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Perfect SCORE SCORE
Score CDO DAVAO
1.) CONTENT 40
2.) PRESENTATION 30
a. Creativity and integrity (10)
b. Ability to hold the interest of others (10)
c. Ability to stimulate group participation (10)
3.) DELIVERY 10
a. Grooming (2)
b. Poise (2)
c. Voice (3)
d. Diction (3)
4.) RESPONSE TO QUESTIONS 15
a. Making sound judgement (10)
b. Ability to express self (5)
5.) ATTITUDE 5
a. Attitude towards comments and suggestions
TOTAL SCORE 100
GRADE
Case Study Rating Sheet
Liceo de Cagayan UniversityCollege of Nursing
NCM501203A Care Study
PATIENT RR
Schizophrenia undifferentiated
Submitted to
Name of faculty
A Partial Requirement for NCM 501203
Submitted byYAP, ROY D. II
LAPURA, JUNILYN P.CAHILES, JOHANNA KHRYSTYNE C.
CELIZ, RUFFA CARLAOREJANA, MARICRIS
GALLENERO, CHARISSE MAEABENOJA, EXCELSIOR
MAYORDOMO, JC JAMESCREDO, MICHAEL ANGELO
SABANDO, RICK PAULDUCO, ANNACEL
GROUP D4
Table of Contents
I. Introduction
A. Overview ………………………….. B. Objective and Purpose of the Study ………………………….. C. Scope and Limitation ………………………….. D. Spot Map ………………………….. E. Patient’s Profile …………………………...
II. Anamnesis
A. Maternal and Paternal Lineage …………………………… B. Parents …………………………… C. Subject ……………………………
III. Course in the Hospital
A. Mental Status Exam …………………………… B. Progress Notes ……………………………
IV. Psychodynamics ……………………………
V. Laboratory Exam and Results Of Psychological Test
A. Neuropsychological Test …………………………… B. Laboratory test if any ……………………………
VI. Diagnosis ……………………………
VII. Multi-Axial Diagnosis ……………………………
VIII. Nursing Management ……………………………
IX. Medical Management ……………………………
X. Prognosis and Recommendation ……………………………
XI. Bibliography ……………………………
I. INTRODUCTION
D I. INTRODUCTION
A. Overview
Schizophrenia is a disease affecting the brain that causes distorted and
bizarre thoughts, perceptions, emotions, movements and behavior (Videbeck,
2001). Schizophrenia usually is diagnosed in late adolescence or early
adulthood. The peak incidence of onset is 15 to 25 years of age for men and 25
to 35 years of age for women (APA, 2000). There are 5 types of schizophrenia:
The paranoid type, disorganized type, catatonic type, undifferentiated type, and
the residual type.
Schizophrenia causes distorted and bizarre thoughts, perceptions,
emotions, movements, and behavior. It cannot be defined as a single illness;
rather, schizophrenia is thought of as a syndrome or disease process with many
different varieties and symptoms, much like the varieties of cancer. For
decades, the public vastly misunderstood schizophrenia, fearing it as a
dangerous and uncontrollable and causing wild disturbances and violent
outburst. Many people believed that those with schizophrenia needed to be
locked away from society and institutionalized.
No laboratory test is for schizophrenia currently exists. Although
schizophrenia affects men and women with equal frequency, the disorder often
appears earlier in men, usually in the late teens or early twenties, than in
women, who are generally affected in the twenties to early thirties. Available
treatments can relieve many symptoms, but most people with schizophrenia
continue to suffer some symptoms throughout their lives; it has been estimated
that no more than one five individuals recovers completely.
Schizophrenia affects about 24 million people worldwide. Schizophrenia
is a treatable disorder, treatment being more effective in its initial stages. More
than 50% of persons with schizophrenia are not receiving appropriate care and
90% of these are in developing countries. Care of persons with schizophrenia
can be provided at community level, with active family and community
involvement.
In the Philippines alone, out of 86, 241, 697 population, the
extrapolated prevalence is 697,543 – about .5% to 1% of the population as of
2004. Schizophrenia still ranks among the top causes of disability in the country;
however there are some variations in terms of incidence and outcomes for
different groups of people.
In Northern Mindanao, out of 2, 283, 272 population as of 2005,
there is an estimated number of schizophrenic patient, in every 1000 persons
there are 12 cases of schizophrenia.(Philippines Mental Health Country Profile).
In this study, the main focus will be on Schizophrenia, Undifferentiated Type;
a type characterized by mixed schizophrenic symptoms along with disturbances
of thought, affect and behavior (Videbeck 2004). Atypical symptoms present do
not meet the criteria for the subtypes of paranoid, catatonic, or disorganized
schizophrenia. The client may be observed to exhibit both positive and negative
symptoms; odd behavior, delusions, hallucinations and incoherence (Shives and
Isaac 2002).
B. Objective and Purpose of the Study
The objectives of the study are as follows:
Develop a good working relationship with the client and her family.
