Republic of the Philippines CAVITE STATE UNIVERSITY (CvSU) Don Severino de las Alas Campus Indang, Cavite Philippines

COLLEGE OF NURSING In partial fulfilment Of the requirements in NURS 75 (Curative and Rehabilitative Management II)

SCHIZOPHRENIA UNDIFFERENTIATED TYPE With MENTAL RETARDATION

Presented by: Basa, Leah Cimini, Gio Dimapilis, Joan Dizon, Ria Emelo, Carolline Go, Manuel Jr. Libre, Catherine Ramos, Katrina Rivera, Hadzlyn Rodriguez, Christine Mae Trias, Czarina Vidal, Mariano Jr Group 3 Presented to: Level IV Clinical Instructors

I. Introduction

Human brain is a fascinating control center of human and the human life. It performs so many tasks and functions that enables one to talk, think and respond to internal and external stimuli. The mechanism of its functions has been clearly identified and traced long before. Due to its powerful effect to the human body, any interruptions to its normal activity results to disorders. If happens, the victim becomes unable to express self appropriately, has wrong perceptions of the reality and holds delusional belief; a condition known to be SCHIZOPHRENIA. Schizophrenia, like some other indistinct diseases attacks man in a very soundless, sometimes unknown approach. One cannot say that he/she will be free from the disease on a lifetime. There are so many testimonies from different victims of the disorder throughout the globe. Young, old, men, women, working and non-working are victims. All of them have so many differences, but after the attack of the disease, each one of them is almost alike from one another. They possessed similar signs and symptoms that vary from mild to severe. All of them also wish for something unknown that will help them go back to reality soon enough to escape from the darkness. Schizophrenia affects approximately one percent of the world's population, and onset is most often between 15 and 30 years of age-when society has a maximal investment in a person's development. Therefore, schizophrenia represents a serious problem not only in terms of direct costs and lost productivity but also in terms of lost human potential. Further, patients with schizophrenia utilize a disproportionate share of medical resources. Patients with schizophrenia may constitute as much as 10 percent of the totally and permanently

disabled and a large fraction of the homeless population. For the general physician, the medical care of schizophrenic patients presents a substantial challenge because schizophrenic patients often are unable to supply an accurate medical history and often have difficulty complying with medical treatment for such reasons as homelessness and lack of financial support. Because of suicide and poor access to medical treatment, the mortality of schizophrenic patients is double that of the general population (www.schizophrenia.com). The group, not being able to choose which specific mental disorder to present is very enthusiastic and positive that this manuscript together with the simple and actual presentation will shake and awaken variety of ones emotions. Negative and positive symptoms of the disease that speak how much sufferings the victims of the disease have to endure will be discussed in detailed as well as the different therapeutic ways that student nurses could performed altruistically in order to bring changes and modify behavior of a psychiatric patient thereby facilitating the rehabilitation process.

II. Nursing Assessment

A. Demographic Data

Name of the Patient: Age: Gender: Address: Civil Status: Nationality: Religion: Birthday: Date Admitted: Admitting Diagnosis:
B. Source and Reliability of Information

C.P. 36 years old Male Bagong Pook Ligtong I Rosario Cavite Single Filipino Roman Catholic June 19, 1975 May 2, 2007 Schizophrenia, Undifferentiated t/c Mental Retardation

The primary source of information was the client himself. These and other pertinent data were obtained during our exposure in Cavite Center for Mental Health (CCMH) dated July 23-24, 29-31, and August 5-7 through one-on-one interview and interaction of the client and his student nurse. The group, through the supervision of their clinical instructors and with the CCMHs staff on duty utilized the clients chart (secondary

source of data) to validate different findings as well as to gather some necessary information which he cannot directly provide. C. Reasons for Seeking Care The client was brought by his Uncle in Cavite Center for mental health last June 2, 2007 due to frequent episodes of delusions; I am a 6 year old, and the client demonstrated inability to recognize the name and how he is related to other members of the family. D. History of Present Illness The client has been admitted five times already in Cavite Center for Mental Health. However, it was not written in the clients chart what is the reason behind his frequent admission and how old was he during the first admission. It was written in the clients chart that he has history of smoking cigarettes, drinking liquor, and using prohibited drugs such as shabu and marijuana. When he was admitted last June 2, 2007 in CCMH, he denied of having mental illness and claimed that he was normal. Due to his condition, he was put under suicide and escape precautions by the staffs of the institution. At present, the client is taking different medications as follow: Depakote 500mg, OD (once a day); Clozapine 100g, Risperdal oral solution 1cc, BID (twice a day), and Levomepromazine 100mg HS (Hour of sleep-8pm or 9pm).

E. General State of Health The client was diagnosed of having Schizophrenia, Undifferentiated Type with Mental Retardation according to his available chart as well as how we were advised by the staff of the rehabilitation ward. He is being given different medications or drugs as mentioned to manage the disorder. However, different disturbances were still noticeable at him including disturbances in psychomotor, affect, cognition and judgment. (Note: different disturbances showed by the client will be explained further and in detail in the Mental Status Examination). The client has a medium-built body and has a fair brown to white skin complexion. There were some wounds present on the clients skin and buttocks that resulted from his frequent scratching due to scabies. According to him, he has the skin disease two weeks prior to our interaction with him. The group noticed that when wounds in a certain area dried up, new wounds appear close to the area of previous infestation.

