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I.

INTRODUCTION Schizophrenia is a group of psychotic reactions that affect multiple

areas of an individuals functioning including thinking and communication, perceiving and interpreting reality, feeling and demonstrating emotions and behaving in a socially accepted manner. This condition causes distortion and bizarre behavior, thoughts, movements, emotions and perceptions. This condition is usually diagnosed in late adolescence or early adulthood and rarely manifest in childhood. The symptoms of schizophrenia are divided into two major categories; the positive and negative symptoms. The positive symptoms include delusions and its types, hallucinations, loose associations and bizarre or disorganized behavior while the negative symptoms includes restricted emotions, anhedonia, avolition, alogia, catatonia and social withdrawal. Most clients with schizophrenia have a mixture of both types of symptoms. The diagnosis of this condition usually is made when the person begins to display more actively positive symptoms of delusions, hallucinations and disordered thinking. Onset may be abrupt but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, loss of interest and neglected hygiene. Schizophrenia is also classified into five types and diagnosed according to the clients predominant symptoms. Paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations and occasionally excessive religiosity, hostility and aggressive behavior. Disorganized type is characterized by inappropriate or flat affect, incoherence, loose associations, disorganized speech and disorganized behavior. The catatonic is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by waxy flexibility or stupor. Excessive motor activity is apparently purposeless and not influenced by external stimuli. Other features include extreme negativism, echolalia, echopraxia or even mutism. Undifferentiated type is characterized by mixed schizophrenic symptoms of other types along with disturbances of affect and behavior. The last type which is residual is characterized by the

absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. Our client was diagnosed and classified he as schizophrenia, mixed

undifferentiated particular type.

type.

Which

means,

that

demonstrated

schizophrenic symptoms of others but not enough of them to define its

THEORETICAL FRAMEWORK According to Learning Theory, the irrational ways of handling situations, the distorted thinking and the deficient communication patterns of person with schizophrenia are a result of poor parental models in early childhood. Children learn what they are exposed to on daily basis, from parents who have their own significant emotional problems. Thus, the child does not develop skill forming good interpersonal relationships which he possesses when he grows up. If this was not to be resolved, it will lead to some emotional distortions. Sullivan was the principal proponent of learning theory, believing that the developing individual was shaped by social interactions. For Therefore, the complex feelings, thoughts and behavioral expressions grew out of the individuals experiences with those closest him. example, if the childs father was mean and dictatorial, the perception may have generalized to other men in positions with authority. Or if the childs mother coped problems by projecting blame onto others, the child learn this pattern of behavior and alienated others by putting it into practice. As what the child have seen at early stage of life, that was the things he will be doing when he grow up to cope problems and save his ego identity. This theory, we think, was indicated to our client who had difficulty in coping when he was still at his normal state of life. Later in his life, problems and other stimulus triggered the development of his present condition and so he was diagnosed to have schizophrenia, undifferentiated type. This is in relationship with the clients relationship with the other members of the family especially to his parents who raised him as a child. He grew up with a mean father who physically abuses him and a mother

who wasnt always there when he needed her. And from this case, the client tends to blame his mother for the development of the condition. OBJECTIVES General Objective At the end of our case presentation, the group 3 presenters and also the audience will be able develop our skills in making comprehensive case studies, gain knowledge about schizophrenia and its types and have a good attitude towards each member of the group. Specific Objectives At the end of our case presentation, the group 3 presenters and also the audience will be able to:
Have a broader knowledge about schizophrenia and its types,

Use critical thinking to identify areas of care that could benefit from additional research,

Assess the mental status of the patient with schizophrenia, Identify the supportive and rehabilitative needs of patient with schizophrenia,
Discuss the predisposing factors, precipitating factors, signs and

symptoms and psychopathology of schizophrenia,


Develop comprehensive Nursing Care Plans for patient with

Schizophrenia, Make appropriate Drug Study, Evaluate the effectiveness of antipsychotic medications for clients with schizophrenia,
Evaluate your own feelings, beliefs, and attitudes, regarding clients with

schizophrenia, and

Have a good attitude towards each member o the group.

II.

BIOGRAPHICAL DATA

Patients Name: Age: Birthplace: Address: Gender: Marital Status: Religion: Occupation: Nationality:

JJ 42 years old MHLI MHLI Male Married Roman Catholic Laborer Filipino Elementary Undergraduate February 25, 2012, 5:00 pm Undifferentiated Schizophrenia Dr. B Undifferentiated Schizophrenia, Manageable

Educational Attainment: Date & Time of Admission: Admitting Diagnosis: Attending Physician: Final Diagnosis:

III.

