I.
INTRODUCTION
Psychiatr Psychiatric ic disorders disorders place a substantia substantiall burden and suffering suffering on clients, clients, their families, families, society, and the healthcare system. Caring for clients with psychiatric problems is complex and requir requires es and underst understandi anding ng of neurob neurobiol iologi ogical cal,, cognit cognitive ive,, and psychos psychosoci ocial al underpi underpinni nnings ngs associated with specific psychiatric conditions. Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Increased dopamine activity in the mesolimbic pathway of the brain is commonly found in people with schizophrenia. Recent research reveals that schizophrenia may be a result of faulty neur neuron onal al devel develop opme ment nt in the the feta fetall brai brain, n, whic which h deve develo lops ps into into full full-bl -blow own n illn illnes esss in late late adolescence or early adulthood. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The symptoms of schizophrenia are categorized into two major categories: The positive or hard symptoms which include: •
Ambivalence: Holdin Holding g seemin seemingly gly contrad contradict ictory ory belief beliefss or feelin feelings gs about about the same same
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Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of content)
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Anhedonia: Feeling no joy or pleasure from life or any activities or relationships
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Apathy: Feeling of indifference toward people, activities, and events
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Blurred affect: Restricted range of emotional feeling, tone, or mood
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Psychologi ogical cally ly induced induced immobi immobili lity ty occasi occasional onally ly marked marked by period periodss of Catatonia: Psychol agitation or excitement; the client seems motionless, as if in a trance
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Flat affect: Absence of any facial expression that would indicate emotions or mood
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Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks
The DSM-IV-TR contains five sub-classifications of schizophrenia: •
Paranoid type: Where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code F20.0)
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Named hebephr hebephreni enicc schizo schizophr phreni eniaa in the ICD. ICD. Where Where thought thought Disorganized Disorganized type: Named disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1)
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Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code 295.2/ICD code F20.2)
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Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)
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Residual type: Where positive symptoms are present at a low intensity only. (DSM code
A. Demographic Data Patient name:
Danillo Dimaala
Historian:
JI Raymond AE De Joya
Hospital:
CCMH
Consultant:
Dr. Escaño
Date Interviewed:
8/15/10
B. General Data
This is a case of D.D., a 44 years old right handed male, single, the eldest among his six siblings. Born and currently residing in Nasugbu, Batangas. A High School Graduate and works as water pump tender in a sugar factory in Batangas. He is a Roman Catholic who speaks Tagalog and English, accompanied by his mother to seek consultation to a Psychiatrist for the first time in Cavite Center for Mental Health last August 13, 2010. C. Chief Complaint
Patient complained of “nagugulat pag nakakita ng babae at lalaki” D. Premorbid Personality and Level of Functioning
The patient is a calm and happy person. He loves his family and friends very much. He has lot of friends and works well with his colleagues for 16 years. He has no problems or conflict among his family, friends and other people. E. History of Present Illness
5 years prior to consultation, the patient had itchiness and soreness around the area of his penis. There are white-wormy-like rigid structures in his pubic area with erythema and rashes. Patient has black papules present around his body. Patient doesn’t have any history of psychiatric or mental illness. He has a primary love doctor. Patient’s sister died at Diabetes mellitus complications (3rd Sibling). Review of systems: (+) itchiness on penile area G. Family Profile
The Dimaala family is a very kind and supportive family among its household members. They are very supportive among each other. The family members are very supportive on the patient’s illness and the death of his third sister with the arrangements. Dennis, the youngest among the patient’s sibling is the closest sibling to the patient. Dante, 43 years old male, is the second sibling in the family. He is a kind and gentle person. He has no work and helps the family. Divira, 41 years old female, is a seamstress but died of Dm complications yet she is a very humble person. Dennis, 39 years old male, is a pig caretaker and a very happy person. Dolor, 37 years old female, is a housewife and a very supportive mother. Darwin, 35 years old male, sells in a sari-sari store near their house and a very funny and disobedient person at times. H. Genogram
B. Early Childhood He was properly breastfed and bottle-fed. Feeding habits, ea rly development, and toilet training are unremarkable. No tantrums, night tremors, or thumb sucking noted. C. Middle Childhood The patient is cooperative and participative in pre-school activities. He has a lot of friends and has average academic performance. There is no history of hair pulling, cheating, or lying. D. Late childhood He hates sports and joining extra-curricular activities. He has average academic performance. He has strong self-esteem and loves helping people. There is no history of smoking, intake of alcohol, illicit drug use, etc. E. Adulthood Patient doesn’t attend Sunday mass for 5 years and goes to church activities before his illness. Patient has no problems with his work, colleagues, a nd started drinking alcohol when he was 20 years old. He never invited or dated a girl in his life.
