Schizophrenia Undifferentiated

INTRODUCTION: Schizophrenia

Schizophrenia is a clinical syndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long lasting. The disorder usually begins before age 25, persists throughout life, and affects persons of all social classes. Although schizophrenia is discussed as if it is a single disease, it probably comprises a group of

disorders with heterogeneous etiologies, and it includes patients whose clinical presentations, treatment response, and courses of illness vary. There is no laboratory test for schizophrenia.

HISTORY Eugene Bleuler Bleuler coined the term schizophrenia. He chose the term to express the presence of schisms between thought, emotion, and behavior in patients with the disorder. Bleuler stressed that, unlike Kraepelin's concept of dementia precox, schizophrenia need not have a deteriorating course. This term is often misconstrued, especially by lay people, to mean split personality. Split personality, called dissociative identity disorder, in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) differs completely from schizophrenia. The Four As Bleuler identified specific fundamental (or primary) symptoms of schizophrenia to develop his theory about the internal mental schisms of patients. These symptoms included associational disturbances of thought, especially looseness, affective disturbances, autism, and ambivalence, summarized as the four As: associations, affect, autism, and ambivalence. Bleuler also identified accessory (secondary) symptoms, which included those symptoms that Kraepelin saw as major indicators of dementia precox: hallucinations and delusions.

SYMPTOMS The symptoms of schizophrenia are divided into two major categories: positive or hard symptoms/signs and negative or soft symptoms/signs.

Positive Hard Symptoms Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation Associative looseness: Fragmented or poorly related thoughts and ideas Delusions: Fixed false beliefs that have no basis in reality Echopraxia: Imitation of the movements and gestures of another person whom the client is observing Flight of ideas: Continuous flow of

Negative or Soft Symptoms Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feelings of indifference toward

people, activities, and events Blunted affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

verbalization in which the person jumps rapidly from one topic to another Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality Ideas of reference: False impressions that external events have special meaning for the person Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

TYPES The following are the types of schizophrenia according to the DSM-IV-TR (APA, 2000). The diagnosis is made according to the clients predominant symptoms: Schizophrenia, paranoid type: characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior. Schizophrenia, disorganized type: characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type: characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless and is not influenced by external stimuli. Other features include extreme negativism, mutism, peculiarities of voluntary movement, echolalia, and echopraxia. Schizophrenia, undifferentiated type: characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior Schizophrenia, residual type: characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations.

ETIOLOGY 1. Physiological a. Genetics. Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population. Whereas the lifetime risk for developing schizophrenia is about 1 percent in most population studies, the siblings or offspring of an identified client have a 5 to 10 percent risk of developing schizophrenia (Ho, Black, & Andreasen, 2003). Twin and adoption studies add additional evidence for the genetic basis of schizophrenia. b. Histological Changes. Jonsson and associates (1997) have suggested that schizophrenic disorders may in fact be a birth defect, occurring in the hippocampus region of the brain, and related to an influenza virus encountered by the mother during the second trimester of pregnancy. The studies have shown a disordering of the pyramidal cells in the brains of schizophrenics, but the cells in the brains of nonschizophrenic individuals appeared to be arranged in an orderly fashion. Further research is required to determine the possible link between this birth defect and the development of schizophrenia. c. The Dopamine Hypothesis. This theory suggests that schizophrenia (or schizophrenia-like symptoms) may be caused by an excess of dopamine-dependent neuronal activity in the brain. This excess activity may be related to increased production or release of the substance at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms (Sadock & Sadock, 2003). d. Anatomical Abnormalities. With the use of neuroimaging technologies, structural brain abnormalities have been observed in individuals with schizophrenia. Ventricular enlargement is the most consistent finding; however, sulci enlargement and cerebellar atrophy are also reported.

