A Case Study On

“UNDIFFERENTIATED SCHIZOPHRENIA”

In Partial Fulfillment of the Requirements in NCM- RLE

(Psychiatric Exposure)

Submitted to:
Ms. Marie Lyn Al Bayouk, RN
Ms. Evelyn Alba, RN
Ms. Maria Elsie Callueng, RN, MAN
Ms. Mary Jane Guiang, RN
Ms. Maria Delma Mausisa, RN, MAN
Ms. Cecilia Grace Acuña, RN
Clinical Instructors

Submitted by:
ANQUE, Joanna Grace Ruby GARLIT, Irish
BACARON, Loumelyn Rose GONZAGA, Kimberly Anne
BAUTISTA, Ericka MAGSIPOC, Rubnie Jhum
BUTT, Kanval OBANDO, Sherilyn
CLAVANO, Rock PUERTO, Angelee
DALHOG, Aaron REPITO, Desiree
BSN – 4B Male Ward Group
ROSALIN, Jeffrey
SANTOS, Amifaith
SENARILLOS, Mary Rose
SUCALDITO, April May Anne
UNTALAN, Benjamin Alejandro

Date Submitted:
October 22, 2010

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 TABLE OF CONTENTS

Table of Contents……………………………………………………………

I. Introduction

A. Overview………………………………………………………………

B. Objective

B.1 General Objective………………………………………………

B.2 Specific Objectives…………………………………………………….

II. Anamnesis…………………………………………………………………………

A. Informants…………………………………………………………………….

B. Maternal and Paternal Lineage…………………………………………………..

C. Parents…………………………………………………………………………….

D. Siblings………………………………………………………………………

III. Personal History…………………………………………………………………….

IV. Course in the Hospital……………………………………………………………..

A. Mental Status Examination……………………………………………….

V. Progress Notes……………………………………………………………….

VI. Psychopathophysiology……………………………………………………..

VII. Psychodynamics…………………………………………………

A. Tabular Presentation of the Predisposing Factors and Rationale…………………

B. Schematic Diagram………………………………………………………….

VIII. Differential Diagnosis…………………………………………………………….

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IX. Multi-Axial Diagnosis DSM-IV TR……………………………………………..

X. Summary…………………………………………………………………………..

XI. Nursing Care Plan………………………………………………………………...

XII. Medical Managements…………………………………………………………

A. Doctor’s Order…………………………………………………………………..

B. Psychopharmacotherapy……………………………………………………..

XIII. Prognosis and Recommendation………………………………………………

XIV. Discharge Planning……………………………………………………………

XV. Bibliography……………………………………………………………………

Appendices

A. Spot Map………………………………………………………

B. Genogram……………………………………………………

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 INTRODUCTION

OVERVIEW

How human brain works is the most complex toil in the human body. A serious

damage in it can change lives. A change can be on a person’s thoughts, perceptions,

behaviors, movements and emotions. These changes can possibly harm a person’s

family or worst the community he lives in.

Schizophrenia is not a terribly common disease but it can be a serious and chronic

one. The appearance of its manifestations differs among patients and the duration of

the disorder. The disorder usually begins before the age of 25 and continues

throughout life time. Both patients and their families often suffer from poor care and

social barring.

Early Greek physicians described delusions of grandeur, paranoia, and deterioration

in cognitive functions and personality. It was not until the 19th century, however that

schizophrenia emerged as a medical condition worthy of study and treatment. Emil

Kraepelin (1856 -1926) and Eugene Bleuler (1857 -1939) are the two major figures in

psychiatry and neurology who studied schizophrenia. Kraepelin first named the

disorder as dementia precox, a term that emphasized the change in cognition and

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early onset of the disorder. It was Bleuler who coined the term schizophrenia, which

replaced dementia precox in the literature.

Worldwide about 1 percent of the population is diagnosed with schizophrenia. About

1.5 million people will be diagnosed with schizophrenia this year around the world.

About 90% of schizophrenic patients seek treatment between 18-55 years old. Male

and female equally affected, Symptoms of schizophrenia appear earlier in males.

More than 1/2 of all male schizophrenic patients and 1/3 of all female patients are

first admitted to psychiatric hospitals before 25. It is considered to be one of the top

ten causes of long-term disability worldwide.

In the Philippines, a study conducted in three primary health centers situated in an

urban slum in Manila, showed that 17% of adults and 16% of children had mental

disorders. ). According to study done, 697,543 out of 86,241,697 of Filipinos or

approximately 0.8% are suffering from schizophrenia .A study in 1988-1989 in a

barrio in San Jose Del Monte Bulacan, showed the prevalence of adult schizophrenia

to be 12 cases per 1000 persons. Here in Davao, Dr. Padilla said that the Davao

Mental Hospital receives an average of eight to 10 patients a day suffering from

schizophrenia, depression and bi-polar illnesses.

DSM – IV – TR (Diagnostic and Statistical Manual on Mental Disorders 4 th Text

Revised) classifies the subtypes of schizophrenia as paranoid, catatonic,

undifferentiated, and residual, based predominantly on clinical presentation. Patient

X, admitted in the Crisis Intervention Unit (CIU) of the Davao Mental Hospital, was

diagnosed with undifferentiated schizophrenia. The said disorder is hoped to be

discussed thoroughly in this study.

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OBJECTIVE

GENERAL OBJECTIVE:

This study aims to discuss the causes and factors that will contribute to the onset

of the condition of the patient.

SPECIFIC OBJECTIVE:

1. Establish a trusting and therapeutic relationship with Patient X and his family.

2. Gather pertinent data from the patient, family, and other informants regarding

patient’s condition.

3. Identify precipitating and predisposing factors that are possibly involved in the

development of the presented disorder.

4. Determine the family history related to the condition of the patient that is relevant

to the study.

5. Trace the psychopathophysiology of the condition.

6. To learn drug actions, and side effects of medication given to the patient.

7. Formulate Nursing Care Plan suited to the patient’s condition.

8. Render health teaching to the patient, family and community.

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SCOPE AND LIMITATION

This study was accomplished during the Psychiatric Nursing exposure at the Davao

Mental Hospital located at the J.P Laurel Avenue, Davao City last September 28 to

October 15, 2010. This case study focused on a certain patient living at Panabo City. The

patient was diagnosed to have Schizophrenia, undifferentiated and was admitted at Davao

Mental Hospital last September 29, 2010 and discharged from CIU last October 4, 2010.

The group gathered ten informants including his relatives, friends, neighbors, and family

members. The interviewers gathered significant information which is helpful in knowing

the present condition of the patient. The information comprised the familial history and

the patient’s life.

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 PATIENT’S PROFILE

Name of Hospital: Davao Mental Hospital

Address: J.P. Laurel Avenue, Bajada, Davao City

Patient’s Name: Patient X

Ward/Room/Bed Service:Crisis Intervention Unit

Address: Guava St. Phase I, Brgy. Cagangohan, Panabo City

Age: 22

Gender: Male

Birth date: January 9, 1987

Civil Status: Single

Nationality: Filipino

Religion: Roman Catholic

Ordinal Position: 5th Child

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Educational Attainment: 3rd Year High School

Father’s Name: Mr. A Sr. (Deceased)

Occupation: Citizenship Advancement Training

Mother’s Name: Mrs. A

Occupation: Fruit Vendor

Date of Admission: September 29, 2010

Time of Admission: 10:00 am

Date Discharged: October 4, 2010

No. of Days Admitted: 5 days

Admitting Physician: Dr. Sayon

Type of Admission: New

Principal Diagnosis: Schizophrenia, undifferentiated

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 ANAMNESIS

INFORMANTS

INFORMANT #1

Name: Mrs. A

Age: 55 years old

Relationship: Mother

VISAYAN VERSION:

According to the informant her son was born in Minda Carmen. They lived at Panabo

province (please refer to the spot map) for 11 years. Patient A starts working as

“konductor” at the age of 16 at Tres Marias. He only reached 3 rd year high school

because he joined gang and was terminated at school. At the age of 18 he was brought to

Dela Rosa Rehabilitation Center. He keeps on saying to his mother that there are lots of

cigarettes. They found out that he was using marijuana and prohibited drug like shabu.

