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I.

INTRODUCTION

Psychiatric disorders place a substantial burden and suffering on clients, their families,
society, and the healthcare system. Caring for clients with psychiatric problems is complex and
requires and understanding of neurobiological, cognitive, and psychosocial underpinnings
associated with specific psychiatric conditions.

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses


masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms.
Increased dopamine activity in the mesolimbic pathway of the brain is commonly found in
people with schizophrenia. Recent research reveals that schizophrenia may be a result of faulty
neuronal development in the fetal brain, which develops into full-blown illness in late
adolescence or early adulthood.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and
behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process
with many different varieties and symptoms. It is usually diagnosed in late adolescence or early
adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of
age for men and 25 to 35 years of age for women.

The symptoms of schizophrenia are categorized into two major categories:

The positive or hard symptoms which include:


• Ambivalence: Holding seemingly contradictory beliefs or feelings about the same
person, event or situation
• Associative looseness: Fragmented or poorly related thoughts and ideas
• Delusions: Fixed false beliefs that have no basis in reality
• Echopraxia: Imitation of the movements and gestures of another person whom the client
is observing
• Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from
one topic to another
• Hallucinations: False sensory perception or perceptual experiences that do not exist in
reality
• Ideas or reference: False impressions that external events have special meaning for the
person
• Perseveration: Persistent adherence to a single idea or topic, verbal repetition of a
sentence, word, or phrase; resisting attempts to change the topic

Negative or soft symptoms which included:


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• Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of
content)
• Anhedonia: Feeling no joy or pleasure from life or any activities or relationships
• Apathy: Feeling of indifference toward people, activities, and events
• Blurred affect: Restricted range of emotional feeling, tone, or mood
• Catatonia: Psychologically induced immobility occasionally marked by periods of
agitation or excitement; the client seems motionless, as if in a trance
• Flat affect: Absence of any facial expression that would indicate emotions or mood
• Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

The DSM-IV-TR contains five sub-classifications of schizophrenia:

• Paranoid type: Where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code
F20.0)
• Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought
disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1)
• Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless
movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code
295.2/ICD code F20.2)
• Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)
• Residual type: Where positive symptoms are present at a low intensity only. (DSM code
295.6/ICD code F20.5)

Families and society are affected by schizophrenia too. Many people with schizophrenia
have difficulty holding a job or caring for them, so they rely on others for help. Treatment helps
relieve many symptoms of schizophrenia, but most people who have the disorder cope with
symptoms throughout their lives. However, many people with schizophrenia can lead rewarding
and meaningful lives in their communities. Researchers are developing more effective
medications and using new research tools to understand the causes of schizophrenia. In the years
to come, this work may help prevent and better treat the illness.

II. PSYCHIATRIC MENTAL HEALTH NURSING HISTORY

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A. Demographic Data
Patient name: Danillo Dimaala
Historian: JI Raymond AE De Joya
Hospital: CCMH
Consultant: Dr. Escaño
Date Interviewed: 8/15/10
B. General Data

This is a case of D.D., a 44 years old right handed male, single, the eldest among his six
siblings. Born and currently residing in Nasugbu, Batangas. A High School Graduate and
works as water pump tender in a sugar factory in Batangas. He is a Roman Catholic who
speaks Tagalog and English, accompanied by his mother to seek consultation to a
Psychiatrist for the first time in Cavite Center for Mental Health last August 13, 2010.

C. Chief Complaint

Patient complained of “nagugulat pag nakakita ng babae at lalaki”

D. Premorbid Personality and Level of Functioning

The patient is a calm and happy person. He loves his family and friends very much. He
has lot of friends and works well with his colleagues for 16 years. He has no problems or
conflict among his family, friends and other people.

