I.

Introduction This Case Presentation was done to learn more about schizophrenia paranoid type, this particular case is about a single mother that suffered post partum psychosis 4 weeks after giving birth (1992), she was able to recover completely, the present psychosis develop after a work accident in which she develop paranoia, we the graduate students of Liceo De Cagayan University, Masters in Nursing major in Psychiatric Nursing, found interest in the case since this is a mother and son admission In the institution (New Day Recovery Center) it is very rear to see this kind of admission in which the mother is not aware that she also has Schizophrenia like her son. Objective In 1week of affiliation in the House of Hope, we can gather appropriate data to study this particular case. Spot Map The site for home visit and family interview was not materialized to the groups limitation. Scope and limitation We are limited to the data present in the residents chart and information given by the client in a interview, we are not able to visit the family due to time and financial factors. Definitions SCHIZOPHRENIA PARANOID TYPE - Paranoid type schizophrenia is a mental illness that involves false beliefs of being persecuted or plotted against.

BIPOLAR DISORDER MANIC TYPE - is a condition displayed in the person suffering from Type 2 Bipolar Disorder. The Bipolar Disorder Type 2 borders on Mania. A person faces bouts of depressive episodes at intervals recurring between months, weeks and even days. Generally, the frequent recurrence is caused by leaving the situation unattended and this aggravation causes the episode to happen again and again. A person suffering from Bipolar Disorder Manic Depression has a very low self esteem and avoids any social interaction. They also prefer to live in isolation. SCHIZOAFFECTIVE DISORDER - is a psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood that alternate with, or occur together with, distortions in perception.

Patients Profile Name: Mr. E Primary Care Provider: Mrs. JBC DOB March 30,1989 Race: Marital Status: Single Age: 49 years old Sex: Male Ethnicity: Filipino No. Marriages: 0 Room No. male ward

If married/divorce/separated/widowed, how long? At the age of 28 her boy friend left her with her unborn child Occupation/School (Grade): Kakanin and vegetable Vendor Highest Educational Level: Elementary Graduate Religious Affiliation: Catholic City of Residence: Sto. Thomas, Davao Del Norte Name/Phone # of Significant Other: Mrs. JBC (mother) and Mr. EBC ( brother) Primary Dialect/Languag Spoken: Filipino (Visayan) Chief Complaints (in patients own words): ipa tambal nako akoa anak kay na lain ang huna huna DSM-IV TR Diagnosis (previous/current): schizophrenia paranoid type vs. bipolar disorder manic type vs. schizoaffective disorder. Nursing Diagnosis: Potential to harm others and self related to psychotic episode

II. ANAMNESIS Araceli became a single mother at the age of 28. Her boyfriend abandoned her and her unborn child for an indefinite reason. A year after giving birth, Araceli experienced the so called bughat-tingag, wherein her family noticed her to act indifferently. But after sometime, she was able to recover from the said illness. Araceli raised her son alone despite of poverty they are facing. She was engage in vending kakanin, vegetables, and other goods. She also worked as a househelp. In 2001, while she cooked food for her employer, the gas stove exploded and the kitchen

area was covered with fire. After this incident, her employer noticed sudden change in Aracelis behavior. She became suspicious and doubtful to other people. Araceli stopped working. She exhibited violent and hostile behavior against her family after they had subjected her to Davao Mental Hospital for medical evaluation wherein she was admitted for almost a week. This effort did not succeed since Araceli resisted taking her medications. Since then, family relations became difficult as she displayed violent and hostile behavior against her family. She started to hate her family and blame other people including the government for what had happened to them. Despite her mental condition, Araceli is very attached to her son, John in whom she is very protective of him. She exerted all her efforts to sustain their subsistence yet it was unsuccessful because they lack resources. All their life they endured in too much poverty and helplessness.

III. Course in the Hospital Mental status exam I- Presentation Patient is a 49 year old female Filipina, brown, thin, wearing printed blouse and skirt , hair fixed ,neatly combed, fingernails and toenails trimmed ,is normoactive, appears suspicious with the examiner and her surroundings, cannot maintain eye to eye contact, sits in a slouched position, looks older than her age.