IV.
MENTAL HEALTH EXAMINATION
A. General Description:
He has no auditory and visual hallucinations, illusions, derealization or depersonalization. E. Thought & Process: He has paucity of ideas, no looseness of association, clang association, word salad or neologism. He has flight of ideas, tangential sometimes. He has no echolalia or perseveration. F. Thought & Content: He has delusion of reference and persecutory delusions, but no obsessions. G. Sensorium and Cognition: Patient is alert and conscious. He is oriented to the time place and person. He has intact remote, recent past, resent and immediate recall memory. He has intact concentration. He was having hard time subtracting 7 from 100, 7 from 93 and so on. He was able to spell LIKHA forward and backward. He can write a complete sentence. He can draw a clock hanging on a wall from an actual wall clock. He knows the current President and Vice-president of the Philippines. H. Judgment: He has intact judgment by helping a victim of pick pocketing. I. Insight: The patient is fully aware of the illness and accepts it.
The major parts of the basal ganglia consist of the caudate nucleus, the putamen and the globus pallidus. The basal ganglia is involved in the control of movement. The nucleus accumbens contains neurons that are part of the basal ganglia. Thus, this structure may play a role in the regulation of movement, including the control of complex motor activity and the cognitive aspects of motor control. In addition, this structure has been found to possibly be the area that becomes activated in situations that involve reward and punishment. The
nucleus accumbens is a nucleus of the basal forebrain. It receives dopamine-secreting terminal buttons from neurons of the ventral tegmental area (VTA) and is thought to be involved in reinforcement and attention.
The limbic system has been implicated in learning and memory and emotions. The implication in emotions involves feelings and expressions of emotions, emotional memories and recognition of emotions in other people. TEGMENTUM
The tegmentum consists of an area of the midbrain. It includes the bottom end of the reticular formation, the periaqueductal gray matter, the red nucleus, the substantia nigra and the ventral tegmental area.
The reticular formation is a large structure consisting of many nuclei. It is also characterized by a diffuse, interconnected network of neurons with complex dendritic and axonal processes. The reticular formation receives sensory information and projects axons to the cerebral cortex, thalamus and spinal cord.
NEURONS
other neurons. This vast interconnectedness allows simple neuronal activity to translate into complex neuronal messages creating human behavior.
NEUROTRANSMISSION •
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The basic structure of a neuron includes a cell body (soma), dendrites, axon and axon terminal. Neurotransmission is an electrochemical message that allows neurons to communicate information with one another neuron.
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Electrochemical messages pass from the dendrites (projections from the cell body)
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Through the soma or cell body
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Down the axon (long extended structures)
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And across the synapses (gaps between cells)
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To the dendrites of the next neuron
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After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase
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These neurotransmitters are necessary in just the right proportions to relay messages across synapses
GABA
GABA is the most common inhibitory neurotransmitter in the nervous system and is found throughout the body. Produce calming effects and are target sites for benzodiazepines. Glutamate
Glutamate is an excitatory neurotransmitter that is involved in learning and memory. Alterations in production may play a role in the underpinnings of neurodegenerative disorders, such as Alzheimer’s disease and schizophrenia.
Acetylcholine
Acetylcholine is responsible for muscular movement and has been shown to have a role in memory formation. It was the first neurotransmitter to be discovered, and thus is the best known.
Dopamine
Dopamine has been implicated in numerous functions within the body, including movement, attention, learning, and the reward and reinforcement. Schizophrenia and other psychotic disorders are associated with increased or dysregulation of dopamine
VII.
PSYCHOPATHOPHYSIOLOGY
VIII. Drug Name
Generic Name: Haloperidol Brand Name: Haldol Classification : Antipsychotic
Action
A butyrophenone that probably exerts antipsychotic effects by blocking postsynaptic dopamine receptors in the brain.
