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COLLEGE OF NURSING

A CASE STUDY ON

SCHIZOPHRENIASubmitted to:

Ms. Maribel Murillo RN, MANClinical Instructor

Submitted by:Kristin Abee E. Guarin

SN Batch 2014

I. PATIENT ASSESSMENT DATABASE

A. Personal Data Name: Mr. MP Address: Las Pinas, Philippines Age: 35 Sex: Male Birthday: June 5, 1976 Birth Place: Civil Status: Single Nationality: Filipino Religion: Roman Catholic Educational Attainment: 3rd year college, BS Management Occupation: None Physician: Dr. Cortez Date of Admission: July 14, 2004 Admitting Diagnosis: Schizophrenia

Hospital Name: Mother Theresa A Home that Cares

B. CHIEF COMPLAINT N/A (he doesn’t cooperate upon interview)

C. HISTORY OF PRESENT ILLNESS N/A(he doesn’t answer my question about his present illness)

D. PAST HEALTH HISTORY

N/A (he doesn’t recall his past health history)

E. FAMILY ASSESSMENTName Relation Age Sex Occupation Educational Attainment

Mr. MP Patient 35 Male None 3rd year collegeMr. CP Father 78 Male Doesn’t recall Doesn’t recallMrs. DP Mother 68 Female Doesn’t recall Doesn’t recall

F. SYSTEM REVIEW1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

Not assess because patient doesn’t answer my questions about health perception and health management2. NUTRITIONAL – METABOLIC PATTERN

N/A3. ELIMINATION PATTERN

Patient usually urinates 6 times a day and defecates 2 times daily4. ACTIVITY- EXERCISE PATTERN

0-Feeding 0 -Dressing 0-Grooming0-Bathing 0 -Toileting ____others

Legend:0- Full CareI- Requires use of assistanceII- Requires assistance and supervisions by othersIII- Requires assistance or supervisions from another and equipments and devicesIV – Dependent, doesn’t participate

5. COGNITIVE – PERCEPTUAL PATTERN Hearing: she doesn’t have any hearing problems Vision: she’s having blurred vision and she use reading glass Sensory: our patient is responsive and is able stimulated by closing her eyes and instructed to point what have been pointed on her

skin. There is no problem with sense of taste and smell. Learning Styles: my patient doesn’t answer my question and sometimes not cooperative

6. SLEEP- REST PATTERN According to my patient he sleeps at 9pm to 6am. He also stated that sometimes he had problems in sleeping.

7. SELF- PERCEPTION AND SELF- CONCEPT PATTERN N/A

8. ROLE- RELATIONSHIP PATTERN N/A

9. COPING- STRESS TOLERANCE PATTERN N/A

10. VALUE- BELIEF PATTER N/A

G. DEVELOPMENTAL HISTORY

Theory Age Sex Description

Erickson’s Psychosocial Theory 35 years old MaleIntimacy vs IsolationMr. MP doesn’t answer my questions sometimes and doesn’t participate to the activities because he doesn’t trust me as his nurse.

H. PHYSICAL ASSESSMENTA. General Survey

1. Overall appearance and grooming: upon assessment patient is neat and clean, he manifested a good grooming.2. Actual height and weight vs. ideal body weight: n/a3. Symptoms of distress: he is not answering my question mostly and he prefer to be alone sometimes4. Posture and gait: upon assessment her posture and gait are well coordinated.5. Affect and mood: he is not answering my question mostly and he prefer to be alone sometimes.

B. Regional exam- utilize IPPA technique

1. Hair: Upon inspection, his hair is evenly distributed, thick, its texture is silky and resilient hair and there is no presence of infestation (lice) and variable in amount.Head and face: his head is round, smooth skull contour, symmetric in size and consistent while her face is symmetric in facial movement.

2. Eyes: Upon inspection of the client’s eyes, its eyebrows and eyelashes are symmetrically aligned, curled slightly outward and hair is evenly distributed.

3. Nose: Upon inspection, client’s nose is symmetrical, no discharges, uniform in color, he breaths properly through the nares. 4. Ears: Through inspection, client’s ears are symmetrical; the auricle is aligned with the outer canthus of the eyes and same with the

color of facial skin. 5. Mouth and throat: Through inspection, client’s lips and buccal mucosa is pink in color. No retraction of gums, with incomplete

teeth. Tongue moves freely.6. Neck and lymph nodes: The client’s neck muscles are equal in size, no enlargement of nodules or masses upon palpation. Head

movement is coordinated and smooth movement with no discomfort. 7. Skin: Brown in color, warm to touch and equally distributed by hair. 8. Nails: fingernail plate has convex curvature and an angle of nail plate about 160˚, smooth texture, finger nail and toenail bed color is

pale, with intact epidermis.9. Thorax and lungs: Chest is symmetric, spine vertically aligned, spinal column is straight, right and left shoulder are at same height. 10. Breast and axilla: not assessed11. . Abdomen: not assessed12. Extremities: there is no presence of edema or abnormal findings13. Genitals: not assessed14. Rectum and anus: not assessed15. Neurological/Cranial nerves: not assessed.