Assess and determine the possible precipitating and predisposing factors
that contribute to the development of the disorder.
Assess the client with psychiatric disorder allowing the students to identify
the different abnormal behaviour under Schizophrenia Undifferentiated
Type.
Design a nursing care plan and implement nursing interventions
appropriate to the condition of the client.
The purposes of study are as follows:
Enhance the skills of the students involved and their knowledge by
understanding the essentials towards promotion of mental health.
It gives opportunity to learn different approaches in establishing a nurse-
patient relationship.
Let the family understand the apparent condition of the client.
Help client through the application of the nursing process.
Specific Objectives:
In order to meet the general objective, the group aims to:
1. Gather pertinent data about the client through detailed chart taking, and
effective therapeutic communication and interaction with the client and his
significant others.
2. Commence the patient with his personal data and present and past health
history.
3. Assess client’s mental status thoroughly using axial diagnosis.
4. Determine the etiology factors (precipitating and predisposing) of the
mental disorder.
5. Present the medications given to the client, including their respective
modes of action, indications, contraindications, side effects, nursing
responsibilities, and importance to the client’s condition.
6. Render quality nursing care in line with the formulated nursing care plans;
7. Impart appropriate recommendations to the client, his significant others
and community, medical world, and the group as a part of the nurse’s
holistic care.
8. Establish a trusting nurse-patient relationship with the client and his
significant others through provision of holistic care toward the client and
use of appropriate verbal and non-verbal therapeutic communication skills
with the client and significant others during the data gathering.
C. Scope and Limitation
This study was conducted at Orochain Village Carmen Cagayan de
Oro City, which covers 4 days of visitation. The four days visit includes
gathering of the necessary data and interview of a minimum eight informants.
The said informants are composed of the patient’s family, neighbours, and
relatives.
There were limitations encountered by the group in the conduct of
this study. The home visitation covered only four days. The location of the
area contributed to the difficulty of the group to properly assess the patient
since only a maximum of five persons can enter their house. The patient and
her family resides a squatter’s area. The first 3 days was also limited since
the group needs to conduct the said visit during 9:00-11:00 pm, since her
mother is available only during this time because her mother has a mini parlor
inside their house, thus a minimum of 2 hour was intended for the interaction
of the patient, her family and her neighbours. Information about the client’s
history of illness will be based only the interview with client, client’s mother,
her relative, and some of her neighbours. The expected outcomes of the
interventions initiated and implemented was dependent upon the cooperation
of the patient and her significant others.
The point of reference in locating the residence of Mr. RR, is
Liceo de Cagayan University located at R.N Pelaez Blvd., Carmen, Cagayan
de Oro City. The patient’s residence is approximately 500 meters and is
southwest of the point of reference. In order to reach the area, one has to
take a public utility vehicle, with the routed to Carmen Market, Cagayan de
Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is
Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5 minutes
if traffic is not that worse. But during rush hours, it usually takes around 5-10
minutes of commuting time to reach the area. Upon reaching the area, you
will see a Gasoline Station (Petron). The patient’s residence is approximately
30 meters away from the outpost. You need to start walking straight ahead
then turn right where you will pass by a mini store. After turning right, you
need to walk straight ahead again and turn left pass by 3 houses on the left
and on the right there’s a wall. After passing these houses on the left side the
fourth house from the point of intersection located on your left side is the
residence of patient RR.
The area where the patient is residing is congested urban since it is
described as a “squatter area”. The main sources of income of the people
living in the said area are mini parlor, vendors, by standers, sari-sari store’s
and laborers to name a few. The houses are made up of wooden structure
and are camped up in the area. The people’s past time in the area is
gossiping with their neighbours and singing videoke as well as playing cards.
The patient’s residence is made up of combination of concrete and wooden
structure. Their house is composed of two storeys, the upper part is their bed
room and the lower part of their house is divided into three parts their kitchen,
bathroom, and dining area.
D. SPOT MAP
The point of reference is Northern Mindanao Medical Center Cagayan de Oro City. The patients reference is approximately half kilometer and is
southwest of the point of reference. In order to reach the area, one has to
take a public utility vehicle, with the routed to Carmen Market, Cagayan de
Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is
Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5
minutes if traffic is not that worse. But during rush hours, it usually takes
around 5-10 minutes of commuting time to reach the area. Upon reaching the
area, you will see a Gasoline Station (Petron). The patient’s residence is
approximately 30 meters away from the outpost. You need to start walking
straight ahead then turn right where you will pass by a mini store. After
turning right, you need to walk straight ahead again and turn left pass by 3
houses on the left and on the right there’s a wall. After passing these houses
on the left side the fourth house from the point of intersection located on your
left side is the residence of patient RR.
The type of community that the patient is residing is an urban squatter’s area.
