I.
Objectives of the study General Objectives: This case study aims to: Identify a patient’s health care status Gain more understanding about the patient’s condition Establish plans to meet the actual and potential needs of the patient Specific Objectives: Patient-Centered To be more oriented to health To clarify misconceptions regarding his health condition To involve patient in her own plan of care To promote interdependence Student Centered To provide an individualized plan of care for the patient To participate in the advancement of nursing profession through contributions to practice, education, administration, and knowledge development To deliver specific nursing interventions to address the needs of the patient To evaluate the effectiveness of the care plans
II.
Introduction A. Definition of the case Schizophrenia is a mental disorder characterized by disintegration of thought processes and of emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences. Genetics, early environment, neurobiology, and psychological and social processes appear to be important contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms. Current research is focused on the role of neurobiology, although no single isolated organic cause has been found. The many possible combinations of symptoms have triggered debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. Despite the etymology of the term from the Greek roots skhizein(σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-; "mind"), schizophrenia does not imply a "split mind"
and it is not the same as dissociative identity disorder—also known as "multiple personality disorder" or "split personality"—a condition with which it is often confused in public perception. The mainstay of treatment is antipsychotic medication, which primarily works by suppressing dopamine activity. Psychotherapy and vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, although hospital stays are now shorter and less frequent than they were. The disorder is thought mainly to 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; the lifetime occurrence ofsubstance abuse is almost 50%. Social problems, such as long-term unemployment, poverty and homelessness, are common. The average life expectancy of people with the disorder is 12 to 15 years less than those without, the result of increased physical health problems and a higher suicide rate (about 5%). B. Etiology A combination of genetic and environmental factors plays an role in the development of schizophrenia. People with a family history of schizophrenia who suffer a transient or self-limiting psychosis have a 20–40% chance of being diagnosed one year later.
Genetic
Estimates of heritability vary because of the difficulty in separating the effects of genetics and the environment. The greatest risk for developing schizophrenia is having a first-degree relative with the disease (risk is 6.5%); more than 40% of monozygotic twins of those with schizophrenia are also affected. It is likely that many genes are involved, each of small effect. Many possible candidates have been proposed, including specific copy number variations, NOTCH4 and histone protein loci. A number of genome-wide associations such as zinc finger protein 804A have also been linked. There appears to be significant overlap in the genetics of schizophrenia and bipolar disorder. Assuming a hereditary basis, one question from evolutionary psychology is why genes that increase the likelihood of psychosis evolved, assuming the condition would have been maladaptive from an evolutionary point of view. One theory implicates genes involved in the evolution of language and human nature, but so far all theories have been disproved or remain unsubstantiated.
Environment
Environmental factors associated with the development of schizophrenia include the living environment, drug use and prenatal stressors. Parenting style seems to have no effect, although people with supportive parents do better than those with
critical parents. Living in an urban environment during childhood or as an adult has consistently been found to increase the risk of schizophrenia by a factor of two, even after taking into account drug use, ethnic group, and size of social group. Other factors that play an important role include social isolation and immigration related to social adversity, racial discrimination, family dysfunction, unemployment, and poor housing conditions. Childhood experiences of abuse or trauma are risk factors for a diagnosis of schizophrenia later in life.
Substance abuse
A number of drugs have been associated with the development of schizophrenia including cannabis, cocaine and amphetamines. About half of those with schizophrenia use drugs and/or alcohol excessively. The role of cannabis could be causal, but other drugs may be used only as coping mechanisms to deal with depression, anxiety, boredom, and loneliness. Cannabis is associated with a dose-dependent increase in the risk of developing a psychotic disorder. Frequent use has been found to double the risk of psychosis and schizophrenia. Some research has however questioned the causality of this link. Amphetamine, cocaine, and to a lesser extent alcohol, can result in psychosis that presents very similarly to schizophrenia.
