Wesleyan University- Philippines Mabini Extension, Cabanatuan City
Case Study Mental Affiliation in National Center for Mental Health
Table of Contents I. INTRODUCTION a. Overview……………………………………………………………………………… 3 b. Definition of Related terms…………………………………………………………… 3 c. Signs and Symptoms Manifested by the Client………………………………………...3 d. Defense Mechanism Used…………………………………………………………… .. 3 II. PATIENT’S HISTORY a. Personal data……………………………………………………………………… 3 b. Marks………………………………………………………………………………4 c. Chief Complaints ………………………………………………………………… 4 d. Past Health History……………………………………………………………… ..4 e. Present Health History………………………………………………………….... 4 f. Family History ………………………………………………………… .................5 g. Review of System ………………………………………………………… ...........5 h. Lifestyle and Health Practices- 24H day Description……………………………..5 i. Developmental Stage……………………………..………………………………...6 III. COLLECTING OBJECTIVE DATA
I. INTRODUCTION a. Overview
Patient S.A. has been admitted on April 17. 2013 at 2:03 pm. A 43 years old Female with a final diagnosis of Paranoid schizophrenia. Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. Paranoid schizophrenia is one of several types of schizophrenia, a chronic mental illness in which a person loses touch with reality (psychosis). The classic features of paranoid schizophrenia are having delusions and hearing things that aren't real. With paranoid schizophrenia, your ability to think and function in daily life may be better than with other types of schizophrenia. You may not have as many problems with memory, concentration or dulled emotions. Still, paranoid schizop hrenia is a serious, lifelong condition that can lead to man y complications, including suicidal behavior.
b. Definition of Related terms Schizophrenia- is a group of severe brain disorders in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and disordered thinking and behavior. Paranoid schizophrenia- is the most common type of schizophrenia in most parts of the world. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory
vi. Civil Status: Single vii. Address: Maligaya, Banni, Pangasinan viii. Phone Number: -none as statedix. Educational Level: College Graduate x. Occupation: None xi. Race/ Ethnic Group: Tagalog xii. Religion: Iglesia ni Cristo xiii. Nationality: Filipino xiv. Citizenship: Filipino citizen xv. Language spoken: Tagalog xvi. Source of information: Chart of Patient xvii. Reliability: 99% xviii. Companion upon admission: Father xix: b. Marks Moles: at Right Arm Left side face Right eye Left deltoid Abrasion in the Nape area c. Chief Complaints: i. Chief Complaint upon admission: According to her Father- “Dalawang araw nang hindi umiinom ng gamut” “Kung ano-anong kababalaghan gingawa nya” “Umaalis ng Bahay” “Itapon sa kubeta yung bottle para pakuluan”
f. Family History: nd She was 2 out of four siblings in the family. Her father was a farmer who sold vegetables in the market. She was not closed to her mother, and her mother-in-law is the one who sends her money for her children although she and father of her children are not married. g. Review of System 1. Skin, Hair & NailsSkin – Brown (normal) Hair- Black (presence of Lice and Pus) Nails- Pinkish 2. Head and Neck Head- No headache reported Neck- with abrasion in the nape area 3. EENT & Sinuses Ears- No drainage or ringing ears reported Eyes- Blurred Vision when reading (Farsighted) Nose- No discharges Throat- No pain or hoarseness of voice felt 4. Chest and Lungs Chest- No pain reported Lungs- No shortness of breath or pain reported 5. Heart, Neck Vessels & Central CVS Heart- No pain, distress or palpitations felt Neck vessels- are not distended. Cardiovascular System- No tightness, edema, or orthopnea reported 6. PVS
v. Self-concept and self care The client is aware of her illness vi. Social activities The patient was called as “nanay” by the younger pavilion 3 younger patient. She claimed that she understands the other patient because they are also ill. vii. Spiritual, Cultural, Values and Belief System The patient said she was an Iglesia ni cristo member viii. Education and work She was a Education College Graduate. ix. Stress Level and Management/ Coping Stress Patient A claimed when she is angry, her paranoia will occur… She talks loudly and shouts at her family but never harmed them. x. Environment & Neighborhood Patient S.A. said that the other patient are friendly while she cannot understands the others because of their talkativeness ant apathetic.
i. Developmental Stage i. Theory: Erik Erickson’s Psychosocial Development Generativity vs. Stagnation (Middle adulthood 40-64 years)The client has self confident of raising her child. She is devoted to her family and to their community. She wants her children to be educated and to be good person someday. She is confident of raising her children so that someday, her children will do the same to her.