2. Environmental a. Sociocultural Factors. Many studies have been conducted that have attempted to link schizophrenia to social class. Indeed epidemiological statistics have shown that greater numbers of individuals from the lower socioeconomic classes experience symptoms

associated with schizophrenia than do those from the higher socioeconomic groups (Ho, Black & Andreasen, 2003). This may occur as a result of the conditions associated with living in poverty, such as congested housing accommodations, inadequate nutrition, absence of prenatal care, few resources for dealing with stressful situations, and feelings of hopelessness for changing ones lifestyle of poverty. An alternative view is that of the downward drift hypothesis (Sadock & Sadock, 2003). This hypothesis relates the schizophrenics move into, or failure to move out of, the low socioeconomic group to the tendency for social isolation and the segregation of self from others characteristics of the disease process itself. Proponents of this notion view poor social conditions as a consequence rather than a cause of schizophrenia. b. Stressful Life Events. Studies have been conducted in an effort to determine whether psychotic episodes may be precipitated by stressful life events. There is no scientific evidence to indicate that stress causes schizophrenia. It is very probable, however, that stress may contribute to the severity and course of the illness. It is known that extreme stress can precipitate psychotic episodes (Goff, 2002). Stress may indeed precipitate symptoms in an individual who possesses a genetic vulnerability to schizophrenia. Sadock and Sadock (2003) state: The stress can be biological, environmental, or both. The environmental component can be either biological (e.g., an infection) or psychological (e.g., a stressful family situation) (p. 477). Stressful life events may be associated with exacerbation of schizophrenic symptoms and increased rates of relapse.

EPIDEMIOLOGY In the United States, the lifetime prevalence of schizophrenia is about 1 percent, which means that about 1 person in 100 will develop schizophrenia during their lifetime. The Epidemiologic Catchment Area study sponsored by the National Institute of Mental Health reported a lifetime prevalence of 0.6 to 1.9 percent. According to DSM-IV-TR, the annual incidence of schizophrenia ranges from 0.5 to 5.0 per 10,000, with some geographic variation (e.g., the incidence is higher for persons born in urban areas of industrialized nations). Schizophrenia is found in all societies and geographical areas, and incidence and prevalence rates are roughly equal

worldwide. In the United States, about 0.05 percent of the total population is treated for schizophrenia in any single year, and only about half of all patients with schizophrenia obtain treatment, despite the severity of the disorder. In The Philippines, sixty percent (60%) of the case of mental illness is schizophrenia. It is equally prevalent in men and women and paranoid type schizophrenia is the most common form. Onset of the case is between 15-25 years old with few patients aged after 50 years old.

RECENT UPDATES New research identifies the brain chemicals and circuits involved in mental illnesses like schizophrenia, depression, and anxiety, giving potential new directions to their treatment. In addition, research with children shows that early-life depression and anxiety changes the structure of the developing brain. The findings were presented at Neuroscience 2011, the Society for Neuroscience's annual meeting and the world's largest source of emerging news about brain science and health. One in 17 Americans suffer from a serious mental illness, such as schizophrenia, major depression, or bipolar disorder, making it one of the leading causes of disability. Yet science is only beginning to understand the underlying physical causes of these diseases. New findings shows Childhood anxiety and depression alter the way the amygdala connects to other regions of the brain. This finding may help explain how early life stress can lead to future emotional and behavioral issues.

PSYCHIATRIC NURSING HISTORY

A. Preliminary Identifications Name: Gender: Adress: Birthday: Birth Place: Age: Height: Weight: Marital Status: Occupation: Language: Ethnicity: Nationality: Religion: Siblings: Education: Attending Physician: Mr. Schitz Male *toot* *toot* *toot* *toot* 54 Not assessed Single N/A *toot* Cebuano Filipino Roman Catholic *toot* College Undergraduate (1st year level only) *toot*

Diagnosis: Source of Information:

Schizophrenia Undifferentiated Type Patient - 40% Patients Mother - 50% Chart - 10%

Informants:

Name: Mrs. Mommy Age: Relationship: Mother Length of acquaintance: Interviewers impression or Reliability: 95 %

Chief Complaints: *toot* Personal Identification: *toot* History of Present Illness: *toot* History of Past Illness: *toot*

Previous Admission: *toot* Medications: *toot* Family History: *toot* Psychosexual History: *toot*

ANAMNESIS
Psychosocial History Psychosexual History Cognitive Stages of Development Stages Tasks Fixations

Stages
Prenatal and Perinatal

History

Stages

Age

Tasks

Stages

Age

Tasks

*toot*

Infancy and Early Childhood

*toot*

Trust Vs. Mistrust

0-18 mos Infancy)

*toot*

Oral

0 -18 mos.