E. History of Present Illness

5 years prior to consultation, when the patient fees or meets an individual, he gets
nervous, vision gets blurred, dizzy(slight) and starts to have palpitations. He thinks that
people around him, talk about him, and sometimes likes to hurt or threaten him. He hears
voices inside his head, whether he is alone or not, that tells his unclear or vague commands.
He ignores it and he claims that the voices get mad if he ignores them. Hearing the voices
happens anytime of the day. He is unable to sleep and ends up restless. He claims that people
call him “manyakis”. He consulted to a psychiatrist from nasugbu and prescribed him
medications such as Prozac, Vitamin B Complex, and Rintril. His sleep pattern improved
after taking these medications. After 3 months, he refused to follow-up on his check-up. He
stated to have visual perception of moving shadows and red lights telling him unclear
comments. He claims to have fewer friends at work and accuses his work colleagues of
spreading rumors about him. He plans to resign at work. He usually stays at home after work
and watches TV.

F. Past medical History

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5 years prior to consultation, the patient had itchiness and soreness around the area of his
penis. There are white-wormy-like rigid structures in his pubic area with erythema and
rashes. Patient has black papules present around his body.

Patient doesn’t have any history of psychiatric or mental illness. He has a primary love
doctor. Patient’s sister died at Diabetes mellitus complications (3rd Sibling).

Review of systems: (+) itchiness on penile area

G. Family Profile

The Dimaala family is a very kind and supportive family among its household members.
They are very supportive among each other. The family members are very supportive on the
patient’s illness and the death of his third sister with the arrangements. Dennis, the youngest
among the patient’s sibling is the closest sibling to the patient. Dante, 43 years old male, is
the second sibling in the family. He is a kind and gentle person. He has no work and helps
the family. Divira, 41 years old female, is a seamstress but died of Dm complications yet she
is a very humble person. Dennis, 39 years old male, is a pig caretaker and a very happy
person. Dolor, 37 years old female, is a housewife and a very supportive mother. Darwin, 35
years old male, sells in a sari-sari store near their house and a very funny and disobedient
person at times.

H. Genogram

III. ANAMNESIS
A. Pre-natal and perinatal history
Patient is a planned pregnancy, no pregnant complications noted. No mental or emotional
problems noted. No alcohol or drug taken.
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B. Early Childhood
He was properly breastfed and bottle-fed. Feeding habits, early development, and toilet
training are unremarkable. No tantrums, night tremors, or thumb sucking noted.

C. Middle Childhood
The patient is cooperative and participative in pre-school activities. He has a lot of
friends and has average academic performance. There is no history of hair pulling, cheating,
or lying.

D. Late childhood
He hates sports and joining extra-curricular activities. He has average academic
performance. He has strong self-esteem and loves helping people. There is no history of
smoking, intake of alcohol, illicit drug use, etc.

E. Adulthood
Patient doesn’t attend Sunday mass for 5 years and goes to church activities before his
illness. Patient has no problems with his work, colleagues, and started drinking alcohol when
he was 20 years old. He never invited or dated a girl in his life.

IV. MENTAL HEALTH EXAMINATION


A. General Description:
Patient has upright posture, well-posed, well-groomed and appropriately dressed. He has
no mannerism or ticks. Patient is cooperative and friendly towards the examiner. He
maintains eye contact with the examiner.

B. Speech:
He is quiet, moderate in late of production and in moderate volume. He does not interrupt
the examiner in the interview. He has no monotonous speech.

C. Mood & Affect:


He has a ramous mood with full affect.

D. Perception:

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He has no auditory and visual hallucinations, illusions, derealization or
depersonalization.

E. Thought & Process:


He has paucity of ideas, no looseness of association, clang association, word salad
or neologism. He has flight of ideas, tangential sometimes. He has no echolalia or
perseveration.

F. Thought & Content:


He has delusion of reference and persecutory delusions, but no obsessions.