III. COLLECTING OBJECTIVE DATA
Side Effects GI disturbances in high doses (nausea, vomiting, and diarrhea).
forms of the molecule like dehydroascorbic acid. Ascorbate and ascorbic acid are both naturally present in the body when either of these is introduced into cells, since the forms interconvert according to pH. Vitamin C is a cofactor in at least eight enzymatic reactions including several collagen synthesis reactions that, when dysfunctional, cause the most severe symptoms of scurvy. Nursing Management Instruct Client to take the medication after meals to avoid GI upset. Instruct client to measure and follow the prescribed dosage of the medication to avoid overdosing. Advise the client that yellow discoloration of urine is normal Nursing Management Instruct the client to discontinue the medication, and refer to the doctor. Instruct the client to discontinue the medication, and refer to the doctor. Instruct the client to take the medication after meals to avoid adverse reactions.
Bright yellow discoloration of urine Adverse Effects Rarely, hypersensitivity reaction Flatulence, constipation Heartburn,
Side Effects
The exact mechanism of action of risperidone is not known, but, like other anti-psychotics, it is believed that risperidone affects the way the brain works by interfering with communication among the brain's nerves. Nerves communicate with each other by making and releasing chemicals called neurotransmitters. The neurotransmitters travel to other nearby nerves where they attach to receptors on the nerves. The attachment of the neurotransmitters either stimulates or inhibits the function of the nearby nerves. Risperidone blocks several of the receptors on nerves including dopamine type 2, serotonin type 2, and alpha 2 adrenergic receptors. It is believed that many psychotic illnesses are caused by abnormal communication among nerves in the brain and that by altering communication through neurotransmitters, risperidone can alter the psychotic state. Risperidone was approved by the FDA in December, 1993. most commonly-noted side effects associated with risperidone are extrapyramidal effects (sudden, often
physician for appropriate comfort measures. · Advise patient to use contraception during drug therapy. · Follow guidelines for discontinuation or reinstitution of the drug carefully. Physician’s Order Generic Name Brand Name Classification Mechanism of Action
Biperiden Hydrochloride 2mg P.O. for extrapyramidal symptoms Biperiden Hydrochloride Akineton Antiparkinsonism drug (anticholinergic type) Anticholinergic activity in the CNS that is believed to help normalize the hypothesized imbalance of cholinergic and dopaminergic neurotransmission in the basal ganglia in the brain of a parkinsonism patient. Reduces severity of rigidity, and to a lesser extent akinesia and tremor characterizing parkinsonism; less effective overall than levodopa; peripheral anticholinergic effects suppress secondary symptoms of parkinsonism, such as drooling. • Adjunct in the therapy of parkinsonism
Contraindication
dermatoses • EENT: Blurred vision, mydriasis, diplopia, increased intraocular tension, angle-closure glaucoma • GI: Dry mouth, constipation, dilation of the colon, paralytic ileus, acute suppurative parotitis, nausea, vomiting, epigastric distress • GU: Urinary retention, urinary hesitancy, dysuria, difficulty achieving or maintaining an erection • Other: Flushing, decreased sweating, elevated temperature, muscular weakness, muscular cramping Contraindicated with hypersensitivity to benztropine; glaucoma, especially angleclosure glaucoma; pyloric or duodenal obstruction, stenosing peptic ulcers, achalasia (megaesophagus); prostatic hypertrophy or bladder neck obstructions; myasthenia gravis. • Use cautiously with tachycardia, cardiac arrhythmias, hypertension, hypotension, hepatic or renal dysfunction, alcoholism, chronic illness, people who work in hot environment; hot weather; lactation.