The main sources of income of the people living in the said area are mini
parlor, vendors, by standers, sari-sari store’s and laborers to name a few. The
houses are made up of wooden structure and are camped up in the area. The
people’s past time in the area is gossiping with their neighbours and singing
videoke as well as playing cards. The patient’s residence is made up of
combination of concrete and wooden structure. Their house is composed of
two storeys, the upper part is their bed room and the lower part of their house
is divided into three parts their kitchen, bathroom, and dining area.
E.Patient’s Profile
Initial Name: Patient “RR”
Address: Orochain Village Carmen, Cagayan de Oro City
Date of Birth: January 22, 1982
Age: 29 yrs.old
Birthplace: Cagayan de Oro City
Civil Status: Single
Gender: Male
Nationality: Filipino
Religion: Roman Catholic
Educational Attaintment: Grade 1 (West City Central School)
Siblings: One Sister (Ms. “M”)
Name of Mother: Mrs. “ER”
Name of Father: Mr. “BR”
Height: 5’1”
Weight: 50 kgs.
Date of First Check-up: March 2008
Admitting Diagnosis: Schizophrenia Undifferentiated
Attending Physician: Dr. Eric Boromeo
High School : Not AttendedCollege: Not Attended
Arrest, Court States Probation : NoneVital Signs:
Blood Pressure : 110/80mmhgTemperature : 36.9 cRespiratory Rate : 20cpmPulse Rate : 73bpm
Date Admitted: NoneTime Admitted: NoneFood and drug allergy: (+) chickenUse of street drugs: (+) shabu, Marijuana Use of street alcohol: (+) hard liquors
II. ANAMNESIS
A. INFORMANTS
Informant #1
Name: ER
Sex: Female
Age: 50 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: Mother
Length of time known to patient: 29 years
Apparent understanding of present illness:
“ Nabuang man na akong anak pag-uli nako. Buotan man na siya na bata
kung dili lage mahubog di man jud unta na siya mupalit ug mainom gadaog
daogon man gud na siya.”
Characteristics and attitude of informant:
Informant was very willing to answer the questions being asked. She
speaks openly about the client and is concern about the client’s condition. She is
aware of the unusual behaviour that her son has manifested.
Informant # 2
Name: TR
Sex: female
Age: 82 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: grandmother
Length of time known to patient: 28 years
Apparent understanding of present illness:
“Nagkadipekto na siya sa pangutok sukad atong giburos pa lang na siya
kay iyang mama man gud gainom ug tambal, mao nag kain-ana na siya. Buotan
man na siya na bata kay gapatoo na siya pag sugoon. Dili man niya sala nga na
in-ana siya, sala jud sa iyang mama.gapanglimpiyo pa gani na siya ”
Characteristics and attitude of the informant:
Shows concern to the client and is aware of the unusual behaviours that
his grandson have. She also admits that the patient is very kind and that the
patient follows instructions.
Informant # 3
Name: MTC
Sex: female
Age: 54 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: neighbor
Length of time known to patient: 28 years
Apparent understanding of present illness:
“ing-ana naman na siya pagbalik sukad pa sa bata pa ginapaskwela gani
na siya pero ang problema kay sige siya takas, ug adtong bata pa siya sige lang
siya ug hinoktok lang adtong 10 years old pa siya. “
Characteristics and attitude of the informant:
She has known the client well and she is aware of the unusual behaviour
that the client manifests though she is confused with what the patient’s problem.
Informant # 4
Name: W Y
Sex: Female
Age: 20 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: Neighbor
Length of time known to patient: 14 years
Apparent understanding of present illness:
“buang man na siya kay mukalit di na siya maka istorya ug tarung unya dili
jud na siya. Luoy pa jud kayo na siya kay di na siya kabalo kung piso ba o dili.
Buotan kayo na siya na tao kay dali ra kayo masugo. ”
Characteristics and attitude of the informant:
The informant was aware of the unusual behaviors the patient portrays,
and was very concern to the client’s present condition.
Informant # 5
Name: E A
Sex: male
Age: 37 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: neighbor
Length of time known to patient: since birth
Apparent understanding of present illness:
“ buang man na siya sukad bata pa kay sige gani na siya hinuktok unya
sige takas sa klase. Pero buotan pud kayo na siya na bata kay dali ra jud na
nimo masugo. Gakaluoy lagi ko ana niya na. pero grabi jud na siya kabuotan na
bata bisan unsaon ba bisan in-ana pa na siya.“
Characteristics and attitude of the informant:
The informant is very concern to the patient. And he knows much about
the patient. And he cooperates with the interview.
Informant # 6
Name: J AS
Sex: Female
Age: 58 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: Neighbor
Length of time known to patient: since birth
Apparent understanding of present illness:
“Pagbalik sa iyang mama dani murag nisamot bitaw ang iyang sakit murag
in-ana bitaw. Pero grabe jud na siya kabuotan na bata pero dali ra kayo na
sugoon kay mulihok jud na siya diretso pero mao pud lage sige lang siya ug
daog daogon. Perme na siya kilkilan sa mga tao dani “
Characteristics and attitude of informant:
Concern about the client’s condition and speaks about patient’s behaviour
openly and is cooperative in giving information regarding the client’s condition.
