Far Eastern University Institute of Nursing National Center for Mental Health

I.

INTRODUCTION

Schizophrenia from the Greek roots skhizein (, "to split") and phrn, phren- (, -; "mind") is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. Distortions in perception may affect all five senses, including sight, hearing, taste, smell and touch, but most commonly manifest as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction.

Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals. The mainstay of treatment is antipsychotic medication; this type of drug primarily works by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, and vocational and social rehabilitation are also important. In more serious caseswhere there is risk to self and othersinvoluntary hospitalization may be necessary, although hospital stays are less frequent and for shorter periods than they were in previous times. The disorder is thought to mainly affect cognition, but it also usually contributes to chronic problems with behavior and emotion. People with schizophrenia are likely to have additional (comorbid) conditions, including major depression and anxiety disorders;[7] the lifetime occurrence of substance abuse is around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common. Furthermore, the average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate Undifferentiated schizophrenia: This subtype is diagnosed when the person's symptoms do not clearly represent one of the other three subtypes. Schizophrenia Symptoms Usually with schizophrenia, the person's inner world and behavior change notably. Behavior changes might include the following: Social withdrawal Depersonalization (intense anxiety and a feeling of being unreal) Loss of appetite Loss of hygiene

Delusions Hallucinations (eg, hearing things not actually present) The sense of being controlled by outside forces

Diagnosis Schizophrenia is diagnosed on the basis of symptom profiles. Neural correlates do not provide sufficiently useful criteria. Diagnosis is based on the self-reported experiences of the person, and abnormalities in behavior reported by family members, friends or co-workers, followed by a clinical assessment by a psychiatrist, social worker, clinical psychologist or other mental health professional. Psychiatric assessment includes a psychiatric history and some form of mental status examination. Management The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested. The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the Positive and Negative Syndrome Scale (PANSS). Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid-1950s with the development and introduction of chlorpromazine. A recovery model is increasingly adopted, emphasizing hope, empowerment and social inclusion Psychopathology Schizoprenia is caused by a combination of factors, including genetic vulnerability, environmental factors that occur during a persons development and the dysregulation of neurotransmitters. Several neurotransmitter systems become dysregulated in schizophrenia in particular, the dopamine system. Serotonin, norepinephrine and GABA neurotransmitter systems also play a role in the etiology of schizophrenia. According to the Vulnerability Model of Schizophrenia the disorder is characterized by vulnerability to multiple factors. The risk factors or stressors includes the genetics, age, due to poverty our client demands for money to her mother and major life stressor it happened when the patient loss his job. Moderators or buffers to the stressors includes the social support, intact family and stability of the community. Psychotherapeutic Management 1. 2. 3. Pharmacologic theraphy: positive symptoms respond to traditional antipsychotic drugs; negative symptoms respond more effectively to atypical drugs. Psychotherapy (individual or group counseling) Motivational therapy Art Therapy (Allowing the client to draw on a paper base on what is on their mind.) 4. Music Therapy (Letting the client listen to music to reduce anxiety.) Dance Therapy (Teaching the client to dance and follow the steps.)

Occupational and Vocational Therapy

I. Clients Name: Evangeline Padit II: Setting: Pavilion 10, NCMH

III. Assessment

NORMS
Posture Presentation Eye Conduct Thought Process (Patterns of Speech) Perception Thoughts Mood/Affect Motor Response Kempt (tidy,clean) Fair (Looks in the eye) Normoactive Speech Appropriate Euthymic (responds to stimulus) Coordinated

ACTUAL FINDINGS
Kempt (tidy,clean) Fair (Looks in the eye) Normoactive Speech Appropriate Euthymic (responds to stimulus) Coordinated

INTERPRETATION AND ANALYSIS

Normal Normal Normal Normal Normal Normal

IV. Goals

The client is expected to manifest a sense of participation and willingness to achieve the goals and objective that the nurse implies to promote the maximum level of holistic functioning that the nurse can manage thus interrelating the facts and understanding why does nursing process and such interventions should be done and carried out. To help the client in exposing her feelings and insights that can the client has troubles sharing with others thru Nurse-Patient Interaction. To assess the patient in physical and cognitive aspect.