Establishing trust.

Infancy

*toot*

Primary need for bodily contact and tenderness Prototaxic mode dominates (no relation between experiences) Primary zones are oral and anal. If needs are met, infant has sense of wellbeing; unmet needs lead to dread and anxiety.

- Smokes - Fearful - Mistrusting

Autonom y Vs. Shame and Doubt

18 - 36 mos. (Toodler )

Achieving a sense of control and free will.

Anal

18 - 36 mos.

*toot*

Toilet Training and developing sense of independence and control.

- Stinginess - Rigid thought patterns. - Introvert

*toot*

Middle Childhood

*toot*

Initiative Vs. Guilt

3-6 years (Presch ool)

Beginning development of a conscience; learning to manage conflict and anxiety

Phallic

3-5 years

Establishing sexual identity.

Childhood

*toot*

Parents viewed as source of praise and acceptance Shift to parataxic mode (experiences are connected in sequence to each other) Primary zone is anal. Gratification leads to positive selfesteem. Moderate anxiety leads to uncertainty and insecurity; severe anxiety results in selfdefeating patterns of behavior.

Insecurity

*toot*

Industry Vs. Inferiorit y

6 - 12 years (School Age)

Emerging confidence in own abilities; taking pleasure in accomplishmen ts

Latency

511 or 13 years

Group identification

Juvenile

*toot*.

*toot*

Shift to the sytaxic mode begins (thinking about self and others based on analysis of experiences in a variety of situations). Opportunities for approval and acceptance of others. Learn to negotiate own needs Severe anxiety

- Inferiority - Poor social skills.

Preadolesc ence

may result in a need to control or restrictive, prejudicial attitudes. Move to genuine intimacy with friend of the same sex Move away from family as source of satisfaction in relationships Major shift to syntaxic mode Capacity for attachment, love, and collaboration emerges or fails to develop.

Adolescen ce

*toot*
.

Identity Vs. Role Confusio n

12 - 18 years (Adoles cent)

Formulating a sense of self and belonging

Genital

11 or 15 - adult

Developing social control over instincts.

Adolescen ce

Lust is added to interpersonal equation. Need for special sharing relationship shifts to the opposite sex. New opportunities for social experimentatio n lead to the consolidation of self-esteem or self-ridicule. If the selfsystem is intact, areas of concern expand to

- Financially dependent - Low selfesteem

*toot*

*toot*

include values, ideals, career decisions, and social concerns. Young Adulthood

*toot*

Intimacy Vs. Isolation

18 25/30 years (Young Adult)

Forming adult, loving relationships and meaningful attachments to others.

- Persistent isolation and aloneness - Jealousy

*toot*

GENOGRAM

LEGEND:

- Female

- Deceased - Patient - Smoker

- Gastritis - PTB - Diarrhea and

- Male - Separated Dehydration - Close relationship

- Schizophrenia Undifferentiated

- Kidney Disease

MINI MENTAL STATUS EXAMINATION

Name of Patient:

Date:

DSM IV TR Diagnosis/Impression: Schizophrenia Undifferentiated Age: Gender: Civil Status:

Maximum Score 3 1 3 3 3 2 2 2 3 4 5 31 Actual Score 3 1 3 3 3 2 2 2 3 4 5 31 Normal .