Informant # 7
Name: D H
Sex: male
Age: 48 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: Neighbor
Length of time known to patient: since birth
“buotan kayo na siya na bata. Dali ran a siya masugo unya di pa jud
kabalo mureklamo. Mao raman pud ako nabantayan niya. Pirme man na siya sa
liceo dispatcher man na siya.”
Characteristics and attitude of informant:
The informant was aware that the client has this kind of mental illness
based on the unusual behaviour the client has shown but still shows some
disregard because he is one of those who keeps on dragging the patient to drink.
Informant # 8
Name: L F
Sex: Female
Age: 22 years old
Address: Orochain village Carmen Cagayan de Oro City
Relation to patient: Neighbor
Length of time known to patient: 15 years
Apparent understanding of present illness:
“wala jud kayo ko kabalo adtong bata pa siya pero karon makiingon jud ko
na naa siya daot sa pangutok tungod kay di siya kabalo kung unsa ang piso unya
di siya kaistorya ug tarung. “
Characteristics and attitude of the informant:
Shows willingness and is cooperative in answering the questions,
she is aware of the present situation of the client.
III. Course in the Hospital
A. Mental Status Examination
D1 D2 D3 D4
I. GENERAL
APPEARANCE
Tidy Tidy Tidy Clean
II. GENERAL
MOTILITY
Posture Slouch Slouch Slouch Slouch
Activity Purposeful Purposeful Purposeful Purposeful
Facial expression Suspicious Suspicious Happy Happy
III. Behavior Shy Friendly Friendly Friendly
IV. Patient nurse
interaction
Distant Cooperative Cooperative Cooperative
V. SPEECH
Soft / / /
Loud
Hesitant /
Slurred
Superior
Humor
Frightened
VI. Stream of Talk
Spontaneous
Deliberate / / /
Pressured
Blocking /
VII. Organization of talk
Relevant
Irrelevant
Incoherent
Loose Association / / / /
Flight of Ideas
Tangentiality
Circumstantiality
Perseverance
Clang Association
Neologism
Echolalia
Echopraxia
VIII. Mood and Affect
1. Mood
Euthymic
Depressed
Euphoric / / / /
2.Affect
Flat
Blunt
Angry
Elated / / /
Anxious /
Fearful
IX. Range of Affective
Expression
Consistent
Labile / / / /
Anhedonic
Appropriate to the
situation & feeling
verbalized
X. Perception
Hallucination
-auditory /
-visual /
-olfactory
-gustatory
-tactile
Delusion
-grandeur
-persecutory
-reference
-others(specify)
Illusion
Derealization
Depersonalization
Identification
Thought broadcasting
Déjà vu
Jamais Vu
XI. Orientation and
Memory
1.Identifies date
correctly
No No No No
2.Estimate time of the
day
No No No No
3.Knows where he is Yes Yes Yes Yes
4.Knows the examiner No No No No
5.Recalls activities
done within 24 hours
No No Yes Yes
6.Recalls activities
done within 1 week
No No No No
XII. Neuro-vegetative
functioning
Sleep and Rest Pattern
-normal sleep / / / /
-early morning
awakening
-middle night
awakening
-hyper insomnia
-difficulty in falling
asleep
-interrupted sleep
-others
XIII. Elimination
Bowel 0 1x 1x 0
Bladder 2x 3x 4x 3x
XIV. Abstract Thinking
Ability
Poor Poor Poor Poor
XV. Judgment Poor Poor Poor Poor
B. Description of MSE Result:
First visit (January15, 2011)
I. Appearance and Movement
During our 1st visit, the client looks neat and clean.His gait was
coordinated and smooth. He sat at the doorway and shows
slouchiness in his movement.
II. Speech
He was not hesitant to speak. He was able to answer the questions
but some portrayed loose association that is why we can’t
understand some of what he is saying.
III. Emotional State and Reaction
He was relaxed during the interview
IV. Thought Control
During the first interview, the client cannot recall activities done
within 24 hours, he cannot identify the date correctly, and also he
cannot estimate the time of the day but he knows where he is. The
client wasn’t able to know the examiner well. he was able to listen
well with our conversation but he cannot maintain eye contact.
V. Neuro-Vegetative Functioning
The client has a normal sleep pattern
Second Visit (January 17, 2011)
I. Appearance and Movement
On the second day, the client appears to be tidy. His gait was
coordinated and smooth but tends to slouch most of the time and
doesn’t have an eye to eye contact to us all the time. Conversation
was done at the same venue and the client was interested to talk
with a group and always smiles.
II. Speech
The client talked vividly in soft and low tone. he portrayed loose
association.
III. Emotional State and Reaction
He was more relaxed and feels happy when he sees us.