MEDICAL HISTORY

CHIEF COMPLAINT

The client was admitted to PMHU last February 25 because the client was hostile, physically threats his wife and neighbours, the client was also having delusions, claiming: ako ang presidente sang tanan nga nasyon and speaks most often about him being a soldier. The informant also added that the client is often seen talking to himself. HISTORY OF PRESENT ILLNESS Two weeks prior to admission, Juaning, a 49 year old male, who lives at MHLI, after losing his job from the piggery, he started acting unusual behaviors, Juaning started to withdraw himself from other people; the client started to lose his appetite, he would rather stay in his room all day without eating or drinking. He easily gets angry, he would sometimes yell to his children for no apparent reason. It was also then that the client was often seen talking to himself. According to the client, he sometimes heard voices and saw things which were vague for him. It was February 20, 2012 when Juaning suddenly ran to their neighbours with a metal rod and he started banging on their doors and windows for no apparent reason. He even threatened some of his neighbours of physical assault. His family and neighbours were so shocked about his disturbing behavior, sang una na bulong na ina siya sa mental, pero nagbalik na naman, nag-ayo na ina siya sadto as verbalized by the informant, It was February 24, 2012, Juanings mother was convinced that he needs medical attention and he has to go back to the mental unit, so they brought him to PMHU on February 25, 2012 and was admitted with a diagnosis of Schizophrenia undifferentiated type, under the service of Dr. B. PAST MEDICAL HISTORY According to the mother, Juaning received immunizations during his childhood but she could not remember any of the drugs that were given. Juaning has no known allergies. He hasnt experienced any injury or any surgery. On 2008, the client was admitted at PMHU because of hostility, untoward behaviors and social withdrawal. He was then diagnosed to have Schizophrenia, undifferentiated type. He had been manageable for 2 years. He was then discharged on 2010 due to the progressive state of his condition.

After two years, the patient stopped taking the drugs because of financial instability; thats when he started experiencing having delusions again. PAST FAMILIAL HISTORY The client belongs to a family with a low socio-economic status. They were five siblings in their family, hes the youngest. They already have their own families respectively and he was the only one who has the condition. The client has two children and they were studying at GI. On both paternal and maternal side, they do not have a history of schizophrenia and he was the first to have the condition. The client has a mean father and didnt speak too much about his mother. PERSONAL HISTORY a. Prenatal History According to the mother, when she was still pregnant with Mr. JJ, she had a regular checkup and she had an on and off flu. Mr. JJ was born in a family with a low socioeconomic status. b. Birth and Infancy According to the mother Mr. JJ was breastfed for the first three years. She started bottle feeding him at the age of four. Mr. JJ started walking at the age of one and a half years old. c. Toddlerhood When the client was 2 years old, he started to talk. This was the time when Mrs. J also had her job because the father has no job d. Childhood Mr. J in his elementary days, he is very quiet and always alone inside the classroom. He only has few friends and when he was in grade 3 he sometimes experienced to be bullied by his classmates. His father, in this time a he is a pedicab driver, if Mr. J made mistakes he physically punished by his father. Mr. J plays with his friends in the neighborhood with the same age. e. Adolescence

He was circumcised at the age of 12. He did not pursue his studies. Mr. J was a basketball player in his barangay. Mr. J has introduced someone or his girlfriend in his family it was his first girlfriend but later on their relationship end up after 1 year. At 15 he started to work as a laborer on a piggery in their neighborhood. f. Adulthood After Mr. M.A graduated, he worked in Gaisano, Iloilo as cashier,their he met his first love according to the patient which refused him this was the reason why he isolated himself from friends, and why he filed a resignation letter. He focused on his second job in repairing watches after that incident, but unfortunately his shop was rubbed so he stopped his work. During late adulthood he met his wife working as a schoolgirl to their family after 1 year of their relationship they decided to get married they were supported by Mr. M.As family they even gave them the couples ideal wedding, but things went wrong after 6 years of marriage his wife asked him if she could have a vacation in their place in calinog and Mr. M.A approved it, before she left she widthraw money from their bank account amounting 10,000, this was only revealed when his wife did not comeback and when they called her wifes family they said his wife had not come home. This triggered his disease and up to now he could not forget about this painful part of his life.
Pre-morbid Personality

During his college years he was focused on his studies and forgot other things that a usual adolescent does. He has few friends to confide his problem. He always misses his mother every time he has problem thats why he filed a resignation letter after refused by the girl she love and went home.

