Case Study on Undifferentiated Schizophrenia

Submitted by: Volante,Justine Cyrile D. BSN-Nr42/Group 5

Submitted to: Connie Castro RN

ACKNOWLEDGEMENT The group wishes to express their warmest appreciation to the following people, who, gave us the chance to conduct a case study: First of all, to the Almighty God, who never stopped in loving us and for the continued guidance and protection. To the groups clinical instructor, Mrs. Connie Castro, R.N for her guidance and support in making this study and during the psychiatric nursing exposure , whose knowledge ,suggestions and encouragement helped us in all the time of making this case study. Finally to Ms. Liberty Alcarion RN,MAN for imparting knowledge and learning experience during our lectures onPsychiatric nursing. Without their encouragement and constant guidance, our Psychiatric Nursing exposure would not have been a very meaningful learning experience. The group also wishes to acknowledge the invaluable assistance and cooperation of the staff nurses of the National Center for Mental Health (NCMH) , for allowing us to conduct this study, for assisting us in reviewing the patient files and giving us the opportunity to care for the mentally-ill patients. Special appreciation is extended to the client subjected for this study and other informants for their selfless cooperation, time and entrusting personal information needed for this study. To the group, we would like to show our endless gratitude to each other by specifying our names; Katrina Barlis, Bernadette Bustamante, Paul Dante Janda, Jay Patrick Joaquin, Annie Claire Ty, Justine Cyrile Volante, Stiefen Wingsing ; for the understanding, believing in each other, and teamwork. May we continue working hard for future studies. And lastly, to our parents who have always been understanding and supportive both financially and emotionally. very

Chapter I

Introduction Schizophrenia is a chronic, severe, debilitating mental illness that affects about 1% of the population, more than 2 million people in the United States alone.With the sudden onset of severe psychotic symptoms, the individual is said to be experiencing acute schizophrenia. Psychotic means out of touch with reality or unable to separate real from unreal experiences.There is no known single cause of schizophrenia. As discussed later, it appears that genetic factors produce a vulnerability to schizophrenia, with environmental factors contributing to different degrees in different individuals. There are a number of various treatments for schizophrenia. Given the complexity of schizophrenia, the major questions about this disorder (its cause or causes, prevention, and treatment) are unlikely to be resolved in the near future. The public should beware of those offering "the cure" for (or "the cause" of) schizophrenia.Schizophrenia is one of the psychotic mental disorders and is characterized by symptoms of thought, behavior, and social problems.Symptoms of schizophrenia may include delusions, hallucinations, catatonia, negative symptoms, and disorganized speech or behavior.There are five types of schizophrenia based on the kind of symptoms the person has at the time of assessment: paranoid, disorganized, catatonic, undifferentiated, and residual.Children as young as 6 years of age can be found to have all the symptoms of schizophrenia as their adult counterparts and to continue to have those symptoms into adulthood.Schizophrenia is considered to be the result of a complex group of genetic, psychological, and environmental factors.Healthcare practitioners diagnose schizophrenia by gathering comprehensive medical, family, mental-health, and social/cultural information.The practitioner will also either perform a physical examination or request that the individual's primary-care doctor perform one. The medical examination will usually include lab tests.In addition to providing treatment that is appropriate to the diagnosis, professionals attempt to determine the presence of mental illnesses that may co-occur.People with schizophrenia are at increased risk of having a number of other mental-health conditions, committing suicide, and otherwise dying earlier than people without this disorder.Medications that have been found to be most effective in treating the positive symptoms of schizophrenia are first- and second-generation antipsychotics.Psychosocial interventions for schizophrenia include education of family members, assertive community treatment, substance-abuse treatment, social-skills training, supported employment, cognitive behavioral therapy, and weight management.

Undifferentiated Schizophrenia

The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes.The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome. How Is It Diagnosed? Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic negative symptoms of schizophrenia without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behavior, manifest as a marked loss of interest, idleness, and social withdrawal.

Chapter II

Patient Data Profile Demographic data: Name: Patient X Age: Sex: M Civil Status: Single Religion:Born Again Christian Birth Place:

Birth Date: Date and time of Admission: Presenting Complaint Admitting Diagnosis: Present Health History: . Past medical History:

Family Medical History: . PHYSICAL ASSESMENT

Normal Findings Level of consciousnes s Conscious and Coherent Responsive Skull Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation. Scalp Can be moist or oily.