F. Developmental History Normal Developmental Stage According to the Clients Age (36)

A. Ericksons Psychosocial Theory of Development

The developmental crisis of an individual under this stage is achieving a sense of Intimacy versus Isolation (Young Adult). Intimacy is the ability to relate well with other people, not only with members of the opposite sex but also with ones own sex forming long-lasting friendships. Since an individual needs a strong sense of identity before he/she is able to offer or accept long-lasting friendships, this task grows out earlier in the stage of development. Person without a sense of intimacy may have more difficulty accepting frustrations, responsibilities and falls on greater chances of being isolated and avoidant.

B. Jean Piagets Cognitive Theory Cognition at this stage falls under The Formal Operational Stage, which is said to be the final form of mental and cognitive maturity. When an individual successfully reached this stage, he/she will be able to possess or demonstrate abstract thinking instead of purely concrete reasoning and responses as well as deductive and inductive reasoning.

C. Kohlbergs Moral Development Post conventional stage or often called as mature form of moral reasoning is the moral developmental stage of the client. Normally, an individual is capable of internalizing actions that are righteous even no one is watching him/her. Furthermore, rules and other universal principles are being followed not just because these are righteous but because of avoiding other people of the society become deprived of what is due to their possession.

Analysis of the clients particular stages and development

A. Ericksons Psychosocial Theory of Development

Isolation was developed into the client. He showed negativistic view of self (mutism), prejudices against others and relationship during casual interactions as evidenced by frequent verbalization Wala naming magkakagusto sakin na babae, and kissing and holding hands of other client while outside the rehabilitation ward. Because of this kind of view of self, the client chose to be single. This, according to Erickson resulted when an individual failed to develop trust during infancy or unable to develop a strong sense of identity during the earlier stage of psychosocial development. Rejection from friends and to the opposite sex is very painful leading to minimal social contact to total isolation.

B. Jean Piagets Cognitive Theory During the student nurse-client interaction, the client demonstrated different cognitive disturbances such as poor reasoning, unable to process successful recall of the past and failure to relate event of the past to the present condition. Cognitive maturity was not achieved by the client. This according to Piaget is devastating to an individual because problems will appear very difficult most of the time primarily because of inability to trace and identify causations.

C. Kohlbergs Moral Development According to the client, he sometimes disobeys rules inside the ward especially when he feels like hes not going to benefit from it; he asks cigarette from the other client inside the ward and smokes even if it is not allowed. This shows that the major concern of the client is not to do what is right and what is also good for others. According to Kohlberg, this is a sign of a developed nature of self before others which is an end product of unsuccessful triumph against the previous stage: Preconventional.

G. Review of System and Physical Examination Date Performed: July 24, 2010 SYSTEM ROS includes PHYSICAL ASSESSMENT history of complaints ROS Findings Significance

SYSTEM A. General Health Status

Ayos lang sir. as Temp= 36.4C verbalized by the client during our RR= 16cpm interaction. CR= 91bpm BP=110/70mmHg

B. Integument

Fair skin complexion Skin has of scars from previous wound Lean body built Poor eye contact Slurred Speech and response was good Oriented to time and place Client was cooperative during activities Laging kinakamot, Upon inspection: makati eh White complexion which is the same with other body parts Skin is dry Scattered wounds on the extremities and buttocks: Erythematous plaques with raised borders, some are with pus in it.

Skin that is dry could be a sign of poor nutrition. The characteristics of the clients wound signify the infestations of parasitic burrowing

 Presence of scars in the of mites (sarcoptes scabei) that cause lower left eyebrow Abrasions in both scabies. extremities Severe itching Finger nails are not trimmed. Upon Palpation: Skin is warm to touch. Capillary refill of less than 3 secs. C. Head wala ng buhok, Upon Inspection: makati rin Demonstrates facial symmetry and symmetrical facial movement. He is bald The scalp was dry with scars from the previous wounds Upon Palpation: Head is free from masses or palpable lumps. linaw sir, ayos Upon inspection: With poor eye contact Eyebrows and eyelashes were equally distributed Eyelids are symmetrical as when open and close, without any abnormal discharges and discoloration noted from the eyes. Able to read printed materials slowly but only at specified distance ( not beyond 7 inches apart) Suborbital hematoma about the size of a Philippine 25centavo coin on the right eye is noted.

D. Eyes

Has poor eye contact that could be an indication of the clients inability or failure to develop trust with the student nurses (Peplaus Interpersonal Process of Communicationclient and nurse are both strangers to each other. Trust and rapport must be established first to allay anxiety and for

E. Ears

nakakarinig pareho sir.

F. Nose Sinuses

and Ayos pang-amoy

Upon inspection: Color of the ears is the same of the facial skin but are positioned a little bit lower when compared to outer canthus of the eyes. Able to hear sounds in both ears clearly. Upon palpation: He has round, non-tender palpable mass below the left ear, about the size of a M and M chocolate which is differentiated from the left subclavian nodes. Ears recoil and flexible Upon inspection: Symmetrical and uniform in color Nasal openings were of equal size Patent airway and sinuses Free from nasal discharges

the nurse to foster necessary changes.) Has diminished visual range. Causal factors of hematoma must be identified to intervene properly thus eliminating visual complication in particular. Note: the clients hematoma resulted when he hit the edge of the door of the rest room inside the ward. The position of the ears as compared to the eyes outer canthus is one of the many manifestations of a congenital defect (Down syndrome). Non-tender palpable mass must be monitored. (Its one of the many signs and symptoms of Cancer formationCAUTION US).

