Health Nursing (2nd ed). Lippincott
Williams and Wilkins. pp 396-397

XII. DOCUMENTATION