IV. Thought Control
The client still cannot identify the date correctly and cannot
estimate the time of the day. But he knows where he is.
V. Neuro-Vegetative Function
The client has a normal sleep pattern.
C. Progress Notes
Day 1: January 15, 2011
Specific Objectives:
1. To locate the area
2. To establish trust and rapport with the client and her family.
3. To have a verbal contract and consent both client and family.
4. To make initial assessment.
5. Arrange for the next schedule visit
It was on a Saturday morning when the group went to Orochain
Carmen CDOC to find for a potential client for our care study. We went to
the outpost of the baranggay to ask for any potential client and fortunately
we were given one. Before we arrived to our client’s house we planned
what we do, including the most important assessment. We conducted a
mental status examination.
The consent was obtained from the mother and the client as they
permitted the group to conduct series of interviews with them. The clients
name was patient “RR” and her mother was “Mrs. ER”. We gained the
necessary data’s that we needed from the client, her mother and relatives.
We gather the client’s profile and some other important information
regarding the client.
A verbal contract was made about the number of days we were going
to conduct the interview, health teaching, nursing intervention and length
of time of our visit.
Day 2: January 17, 2011
Specific Objectives:
1. Continue establishing rapport to the client.
2. Continue with the mental status exam.
3. Determine the factor that causes the clients disorder.
4. Trace the client history.
5. Ask the client’s neighbor for some relevant information.
During the second visit, the group continued the mental status exam.
The client cooperates with the group by answering questions being asked
from her although she speaks in a low tone. The group was able to get
some information regarding the client’s condition. Her mother is also very
approachable and friendly to us and never hesitates to answer all our
questions about her son.
IV. PSYCHODYNAMICS
a. Tabular presentation of Predisposing Factors.
FACTORS PRESENT RATIONALE
A. GENETICS There were no traces of
mental illness on the
patient’s maternal side.
On the paternal side
however, it is unknown
due to separation of
patient’s parents and the
patient’s mother does not
have knowledge on
whether or not the
patient’s father has any
family history of being
mentally challenged.
Videbeck (2001) stated
stated that several theories
and studies seem to indicate
that several disorders may
be limited to a specific gene
or a combination of both
genes. According to Colleen
Sullivan, suite 101.com;
close relatives of individual
who have disorders are at
high risk. If you have a
parent, sibling, or a child with
a disorder, there is a 7-10%
chance that you may develop
the same disorder and 8-
10% to develop depression.
B. SEX Patient is an adult male. Sex determines the
community’s expectation of a
person.
C. AGE The patient exhibited mild
onset of illness during his
early childhood. The
worse part of his
condition was clearly
observed when he was in
his mid-twenties, during
which his mother was not
able to personally care
for him as she worked
abroad and the patient
Age of onset seems to be an
important factor in how well
the client fares. Those who
develop the illness earlier
have worse outcomes than
those who developed it later.
(Buchaman and Carpenter,
2000) According to Hagop S.
Akistol M.D. are higher in
younger age groups
especially in the stage
was left to relatives who
didn’t really looked after
his needs.
because of having role
confusion and identity crisis.
b. Tabular presentation of Precipitating Factors
FACTORS PRESENT RATIONALE
A. ENVIRONMENTAL
FACTORS
Lower
socioeconomic
status
Living in large cities
Stressful events
during childhood
Mother is the
breadwinner and only
income earner in the
family.
Patient’s parents
separated when he was
still young. During his
parent’s marriage, his
parents always quarreled
which led to separation.
When a person is insufficiently
provided with his basic needs,
his chances of getting
Schizophrenia increases.
People living in high-density
urban areas are 50 percent
more likely to develop the
disease than people in rural
areas, and economic factors
such as homelessness,
unemployment and poverty
also contribute to the chances
of having the disease.
Studies show that children
growing up in abusive or
otherwise dysfunctional
families are six times more
likely to develop schizophrenia
than their normal counterparts.
Drug and alcohol
intake
During his mother’s
absence, the patient was
left in the care of relatives
who didn’t really looked
after him and just allowed
him to go anywhere and
anytime he desires. He
abused this liberty by
alcohol intake and drug
abuse.
Prohibited drugs such as
cocaine have effects similar to
the positive symptoms of
schizophrenia. These drugs
can also trigger schizophrenia.
There is an increasing amount
of evidence that cannabis
damages the brain and can
lead to schizophrenia. It is
thought that cannabis doubles
a person's risk of
schizophrenia. Alcohol is the
substance most often abused
by people with schizophrenia.
While alcohol can cause a
relapse of symptoms, there is
no evidence to suggest that
alcohol use causes
schizophrenia.
B. LIFESTYLE
C.
Skipping of Meals The patient started to
skip meals when his
mother went to work
abroad. Because he had
the freedom to do
anything he wanted, he
spent his time loitering
around the city and
getting drunk.