G. Mouth and Throat

H. Neck

and inflammation. Pinkish nasal mucosal wall. Able to determine smells of the different foods served appropriately. Upon inspection: Lips are moist. Yellowish teeth and absent lower incisors decayed upper incisors Uvula positioned at the midline. Tonsils are pinkish and not inflamed. Upon inspection: Trachea is located at the midline Free from stiffness Shows adequate and smooth neck movement and motion. Upon palpation: Free from neck tenderness and palpable masses. He has non-palpable neck nodes. Upon Inspection: With the same color with the body Symmetrical chest and chest movement when breathing. Have body odor. Axillaries hairs are present. busog sir. as Upon inspection: verbalized by the With some scratches patient. and scars from healed wounds at the supraumbilical area.

The color of the teeth, missing lower incisors as early as 30 years old and tooth decay could be the result of poor oral hygiene.

I. Breast and Axillary

Body odor that is

distinct from the breath and the food eaten is a sign of poor or unattended hygiene.

J. Abdomen

K. Respiratory

Color is the same with that of the skin. Symmetrical and free from bulges. Upon Auscultation: 6x/min bowel sounds heard over the lower epigastric area. Upon Percussion: All quadrants of the abdomen have tympanic sounds. Upon Palpation: Free from tenderness and abdominal rigidity. Free from palpable pulsations. Hindi naman ako Upon Inspection: hirap huminga. As RR=16cpm verbalized by the Airway is patent and patient. free from obstructions. Symmetrical and synchronized chest retraction and expansion. Free from wheezes or stridor. Upon Palpation: Free from palpable subcutaneous emphysema Upon percussion: Resonant sound is produced. Upon Auscultation: Vesicular sounds heard over the lower lobes of both lungs. Bronchovesicular sounds heard between

the scapula and lateral sterna border. L. Cardiovascular No subjective cues. Upon Inspection: Free from jugular vein distension. Bp=110/70 mmHg Upon Palpation: PR = 91 bpm; regular Skin is warm-to-touch. Palpable radial, temporal, posterior tibialis and dorsalis pedis arteries. Upon Percussion: Dullness is heard when percussed at the midclavicular line. Upon auscultation: S1 (lub) and S2 (dab) sounds are heard over the Point of Maximum Impulse (PMI). kapag Upon inspection: Voids yellowish urine of approximately 80cc after the therapy. Verbalizes urination. N. Reproductive No verbal cues
Genitalia

M. Urinary

umiihi umiinom

painless

not physically assessed. (not examined) tremors and some other psychomotor disturbances are some of the many side effects of psychotics and other
Coarse

O. pagod sir.kulang Upon Inspection: Musculoskeletal tulog as verbalized Demonstrate poor by the client. musculoskeletal coordination. Fine to coarse tremors of the hands and feet more evident at the left

Brief Neurologic Examination

Christopher pangalan ko Taga-cavsu kayo Si Mam Eder ung babae at Sir Rolly ung lalake na nurse Soscialization lagi sa huling araw

extremities. drugs prescribed to Weak appearance of manage schizophrenia. musculoskeletal. Is Able to stand, sit, walk slowly, but has difficulty running and jumping. Demonstrates kyphotic posture. The client is oriented to time, Schizophrenia place and person. Is conscious primarily affects and can able to respond the frontal, although delayed for temporal and sometimes. He has a slurring of hippocampus speech and demonstrates region of the brain echolalia but not all the time. that are respectively He can perceive and process responsible for fine different stimuli and sensations and gross muscle such as pain, heat and cold as movement and well as the different smells and control, speech and tastes of the food served language, memory, appropriately. The client can and interpretation also show purposeful control of of the different the extremities and body sensations and movements. However, tremors stimuli. For of the left hand and feet are schizophrenic visible particularly when the client, these areas client is walking and sitting. of the brain together with the neurological imbalances are damaged. These all result to different positive and negative symptoms of the disease that are most of the time tremendous and life-threatening to its victim.

H. Mental Status Examination

The patient takes a bath every day, wears appropriate dress which is the yellow clothes, stands in kyphotic posture, weak, with poor eye contact. He has fine to course tremors of the extremities more evident at the left extremities especially when walking and sitting on a chair. D I S A. General Appearance and motor behavior T U R B A N C E The patient speaks in a slow manner with slurring and shows disorganization of thoughts/topics and ideas sometimes. Psychomotor Retardation- The patient has a consistent overall slowed movement. It takes a while for him to walk from the chair going close to the board when asked to read. Automatisms- The patient repeatedly holds his head with two hands then looks upward and downward particularly when not doing anything. He always give five and wave his hand whenever he sees familiar persons or faces, e.g., to student nurses.

B. Communication

Mutism- This is the extreme form of negativism. The patient refused to talk about making his own family because according to him, there will be no woman fit for her. Flight of ideas- The patient was telling

D I S T U R B A N C E

something about the car seen in front of us. He was telling that it was his car then suddenly he heard the sound of helicopter passing the area and he said that Robin Padilla was inside the helicopter.

Looseness of associations- the client suddenly talks about Ligtong Highschool when talking about the jeepney and helicopter.

Blocking- There were times in our conversations that the patients abruptly stop talking or sharing his thoughts. This made other client told Traffic!

Echolalia- He will be saying exactly the same answer of other client on certain topic. E.g., Student nurse: Exercise po tayo Perea: Exercise po tayo Student nurse: Tayo na po tayo Perea: Tayo na po tayo Slurred of Speech- The patient has difficulty in speaking. He talked in depth and the words are not pronounced the way it should be and incomprehensible sometimes. Latency of response- The patient takes a few seconds before answering some questions for about 35-45 seconds and sometimes the question should be asked twice so that he can understand what you are trying to say.