INTRODUCTION

Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.

Clinical ManifestationsThe symptoms of schizophrenia are divided into two major categories:A. The positive symptoms include:

delusions and its types, hallucinations, loose associations and bizarre or disorganized behavior

B. The negative symptoms includes: restricted emotions, anhedonia, avolition, alogia, catatonia and social withdrawal.

Diagnostic Test

Clinical diagnosis is developed on historical information and thorough mental status examination. No laboratory findings have been identified that are diagnostic of schizophrenia. Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function tests,

thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body retains excessive amounts of copper), PET scan, CT scan, and MRI.

Rating scale assessment: Scale for the assessment of negative symptoms. Scale for the assessment of positive symptoms. Brief psychiatric rating scale

TreatmentA comprehensive treatment program can include:

Antipsychotic medication Education & support, for both ill individuals and families Social skills training Rehabilitation to improve activities of daily living Vocational and recreational support Cognitive therapy

Nursing Interventions:A. Strengthening Differentiation

Provide patient with honest and consistent feedback in a non threatening manner. Avoid challenging the content of patient’s behavior Focus interactions on patient’s behavior. Administer drugs as prescribed while monitoring and documenting patient’s response to drug regimen. Use simple and clear language when speaking with the patient. Explain all procedures, test and activities to patient before starting them

B. Promoting Socialization Encourage patient to talk about feelings in the context of a trusting, supportive relationship. Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions. Use supportive, emphatic approach to focus on patient’s feelings about troubling events or conflicts. Provide opportunities for socialization and encourage participation in group activities. Be aware of personal space and use touch judiciously.

Help patient to identify behaviors that alienate significant others and family members.

C. Ensuring Safety Monitor patient for behaviors that indicate increased anxiety and agitation. Collaborate patient to identify anxious behaviors as well as causes. Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers. Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury. Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action. Frequently monitor the patient within guidelines of facility’s policy on restrictive devices and assess the patients level of agitation. When patient’s level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific

behaviors that indicate self control against are escalation agitation.

ANATOMY AND PHYSIOLOGY

I. StructuresA. 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.

II. Function

A. CNS1. Brain

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.

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.

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.

The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.

  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.

PATHOPHYSIOLOGY

Brain development from conception to early adulthood

Anatomic and functional disruption in neural connectivity and communication

Impairment in a fundamental cognitive process

Impairment in one or more second-order cognitive process

Predisposing factorStress

Low socioeconomics

Disturbance in neurotransmitter system

Looseness of ability in thinking

Impaired ability to perceiveS/Sx: Delusion and hallucination

LABORATORY RESULT

ElectrolytesResult Normal Values Significance

Sodium 136 135-145 Within normal rangePotassium 3.98 3.5-5.0 Within normal range

UrinalysisRESULTS SIGNIFICANCE RESULTS SIGNIFICANCEColor:

Yellow Within normal rangeSugar:

negative Within normal rangeTransparency:

Clear Within normal rangeSpecific gravity:

1.010 Within normal rangeReaction: Microscopic:

Pusleukocytes: Albumin:

Acidic Albumin Within normal range Erythrocytes:

Roentrogenological report Findings:There are hazy infiktrates at both suprahilar area heart is not enlarged diaphragm and sulci are intact

Disorganized thought confusion

Social isolation

ImpressionSuprahilar pneumonitis, bilateral koch's etiology not ruled out

DRUG STUDY

Generic Name: HaloperidolBrand Name: HaldolDrug Classification: AntipsychoticDosage: 20mg 1/4 tab ODIndication: Management of manifestations of psychotic disorders

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block postsynaptic dopamine receptors in the brain, depress the RAS, including those parts of the brain involved with wakefulness and emesis.