When he was nineteen years old he became drug dependent. At 21 years old, his uncle

brought him in Baringot Agusan to work. Last May 27, 2010 his father died, the burial

last for fifteen days. At that time he cannot fell to sleep and he kept on hugging his

father’s coffin. He was taking 100mg of Seroquel as maintenance rather 200mg. The

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informant has 7 children and all of them were delivered via normal spontaneous vaginal

delivery. The informant has spotting of blood while she’s pregnant with Patient A. The

informant went to the doctor for checkup and the result was normal. The informant also

has cough during the pregnancy. Patient A has complete immunization and prenatal

check up according to his mother. According to the informant, Patient A loves his

siblings so much and he has close relationship to his father. The informant was smoking

during her third pregnancy. Patient A was breastfed during his infancy. They don’t

usually cuddle Patient A. Patient A started walking at 8 months old. He started speaking

at the age of 13 months. He started schooling at the age of five. They left him at school

during school hours because he already knows how to go home.

When Patient A was still at the elementary level he really wanted to study, according to

the informant. But when he reached high school level he didn’t want to study anymore.

He also received a grade of 76 in English. His favorite subject was mathematics. He had a

lot of friends both male and female. He goes to church once or twice a month. He stays at

home before he was admitted in this hospital. He had a lot of girlfriends before but few

are in serious relationship. One of the girls that he loved went to Dubai and it gave him

the reason to breakup. The woman was widower and has a child. She always went in their

house and Patient A loves her child.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Mrs. A is very cooperative in interactive and very accommodating. She shared

information about his son’s life. She was well groomed and her speech was spontaneous.

She responded accordingly to the interviewer’s questions.

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Informant #2

Name: Mr. JB

Age: 34 years old

Relationship: brother, second to the eldest

“Sometimes he became angry right after he left home. He became a “konduktor” while he

lived with his friend. Right after he went home he talked often,” as verbalized by the

informant. The informant said “Pag-uli nya sa balay hilomon naman siya, pagkapila ka

adlaw na ing-ana naman sya (pagkatopak). He also becomes wild in our aunt’s house. We

didn’t know that he was using cannabis and methamphetamine. “pormal man siya na

pagkatao” according to the informant. After a few months when my father died he took

drugs again. He plays basketball when he was a kid, he even plays with other children.

He had a friend and co-worker named Ton-ton, his relationship to his co-workers was

good. He had a girlfriend but I don’t know her name. My father is a social drinker, he

smoked but stopped when he was 45 years old. He has hypertension. “stroke man to

iyang dahilan pagkamatay, naa pud si tatay ginatumar na tambal” as told by the

informant. He worked at miners as a chef for 2 weeks. Sometimes my mother experiences

shortness of breath. After my father’s death, fruit vending was the source of our income.

Now my mother supports us financially.

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Characteristics and Attitudes of the Informant:

Upon interviewing the informant we have observed that he was answering in all

questions according to his cognitive knowledge although he was in a hurry because he

had work to do. He was well groomed and his speech was spontaneous. He responded

accordingly to the interviewer’s questions.

Informant #3

Name: Mr. KS

Age: 18 years old

Relationship: Close friend

VISAYAN VERSION:

Ok mana sya kaistorya ug kalit lang muistorya ug lahi “lahi ang tubag”. Buotan,

musogot suguon, dali istoryahon, daghan amigo, sige dula ug basketball.

Dili siya ( Anthony) hilig magsugal aga-tan-aw lang na siya. Usahay lang naga-inom

ug sigarilyo. Naga-videoke.

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Naay sya barkada sa prutasan kauban niya sa paghit-hit. Bago na siya na-admit

gidakop na siya kay nag-wild ug gi-kulata pud siya sa pulis. Naa tong panahon na

nagtan-aw mi ug basketball human gi-ayo niya ang sound system.

Nag-istorya siya sa tindahan Tindera: “ Dong asa man ka gikan? Anthony: “ Nag-adto

ko Baghdad,Iraq. Nag-ingon siya sa usa ka tindera “Te, papalita ko ug redhorse isa

ka case kay mag-inom mi sa akong barkada. May sinsilyo ka 25 sa Milyon na gold?”

ka yang gibayaran ko niya 25 sentavos. Pagkapatay sa iyang papa kay na-depressed

siya. Kadtong naay vigil sa amo gi-ingnan nya ang mga bisita na mulingkod sa ka

manigarilyo ug mangape. Wala siya pili na barkada kung baga “lovable”. Kadtong

naa siya gitulis gi-ingnan niya iyang barkada na ihatag n amino ang imong kwarta sa

akoa kay itumba ko na imong motor. Human wala nako ganahi mamasahero kay gi-

hold-up nako niya.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Upon interview we can observed that he is speaking fluently and it is based upon his

knowledge. He had a lot of stories to tell because he was a close friend to Anthony.

INFORMANT #4

Name: Mr. RD

Age: 39 years old

Relationship: Friend, known him for years

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VISAYAN VERSION:

Dugay name nagkaila. Nagakondoktor siya ug jeep human nikalit lang na torereng

kay napasmohan. Nahibal-an na turiring kay ni-ingon na hayag inyong suga pero

walay andar ang suga. Palapansin sa iyang mga amigo pero sa kalaban masuko.

Kadtong buhi pa iyang papa close sila. ang iyang mga igsoon gikulong siya kay gi-

holdap niya iyang barkada. Ang iyang mama kay nahadlok sa iyang batasan human

nidagan sa pikas balay. Didto sya nagpuyo pila ka simana. Kadtong ulahing tukar

niya kay nanghasi siya sa pulis. Kung mulakaw murag robot.

ENGLISH VERSION:

I’ve known him for a long time. He used to be conductor in a jeepney then suddenly

something is ringing in his ear “natorereng” due to some eating pattern disturbance.

we only knew that he is not in the right condition of his mind when he thought that

our light is bright there is no light switch on.he used to be jolly in his friends but

easily gets angry with his enemy. When his father was still alive they were so bonded.

there was one instance that his brother jailed him because he robbed one of his

friends. His mother fear him because of his behavior he ran off to the other house. his

mother stayed there for a couple of time. last occurrence of his untamed behavior he

robbed a police man. when he walked he seems like a robot.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

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As we have our interview with him, we sense that he willingly shared all his knowledge with our

patient because he knew him so well.

INFORMANT #5

Name: Mr. PC

Age: 58 years old

Relationship: Friend, known him for 13 years

VISAYAN VERSION:

Nagkasuod mi ani diri na sa lugar. Ang iyang papa kay foreman human naa siya mga

buotan na anak, apil na didto si Anthony. Dili man siya dalo na pagkatao. Naa toy usa

na pagkataon na nag-wild siya sa birthday sa anak sa sarhento nya amigo pajud nya.

Maayo man siya na amigo pero pagmabikil siya kay suko jud siya. Mukalit-kalit lang

baya siya. naa toy usa na nabantayan nako siya na naghit-hit. mayo na siya na bata

pinangga kayo na siya. Dili kayo nako kaila iyang mama. Ang iyang mga amigo pare-

pareha lang ug edad nga puro mga lalaki.