Far Eastern University Institute of Nursing Nurse-Patient Interaction Clients Name: Evangeline Padit

ORIENTATION PHASE

NURSE Kumusta na po kayo? Hello po. Ako po si Erika Bianca de Guzman. $th yr student s FEU. Opo ako po ang magiging nurse ninyo para sa araw na ito. Ngayong araw lang po kami at hanggang 4 ng hapon. Magkakaroon po kami ng socialization mamaya. Sali po kayo ha. Bale kung ano man po gusto niyo pag-usapan makikinig po kme at kung may problema kayo pwede rin natin itong pag-usapan. Lahat po ng pag-uusapan natin ay patungkol po lahat sa inyo. Ngayon po may mga ilang bagay lang po kaming tatanungin sainyo. Ayos lang po ba? Alam niyo po ba ang araw ngayon?

PATIENT Mabuti naman Hello nurse Erika, ikaw ba ang nurse ko.?

NON VERBAL CUES Maintains eye contact Maintains eye contact

ANALYSIS Broad openings encourages patient to talk

EVALUATION The nurse patient interaction has been successful at this stage because the client had already shared his ideas, thoughts and feelings with the student nurse. The client has a good attitude. She cooperates well within the interaction period.

COMMENTS OF CI

The client nods Ah ganun po ba mam Erika. Saying naman po. Making available the facts that the client needs. Informing the client of facts increases his knowledge about a topic or lets the client know what to expect. It builds trust. The client shows participation and nod as a sign of agreeing with the student nurse

O sige po mam.

. The clients smiles Opo mam ayos lang

Maintains eye contact Eh alam nyo po ba kung nasaan po kayo? Ano po yung kompletong pangalan niyo? Kelan po yung birthday niyo? February 01 po. Ilang taon na po kayo? May asawa po ba kayo? Saan po kayo nakatira? Ako po si Evangeline Padit August 6, 1978. Kayo po mam kelan birthday nyo? Ah. 31 y/o na ako Opo October 15 ngayon. Nasa mental hospital po Maintains eye contact, smiles Maintains eye contact, smiles

Maintains eye contact

Far Eastern University Institute of Nursing Nursing Care Plan

CUES

NURSING DIAGNOSIS Altered Family process related to Ambivalent family system/relationships secondary to undifferentiated schizophrenia

ANALYSIS

GOAL AND OBJECTIVES Goal: After 5 days of nursing interventions, the client will demonstrate improvement in communications (clear), problemsolving, behavior control, and affective spheres of family functioning. Objectives: 1. Verbalize realistic perception of roles within limits of individual situation.

INTERVENTIONS

RATIONALE

EVALUATION

Altered family processes occur as a result of the inability of one or more members of the family to adjust or perform, resulting in family dysfunction and interruption or prevention of development of the family. Family development is closely related to the developmental changes experienced by adult members. Over time families

Independent 1. Determine current and pre illness level of family functioning. Note factors such as problem-solving skills, level of this interpersonal relationships, outside support systems, roles, boundaries, rules, and communications.

1. Provides information about client and family to assist in developing plan of care and choosing interventions. These factors affect the familys capacity for returning to precrisis level of adaptive functioning as well as set the tone / expectations for a favorable prognosis. Note:

Effectiveness 1. Was the client able to demonstrate improvement in communications (clear), problemsolving, behavior control, and affective spheres of family functioning? Yes___? No___ ? why__? 2. Was the client able to Verbalize realistic perception of roles within limits of individual situation.? Yes___? No___ ?

must adjust to change within the family structure brought on by both expected and unexpected events, including illness or death of a member, and/or changes in social or economic strengths precipitated by divorce, retirement, and loss of employment. Health care providers must also be aware of the changing constellation of families: gay couples raising children, single parents with children, elderly grandparents responsible for grandchildren or foster children, and other situations. Pg. 125 Williams, Brian; Stacey C. Sawyer, Carl M. Wahlstrom (2005). Marriages, Families & Intinamte Relationships. Boston, MA: Pearson.

2. Encourage and allow member who is ill to handle situation in own way.

Some family members may demonstrate psychopathologies that may make their influence detrimental to the client. 2. Determine whether family is high in expressed emotion (e.g., criticism, disappointment, hostility, solicitude, extreme worry, over protectiveness, or emotional overinvolvement). 2. The emotional climate of the clients family has been shown to significantly affect the clients recovery. Relapse is associated with the expression of certain feelings in specific ways rather than emotional openness itself. Relapse occurs significantly more often in families with a high degree of expressed emotion (EE), especially criticism and hostility. Note: Some studies suggest EE may be more a response to the clients bizarre behavior, rather than a family trait, and may lessen as the condition

why__? 3. Encourage and allow member who is ill to handle situation in own way. ? Yes___? No___ ? why__?