Vertigo, headache Nasal congestion Polyuria Cerebral edema Tremor Ataxia Orthostatic

hypotension Cardiomegaly SIADH Eosinophilia Leucopenia

Coma Severe CNS

depression Bone marrow

depression Blood dyscrasia Circulatory collapse Subcortical brain

damage Cerebral

arteriosclerosis Coronary disease

Drowsiness Blurring of vision

Dry mouth Nausea and vomiting

Tachycardia, bradycardia

insomnia

Provide safety to the patient

Maintain fluid intake and use precautions against heatstroke or heat weather

Monitor electrolytes level Monitor Vital Signs continuously Provide rest and comfort Monitor CBC, BUN, Creatinine Gradually withdraw drug when

patient has been on maintenance

Jaundice Urticaria

Severe hypotension or hypertension

therapy

Generic Name: Diphenhydramine hydrochlorideBrand Name: BenadrylDrug Classification: AntiparkinsonianDosage: 50mg cap HSIndication: Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly intolerant of more potent drugs, for milder forms of disorder

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Competitively blocks the effects of histamine at h1 receptor sites, has atropine-like, anti-pruritic and sedative effects

Fatigue Confusion Blurred vision Headache Diplopia Tremors Palpitations Bradycardia Diarrhea Constipation Urinary frequency

Third trimester of pregnancy

Lactation Used cautiously

with: Narrow angle

glaucoma Asthmatic attack Bladder neck

obstruction Pregnancy

Drowsiness Sedation Dizziness Disturbed

coordination Nausea and vomiting

Provide safety to the patient Assist patient in ambulation

Maintain fluid intake and use precautions against heatstroke or heat weather

Monitor electrolytes level Administer these drugs with food

if GI upset occur Monitor Vital Signs continuously Provide rest and comfort

Anorexia Dysuria rash

Stenosing peptic ulcer

Symptomatic prostatic hypertrophy

Monitor CBC, BUN, Creatinine Gradually withdraw drug when

patient has been on maintenance therapy

Generic Name: Fluoxetine hydrochlorideBrand Name: ProzacDrug Classification: SSRI (Selective Serotonin Reuptake Inhibitor)Dosage: initially 20mg/day tabIndication: treatment of depression; most effective in patients with major depressive disorder

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Acts as an antidepressant by inhibiting CNS neuronal uptake of serotonin; blocks uptake of serotonin with little effect on norepinephrine

Agitation Sedation Seizure Abnormal gait Palpitations Flatulence Cystitis Impotence alopecia

hypersensitivity to fluoxetine and pregnancy

Dizziness Headednes Nervousness

Sweating and dry mouth

Nausea and vomiting Diarrhea

Provide safety to the patient Teach patient about relaxation

technique Increase fluid intake Maintain fluid intake and use

precautions against heatstroke or heat weather

Monitor electrolytes level Eat foods high in fiber Monitor Vital Signs continuously Provide rest and comfort

constipation bradycardia

Generic Name: Fluphenazine decanoateBrand Name: ModecateDrug Classification: AntipsychoticDosage: initial dose, 12.5 – 25mg IMIndication: Management of behavioral complication in patients with mental retardation

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block dopamine receptors in the brain, depress the RAS, including those parts of the brain involved with wakefulness and emesis.

Vertigo, headache Nasal congestion Polyuria Cerebral edema Tremor Ataxia Orthostatic

hypotension Cardiomegaly SIADH Eosinophilia Leucopenia Jaundice Urticaria

Coma Severe CNS

depression Bone marrow

depression Blood dyscrasia Circulatory collapse Subcortical brain

damage Cerebral

arteriosclerosis Coronary disease Severe hypotension

or hypertension

Drowsiness Blurring of vision

Dry mouth Nausea and vomiting

Tachycardia, bradycardia

insomnia

Provide safety to the patient

Maintain fluid intake and use precautions against heatstroke or heat weather

Monitor electrolytes level Monitor Vital Signs continuously Provide rest and comfort Monitor CBC, BUN, Creatinine Gradually withdraw drug when

patient has been on maintenance therapy

Generic Name: ClozapineBrand Name: ZiprocDrug Classification: AntipsychoticDosage: 100mg ¼ tab 2x/week HSIndication: Management of severely ill schizophrenics who are unresponsive to standard psychotic drug

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block dopamine receptors in the brain, depress the RAS, including those parts of the brain involved with wakefulness and emesis.

Tremor Disturbed sleep Sedation Sweating Dry mouth Urticaria Rash leukopenia

Severe CNS depression

History of seizure Granulocytopenia Myeloproliferative

disorders

Drowsiness Sedation Dizziness Headache Nausea and vomiting

Constipation Fever Tachycardia hypotension

Provide safety to the patient

Maintain fluid intake Monitor electrolytes level Eat food rich in fiber Tepid sponge bath Monitor Vital Signs continuously Provide rest and comfort Monitor CBC, BUN, Creatinine Gradually withdraw drug when

patient has been on maintenance

therapy

Generic Name: BiperidenBrand Name: AkinetonDrug Classification: AntiparkinsonDosage: 2mg/day ½ tabIndication: Adjunct in the therapy of parkinsonism

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anticholinergic activity in the CNS that is believed to help normalize the hypothesized imbalance of cholinergic and dopaminergic neutransmission in the basal ganglia in the brain of a parkinsonism patient.