Nursing Consideration:
respiratory secretion, blurring of vision, urinary retention; GI disturbances; blood dyscrasias. Assessment
History: Allergy to any antihistamines, narrow-angle glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy, asthmatic attack, bladder neck obstruction, pyloroduodenal obstruction, third trimester of pregnancy, lactation Physical: Skin color, lesions, texture; orientation, reflexes, affect; vision examination; P, BP; R, adventitious sounds; bowel sounds; prostate palpation; CBC with differential
Interventions
Administer with food if GI upset occurs. Administer syrup form if patient is unable to take tablets. Monitor patient response, and arrange for adjustment of dosage to lowest
Physician’s Order Generic Name Brand Name Classification
Mechanism of Action
Adverse Effects
Report difficulty breathing, hallucinations, tremors, loss of coordination, unusual bleeding or bruising, visual disturbances, irregular heartbeat.
Haloperidol 5mg/cc 1cc IM with BP Precaution Haloperidol Haldol , Peridol , central nervous system agent; psychotherapeutic; antipsychotic ; butyrophenone Potent, long-acting butyrophenone derivative with pharmacologic actions similar to those of piperazine phenothiazines but with higher incidence of extrapyramidal effects and less hypotensive and relatively low sedative activity. Decreases psychotic manifestations and exerts strong antiemetic effect. CNS:Extrapyramidal reactions: Parkinsonian symptoms, dystonia, akathisia, tardive dyskinesia (after long-
Nursing Consideration:
GI:Dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, hypersalivation. Urogenital: Urinary retention, priapism. Respiratory :Laryngospasm, bronchospasm, increased depth of respiration, bronchopneumonia, respiratory depression. Skin:Diaphoresis, maculopapular and acneiform rash, photosensitivity. other:Cholestatic jaundice, variations in liver function tests, decreased serum cholesterol. Monitor for therapeutic effectiveness. Because of long half-life, therapeutic effects are slow to develop in early therapy or when established dosing regimen is changed. “Therapeutic window” effect (point at which increased dose or concentration actually decreases therapeutic response) may occur after long period of high doses.
Target symptoms expected to decrease with successful haloperidol treatment include hallucinations, insomnia, hostility, agitation, and delusions.
treatment. Symptoms are usually dose related and are controlled by dosage reduction or concomitant administration of antiparkinson drugs. Be alert for behavioral changes in patients who are concurrently receiving antiparkinson drugs. Monitor for exacerbation of seizure activity. Observe patients closely for rapid mood shift to depression when haloperidol is used to control mania or cyclic disorders. Depression may represent a drug adverse effect or reversion from a manic state. Lab tests: Monitor WBC count with differential and liver function in patients on prolonged therapy.
ii. Diagnostic Test since Date of Admission
Name of Result Diagnostic Test Complete CBC
Normal Values
Unit of Measurement
Implication
Differential Count Neutrophil
0.76
0.45-0.75
An Increase value may indicate an acute infection.
Lymphocyte
0.19
0.20-0.35
Infection is present.