ENGLISH VERSION:

Anthony and I became friend in this area. his father was a foreman he has children

this include Anthny they were behave children. He used to be generous. There was

one time that he became wild at at one event of his friend, a birthday celebration in a

sergeant’s house. He was a good companion and a friend but a fearful one to his

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 enemy. He suddenly gets irritated. There was one time that I saw him using drugs. He

was loved by many. I don’t really knew his mom. He has the same peers almost all of

it is boys.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Our informant known him for more than 10 years, he speaks fluently and confidently.

Informant #6

Name: Mr. P

Relation: Neighbor/ Friend of patient’s father

Known patient since 1997. When asked about the patient, informant said “But-an, pero

pag mabikil… kusgan jud ng bata na na.” When asked about his most memorable violent

incident with the patient, informant said “kalit kalit magbunal bato sa video karera.”

Informant attested that patient used cannabis in his home. In terms of cigarette smoking,

patient used to smoke 1 pack of cigarettes per day. When informant was asked about the

patient’s father, he said he died because of hypertension and that he was very strict.

When asked about the patient’s mother, he said that the mother was always not home

because she had to go to the market to sell fruits. Informant observed that the patient had

friends of the same age and same sex. He goes to church, but not with the whole family.

Informant observed that the patient is his parents’ favorite child. Patient used to bring

food to his family after work. The last incident that happened between the informant and

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the patient was when the patient went to his home, unable to recognize him as a close

family friend.

Informant #7

Name: Mrs. M

Relation: Neighbor

Known patient since 1995. When asked what she can say about the patient, she said

“Maayo man siya, pero pag mabikil magalit.” Patient brings food to family. He also has

lots of friends. When asked about his most memorable violent incident with the patient,

informant said that the patient once threw a stone that broke their window. Informant also

shared another incident with the patient. He once brought a lot of orchids from his

mother’s garden to his neighbors houses without his mother’s permission.

Informant # 8

Name: Mrs. G

Address:

Relationship: Aunt

Length of time known to patient: 23 years

Apparent Understanding of Present Illness to the Patient:

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Mrs. G verbalized, “ buotan mana na bata si Anthony, bright gane na siya naundang lang

na siya ug eskwela mao to nag konduktor na siya jeep pa davao. Murag na pasmuhan

man gud na siya unya katong nag konduktor na siya nakasaksi na siya nga nay gibaril sa

iyang atubangan mao tong na shock siya didto na nagsugod iya sakit unya namatay

iyahang papa nisamut iyahang sakit. Sa side pud sa mama ni Anthony naa siya pag-

umangkon nga naa sakit sa utok, napasmuhan pud to siya sa bukid man to nahitabu kay

nag-uma man to siya didto, pero step sister lang man to sa mama ni Anthony basin dili

pud to konektado sa Iyahang sakit.”

Characteristics and Attitude of the Informant:

Mrs. G is willing to share information regarding her nephew’s condition, she response

accordingly to our question.

Informant # 9

Name: Mrs. E

Address:

Relationship: Neighbor

Length of time known to patient: 2 years

Apparent Understanding of Present Illness to the Patient:

Mrs. E verbalized, “ ay sa barkada-barkada mana siya basig na impluwensiyahan na siya

mag take ug bawal na gamut, bugoy man gud na iya mga barkada. Pero dili ko sure ana

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kay bag-o lng pud baya me dire unya mahadluk jud ko ana niya kay mututok man na siya

sa balay,last week lang gani to sya nag-wild. ”

Characteristics and Attitude of the Informant:

As we interview Mrs. E, she was very sociable and readily answers our question

regarding the patient’s condition.

Informant # 10

Name: Mrs. F

Address:

Relationship: neighbor

Length of time known to patient: 1 year

Apparent Understanding of Present Illness to the Patient:

Mrs. F verbalized, “ ang pagkabalu nako bag-o lang na siya na kagawas ug mental pero

wala jud ko kabalo sa iyahang sakit. Mahadluk lang mi sa iyaha kay lain man gud na siya

mutan-aw mao na naga pan lock me sa gate namu.”

Characteristics and Attitude of the Informant:

Mrs. F is hesitant to give information due to the fear that the patient will be agitated and

harm their family.

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 MATERNAL AND PATERNAL LINEAGE

PARENTS

Father

Mr. A Senior grew up in Panabo City. He is an employee at a private company for 6

years then he became a commandant for the high school subject CAT (Citizenship

Advancement Training) at Panabo National High School. He wass a good provider to his

family and was generally described as a good person. In the family, he was known to be a

strict disciplinarian. Among his children, the patient was his favorite. In terms of

religious practices, he seldom attends mass. Mr. A Seniors activities includes singing in a

videoke machine and occassional drinking session of alcoholic beverage with his

colleagues. The late Mr. A believed that discipline is a key to have a harmonious

relationship among each family member.

Mother

Mrs. A also grew up in Panabo City. She was a fruit vendor at the public market. She was

described by the informants to be a good and kindhearted person. In terms of discipline,

an informant told the interviewers that he witnessed the mother spanking her kids

whenever they did something wrong. She had a good relationship with her husband but

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was said that she was a very busy person that sometimes she lacks time to spend with her

family.

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SIBLINGS

Joe, 36 years old, is the eldest in the family. He was already married for 7years with

two daughters. He was able to finish first year high school and stopped then after.

This was due to his extreme attachment to his friends and vices. Currently, he resides

at Panabo City and is working at TADECO Company. He was described as a very

sociable person in the entire family.

Jov, 30years old, is the second in the family. He was also married for 5 years with 2

kids. He was the only one in the siblings who was able to reach first year college

level. He was not able to finish schooling due to financial constraints. He was

described as a silent and shy type of person.

Fred, 29 years old, is the third in the family. He was able to graduate in High School.

He is still single and is currently working at the Panabo Port. He was also a shy type

of person and only opens up to those who are very close to him.

Vidi, 27 years old, is the fourth in the family. He also graduated in High School. He is

single and is currently working as a waiter at a local restaurant nearby their residence.

He was described as a simple guy and a very thrifty person.

Anthony is the fifth in the family. He is 23 years of age. He reached 3rd year High

School and was not able to pursue his education due to his vices and recurrent

admission to the psychiatric institution. He was described as a silent type of person

before his sickness but his behavior drastically changed right after he was admitted.

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He became aggressive and anxious most of the time but he calms down when his

mother starts to threat him that she will call the police officers. Anthony starts

working at 18 years old when he became a konduktor (helper) in the jeepney that

travels from Panabo City to Davao City. Currently, he is still staying in their

residence and is still under observation for possible recurrence of aggression that he

exhibits a week prior to admission.

Vani age 22 is a high school graduate. He is the sixth in the family and is working as

a school janitor. He is still single and helps in the family’s finances especially now

that their father is gone. He was described by the neighbor informants to be “budots-

budots” (quirky clothing style) due to his fashion statement. He was also known to be

a member of a gang who was said to be involved in some violent activities.

Vens age 18 is the youngest in the family. He is a high school graduate. He is

currently helping his mother in selling fruits and vegetables in the market. He was

known to be a good person in their community.

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PERSONAL HISTORY

Mrs. A has a poor prenatal check up. She doesn’t have any supplements and she

rarely eats nutritious foods. She also lacks exercise. She verbalized that she took

paracetamol when she have headache or fever when she was pregnant.

BIRTH

She delivered all her children via normal spontaneous vaginal delivery. The first five

children were delivered at home wherein a midwife facilitated the delivery. The two

younger siblings were delivered at the hospital. As for Anthony, he was born on

January 9, 1987 and there were no complications noted upon delivery.