C. Perception, Thought

The way of thinking was far from his age. He

Process

and content D I S T U R B A N C E

thinks concretely with inability to demonstrate abstract thinking and reasoning.. He thinks and talks about simple things like car, sun, clouds, house, mountains, trees, rains, etc. Delusions- The false belief that cannot be corrected by logic. He believes that they have mazda3. He insisted that Ligtong high school is located in Tagaytay City. He believes that he is already 40 years old wherein he is only 36 year old upon verification to his chart. Upon admission he was claiming that he was a 6 years old boy. Preoccupations- this means that recurrent thought or center of particular idea or thought with an intense emotional component. In every interaction, the patient kept saying he wanted to go home because he missed every member of his family.

Mood and the affect are unpredictable.

Blunted affect- the patient most of the time had flat affect. It shows that he was not interested on whatevers happening in the environment but claimed that hes enjoying it and was happy. D. Mood and Affect D I S T U Restricted affect- This means that a person displaying one type of expression. The patient always in serious expressing his thoughts and emotions. Even though he was telling that he was happy, he remained serious and was not even smiling. Labile mood- The patient rapidly changes moods. He was unpredictable. From being serious to funny then serious again.

R B A N C E Apathy- Majority of our planned activities was full of fun, knowledge and most importantly they were therapeutic. The patient seemed to have lack of interest in the activities especially when we had the recreational therapy that includes different plays. He only joined once and he easily gets tired. The patient was orientated to time, place and person that hes having a regular interaction. Some persons outside the institutions like his friends before are unrecognizable. Hes short term and long term memories are impaired. The abstract thinking ability was poor and almost absent. Hes concentration and focus can be easily distracted by nuisance and other stimuli. Alterations in orientation- the person cannot identify the woman who visited him a few months ago if that was his mother or his auntie. Memory impairment- The patient was asked in the ward after having an activity. He was asked about the things they have done for that day and he replied, nagdrawing po. We dont initiated drawing that day. Disturbances in retention and attentionRetention have something to do with the memory of the patient on how he remembers things well that happen in the past. Attention was poor because of the different factors including the environmental factor. Intellectual functioning- This means the inability to use abstract thinking and utilizing concrete thinkingliteral

E. Sensorium and intellectual Process

D I S T U R B A N C E

translations/interpretation. The house is just a house and the sun is a sun. Superficial reasoning is manifested by the client, no causations and cause and effect being used about the topic. D I S T F. Judgment and Insight U R B A N C E The patient sense himself as a bad and useless person. Poor insight- The patient was not able to identify strengths and weaknesses that may affect the response of treatment. He didnt have understanding of his disease and its management. Judgment refers to the ability to interpret ones environment and situation correctly and to adapt ones decisions and behaviors accordingly. Insight is the ability to understand the true nature of ones situation and accept some personal responsibility for that situation.

G. Self-concept

The patient has weak ego and sometimes hopeless about achieving his dreams in life because for him, it will take more time before he finally go home. The patient displayed bizarre behaviors such as not wearing shorts sometimes when inside the ward, kissing other client and masturbating.

The patient has difficulty in maintaining relationship. H. Roles and Relationships The patient did not participate in our activities for two days and stayed inside the ward instead. Sometimes he wanted to go back in the ward even the activity was not yet done and claiming that hes having a headache.

I. Functional Assessment Health Perception The patient was asked about his present condition and he answered, Ayos lang po sir. He seemed not to be in good condition. There was an obvious sadness in his face. He displayed poor eye contact and most of the time answered questions in short statements. The client has history of substance abuse such as smoking cigarettes, alcoholic beverages and marijuana. He is under the rehabilitative phase of treatment in the ward and verbalized willingness to be discharged soon enough to visit and be with his family. Nutritional and Metabolic Pattern

The clients daily food intake is regulated by the staff of the rehabilitation ward. He eats what the rest of the clients inside the ward eat. He said hes not choosing food to eat and verbalized that the food that we served were all good and delicious. Due to fear and to avoid food-drug interaction, foods to be served to him and to other clients need to free from cheese, chocolates and other ingredients that might bring adverse effect. Hes upper central incisors are decayed while the lower incisors were missing already. He too has no reported signs of food and drug allergies. Activity-exercise pattern The different exercises that are initiated by the group are considered to be his form of exercise. It is already a regular session to start the activity for the day. It was noted that the client had difficulty performing the portrayed steps of exercises done by the students but he was trying his best to follow and participate. He had fine to course tremors of the extremities that contribute to movement difficulties. Elimination Pattern The client has no difficulty voiding and defecating every day. Voiding according to him usually follows after drinking water or juice or approximately 40-50cc per hour. Defecation of the client takes place one to two times per day. He said it is usually well formed and with foul odor. Sleep-Rest Pattern

The patient had no sleeping difficulty. Usual sleeping hours of the client ranges from 6-8 hours every night. He wakes up 4am every morning to comply with the institutional policy. At day time, if he is not doing anything or no student nurses to attend them and bring them outside, he takes some naps or watches television which is located at the wall of the ward lobby. Role- Relationship Pattern The client usually isolates himself from other client inside the ward. He only talks when somebody initiated the conversation first but with problems maintaining good and long interaction. He greeted those persons that are familiar to him by waving his hands. He didnt answer when asked about his family and other relatives. Self esteem The patient showed low self-esteem. He also added that he can never have his own family because no woman would have the courage to love someone like him. He often shared about going home again but said that it is a dream. The patient had never been discharged since his admission last 2007. Coping and Stress Management Pattern The client watches television and sleeps when feeling tired or feeling alone and sad. According to him, hes get used to sleeping at day time. Personal Habits

He said that he is just following the routine activities in the area starting from the morning until the time of sleeping. He takes a bath, brushes his teeth, eats regular meals and participates in some activities outside when asked to do so such as sweeping dry leaves with the supervision of the staff on duty. Environmental hazards The client is staying inside the rehabilitation ward together with other clients. Sharps and other hazardous objects and materials are not being kept and allowed inside the ward. Students and visitors are also being informed and advised about things that might threaten their safety. The rehabilitation ward is still spacious and good to accommodate the number of clients they cater at that time. The ward has wide windows and doors that allow direct visualization and monitoring of the clients inside by the nurse on duty.