According to Stuart and
Sundeem (1995). Poverty and
society could abuse
Schizophrenic or some
individuals choose to be
Schizophrenic to cope the
insanity of mother world.
V. Laboratory Exam and results of Psychological Test
Our client has not undergone laboratory exam and psychological testing.
VI. Diagnosis
Schizophrenia, Undifferentiated Type
VII. MULTI-AXIAL DIAGNOSIS
AXIS I SCHIZOPHRENIA, UNDFFERENTIATED TYPE
Schizophrenia is characterized with the following1. anger2. disorganized speech3. inability to take care of personal needs4. incoherence5. hallucinations
Our client Mr. RR manifested negative symptoms which is inability to take care of personal needs and auditory hallucination, which is also a manifestation of undifferentiated schizophrenia.
AXIS II BORDERLINE PERSONALITY DISORDER
A persistent pattern of instability in interpersonal relationship and affects.
1. Frantic effort to avoid real or imaged abandonment. (“di sya ganahan nga pasagdan ra sya, kay katong naa pa ko dubai, gnapasagdan ra man sya iya mga uncle ug ante, murag wala ra sila pakialam sa iya” as verbalized by the mother.)
2. Impulsivity in or at least two areas that are self damaging such as cigarette smoking and substance abuse.
3. Affective instability due to marked reactivity (easily got mad and hitting others with anything he gets to)
4. Inappropriate, intense anger or difficulty controlling anger (“gawild gapamunal ug kahoy”as verbalized by the mother)
5. transient, stress-related paranoid ideation or severe dissociative symptoms (“ feeling niya gainterviewhon siya sa tanang tao pag mangutana sa iya” as verbalized by the mother)
AXIS III FOR GENERAL MEDICAL CONDITIONS
NONE
AXIS IV PROBLEM RELATED TO SOCIAL ENVIRONMENT
RVR has difficulty making friends due to his condition since birth
AXIS V GLOBAL ASSESSMENT OF FUNCTIONING
The GAF scaling of RVR. is 51-60
Moderate symptoms RVR has inability to take care of personal needs
Moderate difficulty in social functioningRVR has only few friends
Substance induce psychotic disorder
A. prominent hallucination or delusion. Note: Do not include hallucination if the persons has insight that they are substance induced.
B. there is evidence from the history, physical examination or laboratory findings of :
the symptoms in criterion a developed during or within a month of substance Intoxication or withdrawal
medication is etiologically related to disturbance
C. The disturbance is not better accounted for by a psychotic disorder that is not substance induce. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induce might include the following:
The precede the onset of the of the substance use ( medication use)
The symptoms persist for substantial period of time (about a month)After the cessation of acute withdrawal or severe intoxication, or are substantial in excess of what would be expected to be given the type or amount of the
substance used or duration of use: or there is other evidence that suggest the existence of independent non-substance-induce Psychotic disorder
D. the disturbance does not occur exclusively during the course of delirium
Note:this diagnosis should be made instead of diagnosis of substance Intoxication or substance withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficient severe to warrant independent clinical attention.
VIII. NURSING MANAGEMENT
A. IDEAL NURSING MANAGEMENT
1.) Disturbed thought processes related to physiologic changes due to substance abuse
INTERVENTION: RATIONALE
►Be sincere and honest when communicating with the client. Avoid vague or evasive remarks.
Delusional client are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.
►Do not make promises that you cannot keep.
Broken promises reinforce client’s mistrust to others.
►Encourage client to talk with you but do not pry for information.
Probing increases the client suspicion and interferes with the therapeutic relationship.
►Recognize the client delusion as the client’s perception of the environment.
Recognizing the client perceptions can help you understand the feelings she’s experiencing.
►Initially, do not argue with the client or try to convince the client that delusions are false or unreal.
Logical argument does not dispel delusional ideas and can interfere with the development of trust.
►Interact with the client on the basis of real things; Do not dwell on the delusional materials.
Interacting about reality is healthy for the client.
2.) Ineffective Family Coping related to exhausted supportive capability of family members
INTERVENTION: RATIONALE
Assess family history; explore roles of family members, circumstances involving drug use, strengths, and areas for growth.
Determines areas for focus, potential for change.
Explore hoe the significant others has coped with the
Co-dependent also suffers from the same feelings as the patient (e.g
addict’s habit, e.g denial, repression, rationalization, hurt, loneliness, projection
anxiety, self-hatred, helplessness, low self-worth, and guilt) and needs help in learning new effective coping skills.
Determine understanding of current situation and previous method of coping with life’s problems
Provides information on which to base present plan of care
Assess current level of functioning of family members
Affects individual’s ability to cope with the situation
Determine extent of “Enabling” behaviours being evidenced by family members, explore with patient
“Enabling” is doing for the patient what he needs to do for self. People want to be helpful and do not want to feel powerless to help their loved one to stop drinking and change to behaviour that is so destructive. However, the substance abuser relies on others to cover up own inability to cope with daily responsibilities.