INFANCY AND CHILDHOOD

Anthony was breastfed for 9months. His eruption of teeth occurred at around

4months. At 8 months, he was able to take his first steps. He was able to baby talk at

1year and 1month. The patient was toilet trained at 3years old. At 4 years old an

unexpected incident occurred wherein he fell down 3steps in the stairs and resulted to

few bruises and lesions but there were no any neurologic deficit noted.

PSYCHOSEXUAL HISTORY

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Anthony verbalized that he was already oriented on his sex as a male since he was a

child. He was circumcised at age 8. He had his first girlfriend at age 15. He had 2

succeeding relationships thereafter. He verbalized that he had a serious relationship

with a woman and he got her impregnated but the woman decided to abort the child

and that made him devastated because he wanted a child.

PLAYLIFE

The patient was given toys appropriate for his age. His mother verbalized, “Ay,wala

jud nay problema nang bata-a nah. Grabeh jud nah siya makadula. Daghan pud nah

siya ug amigo.”

SCHOOL HISTORY

At 6years old, he started schooling as a kindergarten student. He received an award at

the end of the school year as a fifth with honors. In elementary years, Anthony was

really eager to excel in school but when he reached high school he became too

involved with his friends and was influenced with their bad habits that’s why he

flanked his English subject.

MARITAL HISTORY

Patient is still single.

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ONSET OF PRESENT ILLNESS

Upon stopping school at age 16 he became a “konduktor” (helper) of the jeep. The

work was very tedious and he skips meals often. He also became influenced to take

illegal drugs and he became addicted to it. He was rehabilitated three times at De La

Rosa rehabilitation Center yet he still continued his vices after discharge. Last May

2010, his father died which precipitated his aggression towards other people which

includes his robbery case. He was then placed by his mother and his siblings on

restrain because he could no longer control his anger. This prompted the family to

seek consult at DMH (Davao Mental Hospital).

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 COURSE IN THE HOPITAL

MENTAL STATUS EXAMINATION

Patient’s Name: Patient A Age: 23 years old

Address: Niceville Subdivision, Cagangohan, Panabo City

CIU Visit September 30, 2010

I. Presentation

A. General Appearance: Fairly Groomed with Good eye contact; akathesia

noted

B. General Mobility:

1. Posture and Gait: (√) Appropriate ( ) Inappropriate

Describe: Normal_____________________________________

2. Activity

( )Normoactive

( ) Psychomotor Retardation

(√) Restless

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 ( ) Agitated

3. Facial Expression (√) Appropriate ( ) Inappropriate

Quality:

(√)Smiling (√) Worried ( ) Angry

(√)Happy ( ) Tensed ( ) Suspicious

( ) Ecstatic ( ) Sad ( ) Frightened

( ) Tearful ( ) Distant

C. Behavior: Restless and anxious

D. Nurse- Patient Interaction

(√)Cooperative ( ) Uncooperative

( ) Initially Only (√) Throughout interview

E. Quality

( ) Warm ( ) Distant ( ) Suspicious

(√)Talkative ( ) Hostile ( ) Others:_________

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II. STREAM OF TALK

A. Character of Talk (√) Spontaneous ( ) Deliberate

B. Organizational of Talk

( ) Relevant ( ) Irrelevant ( ) Incoherent

(√) Circumstantial ( ) Looseness of Association

( ) Tangential (√) Flight of Ideas

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood (√) Euthymic ( ) Depression ( ) Euphoria

( ) Others:_____________________________________________

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 B. Affect: (√) Appropriate ( ) Inappropriate

Quality: ( ) Flat ( ) Blunted ( ) Hostile ( ) Labile ( ) Elated

C. Depersonalization and Derealization ( ) Present (√) Absent

D. Suicidal Potential ( ) Present (√) Absent

E. Homicidal Potential ( ) Present (√) Absent

IV- Thought

A. Delusion

Type: auditory

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 First Home Visit October 06, 2010

I- Presentation

A. General Appearance: Clean clothing, good eye contact, hurried speech

B. General Mobility:

1. Posture and Gait: (√) Appropriate ( ) Inappropriate

Description: Normal_______

2. Activity (√) Normoactive

( ) Psychomotor Retardation

( ) Restless

( ) Agitated

3. Facial Expression (√) Appropriate ( ) Inappropriate

Quality:

(√)Smiling ( ) Worried ( ) Angry

(√)Happy ( ) Tensed ( ) Suspicious

( ) Ecstatic ( ) Sad ( ) Frightened

( ) Tearful ( ) Distant

32
 C. Behavior: Normal

D. Nurse- Patient Interaction

(√)Cooperative ( ) Uncooperative

( ) Initially Only (√)Throughout interview

E. Quality

( ) Warm ( ) Distant ( )Suspicious

(√)Talkative ( ) Hostile ( )Others:_________

II. STREAM OF TALK

A. Character of Talk (√) Spontaneous ( ) Deliberate

B. Organizational of Talk

(√) Relevant ( ) Irrelevant ( ) Incoherent

( ) Circumstantial ( ) Looseness of Association

( ) Tangential ( ) Flight of Ideas

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood (√) Euthymic ( ) Depression ( )Euphoria

( ) Others:_____________________________________________

33
 B. Affect: (√) Appropriate ( ) Inappropriate

Quality: ( ) Flat ( ) Blunted ( )Hostile ( )Labile ( )Elated

C. Depersonalization and Derealization ( ) Present (√)Absent

D. Suicidal Potential ( ) Present (√)Absent

E. Homicidal Potential ( ) Present (√)Absent

IV- Thought

A. Delusion

Type: absent

34
 Second Home Visit October 06, 2010

I- Presentation

A. General Appearance: Clean clothing, good eye contact, hurried speech

B. General Mobility:

1. Posture and Gait: (√) Appropriate ( ) Inappropriate

Description: Normal_______

2. Activity (√) Normoactive

( ) Psychomotor Retardation

( ) Restless

( ) Agitated

3. Facial Expression (√) Appropriate ( ) Inappropriate

Quality:

(√)Smiling ( ) Worried ( ) Angry

(√)Happy ( ) Tensed ( ) Suspicious

( ) Ecstatic ( ) Sad ( ) Frightened

( ) Tearful ( ) Distant

35
 C. Behavior: Normal

D. Nurse- Patient Interaction

(√)Cooperative ( ) Uncooperative

( ) Initially Only (√) Throughout interview

E. Quality

( ) Warm ( ) Distant ( ) Suspicious

(√)Talkative ( ) Hostile ( ) Others:_________

II. STREAM OF TALK

A. Character of Talk (√) Spontaneous ( ) Deliberate

B. Organizational of Talk

(√) Relevant ( ) Irrelevant ( ) Incoherent

( ) Circumstantial ( ) Looseness of Association

( ) Tangential ( ) Flight of Ideas

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood (√) Euthymic ( ) Depression ( ) Euphoric

( ) Others:_____________________________________________

36
 B. Affect: (√) Appropriate ( ) Inappropriate

Quality: ( ) Flat ( ) Blunted ( )Hostile ( )Labile ( )Elated

C. Depersonalization and Derealization ( ) Present (√)Absent

D. Suicidal Potential ( ) Present (√)Absent

E. Homicidal Potential ( ) Present (√)Absent

IV- Thought

A. Delusion

Type: absent

37
 PROGRESS NOTES

Progress Notes

Admission

Date: October 6, 2010

 Oriented on time and place

 poor sleep

 poorly groomed

 conversant with good eye contact

 positive audiovisual hallucination

Analysis: Undifferentiated Schizophrenia

Planning: For Discharge

Brief History: September of 2005 patient was caught taking drugs and was admitted

to Dela Rosa for rehabilitation, he lasted there for 1 month. On October of the same

year he was admitted again, on the second day of his stay he tried to escape but was

captured, he was rehabilitated for 6 months. on 2006 mid year the patient took drugs

again, became violent and often goes amok. the patient was again admitted at Dela

rossa for 7 months. 2007-2010 before the death of his father his mother claimed that

he was normal. after the death of his father he took drugs again and was admitted at

Davao Mental Hospital after he stole money from his friend including previous

violent behaviour in their community.