II- Stream of talk She responded to the question being asked spontaneously.. She speaks in low, soft voice. The client answered one question at a time. Her responses were sometimes irrelevant to the questions being asked. She had circumstantiality. Her accessibility is good. III- Emotional state and reaction Clients mood is sad. She kept on verbalizing about her sons condition. She worries most of the time. She also appeared anxious every time she mentions about her neighbour, Martha. Her affect is appropriate to her mood. potential noted. Depersonalization and Derealizations were absent. IV- Thought Content No Auditory and visual Hallucinations observed during the duty. The patient has Persecutory delusions. She reported being ridiculed and belittled by Martha. She emphasized that MARTHA is the one responsible for her sons illness. As verbalized by patient, iya man ng gidaot ang utuk sa akong anak, kabit na siya sa kung bana and that Martha, her persecutor took all their properties. V- Neurovegetative dysfunction Patient verbalized she sleeps well at night. Her appetite is good She has not experienced diurnal variation. Her libido is fair. Homicidal and suicidal

VI- General Sensorium and Intellectual Status Patient was alert, conscious and is oriented to date time place and person. Her memory is good. Her attention span is fair. Calculation ability is good. Judgment and reasoning are unimpaired. Knowledge on General information is fair and Abstract thinking ability is unimpaired. VIIInsight

Insight is poor. She stated that she was in the institution to look after her son. She denied having mental illness as what people say.

Summary of Mental Status Examination Disturbance in: Presentation Stream of talk ( / ) Emotional state and reaction

( / ) Thought content

Neurovegetative dysfunction General Sensorium and Intellectual Status ( / ) Insight Diagnostic (/) Functional (/)Psychotic Organic Non-psychotic

MENTAL STATUS ASSESSMENT AND TOOL Presenting Problem: Patient appears anxious and suspicious with other people as evidenced by minimal eye contact,eyes gazing, wandering around. APPEARANCE (Describe) Grooming/dress Hygiene Eye contact Posture

Day 1 appropriate Good Poor slouched

Day 2 appropriate good poor slouched

Identifying

features Looks older than her Looks older than her age

(marks/scars/tattoos) Appearance versus stated age

age Overall appearance Fair Fair NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help the client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion with: Tell me more. A less direct and more conversational tone at the beginning of the interview may help reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship. BEHAVIOR/ACTIVITY (Check if present) Day 1 Hyperactive Agitated Psychomotor retardation Calm Tremors Unusual movements/gestures Catatonia Akathisia Rigidity Facial movements (jaw/lip smacking) Other specify: Wringing of hands at times

Day 2

SPEECH (Describe) Slow/Rapid Pressured Tone

Day 1 Fair /

Day 2

Volume (loud/soft) Soft Fluency (mute/hesitation/latency of response) Other specify:

ATTITUDE Is client: (Check if present) Cooperative Uncooperative Warm/friendly Distant Suspicious Combative Guarded Aggressive Hostile Aloof Apathetic Other specify: MOOD & AFFECT Is client: (Check if present) Elated Sad Depressed Irritable Anxious Fearful Guilty Worried Angry Hopeless Labile Mixed (anxious & depressed) Is Clients affect : Flat Blunted or diminished Appropriate Inappropriate/incongruent Other specify:

Day 1

Day 2 /

/ /

/ /

Day 1 / / /

Day 2 / / /

THOUGHT PROCESS (Check if present) Concrete Thinking Circumstantiality Tangentiality Loose Association Echolalia Flight of Ideas Perseveration Clang association Blocking Word Salad Derailment Others Specify: THOUGHT CONTENT Does client have: (Check

Day 1 /

Day 2 /

if Day 1

Day 2

present) Delusions a. Grandiose b. Persecutory / / c. Reference d. Somatic Suicidal thoughts Homicidal thoughts If Homicidal, towards whom? Obsessions / / Paranoia Phobias Magical Thinking Poverty of Speech Others Specify: NOTE: Questions around suicide and homicide need to be direct. For instance, are you thinking of harming yourself/another person right now? (If another, who?) Clients will usually admit suicidal thoughts if asked directly but will not always volunteer this information. Any threat to harm someone else requires informing the potential victim and the authorities.

PERCEPTUAL DISTURBANCES Is client experiencing: (Check if Day 1 present) Visual Hallucinations Auditory Hallucinations a. Commenting b. Discussing c. Commanding d. Loud e. Soft f. Other Other Hallucination (olfactory/tactile) Illusions Depersonalization Others Specify: MEMORY/COGNITIVE Day 1 Orientation (YES/NO) a. Time b. Place c. Person Memory (Good/Poor) a. Recent b. Remote c. Confabulation (Y/N) Level of Alertness / / / Good Good No conscious Alert

Day 3

Day 2 / / / good Good No conscious alert

INSIGHT and JUDGMENT Day 1 Insight (Awareness of the nature Poor Day 2 Poor

of the illness) Judgment (Good/Poor) Good Good Impulse Control (Good/Poor) Good Good Concentration (Good/Poor) Good Good Attention (Good/Poor) Fair Fair Others Specify: NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help the client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion with: Tell me more. A less direct and more conversational tone at the beginning of the interview may help reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship.