Provide information about enabling behavior, addictive disease characteristics for both user and non-user co-dependent
Awareness and knowledge provide opportunity for individuals to begin the progress of change.
Provide factual information to the patient and family about the effects of addictive behavior on the family and what to expect after discharge.
Many patients/ significant others are not aware of the nature of the addiction. If the patient is using legally obtained drugs, may believe this does not constitute abuse.
Encourage significant others to be aware of their own feelings, look at the situation with perspective and objectivity. They can ask themselves. “am I being conned?” am I acting out of fear, shame, guilt or anger? Do I have a need to control?”
For self awareness of the significant others, to be able for them to handle situations involving the patient.
3.) Sleep pattern disturbances related to psychological stress
INTERVENTION:
Consult psychiatrist in arranging medication regimen
- to maximize night time and minimize day time sedation
Give sleep medication as - Provide rest.
needed. Teach relaxation technique
Encourage day time activity and discourage day time naps.
- This will exhaust the patient during the day time which will give them the opportunity to rest well at night.
Determine normal sleep habit and changes that are occurring
-assesses need for and identifies appropriate interventions
Obtain comfortable bedding, provide some of own possessions ex. Pillow
-increases comfort for sleep as well as physiologic/ psychologic support
Establish sleep routine suitable to old pattern and new environment
-when new routine contains as many aspects of old habits as possible, stress and related anxiety maybe reduced.
Encourage some light physical activity during the day, make sure patient stops activity several hours before bedtime
-daytime activity can help patient expend energy and be ready for night time sleep. However, continuation of activity close to bedtime may act as a stimulant, delaying sleep
Provide warm bath and massage, warm milk, wine or brandy at bedtime
-promotes a relaxing soothing effect. Note; milk has no prolific qualities, enhancing synthesis, and neurotransmitter that helps patient fall asleep faster and sleep longer.
B. ACTUAL NURSING MANAGEMENT
S
“Oo gamata-mata ko pag tungang gabii kay naa koy makit-an na tigulang ug bata” as verbalized by the client.
O
Weak & Drowsy Inattentive, irritable Midnight awakening Less than 8 hours of sleep
ASleep Pattern Disturbance related to psychological stress as evidenced
by visual hallucination
P
Short term: At the end of 1 hour, the client will be able to express the feeling of being well rested.
Long term: At the end of 4 days, the client will specify the number of hours of sleep without interruption.
I
Independent:
1) Discouraged naps during the day
2) Instructed to restrict intake of caffeine (eg. coffee, tea, cocoa, cola drinks)
3) Encouraged to engag in physical activities/exercise during morning and afternoon. Instructed to restrict activity in the evening prior to bedtime
4) Allowed the client to identify the circumstances that interrupted her sleep and frequency
5) Evaluated level of stress/orientation as day progresses.
Rationale
Not to alter the sleep pattern at night
May stimulate CNS, interfering with relaxation and ability to sleep
Enhances sense of fatigue and promotes sleep/rest, evening activity may actually stimulate client and interfere with/delay sleep
To evaluate sleep pattern and dysfunctions
Increasing confusion, disorientation, and uncooperative behaviors may interfere with restful sleep pattern
EAt the end of 4 days, the client was able to establish adequate normal sleeping pattern.
S
“Gi- kapoy na gyud ko og ayo. Kadugayan naluoy na cguro siya sa ako, kadugayan miingon siya nga-higti nlng ko ma para di ka kapoyan.” As verbalized by the mother.
O Financial instability
AIneffective Family coping related to exhausted supportive capability of
family members
P
Short term: At the end of 1 hour, the client’s family will be able to identify resources within themselves deal with the situation.
Long term: at the end of 4 days, the client’s family will be able to visit regularly and participate positively in care of the client, within limits of abilities.
IIndependent:
1) Had established rapport and acknowledged difficulty of the situation for the family.
2) Determined current knowledge of the situation.
3) Discussed underlying reasons for the client’s behavior with the family during visit.
4) Encouraged the family members / SO to provide support through visitations.
Dependent 1) Refer to appropriate
resources for assistance as indicated (e.g., counselling, spiritual support)
Rationale May assist family to accept
what is happening and be willing to share problems with caregivers.
Lack of information or unrealistic perceptions can interfere with family members/ client’s response to illness.
When family members know why client is behaving in different ways, it helps them understand and accept/ deal with situation.
It provides the family opportunity to talk with the client, thus, reducing the anxiety and allows expression, as well as opportunity to make future plans and share support.
May need additional assistance in resolving family issues.
EAt the end of 4 days, the family expresses more realistic understanding and expectations of the client
S“Maligo raman siya kung ganahan pero ang gasabonan ra kay ulo ug
abaga. Pero ako jud magligo niya.” As verbalized by the mother.
