De Ocampo Memorial College College of Nursing

NATIONAL CENTER FOR MENTAL HEALTH

In partial fulfillment for the requirements on psychiatric nursing

Undifferentiated Schizophrenia

Joeyneil Kenneth M. Licardo BSN IV 1 Group 2

Ms. Laarne Dumag -Clinical Instructor-

Introduction Mental Health and Mental Illness are states of human existence having precise definitions. Mental Health is a state of emotional, psychological and social wellness evidenced by interpersonal relationships, effective behavior coping, positive self-concept and emotional stability. While mental illness is a clinically significant behavioral or psychological syndrome or patterns that occurs in an individual and that is associated with present distress, associated with present distress, increased risk of suffering, death, disability and loss of freedom such disorders are defined by a combination of affective, behavioral, cognitive or perceptual components, which may be associated with particular functions or regions of the brain or nervous system, often in a social context. The recognition and understanding of mental health conditions have changed over time and across cultures, and there are still variations in definition, assessment and classification, although standard guideline criteria are widely used. Over a third of people in most countries report problems at some time in their life which meet criteria for diagnosis of one or more of the common types of mental disorder. In our exposure in National Center for Mental Heath in the Philippines (NCMH), being a student nurse for mental health was great lifetime experience, it fulfills our career as a health provider; benefit us and our resident to give best nursing care. Handling a mentally challenged person was difficult task to do, but with our determination to cope with this situation, we have support system including our knowledge, skills and our clinical instructor, to provide us to face the behavior and stressful events inside the institution. One of the leading mentally disorder is Undifferentiated Schizophrenia. Residents in this condition have the characteristic of positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized, or catatonic subtypes.

Objectives: Main Goal y To be able to utilize appropriate psychiatric management in order to lessen the sign and symptoms, and to decrease in the secondary illnesses in the existing condition. Specific Objectives y To be able to establish therapeutic nurse-patient interaction to collect data and history about the resident, and will contribute to the nurse and to the resident. y To be able to apply the nursing process to the fullest extent of their capabilities. y y To establish problem-solving approach to develop nursing care plan. To be able to apply the support system, including individuals, families and community groups are assisted to achieve satisfying and productive patterns of living through health teaching. y To be able to participate in environmental structure to establish and maintain a therapeutic milieu.

1. Resident Identification a. Age: 47 yrs old b. Ethnicity: Pilipino c. Gender: Female

2. Medical History a. Chief Complaint: Nahilo ako dahil sa gutom nuong naglalakad ako sa harap ng hotel tapos ay umupo ako saglit tapos nakita ako ng tanod na inaatake ako ng epilepsy as verbalized by the resident. October 31, 1997, the resident stated false statement, she was brought by Lita Merino of Bulacan, a barangay health worker due to disturb behavior.

b. History of present illness: the resident was brought by a barangay health worker named Lita Merino of Bulacan, due to disturbed behavior. She stated that she was hungry and tired, and then she suffered epilepsy. One day prior to confinement, she hacked her daughter on the neck that motivates the barangay health worker to report the resident in the police station, and referred to the national center for mental health due to disturbed mental condition. c. Past Medical/Psychiatric History: the resident stated that when she was 8 yrs old she already suffers epilepsy but did not consult and take medications. But she remembered that her father gave her sambong after the epilepsy occurred. When she drink sambong juice, her headache was reduced the effect. d. Family Medical History: Denies any family history of the disease.

e. Physical Assessment General Survey y Resident is active, coherent, ready to participate and approachable. General Appearance y Resident is not in distress y Relax y Coordinated y Attentive Vital Signs Temperature: 36.2 Pulse Rate: 80bpm Body Parts Skin: y General Color Inspection Respiratory rate: 21bpm Blood Pressure: 110/70 Actual Findings Normal Findings Analysis