Monocyte
0.05
0.02-0.06
Normal
IV. PYSCHOPATHOPHYSIOLOGY Anatomic abnormalities Neuroimaging studies in patients with schizophrenia show abnormalities such as enlargement of the ventricles, decreased brain volume in medial temporal areas, and changes in the hippocampus. These findings are of interest more for research purposes than for clinical application. Interest has also focused on the various connections within the brain rather than on localization in a single part of the brain. Magnetic resonance imaging (MRI) studies show anatomic abnormalities in a network of neocortical and limbic regions and interconnecting white matter tracts. A metaanalysis of studies using diffusion tensor imaging (DTI) to examine white matter found that 2 networks of white-matter tracts are reduced in schizophrenia. In the Edinburgh High-Risk Study, brain imaging showed reductions in whole-brain volume and in left and right prefrontal and temporal lobe volumes in 17 of 146 people who were at high genetic risk for schizophrenia. The changes in prefrontal lobes were associated with increasing severity of psychotic symptoms. In a meta-analysis of 27 longitudinal MRI studies comparing schizophrenic patients with control subjects,
subclass of glutamate receptors because NMDA antagonists, such as phencyclidine and ketamine, can lead to psychotic symptoms in healthy subjects. Inflammation and immune function
Immune system function is disturbed in schizophrenia . Overactivation of the immune system (eg, from prenatal infection or postnatal stress) may result in overexpression of inflammatory cytokines and subsequent alteration of brain structure and function. For example, schizophrenic patients have elevated levels of proinflammatory cytokines that activate the kynurenine pathway, by which tryptophan is metabolized into kynurenic and quinolinic acids; these acids regulate NMDA receptor activity and may also be involved in dopamine regulation. Insulin resistance and metabolic disturbances, which are common in the schizophrenic population, have also been linked to inflammation. Thus, inflammation might be related to both the psychopathology of schizophrenia and to metabolic disturbances seen in patients with schizophrenia.
Neurochemical factors likely involve dopamine, serotonin, norepinephrine, glutamate, and gammaaminobutyric acid neurotransmission. Glutamate (glu), involved in learning and memory, may be responsible for some of the cognitive symptoms; glu is necessary for the breakdown of dopamine and other transmitters, which affects the efficiency of prefrontal information processing. Excessively high levels of norepinephrine are associated with positive symptoms, while paranoid symptoms have been related to increased dopamine aactivity. No single neurotransmitter is clearly responsible for schizophrenia. Schizophrenia often disrupts the filtering process, causing sensory overload; when there are too many messages arriving at the cortex at the same time, thinking becomes disorganized and fragmented.
V. NURSING CARE PLAN Name: Patient S.A. Diagnosis: Paranoid Schizophrenia Date and time: May 19, 2013 (7am-3pm) Assessment Diagnosis Planning Implementation Subjective Disturbed Long term Goal: Independent Data: sleep To provide health Intervention: “Hindi ako pattern teaching about using Explain to the client makatulog related to anti-head lice shampoo the procedures and its kasi head lice and proper prevention of purpose madaming and pus getting a pus. akong kuto at may pigsa pa Short Term Goal: Instruct patient to sit ako sa ulo” as After 16 hours of duty, instead of stand during manifested by The patient will be able care and other the mother. to relieve itchiness by activities. using small spacedObjective combed and Instruct patient to Data: comb her hair using Presence of thin-spaced comb to Lice, with Pus decrease presence of at the occipital lice and nits. area Assist the patient in Shampooing by the use of anti-lice shampoo while giving instruction how often to apply the said shampoo
Scientific Rationale
Instruct patient to avoid skin contact to
To increase activity level as tolerated
The patient is able to improve her activities of daily living especially her sleep hours.
Goal met:
To reduce anxiety of the patient. To prepare the patient for the Procedure.
Evaluation
To provide independency while giving a health teaching
The patient will be able to return demonstration.
To avoid another incidence of having pus 18
the patient with open wound
Apply Povidone Iodine in the Pus area
For infection and to avoid futher complication
REFERENCES: http://www.nimh.nih.gov/health/publications/schizophrenia/what-is-schizophrenia.shtml http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862 http://www.mayoclinic.com/health/schizophrenia/DS00196 http://www.schizophrenia.com/szparanoid.htm http://www.scribd.com/doc/52857393/Paranoid-Schizophrenia-Case-Study http://emedicine.medscape.com/article/288259-overview#aw2aab6b2b3aa http://allnurses.com/nursing-student-assistance/pathophysiology-of-schizophrenia-276654.html http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862/DSECTION=risk-factors http://www.nlm.nih.gov/medlineplus/ency/article/000936.htm
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