III.

Problem List Problem No. Problem Date identified Date Resolved

Actual Active /Problems Risk or Potential Problem

DISTURBED SENSORY PERCEPTION; AUDITORY Cues/Data Nursing Diagnosis Disturbed sensory perception; Auditory related to biochemical imbalances specifically increased dopamine levels Background Knowledge Patients with disturbed sensory perception experiences changes in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted or impaired response to such stimuli. Goal Short Term After two hours of nursing intervention, the client will be able to recognize and correct false belief w Long Term After weeks of nursing intervention, the patient will regain normal level of cognition and maintain reality orientation. Established rapport. To build trust and facilitate expression of thoughts and feelings. To assess degree of sensory impairment. GOAL MET Patient was freed from injury and was kept safe. He was able to recognize presence of sensory impairment. Intervention Rationale Evaluation

Subjective: Yan ung naririnig ko na kotse kagabi kaya hindi ako makatulog, as verbalized by the patient.

Observed for behavioral responses like hallucination, delusions, withdrawal, inappropriate affect, confusion/ disorientation. Encouraged patient to talk about his feelings and perceptions in a therapeutic manner. Reoriented the patient to

Objective: Poor concentration Altered communication pattern (confabulations) Hallucinations Labile mood

Probing may increase suspicion and interferes with good nursepatient relationship.

person, place, time and events as necessary. Provided safe, quiet and calm environment. Provided strict supervision.

To promote normalization of response to stimuli. To avoid injuries and over stimulation that my trigger increase anxiety level and aggressive behavior. Provides sensory stimulation and will reorient patient to reality.

Involved patient in different treatment modalities such as music therapy and remotivation therapy. Scheduled structured

Provides stimulation without undue

activity and rest periods with clear, simple directions/ rules and simple sentences.

fatigue. Clear and consistent limits provide a secure structure for the patient. Interacting with reality is therapeutic to the patient. Never accept the hallucinations as reality- it will reinforce delusion (Videbeck).

Presented reality concisely and briefly.

Enhances commitment and continuation of plan, optimizing outcomes.

Provided explanations of and planned care

with the client.

DISTURBED THOUGHT PROCESS Cues/Data Nursing Diagnosis Disturbed thought process related to increased dopamine levels as evidenced by delusional thoughts, distractibility and impaired judgement secondary to schizophrenia undifferentiated type. Background Knowledge One of the many symptoms of schizophreni a, undifferentiat ed type is the pronounced delusions. Delusion which is a false and fixed belief that cannot be corrected by logical reasoning. When confronted and corrected, client might experienced anxiety and Goal Short Term Within the shift the patient will respond to realitybased interactions initiated by the student nurse appropriatel y. Long Term After 4 months of nursing intervention with proper medical management, the patient will regain his normal and usual orientation to reality. Assessed the clients condition including nature of the problem, current level of functioning and effect of the delusional thoughts to his life. Assessed the patients thoughts process. Noted orientation to time, place, person, insight and judgment. Assessed the patients attention span and ability to make decisions or problem solve. Established rapport. To evaluate the extent of thought process disturbance GOAL MET. The patient was able to interact with the student nurse and expressed his thoughts and feelings with no inhibitions. Intervention Rationale Evaluation

Subjective: Meron kaming mga kotse at helicopter ang driver si robin, as verbalized by the patient.

Objective: Delusional thinking Non reality based thinking Short attention span Distractibility Impaired judgment

To determine the patients ability to participate in planning care.

To build trust and facilitate expression of thoughts and feelings.

might withdraw self from the previously established relationship between the nurses.

Established alternate means of self expression such as writing and drawing. Maintained a safe, pleasant, quiet environment and approached the client in a slow, calm manner. Scheduled structured activity and rest periods with clear, simple directions/ rules and simple sentences. Listened to the patient with regard and sincerity.

To recognize the clients perceptions and understand the patients feelings. To inhibit stimulation of the client that will improve escalate his delusions. Provides stimulation without undue fatigue. Some client when overwhelmed experience thought disturbances. Listening conveys to the client that he is worthwhile as a person and worth talking to. According to Videbeck, they are very sensitive attention seeker and needs to be attended to

facilitate or foster necessary changes. Exploring the content of the client delusion does not reinforce his false belief. It is a strategy in order to determine the falseness or truthfulness of what he said in order to correct in a nonthreatening manner. Empathy conveys caring, interest and acceptance. When this type of client perceives that someone is willing to listen and help them when in need, self integrity and worth are preserved and increased. Some therapies are facilitated to serve

Explore the content of the clients delusional thought and presented reality concisely and briefly.

Showed empathy regarding the patients feelings; reassured patient of presence and acceptance.

Emphasized the importance of cooperation with therapeutic regimen such as small group therapy and Remotivational therapy.

as catharsis; through which the client will be able to deal little by little the different events of the past and present helping them instil positive self- coping mechanisms.