IV. V.

PSYCHOPATHOLOGY PREMORBID PERSONALITY

PAST PERSONAL HISTORY According to the mother, when she was still pregnant with Mr. J, she had an on and off flu. During his childhood, Mr. J grew up with a strict father who physically abuses them. His mother works at LI which is far from their home, thats why their mother wasnt always there for them when they needed her. Their mother goes home only once a week. Sometimes, his mother and father fights because of the way his father disciplines them and also because of his fathers vices. Mr. J was often bullied during his elementary years. During his adulthood, Mr, J married Mrs, J who works as a laborer. They had 3 children. The client was a graduate of College Degree at the University of the East. She was married and has three children. Shes been affiliated religiously at their church as a member and she was been active to their church activities. She spends most of her time on her affiliation and has a normal state dealing with her colleagues. A. PAST SOCIAL HISTORY The client was an active member of her Religious affiliation. She was dedicated and goes along with her colleagues religiously and acts accordingly. Shes fond of dealing with her co-members. The client always remembers that she was singing at their church with other group members. The clients social atmosphere changed when one day she was not already a member of their church. She always claimed that she was rejected due to the wrong doing of her mother. She became socially withdrawn, suspicious and later became hostile and has disorganized behavior. VI. A. MENTAL STATUS EXAM General Appearance

The client appears to be at his stated age of 42 years old, wears a white sando and a pair of loose slacks, well groomed and with good personal hygiene. The client has a good posture, gait and coordination. During interaction, he does not maintain eye to eye contact. Sometimes, he does not display appropriate affect or facial expression upon talking about a certain situation. He has a dark skin tone, with good body built. Upon introductory phase, the client considered the interview as a normal thing, daw pirme man lang ko di gina-interview as verbalized by the patient. B. General Behavior and Activity

The client does not maintain eye to eye contact during interactions; there are times that he looks at the interviewers eyes during conversation but only for a few seconds. The client speaks in a soft but audible manner. There

are times that he was restless where he cant remain still. He also exhibits agitation and he even walked away at the middle of an interview. C. Speech and Content

The client speaks in a soft but audible manner. During an interview, the client suddenly stopped talking in the middle of a sentence and remained silent for a few minutes. Most of the time, the client speaks of unrelated topics, such as: ako si Juaning, pero alyas ko lang ina! Ako ang presidente sang bilog nga nasyon! The client speaks about his experiences when he was an army: sang military pa ko damu ako sang armas kag granada! but upon validation of his statements, we found out that hed never been an army, that he was instead a worker in a piggery for 14 years. Usually, when the client is asked, he answers questions irrelevantly. D. Sensorium

In order for us to assess the sensorium, we prepared some set of questions during the nurse-patient interaction. Orientation NPI: March 7, 2012 Nurse: nung, ako si Anil, halin sa College of St. John, ang imo student nurse subong nga aga, ano gane imo pangalan nong? Patient: ako si *******. Nurse: sa diin kita subong gane nung *******? Patient: ari sa Mental Hospital Memory NPI: March 7, 2012
Immediate recall

Nurse: nung, ano gane ang akun pangalan? Patient: Anil, halin sa La Salle Roxas. Recent recall Nurse: nung ano kagina aga inyo sud-an pagpanyaga? Patient: karne nga sinabawan kag tuloy nga pinirito. Long term recall Nurse: nung, pwede mo malawag ang pangalan sang imo mga puya? Patient: ang subang si ******, ang pangaduwa si ******, amo lang ina ang akun mga puya, indi ina sila makasuldado kay puro baye. E. Judgment and Insight

The clients judgment is impaired, he sometimes does not sleep when he needs to, he needs constant reminder from his watcher to take a bath when his clothes are soiled, and he sometimes complain that hes hungry but doesnt eat when the food is served. Some of his perceptions were unrealistic

and inconsistent. He cannot formulate and think of solutions which in solving his problems. The client is not oriented to reality because of his delusions. Hes not really knowledgeable and aware of his present condition that he was at the mental unit for his mental problem. According to the client, his illness is manageable. Hes not familiar about the importance of rehabilitation, medication regimen and psychotherapies to his progression. F. Affect and Mood