Efficiency: Were the interventions efficiently meet the clients needs? ___YES___ NO Why? Adequacy: Were the interventions enough to meet the clients needs? ___YES___ NO Why? Appropriateness: Were the interventions appropriate for the clients situation? ___YES ___NO Why? Acceptability: Were the interventions

persists and the family becomes used to the symptoms. 3. Provide opportunity for family members to discuss feelings, impact of disorder on family, and individual concerns. 3. Feelings of guilt, shame, isolation; loss of hopes /expectations regarding client; and concerns for personal and client safety have an impact on familys ability to manage crisis and support client. Chronic nature of condition, with a wide range of socially, emotionally, and intellectually disabling symptoms that come and go unpredictably, can exhaust family physically, emotionally, and financially. The disproportionate allocation of resources can create deep feelings of resentment and family conflict as time and energy are focused on the client to the possible exclusion of the needs of

acceptable for the clients situation? ___YES___ NO Why?

other family members, and monetary expenses may restrict the family members ability to take vacations, go to college, or even consider retirement. 4. Assess readiness of family members /significant other(s) to participate in clients treatment. 4. Family theorists believe that the identified patient also represents disintegrated /enmeshed schizophrenogenic family system. Aftercare of client must include family /SO(s) to raise level of interpersonal functioning. 5. The family that already has maladaptive coping skills may have difficulty dealing with diagnosis and implications of a long-term illness. Clients behavior may be difficult and embarrassing for some families who have problematic coping skills or have a high profile in the community.

5. Provide honest information about the nature and seriousness of the disorder and enlist cooperation of family members to help client to remain in the community.

6. Promote family involvement with nurses /others to plan care and activities.

6. Involvement with others provides a role model for individuals to learn new behaviors /ways of handling stress, and problemsolving. 7. Clients success in treatment depends on effective change of whole systems rather than treatment of clients behaviors as a separate entity. 8. Promotes healthy interaction, allows for timely problemsolving, and maintains effective relationships. 9. Family that has previously functioned well has skills to build on and can learn new ways of dealing with changed family structure and challenges of marginally functioning family member. The nurse can provide an

7. Help client /family/SO(s) to identify maladaptive behaviors and consequences. Support efforts for change.

8. Establish /encourage ongoing open communication within the family.

9. Help family identify potential for growth of family system and individual members. Role-model positive behaviors during this process.

example for learning new skills. 10. Assess readiness of the family /SO(s) to reintegrate client into system, such as familys ability to use assistance or to cope with crisis appropriately by adaptation or change. Collaborative 11. Promote family involvement in behavioral management programs. Discuss negative aspects of blame and ways to avoid its use. 11. Helps family members to realize that, although they can have a positive or negative influence on the course of the illness, they are doing the best they can in a difficult situation, and communication /problem-solving skills can be learned to reduce stress. Blaming themselves or the client is counterproductive, and it is more important to talk about individual responsibility. 12. Multiple stressors, labile 10. Ability to tolerate and assist with management of client behavior affects clients reentry into the family system.

12. Encourage family to participate in family

education, therapy, community support groups.

nature of disorder, lack of definitive treatment options, or lack of resolution of condition increases likelihood of family conflict, disorganization, and even dissolution. Providing the family with information about the disorder; showing them how to help the client, without neglecting family members needs; and better ways to communicate with one another and with the client; as well as training family to identify and solve problems as they arise enhances familys coping abilities and may lessen the clients risk of relapse. 13. When bizarre behavior is difficult for family to manage, assistance /support may enhance coping abilities, improve the situation, and

13. Promote involvement with mental health treatment team (e.g., mental health center, family physician/ psychiatrist, psychiatric/ public health nurse,

social/ vocational services, occupational /physical therapist), and respite care, when necessary.

provide opportunity for individual growth, thereby strengthening the family unit. Having the opportunity to take time away from the situation enhances the familys ability to manage the clients long-term illness. 14. Aftercare may include efforts to enlarge social spheres and increase clients /familys level of functioning, enhancing ability to manage long- term illness and enabling the client to remain in the community.