Indication
psychotic disorders
chronic psychosis requiring prolonged therapy
nonpsychoti c behavior disorders
DRUGSTUDY Contraindicatio n Hypersens itivity to drug, tartrazine, sesame oil or benzyl alcohol
Adverse Reaction
CNS: confusion, drowsiness, restlessness, sedation, lethargy, insomnia, vertigo, dyskinesia, seizures, neuroleptic, malignant syndrome
CV: hypotension, hypertension
Tourette syndrome
Delirium
Nsg Consideration
Monitor CNS status closely, cardiovascular status and respiratory status
Advice patient to minimize GI upset by eating frequent small serving of meal
Instruct patient to report signs and symptoms of serious adverse reaction
EENT: blurred vision, dry eyes
GI: constipation, drymouth, anorexia
GU: urinary retention, menstrual irregularities, gynecomastia
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HEMATOLOGIC : anemia
RESPIRATORY: dyspnea
Drug Name
Action
Indication
Contraindicatio n
Adverse Reaction
Nsg Consideration
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Generic Name: Clozapine Brand Name: Leponex Classification : Antipsychotic
Unclear. Thought to interfere with dopamine binding in limbic system of CNS, with high affinity for dopamine receptors
Schizophre nia in patient unresponsive to other therapies
hypersensi tivity to drugs
uncontroll ed seizure
severe CNS depression or coma
CNS: sedation, drowsiness, dizziness, vertigo, insomnia, disturbed sleep, nightmares, restlessness
CV: tachycardia, hypotension, hypertension, chest pain
EENT: visual disturbances
GI: dry mouth, constipation, nausea, vomiting, excessive salivation
GU: urinary frequency or urgency, urine retention
Respi: repiratory arrest
Patient monitoring 1. Monitor wbc count weekly for 6 months 2. Monitorecg and liver function test 3. If drug must be withdrawn abruptly, monitor patient for psychosis and cholinergic rebound (head ache, nausea, vomiting and diarrhea)
Patient teachings 1. Tell patient to allow orally disintegrating tablet to dissolve in mouth 2. Advise patient to immediately report of new onset of lethargy, weakness, fever, sore throat. Malaise, mucous membrane ulcers, or other signs and symptoms of infections
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Drug Name
Action
Generic Name: Diphenhydrami de
Interferes with histamine effects at h1 receptors site; prevents but doesn’t reverse histaminemediate response.
Brand Name: Celestamine Classification : Antihistamine
Indication
Contraindicatio n
Allergy sypmtoms caused by histamine release
nausea and vertigo, cough
dyskinesia; parkinsons disease
hypersensi tivity to drug Alcohol intolerance
Acute asthma attacks
mild nighttime sedation
MAO inhibitor use within past 14 days
Breastfeed
ing Neonates, premature infants
Adverse Reaction
CNS:
Drowsiness, dizziness, headache, paradoxical stimulation (especially in children)
CV:
Hypotension, palpitations, tachycardia
EENT:
Blurred vision, tinnitus
GI:
Diarrhea, constipation, dry mouth
Nsg Consideration
Patient monitoring: monitor cardiovascular status Patient teaching: 1. Advise patient to avoid alcohol 2.Caution patient to avoid driving and other hazardous activities until he knows the drug effects 3.Review all significant adverse reaction
GU:
Dysuria, urinary frequency or retention
Skin:
Photosensitivity Other:
decreased appetite, pain at I.M. injection site
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Drug Name
Generic Name: Clonazepam Brand Name: Rivotril Classification : Anticonvulsant
Action
May enhance activity of gamma-amino butyric acid, and inhibitory neurotransmitter in CNS
Indication
Contraindicatio n
Nsg Consideration
CNS: fatigue, drowsiness, behavioral changes, depression and reduced intellectual ability
Paient monitoring 1. Monitor patient for respiratory depression 2. Monitor hematologic and liver function test results
LennoxGastaut syndrome, atypical absence seizures, akinetic and myoclonic seizures
severe hepatic disease
Panic disorder
Acute manic episodes of bipolar disorder
Adjunct treatment for schizophrenia
hypersensi tivity to drug or benzodiazepin es
Adverse Reaction
acute angle-closure glaucoma
CV: palpitations EENT:, blurred vision, diplopia, nystagmus, sinusitis, rhinitis, pharyngitis,
GI: constipation, diarrhea, hypersalivation
Periodic leg movements during sleep
Caution: tell patient not to stop taking drug abruptly, advise patient not to drink alcohol which may increase drowsiness, dizziness, and risk for seizures
Parkinsonia n dysarthria
Neuralgias
GU: dysuria, nocturia, urinary retention, dysmenorrhea, delayed ejaculation, erectile 18
dysfunction Respi: respiratory depression, shortness of breath Adverse Reaction
Drug Name
Generic Name: Akineton Brand Name: Biperiden Classification : Antiparkinsonian
Action
Synthetic anticholinergic drug, blocks cholinergic responses in the CNS
Indication
Parkinsonia n syndrome especially to counteract muscular rigidity and tremor, extrapyramidal symptoms
Contraindicatio n narrow angle glaucoma
mechanica l stenoses in gastrointestina l and mega colon, prostatic adenoma and diseases leading to perilous tachycardia
hypersensi tivity to bipereden.