DSM-IV-TR MULTIAXIAL CLASSIFICATION AND TOOL Allows for assessment on various axes, which provides information on different domains, and assists in planning interventions and identifying outcomes. AXIS I Clinical Disorder Schizoaffective vs. bipolar disorder,vs. (or focus of clinical attention) [Include diagnostic code/DSM IV AXIS II name] Personality Disorders/ Mental Retardation [Include diagnostic code/DSM IV AXIS III AXIS name] General Medical Condition [Include ICD-9-CM code/name] Psychosocial/Environmental None Family/primary support group None Paranoid schizophrenia

IV

[family/primary

support

group/

social/occupational/educational/ AXIS V health care/legal/crime/other] Global Assessment of Functioning 75 (GAF) Current/hospital : Highest level past year/discharge:

IV. PSYCHODYNAMICS A. A tabular presentation of the Predisposing Factors FACTORS I. Predisposing Factors a. Gender and Age PRESENT Patient is a 49 year old female RATIONALE According to Kaplan,

Schizophrenia is equally prevalent in men and women. The two

genders differ, however,

in the onset and course of illness. Unlike men, women display a

bimodal age distribution, with a second peak

occurring in middle age. Approximately 3 to 10 percent of women with Schizophrenia present

with disease onset after age 40. About 90

percent of patients in treatment Schizophrenia between years old. b. Birth Season Patient was born on June 26, 1962. According Persons to who Kaplan, develop 15 and for are 55

Schizophrenia are more likely to have been born in the winter and early spring and less likely to have been born in late spring and summer. In

the Hemisphere, the United

Northern including States, with

persons

Schizophrenia are more often born in the months from January to April. In the Hemisphere, Southern persons

with Schizophrenia are more often born in the months from July to

September. II. Precipitating Factors a. Socioeconomic & Cultural Factors Patient was raised from a severely poor family. Patients father was a farmer while the mother was a yaya. According to Kaplan,

because Schizophrenia begins early in life,

causes significant and long-lasting impairments, heavy hospital makes for and

demands care,

requires ongoing clinical care, rehabilitation, and

support financial illness

services, cost in the of

the the

United

States is estimated to exceed that of all

cancers combined. b. Developmental Fixation Patient has been noted to be paranoid and wary of the environment. Trust vs Mistrust issues. Also supported by the incident when the gas stove of her employer she was using exploded. According Sigmund postulated Schizophrenia from to Kaplan, Freud that resulted

developmental

fixations that occurred earlier than in those the of These

culminating development neuroses.

fixations produce defects in ego development and Freud postulated that

such defects contributed to the symptoms of

Schizophrenia.

V. Multi-Axial Diagnosis and Nursing Diagnosis

AXIS AXIS 1 CLINICAL DISORDER SCHIZOPHRENIA PARANOID TYPE VS BIPOLA . R DISORE R MANIC TYPE AXIS 2 PERSONALI TY DISORDER AND MENTAL RETADATIO N PEROSONALITY DISORDER CLUSTER A PARANOID TYPE VS SCHIZOAFFECTIVE . DISORDER

AXIS 3

GENERAL MEDICAL CONDITION

AXIS 4

PSYCHOSO CIAL AND ENVIRONME NTAL PROBLEMS

AXIS 5

GLOBAL ASSESSMEN T OF FUNCTIONIN G SCALE 31 40

Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

THERAPEUTIC NURSING MANAGEMENT 1. ENVIRONMENT provide a safe environment

2. PSYCHOLOGICAL TREATMENT Behavior therapy: behavior is modified to meet acceptable social norms Social skills training: may use role play in teaching clients way to improve interpersonal skills Self monitoring: clients become more aware of their symptoms

3. SOCIAL TREATMENT MILIEU THERAPY: manipulate environment for optimal benifit FAMILY THERAPY: is aimed at assisting the family to cope with the long-term effects of the clients illness and help the client function more effectively. GROUP THERAPY: is predominately use for the long term course of the illness. NURSING INTERVENTIONS: a. Allow client to make some choices b. Increase the type , frequency, and intensity of social interaction gradually over time c. Reassess the clients mental state particularly in terms of agitation, increasing anxiety and aggression

d. Implement a plan to help the client learn problem solving strategies e. Reassess for harm to self and or others FOR DELLUSIONS: a) Staff should not affirm the clients delusions or argue with the client about them b) Present reality in a non-confrontational manner c) Reinforce reality by responding to anything that is real d) Encourage discussion of fears, anxiety and anger as a way to deal with the emotional effects on the client e) do not move suddenly, touch the client or stand in the doorway, blocking the exit f) Do not insist that the client provide detail regarding the hallucination because this may increase the clients level of anxiety g) Help the client identify impersonal or universal pronouns such as they. Staff should use personal or proper names with the client and avoid overuse of impersonal pronouns. h) Encourage the client to participate in activities that require attention or physical skills when appropriate as a distraction technique i) Assess clients anxiety level and intervene as required. For hallucinations: a. Staff should not affirm clients hallucination argue with the client about them.