Actual Findings Conscious andooriented time & date Responsive

ANALYSIS normal

Head (Skull, Scalp, Hair)

The clients head has Abnormal poor a round skull contour. hygiene because The hair is thin. The scalp of the presence is smooth and firm with of dandruff dandruff. No lesions noted.

 No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation. Hair Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry. Eyebrows Symmetrical and in line with each other. Maybe black, brown or blond depending on race. Eyes Evenly distributed. Eyes Evenly placed and inline with each other. Non-protruding. Equal palpebral fissure. Eyelashes Evenly distributed. Her eyes are symmetrical, black in color, almond shape.. Conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink. Normal

 The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye. Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. Ears The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process. The ear canal has normally some cerumen of inspection. No discharges or lesions noted at the ear canal. On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in

Ears are symmetrical with no discharge. The clients auricles have the same color as the facial skin. It is mobile, firm, and not tender. The pinna recoils often as it is folded.

NORMAL

Color External nose is symmetric and straight. - Symmetric and straight Cilia present upon Nasal - No discharge or flaring inspection. septum is not deviated. - Uniform color Both nostrils are patent as each nostrils are - Not tender and no being ocluded. No lesions discharge, tenderness - Patent nares and lesions noted. Nose - Mucosa is pink - Clear, watery discharge - Nasal septum intact and in midline Facial Sinuses - Not tender Teeth and Gums - 32 adult teeth - Smooth, white, shiny tooth enamel - Pink gums (bluish or dark patches in darkskinned clients) - Moist, firm texture to gums - Smooth, intact dentures Tongue/Floor of the Incomplete set of teeth Abnormal poor and yellowish color. hygiene Bleeding gums when brushing teeth with dental carries. Normal

Nose

Mouth

Mouth - Central position - Pink color (some brown on borders for dark-skinned clients); moist; slightly rough; thin whitish coating - Moves freely; no tenderness - No prominent veins and palpable nodules Uvula - Midline Oropharynx and Tonsils - Pink and smooth posterior wall - No discharge The clients head is coordinated with 2.No visible mass or smooth movements lumps. and no discomfort. The neck supports the head 3. Symmetrical properly. No presence 4.No jugular venous of abnormal swelling or distension (suggestive of masses. cardiac congestion) 1.The neck is straight. 5. The trachea is palpable. It is positioned in the line and straight. Lymph nodes 1.May not be palpable. Normal

Neck

Maybe normally palpable in thin clients. 2. Non tender if palpable. 3. Firm with smooth rounded surface. 4. Slightly movable. 5. The thyroid is initially observed by standing in front of the client and asking the client to swallow. Thyroid 1. Normally the thyroid is non palpable. 2. Isthmus maybe visible in a thin neck. Posterior Thorax - Chest symmetric - Spine vertically aligned - Skin intact; uniform temperature Thorax and Lungs - Chest wall intact; no tenderness; no masses - Full and symmetric chest expansion (3-5cm gap) - Bilateral symmetry of vocal fremitus He has normal Respiratory rate of 18 breaths per minute. Normal

Anterior Thorax - Quiet, rhythmic, and effortless respirations - Full symmetric excursion - Bronchial and tubular breath sounds upon auscultation on trachea - Neck veins JVD at 45 - Carotid arteries: - Palpation (Amplitude and contour) upstroke and amplitude are bilateral - Auscultaion no bruits - Precordium Heart - Inspection no lifts or heaves - PMI not visible - Palpation no parasternal impulses and no thrills -PMI palpable in 5th ICS, MCL, equal size - Auscultation: - S1 heard best at apex, nl intensity Heart Rate is 94 bpm. Normal No gallops, murmurs rubs.

- S2 heart best at base, nl splitting, A2 > P2 - Extra sounds no S3, S4 - No murmurs

The abdomen is uniform in color. Its rounded and has a symmetric contour. No tenderness was palpated The client has a brownish complexion. A capillary refill of 3 seconds was noted. No lesions and scars noted. Able to extend arms in front or push them out to the side.

Normal

Normal

- No edema - Skin texture resilient and moist - Capillary refill test: immediate return of color (2-3 sec) - Limbs not tender - Symmetric in size - No edema - Skin texture resilient and moist - Capillary refill test: immediate return of color (2-3 sec) - Limbs not tender

Upper Extremities

Lower Extremities

Dry skin and with some lesions and bruises on legs. With color deviation, darker brown complexion compared to upper extremities.