Memory loss Agitation Depression Drowsiness Tachycardia Palpitations Hypotension Rash Urticaria weakness

Glaucoma Pyloric or duodenal

obstruction Stenosing peptic

ulcer Achalasia Prostatic

hypertrophy Myasthenia gravis

Disorientation Confusion Blurred vision Dizziness Light-headednes Nervousness

Dry mouth Nausea and vomiting Diarrhea

constipation bradycardia

Provide safety to the patient Orient patient about time, place,

event or things around her. Teach patient about relaxation

technique Maintain fluid intake and use

precautions against heatstroke or heat weather

Monitor electrolytes level Eat foods high in fiber Monitor Vital Signs continuously Provide rest and comfort Monitor CBC, BUN, Creatinine Gradually withdraw drug when

patient has been on maintenance

therapy

LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY1. Disturbed thought processes related to inability to trust evidenced by delusional thinking.2. Social Isolation related to alteration in mental status3. Situational low self-esteem related to cognitive impairment

NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective:

Objective:>inability to trust >lack of interest

Disturbed thought processes related to inability to trust evidenced by delusional thinking.

After 1-2 days of rendering nursing interventions, the patient will be able to develop trusting relationship with nurse

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks.

Be consistent in setting expectations, enforcing rules, and so forth.

Do not make promises that you cannot keep.

Encourage the client to talk

Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.

Clear, consistent limits provide a secure structure for the client.

Broken promises reinforce the client’s mistrust of others.

Probing increases the

After 2 days of rendering nursing interventions, the patient was develop trusting relationship with nurse

with you, but do not pry for information.

Explain procedures, and try to be sure the client understands the procedures before carrying them out.

Initially, do not argue with the client or try to convince the client that the delusions are false or unreal.

client’s suspicion and interferes with the therapeutic relationship.

When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff.

Logical argument does not dispel delusional ideas and can interfere with the development of trust

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective:

Objective:>uncommunicative>seeks to be alone> projects hostility>sad/dull affect

Social Isolation related to alteration in mental status

After 1-2 days of rendering nursing interventions, client will identify feelings of isolation

>establish a therapeutic relationship by being emotionally present and authentic

>observe for barriers to social interaction

>provide positive reinforcement when the client seeks out others

>being emotionally present and authentic fosters growth in relationships and decrease isolation

>adequate information should be gathered so appropriate interventions can be planned

>social support contributes to positive well being

After 1-2 days of rendering nursing interventions, client will identify feelings of isolation

>discuss causes of perceived or actual isolation

>the individual’s experience of illness; the circumstances of everyday living that influence a quality of life

Assessment Nursing Diagnosis

Planning Interventions Rationale Evaluation

Subjective:

Objective:> lacking eye contact>little interest in activities>lack of social interaction

Situational low self-esteem related to cognitive impairment

After 2-3 hours of rendering nursing interventions, the patient will verbalize understanding of things that precipitate current situation and demonstrate behaviors that show positive self-esteem.

Encourage client to express honest feelings in relation to loss of prior level of functioning

Revise methods for assisting client to express feelings properly.

Encourage client’s attempts to communicate. If verbalizations

Client may be fixed in anger stage of grieving process, which is turned inward on the self, resulting in diminished self-esteem.

To explore the feelings of the client thereby allowing him to acknowledge his own strength and weakness

The ability to communicate effectively with others may

After 3 hours of rendering nursing interventions, the patient was verbalized understanding of things that precipitate current situation and demonstrated behaviors that show positive self-esteem.

are not understandable, express to client what you think he intended to say. It is necessary to reorient client frequently.

Encourage reminiscence and discussion of life review

Encourage to participate in activities

Offer support and empathy

enhance self-esteem

Help client resume progression through the grief process associated with disappointing life events and increase self-esteem

Positive feedback from group members will increase self-esteem

Focus on accomplishments to lift self-esteem

DISCHARGE PLAN Medication:

Instruct patient to continue taking her medications

Do not stop abruptly taking the medications

Report any complications or severe effects of drugs to your health care provider

Exercise:

Encourage patient to have regular exercise even he is at their home.

Treatment:

Instruct patient to continue taking her medications.

Clinical Follow-up:

Instruct patient to have her follow-up check- up after one week.

Diet:

Advise the patient to eat green leafy vegetables, rich in iron and vitamin C

Danger signs:

Instruct patient to seek medical advice to physician if she experiencing discomfort and complications