b. Presently reality in non-confrontational manner (I dont see, hear etc., ) c. Help the client to understand the triggers that most often elicit a hallucinatory experience. d. Encourage discussion of fears, anxiety and anger as a way to deal with the emotional effects on the client e. Do not move suddenly, touch the client or stand in the doorway , blocking the exit. f. Reinforce reality by responding verbally to anything that is real. Identify false beliefs about the real situation g. Increase the frequency, duration and intensity of clients socialization. h. Do not insist that the client provide detail regarding the hallucination because this may increase the clients level of anxiety. i. Observe for speech that is inappropriate to the situation. j. Help the client to use problem solving strategies k. Encourage the client to participate in activities that require attention or physical skill when appropriate as a distraction technique.

CRITERIA Onset of illness

RATING( state VI. Prognosis and Recommendations whether good, fair, or, poor) 1991 one year Good after giving birth of his son - experience psychosis such as paranoia delusion.

DOCUMENTATION Individuals with later onset (female) have less evidence of structural brain abnormalities, cognitive impairment, display a better outcome. (P308 Schizo and Other Psychotic disorders DSM-IVTR) 5-10 yr period after the first Psych hospitalization good outcome (Kaplan and Saddocks 2001) Individuals with later onset (female) have less evidence of structural brain abnormalities, cognitive impairment, display a better outcome. (P308 Schizo and Other Psychotic disorders DSM-IVTR) No family history of schizo. (P309 Schizo and other psychotic disorders DSM IV TR)

Duration of illness

20 years (lucid interval)

Good

Age

28

Good

Precipitating factors

Mood and affect Attitude and willingness to take medication

When her husband left her one year after giving birth of her child. Gas stove explosion. Condition of her child Appropriate affect Willing( he is taking the right dose at the right time)

Good

Good Good

Well medicated Patients compliance to medication can enhance the possibility to have optimum health and for her to stay healthy and well. (Fincham. Patient compliance with medications: issues and opportunities. P 13)

VI. Bibliography

Kaplan & Sadocks (2003).Synopsis of Psychiatry. 9th edition. Videbeck.Psychiatric Mental Health Nursing 2nd ed. Diagnostic and statistical Manual of Mental Disorder 4th ed Fortinash, K. (2007). Psychiatric Nursing Care Plans. 5th edition Stuart, Gail. (2005). Principles and Practice of Psychiatric Nursing. 8th edition Bersabe, R., Mental Health Nursing: Simplified Approach, 1st edition, 2009.

TABE OF CONTENTS
I Introduction A. Overview B. Objective and purposed of the study. (SMART: specific, measurable, attainable, realistic and time bounded) C. Scope and limitation D. Spot Map E. Patients Profile II Anamnesis A. Maternal and Paternal Lineage Give the salient characteristics which might influence the personality of parents and subject B. Parents Give the salient personality traits of each and his/her relationship with each of the siblings and, more specially, the subject. C. Subject 1. Starting from conception to the time the patient was admitted in the hospital 2. Give the salient traits on the different stages of the development 3. Include the precipitating and predisposing factors (see guide questions) Course in the hospital A. Mental Status Examination upon initial introduction and succeeding visitation B. Progress Notes and other observations on the succeeding interactions (at least 5 home/hospital visits) Psychodynamics A. Tabular Presentation on the predisposing factors and rationale

III

IV

B. Schematic Presentation V Multi-Axial Diagnosis and Nursing Management With emphasis on the psychological problem and applicable health teachings Prognosis and Recommendation A. For the individual, family and community if any B. Criteria for prognosis basing from the following: a. Onset of Illness b. Duration of illness c. Precipitating factors d. Mood and affect e. Attitude toward taking medications and treatment f. Any depressive features g. Family support Bibliography

VI

VII

Liceo de Cagayan University School of Graduate Studies Masters in Nursing 3nd Trimester SY 2010 - 2011

Case Analysis

A Written Report

Submitted to: Ms. Ma. Dolores D. Mercado, RN, MAN Professor of the School of Graduate Studies Liceo de Cagayan University

In Partial Fulfillment of the Requirements PN 304

Submitted by:
HENRY CHAVES RN SALLY GRANADA RN LENDON LIM RN BEATRICE LA VICTORIA RN RENZI PEPITO, RN SAMUEL SUDARIO RN