G. Sensorium and Cognition:


Patient is alert and conscious. He is oriented to the time place and person. He has
intact remote, recent past, resent and immediate recall memory. He has intact
concentration. He was having hard time subtracting 7 from 100, 7 from 93 and so on. He
was able to spell LIKHA forward and backward. He can write a complete sentence. He
can draw a clock hanging on a wall from an actual wall clock. He knows the current
President and Vice-president of the Philippines.

H. Judgment:
He has intact judgment by helping a victim of pick pocketing.

I. Insight:
The patient is fully aware of the illness and accepts it.

J. Reliability:
He has established good rapport to the examiner.

V. FINAL DIAGNOSIS
Undifferentiated Schizophrenia
It is characterized by mixed schizophrenic symptoms (of other types) along with disturbances
of thought, affect and behavior.
VI. ANATOMY & PHYSIOLOGY IN SCHIZOPHRENIA

THE BRAIN

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Structures of the brain that are implicated in schizophrenia focus on three systems
in the brain: the Basal Ganglia, Limbic System and Tegmentum.

BASAL GANGLIA

The basal ganglia is a collection of subcortical (beneath the


cortex) nuclei in the forebrain (front area of the brain). The cortex is the
brain matter that makes up the outside of the brain; cortex literally means
"bark," so you can think of it as the bark of the brain.

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The major parts of the basal ganglia consist of the
caudate nucleus, the putamen and the globus
pallidus.

The basal ganglia is involved in the control


of movement. The nucleus accumbens contains
neurons that are part of the basal ganglia. Thus,
this structure may play a role in the regulation of
movement, including the control of complex motor
activity and the cognitive aspects of motor control.
In addition, this structure has been found to
possibly be the area that becomes activated in
situations that involve reward and punishment.

The

nucleus accumbens is a nucleus of the basal


forebrain. It receives dopamine-secreting terminal
buttons from neurons of the ventral tegmental area
(VTA) and is thought to be involved in
reinforcement and attention.

LIMBIC SYSTEM

This system consists of a


couple of brain structures. First it
includes several regions of one
form of cortex called the limbic
cortex; this cortex is also known as
the cingulate cortex as shown in
the picture.

Besides the limbic cortex, the most


important parts of the limbic
system are the hippocampus and
the amygdala.

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The limbic system has been implicated in learning and memory and emotions. The implication
in emotions involves feelings and expressions of emotions, emotional memories and recognition
of emotions in other people.

TEGMENTUM

The tegmentum consists of an area of the midbrain. It includes the bottom end of the reticular
formation, the periaqueductal gray matter, the red nucleus, the substantia nigra and the ventral
tegmental area.

The reticular formation is a large


structure consisting of many nuclei. It is
also characterized by a diffuse,
interconnected network of neurons with
complex dendritic and axonal processes.
The reticular formation receives sensory
information and projects axons to the
cerebral cortex, thalamus and spinal
cord.

NEURONS

Cells in the nervous system are called neurons. The neuron is an information processing and
transmitting cell that undermines all bodily functions. It is estimated that the human brain
contains over 100 billion neurons, with each neuron potentially communicating with hundreds of

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other neurons. This vast interconnectedness allows simple neuronal activity to translate into
complex neuronal messages creating human behavior.

NEUROTRANSMISSION

• The basic structure of a neuron includes a cell body (soma), dendrites, axon and axon
terminal.

• Neurotransmission is an electrochemical message that allows neurons to communicate


information with one another neuron.

• Electrochemical messages pass from the dendrites (projections from the cell body)

• Through the soma or cell body

• Down the axon (long extended structures)

• And across the synapses (gaps between cells)

• To the dendrites of the next neuron

NEUROTRANSMITTERS

• Neurotransmitters are the chemical substances manufactured in the neuron that aid in the
transmission of information throughout the body. They either excite or stimulate an
action in the cells (excitatory) or inhibit or stop an action (inhibitory).

• These neurotransmitters fit into specific receptor cells embedded in the membrane of the
dendrite.