Prenatal
Factors such as hypoxia and infection, or stress and malnutrition in the mother during fetal development, may result in a slight increase in the risk of schizophrenia later in life. People diagnosed with schizophrenia are more likely to have been born in winter or spring (at least in the northern hemisphere), which may be a result of increased rates of viral exposures in utero. This difference is about 5 to 8%. C. Incidence Schizophrenia affects around 0.3–0.7% of people at some point in their life, or 24 million people worldwide as of 2011. It occurs 1.4 times more frequently in males than females and typically appears earlier in men—the peak ages of onset are 20–28 years for males and 26–32 years for females. Onset in childhood is much rarer, as is onset in middleor old age. Despite the received wisdom that schizophrenia occurs at similar rates worldwide, its prevalence varies across the world, within countries, and at the local and neighborhood level. It causes approximately 1% of worldwide disability adjusted life years. The rate of schizophrenia varies up to threefold depending on how it is defined.
D. General signs and symptoms Hallucinations (most reported are hearing voices) Delusions (often bizarre or persecutory in nature) Disorganized thinking and speech Loss of train of thought Withdrawal Sloppiness of dress and hygiene Loss of motivation and judgment Emotional difficulty (lack of responsiveness) Impairment in social cognition Social isolation E. Theoretical framework Lydia Hall’s Key Concepts of Three Interlocking Circles Theory Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team. III.
Patient’s profile A. Patient’s data Name: F.P.P Address: c/o previous warden office, Occidental, Mindoro Date of Admission: October 15, 2008 (1:40pm) Age: 50 years old Birthday: October 7, 1960
General Data: She was brought by escorts to the forensic psychiatry service of the National Center for Mental Health admitted on May 27, 2007 per court order dated Jan. 23, 2007. Last Mental Status Examination: The patient was seen as an adult female, fairly groomed and kempt with long hair and dark complexion. Mood was euthymic with appropriate affect. Speech was normal and productive and spontaneous. She gave a fair account of herself. She was able to state her case but she claimed that she was just framed up. She denied perceptual disturbances and morbid thought. No delusions were elicited. She claimed that she is ready to appear in court and was aware of the possible condition. She denied suicidal and homicidal thoughts. She had good orientation and impulse control. Her insights and judgments were fair.
Admitting Diagnosis: Schizophrenia, Undifferentated. General Observation: Subject is fair-skinned woman with medium physique and long hair. She was seen wearing NCMH patient’s uniform and was fairly kempt in appearance. Meanwhile, she was disoriented to time but was compliant to assigned tasks. When queried about the pending case and subsequent confinement to the center, she became teary-eyed. She is facing murder charges and was previously incarcerated although she denied having having committed any offense as she verbalized, “Malabo akong makagawa ng masama sa sarili ko o sa kapwa man, pinilit nila akong pumunta dito”. Assessment and remarks: Based on the history, mental status examination and observations, the patient was found to be suffering from psychosis classified as Schizophrenia. The nature and characteristics of this mental disorder have been described in the previous report dated September 17, 2007. At present, the patient is in improved state and is therefore deemed competent to stand the rigors of court trial. Psychological report: Test administered:
Wechsler Adult Intelligence Scale- R Bender Visual Motor Gestalt Test Draw a person test Sach’s Sentence Completion Test
Test results and evaluation: WAIS- R Verbal Scale IQ = 71 Performance Scale IQ = 77 Full Scale IQ = 73 Classification: Borderline Current endorsement is along the borderline range although pre-morbid IQ is gauged as dull normal. Most of her cognitive attributes are poorly retained while slight lowering is evident on the areas of attention span and foresight. Meanwhile, learning ability, social judgment and visual- motor coordination are impaired. Test- data bespeak of an anxiety- laden woman who feels inept in attending to her needs as well as resolving her problems so that she frequently feels frustrated and dissatisfied with
her life. Her social interactions are also affected due to her tendency to manifest a hostile and aggressive mode of behavior even when slightly provoked. This makes her prone to rejection and censure remarks from her milieu which in turn eventually gives rise to selfpity and sadness. At times, she is even inclined towards withdrawal and denial mechanisms in order to protect her fragile self- esteem from perceived threat within her immediate environment. Immaturity and fear of assuming responsibility for her actions are further uncovered. Depressive trends are prominent so that ego functioning is also ineffective. IV.