Attending Physician:
Evaluation Activity

Area of Mental Function Evaluated Orientation to time Orientation to Place Attention and Immediate Recall Abstract Thinking Recent Memory Naming Objects Ability to follow simple verbal commands Ability to follow simple written commands Ability to use language correctly Ability to Concentrate Understanding spatial relationships TOTAL SCORE

Assessed by:

Date: Time:

Name of Patient: DSM IV TR Diagnosis/Impression: Age: Gender: Civil Status:

Maximum Score 3 1 3 Actual Score 3 1 3

Date:

Attending Physician:
Evaluation Activity

Area of Mental Function Evaluated Orientation to time Orientation to Place Attention and Immediate Recall Abstract Thinking Recent Memory Naming Objects Ability to follow simple verbal commands Ability to follow simple written commands Ability to use language correctly Ability to Concentrate Understanding spatial relationships TOTAL SCORE

3 3 2 2

3 3 2 2

4 5

4 5

COMPREHENSIVE MENTAL STATUS EXAMINATION

WEEK 1 General Appearance Patient wearing white t-shirt and blue short pants with black slippers, well groomed, nails trimmed and clean, combed hair and brushed his teeth daily, take a bath everyday, seems happy while interacting with other patients near the entrance. WEEK 2 Patient wearing dark blue tshirt and dirty red short pants with black slippers, well groomed, nails trimmed and clean, combed hair and brushed his teeth daily, take a bath every day, sometimes look depressed and sometimes happy, cooperate with his student nurse and interact with other people, take his medications and eat his breakfast, lunch and dinner. PROBLEM IDENTIFIED Social Isolation Self-care Deficit EVALUATION General appearance was assessed objectively.

General Mobility

Patient has a normal gait and posture, can walk and stand normally. Patient is normoactive, friendly, cooperative and warm. Patient has spontaneous character; organization of talk is relevant and has good accessibility.

Patient has a normal gait and posture, can walk and stand normally. Patient is normoactive, friendly, cooperative and warm. Patient has spontaneous character; organization of talk is relevant and has good accessibility.

No problem identified

General mobility was assessed objectively.

Speech Pattern

No problem identified

Speech pattern was assessed objectively.

Emotional State and Reaction

Patient has euthymic mood and Patient has euthymic mood and No problem identified appropriate flat affect with a rate appropriate flat affect with a rate of mood 8/10. Patient looks of mood 8/10. Patient looks friendly because he always friendly because he always smile, looks happy, cooperative, smile, looks happy, cooperative, obeys instructions, interacts withobeys instructions, interacts with his student nurse, easy to talk his student nurse, easy to talk with, shows interest in doing with, shows interest in doing things, loves to talk with things, loves to talk with someone who looks friendly but someone who looks friendly but he chooses sometimes people he chooses sometimes people

NPI was the key tool used to assessed patients emotional state, it was assessed subjectively.

he would like to talk with and to he would like to talk with and to be with. be with.

Thought Content

Patient likes to talk about assembling his motor vehicle and the most important thing for him is his motor and his mother. He viewed himself as a shy person, and dont want to be in a crowded and noisy place, he wanted to live in a peaceful place. He has a delusion type of erotomania in which he thinks that someone is inlove with him. He never attempt commit suicide or homicide. He didnt have preoccupation but at times he ruminates and regrets the things that he had done, like when he broke his components and when he kicked his mother. Patient is paranoid coz he didnt easily trust people like her mother and other student nurse. He chooses those persons hed like to interact with. In terms of perceptual disturbances, patient has negative hallucinations, depersonalization or derealizations nor illusions. Patient has a normal sleep, with good appetite and diurnal variation, weight and libido not assessed. Patient is well oriented to time, person and place. He is always alert, can calculate numbers, can count and can solve some mathematical