SELF CARE DEFICIT Cues/Data Nursing Diagnosis Background Knowledge Goal Short Term Long Term GOAL MET. Self-care deficit is typical expectation for client with schizophrenia of any type. According to Lippincotts Nursing Review for NCLEX, selfdirected activities that used to be attended by the client seemed to be overwhelmin g to them. After two hours of nursing intervention, the client will be able to perform some if not all of the different activities of daily living directed to maintain good personal hygiene such as brushing of teeth and taking regular bath. To promote good hygiene and physical comfort Assessed the clients condition tracing the underlying reason of self-care deficit. Established rapport with the patient. Serve as baseline data. Intervention Rationale Evaluation

Subjective: Ayoko na stated by the patient when he was told to lengthen the duration of brushing his teeth Self-care deficit: Hygiene related to cognitive impairment as manifested by body odor, dental Objective: carries and has body odor severe itching of skin 2 to (+) dental carries Schizophreni a, severe itching undifferentiat of skin ed type. 3-5 seconds duration of brushing his teeth

To be able to build therapeutic relationship with the patient that will serve as a ground for instilling changes as planned.

After two hours of nursing intervention, the client initiated brushing his teeth and verbalizes that hell take a bath every day.

Determined the individual strengths and skills of the patient in performing self care.

To find out the degree of impairment and the intervention needed.

- To correct patients way of performing selfcare while promoting selfcare independence.

- To enhance commitment to plan, optimizing outcomes and supporting health promotion.

They

- To schedule activities conforming t

eventually lose the initiative to perform different activities of daily living such as brushing the teeth, changing clothing and even putting on their slippers. It is therefore the responsibility of the nurse or the caregiver to assist the client little by little in the performance of daily living to facilitate independence as soon as

Assisted the client in performing self-care activities such as in brushing his teeth.

To facilitate and help the client perform necessary activities to maintain good oral hygiene.

Encouraged the client verbalization and perception about hygiene and the different activities to maintain good hygiene.

In a manner that will not challenge the client, perception or insight of the client about the problem will provide the nurse an idea on which to start or give emphasis first. Setting contract is therapeutic and enhances the clients eventual taking

Set contract with the client that before each interaction with the student nurse,

possible to avoid total dependence of the client. If necessary, structured activity and tasks must be planned to cope the clients situation.

starting the next day, he should have taken a bath before going out and will brush his teeth before the activity starts.

independence in performing selfcare. Skinners operant conditioning Theory states that the behavior that is rewarded and accepted, clearly understood by the client is the behavior that is continued.

Emphasized the importance of good oral and personal hygiene.

Client who loses the initiative of doing self-care also loses the sound judgment of its importance. Most often than not, when client recognized and perceived the

benefits of doing such, instruction and fostering changes take place in abit.

IMPAIRED SKIN INTEGRITY Cues/Data Nursing Diagnosis Impaired skin integrity related to mechanical factor/press ure as evidenced by the presence of the distributed/s caterred wounds and scratches secondary to parasitic infestation (sarcoptes scabei). Background Knowledge The clients impaired skin integrity is due to frequent scratching due to itchiness. This was brought by the infestations of the parasitic mites that the other client in the rehabilitation ward also acquired. The epidermal and dermal layer of the Goal Short Term After 2 hours of nursing intervention, the client will be able to recognize, understand and participate with the different necessary activities or preventive measures in order to preserve skin integrity. Long Term After one month of nursing intervention, the client will be able to regain the normal and usual skin integrity. Assessed patients condition; characteristics of wounds and scratches as well as the different areas that are affected. To determine the degree of the problem. Goal Unmet. The client cannot control himself from scratching the wounds and skin especially when itchy. Intervention Rationale Evaluation

Subjective: Kati Sir, kati. as verbalized by the patient.

Objective: (+) rashes that progresses throughout the extremities and buttock (+) abrasions and lesions in both extremities scars from previous

Noted skin color, texture characteristics of lesions including color changes, width, depth, odor and discharges.

To identify the degree of skin damage and for future comparisons.

Determined nutritional status.

Malnutrition may contribute in delayed healing of tissue.

- Itching can be a side effect of psychotropic drugs.

- To identify risk for self- inflict injury and ability to perform selfcare skills.

- To identify areas to be addressed in teaching plan and potential referral needs.

wound skin warm to touch

skin are damaged which loses the integrity of the skin to protect the inner layer from mechanical or chemical attack.

Ascertain attitudes of an individual about the wounds and scratches that he has.

To identify the amount and the type of teaching approach necessary to address the problem.

Applied povidoneiodine on wounds and covered them with sterile gauze.

To prevent complications of the wounds.

Inspected the clients skin and wounds every day before and after interaction.

To monitor healing progress as well as id complication exist.

Cut/trimmed the clients nails into short.

To prevent damage to the skin when itchiness is felt.

Informed the client about the importance of good personal hygiene in facilitating wound healing.

To instil the clients responsibility in preventing wound complication thus facilitating faster healing of the wounds.

Advised the client not to touch, rub or scratch the wounds by bare hands especially if hands are not washed with soap and water before doing so.

To prevent wound contamination.