38
Admitting Impression: Undifferentiated Schizophrenia

Medication:

 Fluphenazine

 Trifluoperazine

 Chlorpromazine

 Perphenazine

 Thioridazine

Procedure: CBC

Recommendations: Continue Meds

39
PSYCHOPATHOPHYSIOLOGY

40
 PSYCHODYNAMICS

TABULAR PRESENTATION OF THE PREDISPOSING

FACTORS AND RATIONALE

Predisposing factors

Factors Present Rationale

Sex The patient is male. Schizophrenia affects

both male and female

with equal frequency.

Age The patient is 23 years Schizophrenia is

old. usually diagnosed in

late adolescence or

early adulthood. Peak

incidence of onset is

15-25 years of age for

men and 25-35 years of

age for women.

(Videbeck p. 297, 2nd

edition)

41
Genetics/Hereditary The patient’s first The genetic or

cousin from the hereditary

mother side has a predisposition theory

psychiatric problem suggests that the risk of

brought by starvation. inheriting

Schizophrenia is 10%

in those who have one

immediate family

member with the

disease. (Psychiatric

Mental Health Nursing,

5th edition. By Shrives,

p.263).

Characteristics/Personality Stressed An interpersonal

approach to the
Depressed
etiology of

schizophrenia is based

on the theory that there

exist a pre-disposition

of the personality under

high level of stress.

Precipitating Factors

42
Factors Present Rationale

Peer Influence The patient started According Horrocks and

using marijuana and Benirnoff, the peer

shabu when he worked group is the

as a bus conductor at adolescence’s real

the age of 16. world, providing a stage

upon to which to try

himself and others.

Family The father and his Lack of loving and

brothers are occasional nurturing caregivers, one

drinkers. His mother of many other factors, is

spends most of her time thought to be

in the market where she responsible for mental

works. The patient and problems in later life.

his siblings are always (psychiatric nursing 3rd

left at home to tend to edition, Keltner).

themselves. The

patient’s father died

early this year.

Vices The patient is a smoker Teenagers tend to have

and alcoholic drinker. vices due to peer

The patient also uses pressure. Cannabis and

cannabis and shabu. shabu increases

43
 dopamine levels in the

brain. An increase in

dopamine level in the

brain is possibly linked

to schizophrenia.

Emotional Trouble The patient was According to Manfreda

depressed when he and Krapmitz, drives

broke up with his may be expressed in an

girlfriend, Loch. He individual’s behavior

claims to have fallen reaction to everyday

over heels for her. incidents such as

disappointments,

rejections, deprivations,

marital difficulties,

failure in one ambition,

inferiorities, and

economic reverses.

Low Socio-Economic The patient now Social causation

Status belongs to a low income hypothesis proposes that

family because his stresses experienced by

father, the breadwinner, members of low socio-

died early this year. economic group

Before that, the patient contribute to the

44
lived an easier life, but development of

was still prompted to Schizophrenia.

work as a bus (Synopsis of Psychiatry

conductor. by Kapplan, p. 462)

45
SCHEMATIC DIAGRAM

Trust vs. Mistrust

(Infants, 0 to 18 months)

Mother
Experienced vaginal Father
spotting during Rarely have time with the
pregnancy for 2 patient due to work conflicts
months bit was able to
continue pregnancy
until full term
Optimal care was not
given due to lack of
attention because she
still had 4 older
children to take care of
Needed to attend Patient
family business in the Limited attention and care
market, thus, limiting Limited feelings of security and
time with the patient belongingness
Bottle-fed with Attachment to the mother not very
mother’s milk well developed

46
Task Achieved: Mistrust

47
 Autonomy vs. Shame & Doubt

(Toddlers, 18 months to 3 years)

Mother Father
Doesn’t personally supervised Preoccupied with his work as an
the patient’s activities employee at TADECO (private
Had 4 other children at home company)
Allows her children to play with
others
Able to toilet train the patient

Toilet Train Patient

 Age 3- able to go to  Loves to play logical
the bathroom when games with different
has the urge to urinate colors and shapes
or defecate
 If unable to go the
bathroom on time,
mother punishes
patient through
spanking

Task Achieved: Autonomy

48
 Initiative vs. Guilt

(Preschool, 4 to 6 years)

Siblings Father Mother

Initiate play with Disciplinarian father Had another baby
younger brother boy
Has limited time to
her other children

Patient
Loves to play outside with friends
Plays shatong, tumba lata, etc.
Shy type but energetic as well as thoughtful child
Inadequate maternal support and guidance
But developed sense of initiative through the
people surrounding him (e.g. nanny)

Task Achieved: Initiative

49
 Industry vs. Inferiority

(Childhood, 7 to 12 years)

Mother Father
Arrived home late and Very strict and implements
sometimes never slept in discipline within the family
their house due to work Among his children, patient
conflicts was his favorite
Less time spent with her
family

Patient
Age 9- started smoking
Age 10- started drinking alcoholic
beverages
Became a varsity player in running, “1
km dash”, as verbalized by the patient
Awarded “Athlete of the Year”

Task Achieved: Industry

50
 Identity vs. Role Confusion

(Adolescents, 13 to 18 years)

Mother Father
Less supervision Worked as a CAT
Preoccupied with her work Commandant at Panabo
National High School
Spent less time with the
family

Friends Patient
Influenced patient to join  Heavy drinker
fraternities  Had a girlfriend for
Most were males the first time but for
Interested in girls a short period
Influenced patient to take  Joined in different
prohibited drugs such as fraternities for
shabu, marijuana, etc. comfort and security
 Age17- influenced
to take prohibited
drugs such as
marijuana, shabu,
etc.

Task Achieved: Identity

51
 Intimacy vs. Isolation

(Young Adults, 19 to 34 years)

Mother Father
Out of house to work Very strict when at home
Seldom spends time with his
family

Siblings Miss Wa
Not supportive with his lovelife Last girlfriend of the patient
Social drinkers Impregnated by the patient but
Busy with their own aborted the child
relatioonship Broke up with the patient
because of the involvement of a
third party

Patient
Deeply in love with Miss Wa
Wanted to have a baby
Impregnated with Miss Wa but was
disappointed for the child has been aborted
Broke up with Miss Wa
Depressed because of his father’s death
Took prohibited drugs (shabu, marijuana, etc.)-
leads to being hostile, hallucinations, delusions

Task Achieved: Isolation

52
 DIAGNOSIS

COMPLETE DEFINITION OF DIAGNOSIS

Definition of the complete Diagnosis

Schizophrenia

Schizophrenia is one of the most common causes of psychosis. It is not characterized by

a changing personality; it is characterized by a deteriorating personality. Simply,

schizophrenia is one of the most profoundly disabling illnesses, mental or physical. It is a

diagnostic term used by mental health professional to describe a major psychotic

disorder. It is characterized by disturbances in thought and sensory perception

(hallucinations, delusions), thought disorders, and by deterioration in psychosocial

functioning.

Source: Keltner, et. al, Psychiatric Nursing (p. 351).3rd Edition (1999) Philippines: C&E Publishing Inc.

Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the
world. People with schizophrenia have an altered perception of reality, often a significant

loss of contact with reality. They may see or hear things that don’t exist, speak in strange

or confusing ways, believe that others are trying to harm them, or feel like they’re being

constantly watched. With such a blurred line between the real and the imaginary,

53
schizophrenia makes it difficult—even frightening—to negotiate the activities of daily

life. In response, people with schizophrenia may withdraw from the outside world or act

out in confusion and fear.

Source: Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing,

Quezon City, Phils. (2004)

Schizophrenia is a disorder associated with a variety of a complex combination of

symptoms, including hallucinations, delusions, disorganized speech, disorganization, flat

affect, alogia, and avolition (APA, 2000; Bleuler, 1950). Persons experiencing an earlier

onset of schizophrenia usually have more problems with movement from adolescence

into adulthood and development of inappropriate social relationships and interactions.The

course of the disease may be different for each person, depending on when the disorder

manifests itself and if symptoms of the schizophrenia are compounded by a person’s use

of alcohol or other substance (Brunette and Drake, 1998).

Source: Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 347). Australia; Clifton

Park, NY: Thomson/ Delmar Learning (2003).

Undifferentiated

This type is characterized by some symptoms seen in all of the other types but not
enough of any one of them to define it a particular type of schizophrenia.

Source: Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing,

Quezon City, Phils. (2004)

54
Undifferentiated schizophrenia is manifested by pronounced delusions, hallucinations,
and disorganized thought processes and behavior.

Source: Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 348). Australia; Clifton

Park, NY: Thomson/ Delmar Learning (2003).

Undifferentiated Schizophrenia usually is a characterized by atypical symptoms that do

not meet the criteria for the subtypes of paranoid, catatonic, or disorganized

schizophrenia. The client may exhibit both positive and negative symptoms. Odd

behavior, delusions, hallucinations, and incoherence may occur. Prognosis is favorable if

the onset of symptoms is acute or sudden.

Source: Psychiatric Nursing: biological & behavioural concepts (Deborah Antai-Drong)thomson/Delmar learning;c

2003.

55
DIFFERENTIAL DIAGNOSIS

DSM IV TR identifies five subtypes of schizophrenia: paranoid, catatonic, disorganized,

undifferentiated, and residual (American Psychiatric Association, 2000).

Paranoid Type

Clients exhibiting paranoid schizophrenia tend to experience persecutory or grandiose

delusions and auditory hallucinations. They also may exhibit behavioral changes such as

anger, hostility, or violent behavior. Prognosis is more favorable for this subtype of

schizophrenia than for the other subtypes of schizophrenia.

Patient exhibits grandiose delusion, auditory hallucinations, anger, hostility, and violent

behavior. Patient do not exhibit persecutory delusions.

Catatonic Type

Psychomotor disturbances, such as stupor, rigidity, excitement, or posturing, are the

prominent feature of catatonic schizophrenia. Echolalia and echopraxia are also features

of catatonic schizophrenia. Clients are at risk medically because of extreme withdrawal.

Patient do not exhibit stupor, rigidity, echolalia, echopraxia, and extreme withdrawal.

Instead, patient demonstates anxious movements of the hands and feet and was open to

the student nurses during interview.

Disorganized Type

The client experiences a disintegration of personality and is withdrawn. Speech may be

incoherent. Behavior is uninhabited. Prognosis is poor.

56
Patient do not exhibit social withdrawal and poor hygiene. Patient sometimes exhibit

incoherent speech.

Residual Type

Residual schizophrenia is the subtype used to describe clients experiencing negative

symptoms following at least one acute episode of schizophrenia.

Patient do not exhibit negative symptoms.

57
 MULTI-AXIAL DIAGNOSIS DSM-IV TR CRITERIA

FOR DIFFERENTIAL DIAGNOSIS

Characteristic Symptoms: two or more of the following present for a significant portion

of the time during a month period:

1. Delusions [√ ]

2. Hallucinations [√ ]

3. Disorganized Speech [√ ]

4. Grossly Disorganized or Catatonic Behavior [ X]

5. Negative Symptoms [X ]

A. Social / Occupative Dysfunction:

1. Work, Interpersonal Relations, or self – care is markedly below the Level [√ ]

Achieved prior to onset.

2. Duration: Continuous signs of the disturbance persist for at least [√ ]

6 months.

3. Schizoaffective and mood disorder with Psychotic features have been

ruled out. [ X]

58
4. Exclusion of substance abuse and general medical condition. [ X]

TOTAL: 5 / 9 X 100 = 55.55%

59
POSITIVE SYMPTOMS

 Anxiety [ √]

 Bizarre Behavior [ √]

 Delusions [ √]

 Hallucinations [ √]

 Agitation [ √]

 Aggressiveness [ √]

 Hostility [ √]

 Somatic Complaints [ X]

 Suspiciousness [ √]

 Cognitive Disorganization: Looseness Association and Tangentiality [ √]

 Speech Disturbances [ √]

 Inappropriate affect [ X]

TOTAL: 10 / 12 X 100 = 83.33%

NEGATIVE SYMPTOMS

 Motor Retardation [ X]

 Absence of Pleasure [ X]

 Intellectual Impairment [ X]

 Social Withdrawal and Isolation [ X]

 Depressed Mood [ X]

60
 Apathy and Disinterest [ X]

 Poor grooming and Self – Care [ X]

 Lack of Thoughts [ X]

 Lack of Goal Directed Behavior [ X]

 Blunted Affect [ X]

TOTAL: 0 / 10 X 100 = 0%

A. CATATONIC

 Extreme Psychomotor Retardation and Posturing [ X]

 Catatonic Excitement [ X]

 Extreme Psychomotor Agitation [ √]

 Purposeless Movements which may harm self or others [ X]

 Negativism [ √]

 Waxy Flexibility [ X]

 Stupor [ X]

 Echolalia [ X]

 Echopraxia [ X]

 Delusions [ √]

 Extreme Withdrawal [ X]

 Selective Mutism [ X]

TOTAL: 3 / 12 X 100 = 25%

61
 B. PARANOID

 Delusions [ √]

 Hostile [ √]

 Argumentative

[ X]

 Aggressive [ X]

 Hallucinations [ √]

 Suspicious [ √]

 Social Impairment [ √]

 Regression Behavior [ X]

 Anger [ X]

 Violent Behavior [ √]

 Threat to safety of self or others [ √]

TOTAL: 7 / 11 X 100 = 63.63%

C. DISORGANIZED

 Flat or inappropriate affect [ X]

 Bizarre Behavior [ X]

 Social impairment [ √]

 Flight of ideas [ √]

62
 Incoherent Speech [ √]

 Disintegration of personality [ √]

 Withdrawn [ X]

 Poor personal hygiene and grooming [ X]

TOTAL: 4 / 8 X 100 = 50%

D. UNDIFFERENTIATED

 Odd Behavior [ √]

 Delusions [ √]

 Hallucinations [ √]

 Incoherence [ √]

TOTAL: 4 / 4 X 100 = 100%

E. RESIDUAL

 History of at least a previous episode of Schizoprenia with prominent

psychotic symptoms [ √]

 Shy [ X]

 Easily Irritated [ √]

 Perceived as Peculiar [ X]

 Emotional blunting [ X]

 Illogical thinking [ √]

 Disorganized behavior [ √]

63
 Absence of prominent delusions and hallucinations [ X]

TOTAL: 4 / 8 X 100 = 50%

I. SCHIZOAFFECTIVE DISORDER

 Has strong element of either Depression or Euphoria effect [ X]

 May be Depressed, Retarded or Suicidal [ X]

 Expressed observed delusions of persecution, complains of being

controlled by outside forces [ X]