Patient likes to talk about assembling his motor vehicle and the most important thing for him is his motor and his mother. He viewed himself as a shy person, and dont want to be in a crowded and noisy place, he wanted to live in a peaceful place. He has a delusion type of erotomania in which he thinks that someone is inlove with him. He never attempt commit suicide or homicide. He didnt have preoccupation but at times he ruminates and regrets the things that he had done, like when he broke his components and when he kicked his mother. Patient is paranoid coz he didnt easily trust people like her mother and other student nurse. He chooses those persons hed like to interact with. In terms of perceptual disturbances, patient has negative hallucinations, depersonalization or derealizations nor illusions. Patient has a normal sleep, with good appetite and diurnal variation, weight and libido not assessed. Patient is well oriented to time, person and place. He is always alert, can calculate numbers, can count and can solve some mathematical

No problem identified

Nurse patient interaction:

Neurovegetative Functions

No problem identified

General Sensorium and Intellectual Status

No problem identified

Nurse patient interaction:

question/abstract, can understands what student nurse wants him to answer and he can response slowly but surely correct, can interpret the information given to him but it takes a time before he can finalize his answers, sometimes he is able to deal with concepts; he can identify things which is not belong to the group and can give meanings when you ask him to say something about certain things, has the ability to understand certain facts and draw conclusions from relationships, can recall immediate, recent and remote memory, has an insight and his ego defense mechanism: acting out.

question/abstract, can understands what student nurse wants him to answer and he can response slowly but surely correct, can interpret the information given to him but it takes a time before he can finalize his answers, sometimes he is able to deal with concepts; he can identify things which is not belong to the group and can give meanings when you ask him to say something about certain things, has the ability to understand certain facts and draw conclusions from relationships, can recall immediate, recent and remote memory, has an insight and his ego defense mechanism: denial.

PEROS
Subjective General Health Survey .

WEEK 1 Objective Problem Identified Objective

WEEK 2 Problem Identified

No Problem Identified

Self- Care Deficit

Integumentary System

Self- Care Deficit

Self- Care Deficit

HEENT a. Head and Face

No problem identified

No Problem identified

b. Eyes No problem identified No problem identified

c. Ears

No problem identified

No problem identified

d. Nose

No problem identified

No problem identified

e. Oral Cavity No problem identified No problem identified

Neck No problem identified No problem identified

Respiratory System

No problem identified

No problem identified

Cardiovascular System Breast and Axilla

No Problem Identified.

No problem identified

Gastointestinal System/ Abdomen

No Problem Identified.

No problem identified

Genitourinary System Musculoskeletal System Neurologic System .

No problem identified

No problem identified

No problem identified

No problem identified

No problem identified

No problem identified

No problem identified Lymphatic / Hematologic System No problem identified Endocrine System No problem identified

No problem identified

No problem identified

No problem identified

Spiritual Assessment *toot* Cultural Assessment *toot*

DIAGNOSTIC TEST
Complete Blood Count Examination White blood cell Hemoglobin Hematocrit MCV(Mean corpuscular volume) MCH(mean corpuscular hemoglobin) Red blood count MCHC RDW MPV Platelet count Results 6.6 133 0.40 95.0 Normal Values 4.8-10.8 140-180 0.42-0.52 80-94 Interpretations Date: Significance results

31.6

27-31

4.2 332 12.4 7.3 335

4.7-6.1 330-370 11-16 7.2-11.1 150-400

DIFFERENTIAL COUNT Examination Neutrophils Lymphocytes Monocytes Eosinophils Basophils Stab Atypical Lymphocytes Metamyelocytes Myelocytes Blast Results 65.3 24.3 6.5 3.7 0.2 0 0 0 0 0 Normal Values 40-75 19-48 3-9 0-7 0-2 Interpretations Significance results

CHEMISTRY Creatinine SGPT SGOT 1.22 28.2 22.1 0.9-1.3 0.0-41.0 0.0-35.0 Normal Normal Normal

PSYCHODYNAMICS

CONCEPT MAP: Schizophrenia Undifferentiated

Head Trauma

Intrauterine Influences: STRESS

Poverty

Stressful Life Situation: Separation of Parents

Brain physiology alteration

Distubance in brain development Failure of coping mechanisms: Acting Out Denial

LEGEND:
Predisposing Factors Pathogenesis Medications Nursing Diagnoses Precipitating Factors Signs & Symptoms

Decreased brain volume

Continued disequilibrium
Diagnostic Tool

Functional Deficit

Temporal Deficit Biperiden 2mg/tab, 1 tab per day Positive Symptoms

Frontal Deficit

Detachment to reality

Ineffective coping r/t inabitlity to trust/ low self-esteem/ inadequate support systems/ possible hereditary factors.