Abnormal because presence bruises lesions.

of of and

- Symmetric in size

Neurological Examination GCS 13,oriented to time and place ,cooperative ,cranial nerves intact ,speech is comprehensible CN I not assessed CN II-pupils CN III , IV,VI-intact extraocular muscles CN V-intact CN VII- no facial symmetry CN VIII-intact hearing CN IX,X-intact gag reflex,can swallow CN XI-can shrug shoulders CN XII-tongue midline Theories of Development Erik Eriksons developmental theory divides the human life cycle into eight distinct psychosocial stages ,each with its own conflicts to be resolved significant relationships and favorable outcomes .Conflicts that are not resolved in a timely fashion cause . Diagnostic Examination

Gross Examination Date: 8/29/12 Color: Yellow Transparency: Clear Specific Gravity: 1.015 pH: Alkaline Protein: Negative Sugar: Negative

Microscopic Examination WBC: Negative RBC: Negative Epithelial Cells: Few Mucus Thread: Few Amorphous Phosphate: Few

*For Complete Blood Count Monthly 9/29/12

Anatomy and Physiology Structure and Function of the nervous System I.Structures There are 2 main divisions of the Nervous System; the CNS and the PNS. The Central Nervous System (CNS) includes the brain and spinal cord. The Peripheral Nervous System (PNS) includes the nerves. There is another division of the Nervous System called the Autonomic Nervous System, which includes organs that work without you thinking about them. 1.The CNS is composed of the brain and spinal cord. 2.The PNS is composed of the pairs of the cranial nerves and the 31 pairs of the spinal nerves . 3.The ANSis compromised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord .Its peripheral division is made up of visceral afferent and efferent nerve fibers as well as autonomic and sensory ganglia B.The brain is covered by three membranes . 1. The dura mater is a thick, durable membrane, closest to the skull 2. The arachnoid membrane is a delicate serous membrane 3. The pia mater is a vascular membrane .

C. The Spinal Cord is connected to the brain and is about the diameter of a human
finger. From the brain the spinal cord descends down the middle of the back and is surrounded and protected by the bony vertebral column. The spinal cord is surrounded by a clear fluid called Cerebral Spinal Fluid (CSF), that acts as a cushion to protect the delicate nerve tissues against damage from banging against the inside of the vertebrae. D. Cerebrospinal fluid (CSF) is a clear colorless bodily fluid produced in the choroid plexus of the brain. It acts as a cushion or buffer for the cortex, providing a basic mechanical and immunological protection to the brain inside the skull and serves a vital function in cerebral autoregulation of cerebral blood flow. II.Function A.CNS 1.Brain The brain is one of the largest and most complex organs in the human body. It is made up of more than 100 billion nerves that communicate in trillions of connections called synapses. The brain is made up of many specialized areas that work together: The cortex is the outermost layer of brain cells. Thinking and voluntary movements begin in the cortex. The brain stem is between the spinal cord and the rest of the brain. Basic functions like breathing and sleep are controlled here. The basal ganglia are a cluster of structures in the center of the brain. The basal ganglia coordinate messages between multiple other brain areas. The cerebellum is at the base and the back of the brain. The cerebellum is responsible for coordination and balance. The brain is also divided into several lobes: The frontal lobes are responsible for problem solving and judgment and motor function. The parietal lobes manage sensation, handwriting, and body position. The temporal lobes are involved with memory and hearing. The occipital lobes contain the brain's visual processing system. The brain is surrounded by a layer of tissue called the meninges. The skull (cranium) helps protect the brain from injury.

B.The PNS control all the organs of the body C.The ANS regulates body functions such as digestion,respiration,and cardiovascular function.the fight or flight response . 1.The sympathetic nervous system serves as an emergency preparedness system .the fight or flight.

Discharge Planning
MEDICATIONS: Encourage to continue medications as ordered. Explain to the client about the action and side effect of each drug that she takes. EXERCISE: Encourage the patient to have regular exercise. TREATMENTS: for the signs and symptoms of recurrence of disease. HEALTH TEACHINGS: Encourage to provide calm and comfortable environment. Encourage to maintain clients safety. OPD CHECK-UP Inform the patient about the importance of follow up checkup and comply with the schedule of his treatments and checkup. DIET: Encourage intake of nutritious foods. Advised increased oral fluid intake. SPIRITUAL: Encourage the patient to have strong faith in God and do not lose hope regarding his situation and always pray and thank Him for all the blessing he received from Him.