Inspection and Palpation

o Light to dark o Brown and brown skin color, uniform skin color and feels warm, with no lesions. (+) lesions, rashes and scars

y Texture y Moisture Head: y Size, Shape and Symmetry

o Rough and Soft o Skin is dry and has flakes

o Smooth and Soft o No signs of dryness and flaking. o face is symmetrical, centered-head position

o face is symmetrical, centered-head position

Hair: y Distribution y Color y Texture

o Equal distribution o Equal distribution of hair of hair o Black color o Smooth o Black color o Smooth

Eyes: y Pupil

Inspection

o pupil is equally round and reactivated to light accommodation

o pupil is equally round and reactivated to light accommodation

y Eye lids y Sclera y Iris Ears: y Outer Ears Inspection

o pinkish dark color o pinkish color o semi dark color o smooth and moist o white in color o smooth and moist

o symmetrically appearance and equally in size o no discharge, clear ear canal, no obstructed object Inspection o same color of the face o symmetrically appearance o no redness in nasal mucosa

o symmetrically appearance and equally in size o no discharge, clear ear canal, no obstructed object

y Inner Ears

Nose: y Color y Appearance y Internal Nose

o same color of the face o symmetrically appearance o no redness in nasal mucosa

Mouth: y Lips y Buccal Mucosa

Inspection

o darkish pink in color, no flakes, no lesions. o Moist with no lesions

o pink in color, no flakes, no lesions.

o Moist with no lesions

y Gums

o darkish pink in color, no bleeding o 4 remaining teeth, no cavity, no dentures o Some of teeth were yellowish in color

o pink in color, no bleeding

y Teeth

o 32 complete teeth no cavity, no dentures o Whitish color of Teeth

Neck: y Active Range of Motion y Color, Size y Thyroid

Inspection and Palpation

o can move flexion, o can move flexion, extension, tilt and extension, tilt and lateral rotation lateral rotation. o brownish color, no lesions o brownish color, no lesions

o non- palpable, no o non-palpable, no pain when pain when palpate palpate Inspection and Palpation

Extremities: y Upper Extremities  Nails

o no cyanosis, no o no cyanosis, no clubbing, pinkish clubbing, pinkish in color, 2 in color, 2 seconds capillary seconds capillary refill refill o pinkish in color, feels warm, rough, (+) tremors, no lesions. o pinkish in color, feels warm, rough, no lesions.

 Palms

 Arms

o Dominant in right o 10/10 muscle arm, weak at left force, no muscle arm (5/10 muscle weakness force)

o Bilateral pulses are strong, and equal(radial pulse) o (+) lesions, scars, and rashes. o Symmetrical in size y Lower Extremities  Nails o no cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

o Bilateral pulses are strong, and equal(radial pulse) o No lesions, scars, and rashes.

o Symmetrical in size

o no cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

 Feet

o pinkish dark color o pinkish color on on the palm of the palm of the the feet, no feet, no lesions lesions o Dominant in right leg, no muscle weakness o (+) lesions, scars, and rashes. o Symmetrical in size o no muscle weakness

 Leg

o no lesions, scars, and rashes.

o Symmetrical in size

f. Review of Systems General: (+) Fever Skin: (+) Itching (+) Scabies (+) Dryness (+) Rashes (+) Change Color Head: (+) Headache (+) Head Injury Eyes: (+) Nearsighted Mouth: (+) Dry Mouth (+) Four Teeth Respiratory: (+) Cough Gastrointestinal: (+) Diarrhea Vascular: (+) Varicose Veins Neurologic: (+) Seizures (+) Tremors Psychiatric: (+) Depressed Mood (+) Stress (+) Disturbing thoughts (+) Memory Loss