Impaired Social Interaction Cues/Data Nursing Diagnosis Impaired social interaction r/t disturbed thought process as evidenced by withdrawn behavior and flat facial expression secondary to the presence of the disease: Schizophrenia, Undifferentiate d type. Background Knowledge Client when cannot tolerate the external and internal stimuli chooses to stay alone and inhibits social interaction. He used to be an active participant of the different activities and claimed to be having a headache to be excused from the group going out. Videbeck Goal Short Term After the shift, the patient will develop trusting relationship with nurse and will demonstrate willingness and desire to socialize with others. Long Term After three weeks of nursing intervention, the client will be able to maintain trusting relationship with others and will be utilize effectively the different social support system available in order to avoid future isolation and social withdrawal. Assessed the clients condition by asking the nurse on duty. To determine the causative factors of the clients withdrawn behavior. This may mean just sitting in silence for a while.Nurses presence may help improve client's perception of self as a worthwhile person. Show unconditional positive regard. Presence, acceptance, and conveyance of positive regard enhance the client's feelings of selfworth. Goal Met: The client was able to join group activities during the socialization day. Intervention Rationale Evaluation

Subjective: Hindi labas sir sakit ulo,as verbalized by the patient.

Spent time with the client.

Objective: - patient did not attend the program twice. Has withdrawn behavior. Sits on bed while staring on his palms. Avoids talking to other client inside the ward.

Develop a therapeutic nurseclient relationship through frequent, brief contacts and an accepting attitude.

identifies this one as a form of clients strategy in order to give time for self to manage internal or external feeling of isolation

Encouraged attendance in group activities paying particular concern on the different benefits those activities will give him.

To enhance interest of the client in participating with the different activities.

Acknowledge that his or her absence Acknowledged was noticed may client's absence from reinforce the any group activities client's feelings of and respect his self-worth. decision without verbal or any form of punishments. Clients when able to verbalize concerns find peace Encouraged the clients verbalization in mind and hearts. This will also of feelings about avoiding interactions provide the nurse and being withdrawn the basis of health teaching or in sometimes. instilling positive coping behaviors if needed.

IV. Anatomy and Physiology THE ANATOMY AND PHYSIOLOGY OF THE HUMAN BRAIN The anatomy of the brain is complex due its intricate structure and function. This amazing organ acts as a control center by receiving, interpreting, and directing sensory information throughout the body. There are three major divisions of the brain. They are the forebrain, the midbrain, and the hindbrain. Brain Divisions A. Forebrain is responsible for a variety of functions including receiving and processing sensory information, thinking, perceiving, producing and understanding language, and controlling motor function. Two major divisions of forebrain: a. Diencephalon = contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control, relaying sensory information, and controlling autonomic functions. b. telencephalon = contains the largest part of the brain, the cerebral cortex. Most of the actual information processing in the brain takes place in the cerebral cortex. B. Midbrain and the hindbrain together make up the brainstem. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. The metencephalon contains structures such as the pons and cerebellum. These regions assist in maintaining balance and equilibrium, movement coordination, and the conduction of sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing, heart rate, and digestion. The Brain Structures
A. Basal Ganglia

Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

B. Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons. C. Broca's Area Speech production Understanding language D. Central Sulcus (Fissure of Rolando)
Deep grove that separates the parietal and frontal lobes

E. Cerebellum Controls movement coordination Maintains balance and equilibrium F. Cerebral Cortex
Outer portion (1.5mm to 5mm) of the cerebrum

Receives and processes sensory information Divided into cerebral cortex lobes G. Cerebral Cortex Lobes
Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition Parietal Lobes - receives and processes sensory information Temporal Lobes -

involved with emotional responses, memory, and speech H. Cerebrum Largest portion of the brain Consists of folded bulges called gyri that create deep furrows I. Corpus Callosum Thick band of fibers that connects the left and right brain hemispheres

J. Limbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions

and the regulation of aggressive behavior

Fornix - an arching, fibrous band of nerve fibers that connect the hippocampus to the

hypothalamus
Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere

for long-term storage and retrieves them when necessary

Hypothalamus - directs a multitude of important functions such as body temperature,

hunger, and homeostasis

Olfactory Cortex - receives sensory information from the olfactory bulb and is

involved in the identification of odors

Thalamus - mass of grey matter cells that relay sensory signals to and from the spinal

cord and the cerebrum K. Medulla Oblongata Lower part of the brainstem that helps to control autonomic functions L. Meninges Membranes that cover and protect the brain and spinal cord M. Olfactory Bulb Bulb-shaped end of the olfactory lobe Involved in the sense of smell N. Pineal Gland Endocrine gland involved in biological rhythms Secretes the hormone melatonin O. Pituitary Gland Endocrine gland involved in homeostasis Regulates other endocrine glands P. Pons Relays sensory information between the cerebrum and cerebellum Q. Reticular Formation

 Nerve fibers located inside the brainstem Regulates awareness and sleep R. Substantia Nigra
Helps to control voluntary movement and regualtes mood. Aqueduct of Sylvius - canal that is located between the third ventricle and the fourth

ventricle Choroid Plexus - produces cerebrospinal fluid Fourth Ventricle - canal that runs between the pons, medulla oblongata, and the cerebellum Lateral Ventricle - largest of the ventricles and located in both brain hemispheres Third Ventricle - provides a pathway for cerebrospinal fluid to flow

S. Wernicke's Area Region of the brain where spoken language is understood

V. Psychopathology

VI. Psychopharmacology

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIO N

ADVERSE EFFECTS

NURSING RESPONSIBILITIES

Generic Name:

Mechanism of action not fully understood: Risperidone Blocks dopamine serotonin Brand Name: and receptors in the Risperdal brain, depresses the Classification: RAS; CNS agent, anticholinergic, antipsychotic, antihistaminic, and atypical alpha-adrenergic blocking activity Dose: may contribute to some of its 1 cc therapeutic and Frequency: BID adverse actions. Presentation: Oral solution

Treatment schizophrenia

of Contraindicated with hypersensitivity to risperidone, lactation. Delaying relapse in long-term treatment of Use cautiously with schizophrenia cardiovascular disease, pregnancy, renal or Unlabeled uses: hepatic impairment, Bipolar disorder; hypotension. treatment of patients with dementia-related psychotic symptoms