Risperidone 2mg, 1 tab BID Labile Mood

Negative Symptoms

Schizophrenia Undifferentiated

Disturbed thought process r/t delusional thinking /possible hereditary factors

Delusions: Erotomania Paranoia Risk for self-directed or otherdirected violence r/t false fixed beliefs, lack of trust and history of violence. interactions with others

Anhedonia

DSM-IV-TR

Social Isolation r/t lack of trust/delusional thinking/past experiences of difficulty in interactions with others

Self-care deficit r/t withdrawal into the self

Symptoms: Delusions + Anhedonia Social/occupational dysfunction Duration: signs of the disturbance persist for at least six months

LIFE CHART

1983 1997-1999

Nov. 24, 1984

December 1989

1996

1997-1999

*toot*

*toot*

*toot*

*toot*

*toot*

*toot* *toot*

*toot*

*toot* *toot*

2000

2002

2006

2008-2009

2010

*toot*

*toot*

*toot*

*toot*

*toot*

*toot* *toot*

*toot* *toot*

*toot*

Aug.-Sept. 2011

Oct 2011

Oct 27, 2011

Nov. 24, 2011

Dec. 10, 2011

*toot*

*toot*

*toot*

*toot*

*toot*

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met: 1. Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment). Delusions Hallucinations Disorganized speech, which is a manifestation of formal thought disorder Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior Negative symptoms - affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation) If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication. 2. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. 3. Duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). Subtypes 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)

Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1) 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) 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)

Residual type: Where positive symptoms are present at a low intensity only. (DSM code 295.6/ICD code F20.5)

PSYCHIATRIC-MENTAL HEALTH NURSING CARE PLAN

Name of patient: Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Implementation Date:

Shift: Ward: References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 309

Nursing Diagnosis: Social Isolation r/t lack of trust/delusional thinking/past experiences of difficulty in interactions with others Cause Analysis: Clients with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase of the illness. A common characteristic of schizophrenic delusions is the direct, immediate, and total certainty with which the client holds these beliefs. Because the client believes the delusion, he or she will therefore act accordingly. For example, the client with delusions of persecution will probably be suspicious, mistrustful, and guarded about disclosing personal information; he or she may examine the room periodically or speak in hushed, secretive tones. Cues Subjective: Objective: -Preoccupation with own thoughts (thoughts of assembling his own bicycle) - Lack of trust: paranoid (poor eye to eye contact, answered questions with hesitations.) Nursing Outcomes STO: Within 4 hours of nurseclient interactions, the client will willingly attend therapy activities accompanied. Intervention Nurse Patients Relationship: - Convey an accepting attitude by making brief, frequent contacts. - An accepting attitude increases feelings of self-worth and facilitates trust. - This conveys your belief in the client as a worthwhile human being. - The presence of a trusted individual provides emotional security for the client. Honesty and dependability promote a trusting relationship. - Honesty and dependability promote a trusting relationship. - A suspicious client may perceive touch as a threatening gesture. Rationale STOE:

Evaluation

Short term goals were met. After 4 hours of nurse-client interactions, the client demonstrated willingness and desire to socialize with others. LTOE: Long term goals were met. After 4 days of nurse-client interactions, the client voluntarily attended group activities; and approached others in appropriate manner for one-to-one interaction.

- Show unconditional positive regard.

LTO: Within 4 days of nurseclient interactions, the client will voluntarily spend time with other clients, student nurses and staff members in group activities.

- Be with the client to offer support during group activities that may be frightening or difficult for him or her.

- Be honest and keep all promises.