g. Mental Status Examination 1. General Description y Appearance- the resident was well groomed, she combed her hair carefully and she applies face powder, in stooping position. y Behavior and Psychomotor activity- She had good eye contact whenever she answered a question and sometimes she looking in other patient when she asked to answer a question. She had a short attention span while in conversation. She had a mannerism of scratching her finger. y Attitude toward examiner- the resident was approachable and cooperative and able to do anything that was asked her to do. She acts what she say when she tells her story. 2. Mood and Affect y Mood- the resident looks depressed when she was alone, and no one calling her attention. When she asked about her daughter she feels depressed because of the past event, that her husband kills her daughter after she gave birth. y Affect- the resident has an appropriate response affect about the topic of the conversation. Sometimes she has no emotion when talked about her father. y Appropriateness- the resident can answer the questions, but some were false statement. 3. Speech- the resident was quite, if she asked a question then thats the time she talk and continue to give a data. 4. Perceptual Disturbance- the resident had a memory loss because of the existing mental disorder that she pretends that her husband kills her daughter but truth was she hacked her daughter seen by the barangay health worker.

5. Thought a. Process or Form of thought- the resident had overabundance of thoughts. She gave a false data about her daughter but she tells a lot of everything about her past. b. Context of Thought- denies any hallucination and illusions, also homicidal ideation. 6. Sensorium or Cognition a. Alertness and level of consciousness- The resident was alert and attentive. b. Orientation- The resident was oriented to time, date, place and names of person around her. c. Memory- Recent she remembers what they eat and what household she do in the morning, Immediate- she cant remember 3 words/items that she asked to memorized, in every 5 minutes, Remote- when she was still a child she remembers when her father got drunk, her father hurt her mother, Recent Past Memory- she cant remember the recent president, and she always saying that Pacquio was the recent president d. Concentration and Attention- the resident had difficulty in subtracting 3 from 100, but she can count up to 1000. e. Capacity to read and write- she can read more on tagalog words, and had difficulty in English word. In her writing, it quite understandable, and can copy the word that was written in a piece of sheet, and can write one sentence more on tagalog but cant write in English word. f. Visuospatial Ability- the resident can draw the images that asked to her, and she can copy an image by herself. g. Abstract Thinking- She cant identify the similarities of 2 objects given to her. h. Fund of Information and Intelligence- She knows what year and her age when she confined in the institution but she dont know when she had a incident report five times in the isolation room, but if it was told to her she remembers the incident.

7. Judgment and Insight- The resident was asked what she will do, if she saw a mother and a child, and the mother was choking her child, she said that, she will go to the mother then asked what was happening, then she will try to help to solve the problem about the mother and the child. She was aware that she had a mental disorder.

3. Psychosocial History a. Personal History i. Marital and relationship history- the resident claimed that shes only 13 years old when her father sell her to a magjuejueteng a 28 years old to become her husband. After 1 year, they were separated but not married because of a family problem. When she was 18 years old, she met a 30 years old guy who works in the bakery with two kids and widow, and then they have a relationship for one year and not married. According to the resident, she had a daughter in her second husband but apparently her husband kill the baby after she gave birth and they were separated by the family of her husband because she did not finish her high school. ii. Sexual History and Preference- according to the resident when her first husband came from work and drunk, her husband abuse her but did not report to the authority. After she was confined in the mental institution she had no longer sexually active. iii. Educational History- she was under graduate, she finished up to grade III elementary. iv. Occupational History- when she was a child she stop going to school, because she want to help her mother to earn money, she sells kakanin in Manila. When she was 10 years old, she travelled to Manila from Quezon to find a job, she said that she was excellent in doing household chores, and apply as a maid. v. Socioeconomic Status- she claimed that they are in middle class. Her father was a fisherman and her mother sells kakanin.

vi. Religious Affiliations- she said that she is Roman Catholic but not able to go to church to pray because of her status but she always pray at night before she sleep. vii. Place of Birth- the resident claimed that she is from Caluag, Quezon, but her chart showed that she is from Sitio Katulad Pulong Sampaloc Dona Remedious Trinidad Bulacan. viii. Legal History- she had a record on police before she referred to the mental institution.