The client seems restless where he cant remain still. He displays a blunted affect (few observable facial expressions) and sometimes, inappropriate affect (affect which is incongruent with mood or situation) during the interview; he sometimes laughs for no apparent reason and displays inappropriate response to a certain condition, just like when we were talking about him losing his job, he smiled. He also exhibits agitation, anxiousness and irritability. He was not really cooperative; he even walked away during an interview. G. Intellect

The clients expressed thoughts were jumbled; he knows things about soldiers, guns, tanks, and other things about war. He wasnt able to pinpoint and defend his answers and if he is asked about the main reason why he was brought to the unit, he cant answer directly. According to him, the reason why he was brought to the unit is that he cannot go to sleep at night, and when we asked him for other reason aside from that, he did not answer. H. Coping Mechanisms

The client isnt good at handling all the stress that arises in his life. When he and his wife are having problems or conflicts, he easily gets disappointed and would react violently and walk away rather than talking about it and solving it. Before his confinement, he was fired out of his job because of his mental condition; this caused him not to sleep for almost a week. He also started to withdraw himself from other people. During his confinement, he spends most of his time sitting on the gazebo at the mental unit. He does his responsibilities at the center such as gardening and cleaning their ward to somehow alleviate his feeling of loneliness. The client sometimes does not attend activities and therapies. I. Defense Mechanism

In the case of our client, he used denial as a defense mechanism. He keeps on insisting that the reason why he was brought to the unit is that he cannot go to sleep at night instead of admitting the reality of the situation that he has a mental illness and the fact that hed been hostile and doing unacceptable behaviors. The patient also shows rationalization, when he is asked about the reason for his termination from his job, he would say that it was because he was getting old and his boss wants him to take a rest,

different from what his co-workers told us that it was because he was often seen talking to himself and that he became aggressive. And one thing that we have also noticed, even though he is not cooperative to activities, he was one of those patients who were really good at gardening; he is substituting a socially acceptable activity for an impulse that is unacceptable, the client displays sublimation.

VII.

PSYCHODYNAMICS

Birth And Infancy (0-18 Months)

THEORY

CHARACTERISTIC OF THE PATIENT PSYCHOSOCIAL STAGES Erik Erickson He trust his family but when it comes to his hallucinations no one can stop him. He keeps on walking on walking. Protect his family against others he suspected other that they are against God. In the hospital Keeps on roaming around in the ward. Looks eye to eye contact in the student nurses. Never shares significant information to caregivers.

PSYCHOSEXUAL STAGES Sigmund Freud Oral Stage The relief of anxiety through oral gratification of needs in the mouth, lips and tongue that includes biting, chewing and sucking. The infant feels attached and unable to differentiate self from mother figure. Anxiety of the mother figure may be passed to the infant. A sense of self s only developed in consequences of ego development. A sense of security and the ability to trust others are derived from the gratification of basic needs.

Trust vs. Mistrust Basic tasks to develop a basic trust in the mothering figure to generalize it to others. If trust is develop during infancy the childs adult behavior will be realistic trust of self and others, confidence in others, optimism and hope, shares openly with others and relates others effectively. Failure to develop trust results to suspiscoiusness to other, fear of criticism and affection, dissatisfaction and hostility, projection of blame and feelings and withdrawal from others.

TODDLER

Autonomy vs. Shame and Doubt (1-3 years During this stage old) the child is learning and independence of control Basic task is to which focus on exactory gain some self-control functions (anus and and independence surrounding areas). within the Voluntary control of anus environment. or toilet training is If autonomy is acquired. develop during If this stage is preschool stage the resolved, more child will have selfpermissive and accepting controland selftoilet training and esteem, pride and attaches feeling of sense of goodwill, importance and simple desirability to feces cooperativeness, production this results to generosity tempered extrovert person, by witholding, delayed productive and altruistic. gratification when If the child were neccessary.

Anal Stage (1.5-3 years old)

At home He shared limited significant information to her family. He fun watcing a porn. Ask the help of his mother to take good care of him.

In the hospital Does not share significant information to caregivers. Stands up if student nurses came in. Look straight to the eye of the student nurse everytime it

NOTE: FOR THE OBJECTIVE PLEASE REFER TOU YOUR PINK (RALPH PSYCHE BOOK)!!!!