TOTAL: 0 / 3 X 100 = 0%

II. MAJOR DEPRESSIVE DISORDER

 Sexual Disinterest [ X]

 Suicidal or Homicidal Ideations [ X]

 Affect, Sadness, Anger, Irritability [ √]

 Decrease in Personal hygiene [ X]

 Tearfulness, Crying, melancholy [ X]

 Self Destructive Behavior [ X]

 Difficulty Concentrating [ √]

 Loss of Energy or Restlessness [ √]

 Anhedonia ( Loss of Pleasure ) [ X]

 Gain or Loss of Weight [ √]

64
  Anger: Self Directed [ X]

 Psychomotor retardation or Agitation [ X]

 Insomnia or Hypersomnia [ √]

 Feeling of Hopelessness, Worthlessness, Helplessness [ X]

TOTAL: 5 / 14 X 100 = 35.71%

III. SUBSTANCE ABUSE DISORDER

 Failure to fulfill major role obligations at work, school or home [ √]

 Recurrent substance use in hazardous situations [ √]

 Recurrent substance related legal problems [ √]

 Continued substance use despite problems [ √]

TOTAL: 4 / 4 X 100 = 100%

65
 SUMMARY

Percentage:

1. Characteristic Symptoms shows Delusions, Hallucinations and Disorganized

Speech

2. Social / Occupative Dysfunction 30%

3. Positive Symptoms 83.33%

4. Negative Symptoms 0%

5. DSM IV Criteria for Schizophrenia Subtypes

A. Catatonic 25%

B. Paranoid 63.63%

C. Disorganized 50%

D. Undifferentiated 100%

E. Residual 50%

6. Schizoaffective Disorder 0%

7. Major Depressive Disorder 35.71%

8. Substance Abuse Disorder 100%

This DSM IV criterion has been used by the group during the first interview of

Anthony.

Using the DSM IV criteria, Anthony showed signs and symptoms of Schizophrenia.

During our interview with Anthony, he manifests Undifferentiated Schizophrenia with

66
the percentage of 100% that was related to his diagnosis. We are able to communicate

and interact with him.

On the other Disorders, Schizoaffective Disorder is 0%, Major Depressive

Disorder is 35.71% and Substance Abuse Disorder is 100%.

Therefore, based on the results of the DSM IV criteria, the group concluded that

Anthony suffers from Undifferentiated Schizophrenia like his diagnosis.

67
NURSING CARE PLAN

68
 MEDICAL MANAGEMENTS

DOCTOR’S ORDER

Nursing/Pharmacological Diagnostic Examination

H E M A T O L O G Y

Name: Patient X Age: 23 yrs old Sex: Male

Date: 09-22-10 Room: CIU

TEST

RESULT

UNIT

REFERENCE

SIGNIFICANCE

FUNCTION/S
CLINICAL

HEMOGLOBIN 150 g/dL Male: 140-170 ↓ = anemia, liver and Hemoglobin is

kidney disease. responsible for binding

Female: 120-
oxygen in the lungs and
150 ↑ = primary and secondary
in transporting the
polycythemia, COPD,
bound oxygen
CHF, burns.
throughout the body

where it is used in

aerobic metabolic

pathways.

ERYTHROCYTES 4.40 10^12/L 4.0 – 6.0 ↓ = anemia, acute and RBCs transport oxygen

(RBCs) chronic haemorrhage, bound to hemoglobin;

69
 leukemia, and chronic also transports small

infection amount of carbon

dioxide.
↑ = primary and secondary

polycythemia,

erythropoietin-secreting

tumors, and renal disorders

LEUKOCYTES 10.95 10^9 /L 5.0 – 10.0 ↓ = leucopenia – viral Leukocytes function as

(WBCs) infections, bone marrow phagocytes of bacteria,

(H)
depression due to drugs, fungi, and viruses,

irradiation, and primary detoxification of toxic

bone marrow disorders. proteins that may result

from allergic reactions

↑ = leukocytosis – acute
and cellular injury, and
infection (degree depends
immune system cells.
on the severity of infection,

age, resistance, and

presence of trauma, tissue

necrosis or inflammation

and haemorrhage)

Differential Count

Segmenters .77 % 0.45 - 0.65 ↓ = neutropenia – Neutrophils are active

in acute bacterial phagocytes; number

eg. Neutrophils (H)
infection, viral increases rapidly during

infection, some short-term or acute

parasitic, blood, infections.

aplastic, and

pernicious anemia,

anaphylactic shock,

and renal disease.

↑ = neutrophilia –

in acute localized

70
 and general

bacterial

infections, gout

and uremia, acute

hemorrhage, and

hemolysis of

RBC’s,

myelogenous

leukemia and tissue

necrosis

Lymphocytes .13 % 0.20 - 0.35 ↓= Lymphocytes are part of

lymphocytopenia / immune system; one

(L)
lymphopenia – group (B cells)

gastrointestinal produces antibodies;

tract and in aplastic other group (T cells)

anemia, immune involved in graft

system rejection, fighting

dysfunction, and tumors and viruses, and

severe or activating B

debilitating disease lymphocytes.

of any kind.

↑ = lymphocytosis

– occurs in certain

chronic diseases

and during

convalescence

from acute

infection

Monocytes .09 % 0.02 – 0.06 ↓= monocytopenia Monocytes are active

71
 (H) – occurs in HIV, phagocytes; number

hairy cell leukemia increases rapidly during

and overwhelming short-term or acute

infection infections.

↑ = monocytosis -

in monocytic and

other leukemia,

myoproliferative

disorders, and other

lymphomas,

recovering state of

acute infections

HEMATOCRIT .38 Female: 0.38 -0.4 ↓ = anemia or Hematocrit is a measure

hemodilution. of the proportion of

(L) Male: 0.4-0.60
blood volume that is
↑ = dehydration,
occupied by RBC’s.
polycythemia or

hemoconcentratio

n.

72
PSYCHOPHARMACOTHERAPY

Pharmacologic Studies

Generic Name: Fluphenazine

Brand Name: Modecate, Prolixin Decanoate, Modecate Concentrate

Indication: Acute and Chronic Psychoses

Action: Alter the effects of Dopamine in the CNS. Possess anticholenergic and alpha-

adrenergic blocking activity.

Contraindicated in: Hypersensitivity. Cross sensitivity with other phenothiazines

may exist. Narrow angle glaucoma. Bone marrow depression. Severe liver or

cardiovascular disease and Hypersensitivity to sesame oil.

Adverse reactions/Side effects: Extrapyramidal reactions, sedation, tardive

dyskinesia, blurred vision, hypotension, tachycardia, photosensitivity and

agranulocytosis.

Interactions:

Pimozide: may have additive adverse caridiovascular effects.

antihypertensive: additive hypotension.

73
 CNS depressants, antihistamines, MAO inhibitors, general anesthetics and

opioids: additive CNS depression

Phenobarbital: may increase metabolism and decrease effectiveness.

epinephrine and norepinephrine: decrease vasopressor response

Amphetamines: decrease pharmacologic effects.

Route/dosage

IM/ subcut (adults): 12.5-25mg initially, may be repeated q 1-4 wk. dosage

may not exceed 100mg/dose.

IM/subcut (Children): 6.25-18.75mg initially, may be repeated q 1-3 wk.

Nursing Consideration:

Assess patient’s mental status (orientation, mood, behaviour) before and

periodically throughout therapy.

Monitor VS especially BP and RR including ECG. May cause q- wave and

T- wave changes in ECG.

Dilute concentrate just before administration in 100cc-240cc of water, milk,

carbonated beverages or fruit juices. Do not mix with caffeine products

(coffee, cola), tannics (tea), or pectinates (apple juice).