skin rashes dyskinesia ataxia twitching impaired speech micturation difficulties fatigue dizziness at higher doses restlessness agitation anxiety confusion
Nsg Consideration
Document indication for therapy, onset of signs and symptoms and other agents tried in outcome of therapy Assess for parkinsonism or EPS, shuffling gait, muscle rigidity, involuntary movement, pill rolling, muscle spasm, drooling before and during treatment
Assess for mental status: affect mood CNS depression worsening of mental symptoms during early therapy
Monitor for constipation cramping pain in the abdomen, 19
and abdominal distension. Increase fluids, add fiber to diet and exercise
Drug Name
Generic Name: Vitamin B complex Brand Name: Crystamine Classification : Vitamins
Action
A coenzyme that stimulates metabolic function and is needed for cell replication, hematopoiesis and nucleoprotein and myelin synthesis.
Indication
RDA for cyanocobalamin
Vit B12 deficiency from inadequate diet, subtotal gastrectomy
Contraindicatio n hypersensi tivity to Vit B12 or cobalt and in those with early Leber’s disease
use cautiously in anemic patient with coexisting cardiac, pulmonary or hypertensive disease
Pernicious anemia or vit B12 malabsorption
Methylmalo nic acid uria
Adverse Reaction
CV: peripheral vascular thrombosis, heart failure GI: transient diarrhea
Nsg Consideration
Determine hematocrit, iron, and Vit B levels before beginning therapy
Obtain a sensitivity test history before administration
Respi: pulmonary edema
Skin: itching, urticaria
Don’t give large oral doses routinely Monitor patient for hypokalemia for first 48 hours
Teach patient using intranasal form how to administer drug
Instruct patient not to take folic acid as a replacement for vitamin B12 20
Drug Name
Generic Name: Vitamin C (Ascorbic Acid) Brand Name: Vita-C Classification : Vitamins
Action
Stimulates collagen formation and tissue repair; involved in oxidationreduction reactions.
Indication
Increases protection mechanism of the immune system
Treatment and prevention of vitamin C deficiency, including a condition called scurvy
Extensive burns, delayed fracture or wound healing, severe febrile or chronic diseases states
Contraindicatio n
Adverse Reaction
Allergy to tartrazine sulfites
Large doses in pregnant patients
GI: diarrhea, heartburn, nausea, vomiting
CNS: faintness, dizziness
Nsg Consideration
GU: gastric urine, renal calculi
When giving for urine acidification, check urine pH to ensure efficacy If using IM, explain that this route may promote better use of the vit by the body
Inform patient or relatives that vitamin is readily absorbed from citrus fruits, tomatoes, potatoes and leafy vegetables
Advise smokers to increase intake of vitamin
To prevent vit C deficiency
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in patients with poor nutritional habits or increase requirements To acidify urine
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IX. ASSESMENT Subjective cues: “Nagugulat ako pag nakakakita ng babae at lalaki” Objective cues: Auditory hallucinations Visual hallucinations Insomnia Restlessness Ramus mood with full affect Paucity of ideas Tangential at times Ideas of reference Persecutory delusions Flight of ideas Has a hard time subtracting 7 from 100, 7 from 93 and so on
DIAGNOSIS
Disturbed thought processes related to presence of psychological conflicts as evidenced by delusions and hallucinations
NURSING CARE PLAN
PLANNING
After 2 weeks of nursing interventions the client will be able to: Interact and respond to reality-based interactions initiated by others Demonstrat e reality based thinking in verbal and nonverbal behavior
INTERVENTION
Be sincere and honest when communicating with the client
RATIONALE
To establish a trusting relationship
Do not make promises that you cannot keep
Explain procedures and be sure the client understands the procedures before carrying them out
Interventions for Delusions: Give positive feedback for client’s success
Interact with the client on the basis of real things, do not dwell on the
Broken promises reinforce the client’s mistrust of others The client feel less likely that he or she is being tricked
EVALUATION
Goal met: After 2 weeks of nursing interventions the client was able to: Socialize with others in reality-based conversations through verbal and nonverbal behavior
Enhances the client’s sense of well being and helps to make nondelusional reality a more positive situation
Interacting about reality is healthy for the client 23
delusional material
Directly interject doubt regarding delusions if client seems ready to accept reality
Interventions for Hallucinations: Elicit description of hallucination
Engage client in reality-based activities such as card playing, occupational therapy, or listening to music
Help present or maintain reality by frequent contact and communication with the client
As the client trust you, he or she may be willing to doubt the delusion if you express your doubt
To protect the client and others. Understanding the hallucination will provide ways to calm or reassure the client
To limit or decrease the recurrences of hallucinations
To maintain reality orientation
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