CNS: Insomnia, anxiety, agitation, headache, somnolence, aggression, dizziness, tardive dyskinesias CV: Orthostatic hypotension, arrhythmias Dermatologic: Rash, dry skin, seborrhea, photosensitivity GI: Nausea, vomiting, constipation, abdominal discomfort, dry mouth, increased saliva

Assessment History: Allergy to risperidone, lactation, CV disease, pregnancy, renal or hepatic impairment, hypotension Physical: Temp, weight; reflexes, orientation; P, BP, orthostatic BP; R, adventitious sounds; bowel sounds, normal output, liver evaluation; CBC, urinalysis, liver and kidney function tests

Respiratory: Rhinitis, Nursing coughing, sinusitis, Responsibilities pharyngitis, dyspnea Maintain seizure precautions, especially Other: Chest pain, when initiating therapy arthralgia, back pain, fever, and increasing dosage. neuroleptic malignant syndrome, diabetes Mix oral solution with mellitus 34 oz of water, coffee, orange juice, or low-fat Adverse effects in Italic milk. Do not mix with

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIO N

ADVERSE REACTION

NURSING RESPONSIBILITIES

Generic Name: Divalproex Sodium Brand Name: Depakote ER Classification: Anti-convulsant Dose: 500 mg Presentation: Tablet

Increases level of gamma/amino butyric in brain, which decreases seizure activity.

Treatment of primary Hepatic dysfunction, urea generalized seizures, cycle disorder and notably absence and myoclonic seizures, and also for partial seizures. Also used to treat acute manic phase of bipolar disorders. For the prophylaxis of migraine.

The most frequent adverse Assess for effects are GI disturbances, complaints. particularly in initiation of therapy. Assess for pain.

GI

Assess for changes in bowel. Assess for EPS. Instruct the patient to inform physician of transient intestinal cramps, increased plasma prolactin levels and if EPS occur.

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIO N

ADVERSE REACTION

NURSING RESPONSIBILITIES

Generic Name: clozapine Brand Name: Clozaril Classification: Antipsychotic s Dose: 100 mg Frequency: Presentation: Tablet

Clozapine has relatively weak dopamine receptorblocking activity at D1, D2, D3 and D5 receptors but has high affinity for the D4 receptor. It has also blocking effects on serotonin, adrenergic histamine H1 and cholinergic receptors.

Management of severely ill schizophrenics who are unresponsive to standard antipsychotic drugs. Reduction of the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder.

Contraindicated with allergy to clozapine, myeloproliferative disorders, history of clozapine-induced agranulocytosis or severe granulocytopenia, severe CNS depression, comatose states, history of seizure disorders, lactation. Use cautiously with CV disease, prostate enlargement, narrowangle glaucoma, pregnancy.

CNS: sedation, dizziness, headache, disturbed nightmares, agitation, salivation, tardive neuroleptic syndrome

History: Allergy to clozapine, myeloproliferative disorders, history of clozapine-induced agranulocytosis or severe granulocytopenia, severe CNS depression, comatose states, history of seizure disorders, CV prostate CV: Tachycardia, disease, narrowhypotension, ECG changes, enlargement, angle glaucoma, hypertension lactation, pregnancy GI: Nausea, vomiting, constipation, abdominal Physical: T, weight; discomfort, dry mouth reflexes, orientation, GU: Urinary abnormalities intraocular pressure, ophthalmologic exam; P, BP, orthostatic BP, Hematologic: Leukopenia, ECG; R, adventitious granulocytopenia, sounds; bowel sounds, agranulocytopenia normal output, liver evaluation; prostate Other: Fever, weight gain, palpation, normal urine rash output; CBC, urinalysis, liver and kidney function tests, EEG Nursing Responsibilisties:

Drowsiness, seizures, syncope, tremor, sleep, restlessness, increased sweating, dyskinesia, malignant

Assessment

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIO N

ADVERSE REACTION

NURSING RESPONSIBILITIES

Generic Name: levomepromazi ne Brand Name: Nozinan Classification: Antipsychotics Dose: 100 mg Frequency: HS Presentation: Tablet

Levomepromazin Schizophrenia e is a phenothiazine with CNS depressant, adrenergicblocking, antimuscarinic, antihistaminic and analgesic activity. It acts by blocking dopamine receptors in the mesolimbic dopaminergic system.

Comatose state Severe CNS depression

Pheochromocytoma Blood dyscrasia.

Hypotension, orthostatic hypotension, tachycardia, QT prolongation; photosensitivity, rash; gynaecomastia, wt gain, irregular menstruation, changes in libido; extrapyramidal effects, dizziness, seizure, headache, drowsiness, neuroleptic malignant syndrome, interference with temperature regulation; constipation, nausea, vomiting, ileus; urinary retention, ejaculatory disorders, incontinence, polyuria, priapism; blood dyscrasias; jaundice, hepatotoxicity.

Assess the client for history of drug allergies, cardiac problems and other drugs prescribed. Inform the client of side effects and encourage to report problems instead of discontinuing medication

Teach client methods of managing or avoiding unpleasant side effects and maintaining medication regimen for: Dry mouth sugar-free fluids and sugar-free hard candy. Client should avoid calorieladen beverages and candy

Potentially Fatal: Arrhythmias. Severe constipation exercise, orthostatic hypotension. increase water and bulkforming foods; stool softener permissible but avoid laxatives photosensitivityuse sunscreen

VII.

Progress Notes