4.Medical Management
Name of Drug (Classification) Haloperidol (Haldol) -Antipsychotics Dosage 10 mg. OD Started: 4/18/99 Ended: 6/30/08 Action Alters the effects of dopamine in the CNS Also has anticholiner gic and alphaadrenergic blocking activity. Diminished signs and symptoms of psychoses Indication Organic Psychoses acute psychotic symptoms Relieve hallucination s, delusions, disorganized thinking severe anxiety seizures Side-effect CNS: extrapyramidal symptom such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures. CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension. EENT: blurred vision, glaucoma GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain. GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia Interpretation Nursing Consideration Assess mental status prior to and periodically during therapy. Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of

 Hematologic: anemia, leucopenia, agranulocytosis Skin: rash, dermatitis, phtosensitivity

dehydration.

Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. Advice patient to take medication as directed. Take missed doses as soon as remembered, within remaining doses

Dilantin (Phenytoin)

100mg

y Phenytoin y Phenytoin y Headache, nausea, is used to is indicated vomiting, constipation, prevent for use as dizziness, and control an drowsiness, trouble seizures anticonvulsa sleeping, or (also called nt drug in nervousness may an people of all occur. If any of these anticonvuls ages. effects persist or ant or Evidence worsen, notify your antiepilepti supporting doctor or pharmacist c drug). It efficacy of promptly.Phenytoin works by phenytoin as may cause swelling reducing an and bleeding of the the spread anticonvulsa gums.

evenly spaced throughout the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea and vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw. y Take this drug exactly as prescribed, with food to enhance absorption and reduce GI upset, or without food but maintain consistency in the manner in which you take it; be especially careful not to miss a dose if you are on

ofseizure a nt was ctivity in derived from the active drugbrain.OTH controlled ER This studies that section enrolled contains patients with uses of this the following drug that seizure are not types: listed in the approved y Partial professiona seizures l labeling y Primary for the drug generalized but that tonic-clonic may be seizures prescribed (grand mal) by your y Phenytoin health care is best professiona used for l. Use this partialdrug for a onset condition seizures. It that is generally is listed in not this section effective only if it against has been generalized so -onset prescribed absence by your seizures or health care infantile

y Immediately if any of these unlikely but serious side effects occur: unusual eye movements, loss of coordination, slurred speech, confusion, muscle twitching, double or blurred vision, tingling of the hands/feet, facial changes (e.g., swollen lips, butterflyshapedrash around the nose/cheeks), excessive hair growth, increased thirst or urination, unusual tiredness, bone or joint pain, easily broken bones.A small number of people who take anticonvulsants for any condition (such as seizure, bipolar disorder, pain) may experience depressio n, suicidal thoughts/attempts, or other mental/mood problems.

once-a-day therapy.
y Do not

discontinue this drug abruptly or change dosage, except on the advice of your prescriber.
y Maintain good oral

hygiene (regular brushing and flossing) to prevent gum disease; arrange frequent dental checkups to prevent serious gum disease.
y Arrange for

frequent checkups to monitor your response to this drug.

y Monitor your

blood or urine sugar regularly, and report any abnormality to

professiona spasms. l.This drug y Phenytoin may also has limited be used to value in treat clonic, certain myoclonic, types of and atonic irregular seizures heartbeats. and in the LennoxGastaut syndrome. It may control the tonic-clonic component of the syndrome.

your health care provider if you have diabetes.

y This drug is not

recommended for use during pregnancy. It is advisable to use some form of contraception other than hormonal contraceptives.
y Wear a medical

alert tag so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication. y CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reactions, tardive dyskinesia y CV: hypotension (increased with IM, IV)
y Assess mental

Chlorpromazine (Thorazine) -Antipsychotic

100g

y Block

dopamine receptors in the brain; also alter dopamine release and turnover.

y Acute and chronic psychoses, particularly when accompanie d by increased

status prior to and periodically during therapy.