14. Provide client /family/SO(s) with assistance to deal with current life situation (e.g., therapy [family / couples/1:1]; aftercare services including daycare centers, night hospitals, halfway houses, sheltered workshops, rehabilitation services).

Far Eastern University Institute of Nursing Drug Study

Name of Patient: Evangeline Padit Diagnosis of Patient: Schizophrenia, undifferentiated Generic/Brand name/Stock dose
Generic Name: Chlorpromazine Brand Name: Thorazine Classification: Antipsychotic

Mechanism of Action
Thorazine is a tranquilizer and antiemetic with a sedating effect.

Route of administration
Per orem

Nursing Responsibilities in giving medication

Thorazine (chlorpromazine) should be administered cautiously to persons with cardiovascular, liver or renal disease. There is evidence that patients with a history of hepatic encephalopathy due to cirrhosis have increased sensitivity to the CNS effects of Thorazine (i.e., impaired cerebration and abnormal slowing of the EEG). Because of its CNS depressant effect, Thorazine should be used with caution in patients with chronic respiratory disorders such as severe asthma, emphysema and acute respiratory infections, particularly in children (1 to 12

Side effects/Adverse reaction

Automatic Nervous System: Anticholinergic effects including dry mouth, blurred vision, constipation, ileus, nasal stuffiness, photophobia. Syncope and impaired temperature regulation have also occurred. Cardiovascular: direct negative inotropic and quinidine-like actions. Its effects on the ECG include prolongation of the PR and QT intervals, blunting of the T wave and depression of the S-T segment. Ventricular arrythmia and sudden death have occurred rarely. Orthostatic Hypotension, Tachycardia, fainting and dizziness CNS: Extrapyramidal reactions, including pseudoparkinsonism (with motor retardation, rigidity, mask like facies, pill rolling and other tremors, drooling, shuffling gait, etc.);

years of age). Because Thorazine can suppress the cough reflex, aspiration of vomitus is possible. Thorazine (chlorpromazine) prolongs and intensifies the action of CNS depressants such as anesthetics, barbiturates and narcotics. When Thorazine is administered concomitantly, about 1 / 4 to 1 / 2 the usual dosage of such agents is required. When Thorazine is not being administered to reduce requirements of CNS depressants, it is best to stop such depressants before starting Thorazine treatment. These agents may subsequently be reinstated at low doses and increased as needed.

dystonic reactions (including periroral spasms, trismus, tics, torticollis, oculogyric crises, protrusion of the tongue, difficulty swallowing, carpopedal spasm, opisthotonos of the back muscles); and akathisia. Dermatologic: Itching, rash, hypertrophic papillae of the tongue, angioneurotic edema, erythema, allergic purpura, exfoliative dermatitis, photosensitivity. Contact dermatitis has occurred in personnel handling solutions or injections of chlorpromazine. Endocrine: Increased prolactin secretion; gynecomastia, galactorrhea, mastalgia, altered libido, menstrual irregularities, weight gain, alterations in glucose tolerance and false positive pregnancy tests have occurred. Gastrointestinal: Nausea, vomiting, increase or decrease in appetite, gastric irritation, constipation, paralytic ileus, rarely diarrhea. Dry mouth. Hematologic: Agranulocytosis, leukopenia, granulocytopenia, eosinophilia, thrombocytopenia, anemia, aplastic anemia, pancytopenia. Agranulocytosis occurs in fewer than 1 in 10000 patients receiving chlorpromazine. Hepatic: Cholestatic jaundice Ophthalmologic: A peculiar skin-eye syndrome. This reaction is marked by progressive pigmentation of areas of skin or conjunctiva and/or discoloration of the exposed sclera and cornea. Opacities of the anterior lens and cornea described as irregular or stellate in shape have also been reported. Patients receiving higher doses of phenothiazines for prolonged periods should

Fluphenazine decanoate Classification: Antipsychotic

Antagonize dopamine neurotransmission at synapses by blocking postsynaptic dopaminergic receptors in the brain.

IM inejction

-Monitor BP for hypotension. -Monitor for fine tongue movement ( may be early sign for tardive dyskinesia) -Supervise suicidal risk patient closely during early therapy ( as depression lessens, energy level improves, increasing suicide potential).

have periodic complete eye examinations. Frequent: hypotension, dizziness, and syncope. Occasional: somnolence, dry mouth, blurred vision,lethargy, constipation or diarrhea, peripheral edema.