O
Inability to keep body clean
Inability to dress appropriately
Poorly combed hair
A
Self-care deficit related to perceptual and cognitive impairment as
evidenced by difficulty keeping body clean and dressing
appropriately.
P
Short term: At the end 30 minutes, the client will be able to
demonstrate proper hygiene.
Long term: At the end of 4 days, the client will be able to perform self-
care and ADL’s at highest level of adaptive functioning possible.
I
1. Identified
presence/severity of
factors that affect
client’s capacity for self-
care.
2. Discussed personal
appearance/grooming
and encouraged
dressing in bright
colors, attractive
clothes. Gave positive
1. Impairment in these
areas can alter client’s
ability/readiness for
self-care.
2. Appearance affects
how the client sees
self. A rundown,
disheveled
appearance conveys a
sense of low self-
worth, whereas an
feedback for efforts.
3. Assisted client with care
of fingernails and
toenails as required.
4. Encouraged client to
perform minimal oral-
facial hygiene after
rising as possible.
5. Encouraged client to
comb own hair,
suggested hair styles
that are low
maintenance.
attractive, well-put-
together appearance
conveys a positive
sense of self to the
client as well as to
others.
3. To promote sense of
well-being
4. To promote sense of
well-being
5. This enables the
client to maintain
autonomy for as long as
possible.
E
The goal was partially met since the client was able to perform self-
care and ADL’s at level of adaptive functioning possible.
IX. Medical Management
Drug Study
Brand Name: LargactilGeneric Name of Ordered Drug: Chlorpromazine HydrochlorideClassification: AntipsychoticDate Ordered: April 2, 2007Dose/ Frequency/ Route : 100mg/tab/PO/ODMechanism of Action: Blocks the post synaptic dopamine receptors in the brain.Specific Indication: To prevent occurrence of psychosis, mania.Contraindications: Hypersensitivity to drugs in those with CNS depression, bone marrow suppression or subcortical damage.Side effects/ Toxic Effects:
CNS: Seizures, Nueroleptic Malignant Syndrome G.I: Dry Mouth, Constipation HEMATOLOGIC: Aplastic Anemia
Nursing Precaution:
Largactil can pass into the breast milk and cause drowsiness and unusual muscle movements in the baby. Therefore, it is not recommended for nursing mothers.
This medicine should not be given to patients diagnosed with Parkinson’s disease, narrowangle glaucoma, cardiovascular disease and epilepsy.
It should not be used concomitantly with other drugs that can cause sedation.
Largactil should not be taken if you are hypersensitive to it.
IX. PROGNOSIS
CRITERIA GOOD PROGNOSIS POOR PROGNOSIS
a. ONSET OF ILLNESS X
b. DURATION OF
ILLNESSX
c. PRECIPITATING
FACTORSX
d. MOOD and AFFECT X
e. ATTITUDE AND
WILLINGNESS TO TAKE
MEDICATION AND
X
TREATMENT
f. ANY DEPRESSED
FEATURESX
g. FAMILY SUPPORT X
On the criteria listed above, six out of seven criteria shows that our client
represents a poor prognosis. His onset of illness is early that is when he is 20
years old. The duration is persistent / recurring whenever client can’t take his
medication or triggered by other depressant factors such as family problems, and
lack of financial support. There are some precipitating factors identified that
contributes to his condition such as poor guidance and family support. His mood
is inappropriate with flat affect evidenced by absence of facial expression that
would indicate emotions. He religiously takes his medications and participates in
minimal therapeutic conversations.
RECOMMENDATION
The group recommends that the client should stay inside their home and
family should provide emotional support and guidance to alleviate client’s
misconceptions regarding his environment, this would provide a therapeutic
outcome to possibly lessen the stressor that would trigger client’s condition.
Support from family members in addition is a huge factor that will encourage
client to take his medications and to provide security to the client. Peer group can
also help client feel as part of the community and as a functioning individual.
Lastly, providing small tasks to the client to divert client’s attention to any factors
that may trigger his condition.
XI. Bibliography
Videbeck Sheila L., Psychiatric Mental Health Nursing 2nd Edition,
Lippincott Williams and Wilkins, 2001, pp 297 – 301
Deglin, Judith H. Davis Drug Guide for nurses, 9 th Edition, 2005 by F.A
Davis company, Philadelphia
Doesnges, Marilyn E., Nursing Care Plan, Guidelines for individualizing
Patient Care, 6th edition, 2002 by F.A Davis Company Philadelphia
F.A Davis, Taber’s Encclopedia Medical Dictionary, 20th Edition, 2005 by
Lippincott Williams and Wilkins, Philadephia.
Keltner et. Al, Psychiatric Nursing 3dr edition 1999.
Nursing Drug Handbook. 27th edition 2007
Sparks, Sheila M, Nursing Diagnosis Reference manual, 5th edition, 2001
by Springhouse Corporation, Pennsylvannia.
The Lippincott Manual of Nursing practice. 7th Edition. Vol.2