 Instruct patient to take medication exactly as directed and not to skip doses or

double up on missed doses. If a dose is missed, take after 1 hr or skip dose and

return to regular schedule if taking 1 dose/day.

 Inform patient of possible extrapyramidal symptoms and tardive dyskenesia.

74
 Inform patient that this drug may turn urine pink or reddish brown.

75
 Phenothiazides

Generic Names with Trade names: trifluoperazine (etrafon, trilafon),

Chlorpromazine (Emetil, Megatil, Emetil plus), Perphenazine (Siquil,

Orap, Neurap), Thioridazine (Mellaril, Novoridazine, Thioril).

Indications: Treatment of acute and chronic psychosesparticularly when

accompanied by increased psychomotor activity.

Actions: Block dopamine receptors in the brain. also alter dopamine release and

turnover. Peripheral effects include anticholinergic properties and anti

adrenergic blockade.

Contraindications: Hypersensitivity, Should not be used on patients with CNS

depression. Severe liver impairment.

Interactions:

Alcohol, antihypertensive and nitrates: additive hypotension effect.

Antacids: may decrease absorption

Phenobarbital: increase metabolism and decrease effectiveness.

CNS depression: additive CNS depression

Lithium: decrease blood levels and effectiveness of phenothiazides.

Levodopa: decrease therapeutic response.

Antithyroid agents: increase risk of agranulocytosis.

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Adverse Reactions: agranulocytosis, akathisia, aplastic anemia, apnea, blurred

vision, confusion, constipation, contact dermatitis, diaphoresis, dizziness,

drowsinesss, dystonic reaction, ejaculation dysfunction, headache,

hypotension, hypothermia, neuroleptic malignant syndrome, orthostatic

hypotension, photosensitivity, pseudoparkinsonism, respiratory

depression, sinus tachycardia, tardive dyskinesia, visual impairment.

Nursing Consideration:

 Assess patient’s mental status during and throughout therapy

 Monitor BP, pulse and respiratory rate before and frequently during dosage

adjustments

 Observe patient carefully to ensure that drugs are taken and not hoarded.

 Monitor patient for onset of akathesia, extrapyramidal effects, dystonia and

parkinsonianeffects.

 Monitor for tardive dyskenesia.

 Monitor for Neuroleptic Malignant Syndrome- fever respiratory distress,

tachycardia, convulsions, diaphoresis, hypotension or hypertension, pallor,

tiredness, severe muscle stiffness and loss of bladder control.

 Administer PO with a full glass of water or milk to decrease gastric irritation.

 Dilute most concentrate in 120ml of distilled or acidified water or fruit juice

just before administration.

 Instruct patient to take medication exactly as directed Instruct patient to

slowly change position to prevent orthostatic hypotension.

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  Medications may cause drowsiness. Caution patient to avoid drinking or other

activities requiring alertness until response to medication is known.

PROGNOSIS AND RECOMMENDATION

Criteria Poor Fair Good Justification

Onset of illness  chronic
Duration of  The patient has been in and out in the

illness rehabilitation center for the past 5

years. The patient had shown sign of

improvement but has relapses.

Precipitating  The precipitating factors include peer

factors influences, family, vices, socio-

economic status, and emotional

problem. As of now patient has

withdrawn from peers and has been

avoiding cigarette smoking, but there

is a risk of relapses.
Mood and affect  Patient has labile mood at first

encounter but he gradually improves

by the time of second visit wherein

he already had appropriate emotional

response. The patient verbalized that

he is willing to take the medication,

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 now he is comfortable with the

treatment regimen as evidenced by

improved sleep.
Any Depressive  The patients have bouts of depression

features when the topics of love discussed.

This just related to the break up with

the formal girlfriend and the recent

death of his father.

Family support  The family, especially the elder

brother expresses that they are

willing to give their emotional and

financial support but as of now the

family is economically depressed.

Computation:

Poor 4 x 1 = 4

Fair 2 x 2 = 4

Good 0 x 3 = 0

Total: 8/6 = 1.33%

The prognosis of the patient is poor having the score of 1.33 based on the computation

and justification. The family of the patient is willing to support the patient but they lack

of financial resources. Also there is possibility of relapses because of non adherence of

the treatment regimen.

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 DISCHARGE PLANNING

Medication

 Instruct the patient to comply the treatment regimen

® To conform to pharmacological regimen and to attain full coarse of prescribed

treatment

 Encourage and instruct the family members to always seek medication advice and

prescription.

® To prevent further complication and for further information.

 Inform the patient about the effect of the drug

® To know what to expect when symptoms occur and to have knowledge about the

drug.

 Instruct the patient, do not discontinue the drug and avoid over the counter drug.

® To avoid drug resistance

 Encourage patient to verbalize concerns regarding the drug and inform the physician if

side effects are occurring.

® To address patient apprehension and prevent underlying factors.

Exercise

 Encourage the client to do daily exercise

®to practice range of motion and to enhance musculoskeletal strength

80
 Encourage adequate rest and sleeping periods.

®to promote comfort and prevent fatigue

 Encourage deep breathing exercise.

®to enhance breathing pattern

 Instructed to void every 2 to 3 hours during the day and completely empty the bladder.

® This prevents over distention of the bladder and compromised blood supply to the

bladder wall

 Maintained good environment free from pollution and stress provoking environment.

®An environment free from pollution may facilitate fast recovery and prevent

recurrence of the disease influenced by unhealthy environment.

Treatment

 Instructed the patient to comply the treatment regimen

®to achieve the effectiveness and expected outcome

 Encouraged the patient to participate diligently in the treatment modalities

advised to him by the physician.

® To hasten the improvement of her health status

 Encouraged the patient to verbalize honest information to the physician and

other health care provider.

® To aid accurate detection of a disease and early medical intervention

 Tell the family that they should take part on the treatment of the patient.

® To strengthen the support system of the client

 Treatment should be taken in a timely manner

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 ® To ensure proper timing of treatment regimen

Hygiene

 Encourage daily bathing and use clean clothing

®to promote proper hygiene and promote proper circulation

 Instruct patient to take care of wounds and do proper wound dressing.

®to prevent infection and prevent the spread of microorganism

 Instruct the patient to do oral hygiene and use soft bristle brush

®to avoid bleeding of the oral mucosa

 Encourage the patient to do the proper hand washing at all times.

®to deter the spread of microorganism

 Instruct the patient to do proper grooming and always trim nails

®to prevent harbor of microorganism in a certain area

Outpatient

 Emphasize to patient the importance of follow up check-up

®to assess the effectiveness of therapy given

 Reiterated health teaching regarding diet and hygiene

®to provide health information and awareness

 Sighted any symptoms other than the usual that may indicate infection and report it

immediately to the physician.

82
 ® To note any unusualities and address it promptly before complications occur

 Instructed significant others to change wound dressing daily, if there is wound.

® To reduce bacterial colonization

Diet

 Encourage patient to eat nutritious food at the right time and right amount.

®to enhance balance diet and avoid malnutrition

 Encourage to drink at least 6-8 glasses of water a day.

®to ensure proper intake of fluids

 Inform the patient to avoid alcohol and cigarette smoking

®to prevent occurrence of symptoms and to prevent alteration in the effectiveness of

the drug

 Inform patient to avoid eating food which is high in tyramine such as cheese and

process meat.

®to avoid alteration in the effectiveness of the drug.

83
 APPENDICES

SPOT MAP

84
GENOGRAM

85
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 Meltzer, H. Y., L. Arvanitis, D. Bauer, et al. "Placebo-Controlled Evaluation of Four

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 Volavka, J., P. Czobor, K. Nolan, et al. "Overt Aggression and Psychotic Symptoms

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