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• After neurotransmitters are released into the synapse and relay the message to the
receptor cells, they are either transported back for later use (reuptake) or are metabolized
and inactivated by enzymes, primarily monoamine oxidase

• These neurotransmitters are necessary in just the right proportions to relay messages
across synapses

GABA

GABA is the most common inhibitory neurotransmitter in the nervous


system and is found throughout the body. Produce calming effects and
are target sites for benzodiazepines.

Glutamate

Glutamate is an excitatory neurotransmitter that is


involved in learning and memory. Alterations in production
may play a role in the underpinnings of neurodegenerative
disorders, such as Alzheimer’s disease and schizophrenia.

Acetylcholine

Acetylcholine is responsible for muscular movement and has


been shown to have a role in memory formation. It was the first
neurotransmitter to be discovered, and thus is the best known.

Epinephrine and Norepinephrine

Epinephrine and norepinepherine act very similarly.


They are associated with vigilance and the fight-or-flight
response. Their activity revs up the sympathetic nervous
system, preparing a body to face danger or run away from it.

Serotonin

Serotonin plays a role in mood,


apptetite, sleep rhythms and arousal.
Decreases in serotonin have been
shown to correlate with clinical
depression and risk for suicide.

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Dopamine

Dopamine has been implicated in numerous functions within the body,


including movement, attention, learning, and the reward and reinforcement.
Schizophrenia and other psychotic disorders are associated with increased or
dysregulation of dopamine

VII. PSYCHOPATHOPHYSIOLOGY

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VIII. DRUGSTUDY
Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n

Generic A butyrophenone  psychotic  Hypersens  CNS:  Monitor CNS


Name: that probably disorders itivity to drug, confusion, status closely,
Haloperidol exerts tartrazine, drowsiness, cardiovascular status
antipsychotic  chronic sesame oil or restlessness, and respiratory status
Brand Name: effects by psychosis benzyl alcohol sedation, lethargy,
Haldol blocking requiring insomnia, vertigo,  Advice patient to
postsynaptic prolonged dyskinesia, minimize GI upset by
Classification: dopamine therapy seizures, eating frequent small
Antipsychotic receptors in the neuroleptic, serving of meal
brain.  nonpsychoti malignant
c behavior syndrome  Instruct patient to
disorders report signs and
 CV: symptoms of serious
 Tourette hypotension, adverse reaction
syndrome hypertension

 Delirium  EENT: blurred


vision, dry eyes

 GI:
constipation,
drymouth,
anorexia

 GU: urinary
retention,
menstrual
irregularities,
gynecomastia

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 HEMATOLOGIC
: anemia

 RESPIRATORY:
dyspnea

Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration


n

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Generic Unclear. Thought  Schizophre  hypersensi  CNS: sedation,  Patient
Name: to interfere with nia in patient tivity to drugs drowsiness, monitoring
Clozapine dopamine unresponsive to dizziness, vertigo, 1. Monitor wbc
binding in limbic other therapies  uncontroll insomnia, count weekly for 6
Brand Name: system of CNS, ed seizure disturbed sleep, months
Leponex with high affinity nightmares, 2. Monitorecg
for dopamine  severe restlessness and liver function
Classification: receptors CNS test
Antipsychotic depression or  CV: 3. If drug must
coma tachycardia, be withdrawn
hypotension, abruptly, monitor
hypertension, patient for psychosis
chest pain and cholinergic
rebound (head ache,
 EENT: visual nausea, vomiting and
disturbances diarrhea)

 GI: dry mouth,  Patient


constipation, teachings
nausea, vomiting, 1. Tell patient to
excessive allow orally
salivation disintegrating tablet
to dissolve in mouth
 GU: urinary 2. Advise patient
frequency or to immediately report
urgency, urine of new onset of
retention lethargy, weakness,
fever, sore throat.
 Respi: Malaise, mucous
repiratory arrest membrane ulcers, or
other signs and
symptoms of
infections