y Monitor BP and

pulse prior to and frequently during

psychomoto y Prevention r activity. Nausea of seizures and vomiting . y Also used in the treatment of intractable hiccups.

y EENT: blurred vision, dry eyes, lens opacities y GI: constipation, dry mouth, anorexia, hepatitis, ileus y GU: urinary retention y Hematologic: agranulocytosis, leucopenia y Skin: photosensitivity, pigment changes, rashes

the period of dosage adjustment. May cause QT interval changes on ECG.

y Observe patient

carefully when administering medication, to ensure that medication is actually taken and not hoarded.
y Monitor I&O ratios

and daily eight. Assess patient for signs and symptoms of dehydration.
y Monitor for

development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis,

hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK.

CONCEPT MAPPING

Disturbed Thought Processes

Risk for OtherDirected Violence

Undifferentiated Schizophrenia

Risk for Suicidal

Disturbed Personal Identity

Name: Ms. L.Z. Religion: Roman Catholic Diagnosis: Undifferentiated Schizophrenia Priority No. 1 Nursing Diagnosis: Risk for other-directed violence

Age: 48 years old Ethnicity: Pilipino

Gender: Female

At risk for behaviors in which an individual demonstrate that she can be physically, emotionally and/or sexually harmful to others. Data Subjective: Kapag nag aaway ang mga engot(Mentally Retarded) nag aawat ako, pero nung nasaktan ako, sinaktan ko na din sila as verbalized by the patient. Objective: y History of hitting others: she had an 5 incident report y History of Hitting family members: she hack her daughter y History of Childhood abuse: when she got married with the age of 13 years old y History of conflictual family background: Outcome After of 8 hours of duty, the resident will expressed her own realistic evaluation and demonstrate self-control. Intervention y Developed therapeutic nurse-client relationship. y Observed for early cues of distress/increasing anxiety y Identified condition such as psychomotor seizures activity y Asked directly if the person was thinking of acting on thoughts/feelings y Accepted client s anger without reacting on emotion basis. Give permission to express angry feeling in acceptable ways and let Rationale y Promotes sense of trust, allowing client to discuss feeling openly. y To give appropriate management. Evaluation After of 8 hours of intervention, the resident were expressed her own realistic evaluation and demonstrated self-control as evidenced by: y expressed calmness when someone hurt him, and will tell to the nurse on duty y not joining the argue, and stayed in the conner.

y to control own behavior

y to determine violent intent

y to promotes acceptance and sense of safety

her father hit them, when her father got drunk.

client know that staff will be available to assist in maintaining control. y Helped client identify more approachable solution/behavior y to lessen sense of anxiety and associated physical manifestation

Name: Ms. L.Z. Religion: Roman Catholic Diagnosis: Undifferentiated Schizophrenia Priority No. 2 Nursing Diagnosis: Diarrhea Unformed stool Data Subjective: Kapag lagi akong kumakain ng giniling at nilagang baboy ay sumasama ang tiyan ko at nagnatatae ako as verbalized by the patient. Objective: y hyperactive bowel sounds y History of taking drugs for diarrhea y three loose liquid stools per day Outcome After of 8 hours of duty, the resident will maintain normal pattern of bowel function.

Age: 48 years old Ethnicity: Pilipino

Gender: Female

Intervention y Monitored Vital signs and intake and output. y Auscultated abdomen

Rationale y To know the baseline data. y To know presence, location, and characteristics of bowel sounds. y To allow for bowel rest/reduced intestinal workload y To decrease stress/anxiety y To prevent dehydration.

Evaluation After of 8 hours of intervention, the resident was maintained normal pattern of bowel function.

y Restricted solid food intake as indicated

y Promoted use of relaxation technique y Increased oral fluid intake and return to normal diet as tolerated. y Reviewed causative factors and appropriate intervention.

y To prevent recurrence.