Anatomy and physiology Structure and function of the nervous system Structures A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord. 2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia. B. The brain is covered by three membranes. 1. The dura matter is a fibrous, connective tissue structure containing several blood vessels. 2. The arachnoid membrane is a delicate serous membrane. 3. The pia matter is a vascular membrane.
C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves – 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral. D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane. Function
A. CNS 1. Brain a. The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions. The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses. The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant hemisphere, the center for interpreting spoken language.
The parietal lobe coordinates and interprets sensory information from the opposite side of the body. The occipital lobe interprets visual stimuli. b. The thalamus further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli. c. Lying beneath the thalamus, the hypothalamus is an automatic center that regulates blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and peripheral nerve discharges associated with certain behavior and emotional expression. It also helps control pituitary secretion and stress reactions. d. The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.
e. The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord. 2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control. B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord.
C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions. 1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-for-fight” response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine. 2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine. Differences in nervous system response The nervous system is one of the first systems to form in utero, but one of the last systems to develop during childhood. A. Accuracy and completeness of the neurologic assessment is limited by the child’s development. B. The child’s brain constantly undergoes organization in function and myelinization. Therefore, the full impact of insult may not be immediately apparent and may take years to manifest. C. The peripheral nerves are not fully myelinated at birth. As myelinization progresses, so does the child’s fine motor control and coordination. D. Early signs of increased intracranial pressure (ICP) may not be apparent in infants because open sutures and fontanelles compensate to a limited extent. E. The development of handedness before 1 year of age may signify a neurologic lesion. F. Several primitive reflexes are present at birth, disappearing by 1 year of age. Absence, persistence, or asymmetry of reflexes may indicate pathology. G. The spinal cord ends at 13 in the neonate, instead of L1-L2 where it terminates in the adult. This affects the site of lumbar puncture. H. Children have 65 to 140 ml of CSF compared to 90 to 150 ml in the adult.
IX. Discharge planning
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Encourage to continue medications as ordered. Explain to the client about the action and side effect of each drug that she takes.
Encourage the patient to exercise regularly. Encourage the patient to do range of motion exercises, and avoid strenuous activities that will compromise his condition.
Encourage supportive measures for the signs and symptoms of the disease.
Encourage to provide calm and comfortable environment. Encourage to maintain client’s safety.
Inform the patient about the importance of follow up check up and comply with the schedule of his treatments and check up.
Encourage intake of nutritious foods. Advised increased oral fluid intake.
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.
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X. Implications of case study
NURSING PRACTICE
This case study want to help health care personnel and nursing students in rendering appropriate care for the patient with Undifferentiated Schizophrenia.
NURSING EDUCATION
This case study want to help nurses and nursing student to understand more the disease process of Undifferentiated Schizophrenia and be able to provide proper management. It also aims to identify complications of the said disease for the nurse to be aware what should be prevented. The nurses and nursing student should also need to know the factors contribute in acquiring this disease to be able to provide health teachings to other people especially to the family of the patient and prevent them from having this disease.
NURSING RESEARCH
This case study aims to provide nurses and nursing student ways to improve their quality of life by preventing the complication of the said disease. This case study also provides essential information about Undifferentiated Schizophrenia. XI. Bibliography
http://nursingcrib.com/case-study/schizophrenia-case-study/ http://search.yahoo.com/search;_ylt=A0oG7lFawmxN6DMAnZJXNyoA?ei=UTF-8&fr=yfp-t701-s&fp_ip=ph&p=thorazine+drug+study&rs=1&fr2=rs-top http://en.wikipedia.org/wiki/Undifferentiated_schizophrenia
CASE STUDY (Schizophrenia, Undifferentiated)
Submitted by: Cambaling, Allen Marie Magayanes, Emy Joy
Submitted to: Beverly Angot, R.N., M.A.N.