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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n

Generic Interferes with  Allergy  hypersensi  CNS: Drowsiness,  Patient


Name: histamine effects sypmtoms tivity to drug dizziness, monitoring:
Diphenhydrami at h1 receptors caused by headache, monitor
de site; prevents histamine  Alcohol paradoxical cardiovascular
but doesn’t release intolerance stimulation status
Brand Name: reverse (especially in  Patient
Celestamine histamine-  nausea and  Acute children) teaching:
mediate vertigo, cough asthma 1. Advise
Classification response. attacks  CV: Hypotension, patient to avoid
:  dyskinesia; palpitations, alcohol
Antihistamine parkinsons  MAO tachycardia 2.Caution
disease inhibitor use patient to avoid
within past 14  EENT: Blurred driving and other
 mild days vision, tinnitus hazardous activities
nighttime until he knows the
sedation  Breastfeed  GI: Diarrhea, drug effects
ing constipation, dry 3.Review all
mouth significant adverse
 Neonates, reaction
premature  GU: Dysuria, urinary
infants frequency or
retention

 Skin:
Photosensitivity

 Other: decreased
appetite, pain at
I.M. injection site

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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n

Generic May enhance  Lennox-  hypersensi  CNS: fatigue,  Paient


Name: activity of Gastaut tivity to drug drowsiness, monitoring
Clonazepam gamma-amino syndrome, or behavioral 1. Monitor patient
butyric acid, and atypical benzodiazepin changes, for respiratory
Brand Name: inhibitory absence es depression and depression
Rivotril neurotransmitter seizures, reduced 2. Monitor
in CNS akinetic and  severe intellectual ability hematologic and liver
Classification: myoclonic hepatic function test results
Anticonvulsant seizures disease  CV:
palpitations  Caution: tell
 Panic  acute patient not to stop
disorder angle-closure  EENT:, blurred taking drug
glaucoma vision, diplopia, abruptly, advise
 Acute manic nystagmus, patient not to
episodes of sinusitis, rhinitis, drink alcohol
bipolar disorder pharyngitis, which may
increase
 Adjunct  GI: drowsiness,
treatment for constipation, dizziness, and risk
schizophrenia diarrhea, for seizures
hypersalivation
 Periodic leg
movements  GU: dysuria,
during sleep nocturia, urinary
retention,
 Parkinsonia dysmenorrhea,
n dysarthria delayed
ejaculation,
 Neuralgias erectile

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dysfunction

 Respi:
respiratory
depression,
shortness of
breath
Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n

Generic Synthetic  Parkinsonia  narrow  skin rashes  Document


Name: anticholinergic n syndrome angle  dyskinesia indication for therapy,
Akineton drug, blocks especially to glaucoma  ataxia onset of signs and
cholinergic counteract  twitching symptoms and other
Brand Name: responses in the muscular  mechanica agents tried in outcome
 impaired
Biperiden CNS rigidity and l stenoses in of therapy
speech
tremor, gastrointestina  micturation
Classification: extrapyramidal l and mega  Assess for
difficulties
Anti- symptoms colon, parkinsonism or EPS,
parkinsonian  fatigue
prostatic shuffling gait, muscle
 dizziness at rigidity, involuntary
adenoma and
higher doses movement, pill rolling,
diseases
leading to  restlessness muscle spasm,
perilous  agitation drooling before and
tachycardia  anxiety during treatment
confusion
 hypersensi  Assess for mental
tivity to status: affect mood
bipereden. CNS depression
worsening of mental
symptoms during early
therapy

 Monitor for
constipation cramping
pain in the abdomen,
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and abdominal
distension. Increase
fluids, add fiber to diet
and exercise

Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration


n

Generic A coenzyme that  RDA for  hypersensi  CV: peripheral  Determine


Name: stimulates cyanocobalamin tivity to Vit vascular hematocrit, iron, and
Vitamin B metabolic B12 or cobalt thrombosis, heart Vit B levels before
complex function and is  Vit B12 and in those failure beginning therapy
needed for cell deficiency from with early
Brand Name: replication, inadequate diet, Leber’s  GI: transient  Obtain a
Crystamine hematopoiesis subtotal disease diarrhea sensitivity test history
and gastrectomy before administration
Classification: nucleoprotein  use  Respi:
Vitamins and myelin  Pernicious cautiously in pulmonary edema  Don’t give large
synthesis. anemia or vit anemic patient oral doses routinely
B12 with coexisting  Skin: itching,
malabsorption cardiac, urticaria  Monitor patient for
pulmonary or hypokalemia for first
 Methylmalo hypertensive 48 hours
nic acid uria disease
 Teach patient
using intranasal form
how to administer drug

 Instruct patient not


to take folic acid as a
replacement for
vitamin B12

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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n

Generic Stimulates  Increases  Allergy to  CNS:  When giving for


Name: collagen protection tartrazine faintness, urine acidification,
Vitamin C formation and mechanism of sulfites dizziness check urine pH to
(Ascorbic Acid) tissue repair; the immune ensure efficacy
involved in system  Large  GI: diarrhea,
Brand Name: oxidation- doses in heartburn, nausea,  If using IM,
Vita-C reduction  Treatment pregnant vomiting explain that this route
reactions. and prevention patients may promote better
Classification: of vitamin C  GU: gastric use of the vit by the
Vitamins deficiency, urine, renal calculi body
including a
condition called  Inform patient or
scurvy relatives that vitamin is
readily absorbed from
 Extensive citrus fruits, tomatoes,
burns, delayed potatoes and leafy
fracture or vegetables
wound healing,
severe febrile or  Advise smokers to
chronic diseases increase intake of
states vitamin

 To prevent
vit C deficiency

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in patients with
poor nutritional
habits or
increase
requirements

 To acidify
urine

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IX. NURSING CARE PLAN
ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective cues: Disturbed thought After 2 weeks of  Be sincere and  To establish a Goal met:
“Nagugulat ako pag processes related nursing honest when trusting relationship After 2 weeks of nursing
nakakakita ng babae to presence of interventions the communicating interventions the client
at lalaki” psychological client will be able with the client was able to:
conflicts as to:
Objective cues: evidenced by  Interact  Do not make  Broken promises Socialize with others in
 Auditory delusions and and respond to promises that you reinforce the client’s reality-based
hallucinations hallucinations reality-based cannot keep mistrust of others conversations through
 Visual interactions verbal and nonverbal
hallucinations initiated by  Explain procedures  The client feel behavior
 Insomnia others and be sure the less likely that he or
 Restlessness client understands she is being tricked
 Ramus mood  Demonstrat the procedures
with full affect e reality based before carrying
 Paucity of thinking in them out
ideas verbal and
nonverbal Interventions for
 Tangential at
behavior Delusions:
times
 Ideas of  Give positive  Enhances the
reference feedback for client’s sense of well-
client’s success being and helps to
 Persecutory
delusions make nondelusional
reality a more
 Flight of ideas
positive situation
 Has a hard
time subtracting
 Interact with the  Interacting about
7 from 100, 7
client on the basis reality is healthy for
from 93 and so
of real things, do the client
on
not dwell on the
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delusional material

 Directly interject  As the client trust


doubt regarding you, he or she may be
delusions if client willing to doubt the
seems ready to delusion if you
accept reality express your doubt

Interventions for
Hallucinations:
 Elicit description of  To protect the
hallucination client and others.
Understanding the
hallucination will
provide ways to calm
or reassure the client

 Engage client in  To limit or


reality-based decrease the
activities such as recurrences of
card playing, hallucinations
occupational
therapy, or listening
to music

 Help present or
maintain reality by  To maintain
frequent contact and reality orientation
communication
with the client

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