- Be cautious with touch. Allow client extra space and an avenue for exit if he or she becomes too anxious. - Orient client to time, person, and place, as necessary.

- Give recognition and positive re inforcement for clients voluntary interactions with others. - Discuss with client the signs of increasing anxiety and techniques to interrupt the responses (e.g., relaxation exercises, thought stopping). Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.
th

- Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors. - Maladaptive behaviors such as withdrawal and suspiciousness are manifested during times of increased anxiety.

- Antipsychotic medications help to reduce psychotic symptoms in some individuals, thereby facilitating interactions with others.

- To prevent occurrence of new problems

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 103-105

Name of patient: Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Implementation Date:

Shift: Ward: References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 313

Nursing Diagnosis: Risk for self-directed or other-directed violence r/t false fixed beliefs, lack of trust and history of violence. Cause Analysis: Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The client may be paranoid and suspicious of the nurse and the environment and may feel threatened and intimidated. Although the clients behavior may be threatening to the nurse, the client also is feeling unsafe & may believe his or her well-being to be in jeopardy. Cues Subjective: Objective: - Lack of trust: paranoid (poor eye to eye contact, answered questions with hesitations.) - Delusions of Erotomania Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will recognize signs of increasing anxiety and agitation and report to staff for assistance with intervention. Intervention Nurse Patients Relationship: - Maintain and convey a calm attitude toward client. - Observe clients behavior frequently (every 15 minutes). Do this while carrying out routine activities. - Anxiety is contagious and can be transmitted from staff to client. - So as to avoid creating suspiciousness in the individual. Close observation is necessary so that intervention can occur if required to ensure client (and others) safety. - Physical exercise is a safe and effective way of relieving pent-up tension. Rationale STOE:

Evaluation

Short term goals were met. After 4 hours of nurse-client interactions, was able to recognize signs of increasing anxiety and agitation and verbalized to report to staff for assistance with intervention. LTOE: Long term goals were met. After 3 days of nurse-client interactions, the client caused no harm to self or others. He also demonstrated trust of others in his environment.

LTO: Within 3 days of nurseclient interactions, the client will not harm self or others.

- Try to redirect the violent behavior with physical outlets for the clients anxiety.

Milieu Management: - Maintain low level of stimuli in clients environment (low lighting, few people, simple decor, low noise level). - Remove all dangerous objects from clients environment - Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive individuals as threatening. - So that in his or her agitated, confused state client may not use them to harm self or others. - This shows the client evidence of control over the situation and provides some physical security for

- Have sufficient staff available to indicate a show of strength to client if

it becomes necessary.

staff. - The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client.

Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.
th

- To prevent occurrence of new problems.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 102-103

Name of patient: Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Implementation Date:

Shift: Ward: References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 318

Nursing Diagnosis: Ineffective coping r/t inabitlity to trust/ low self-esteem/ inadequate support systems/ possible hereditary factors. Cause Analysis: Identifying and managing ones own health needs are primary concerns for everyone, but this is a particular challenge for clients with schizophrenia because their health needs can be complex and their ability to manage them may be impaired. The nurse helps the client to manage his or her illness and health needs as independently as possible. This can be accomplished only through education and ongoing support. Cues Subjective: Objective: - Suspiciousness of others, resulting in: Alteration in societal participation Nursing Outcomes STO: Within 4 hours of nurseclient interactions, the client will develop trust in the SN or at least one staff member. Intervention Nurse Patients Relationship: - Encourage same staff to work with client as much as possible. - In order to promote development of trusting relationship. Rationale

Evaluation STOE: Short term goals were met. After 4 hours of nurse-client interactions, the client was able to eats food from tray and takes medications without evidence of

- Avoid physical contact.

- Suspicious clients may perceive touch as a threatening gesture.

 Inability to meet basic needs Inappropriate use of defense mechanisms

LTO: Within 3 days of nurseclient interactions, the will demonstrate use of more adaptive coping skills as evidenced by appropriateness of interactions and willingness to participate in the therapeutic community. - Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said.

- Suspicious clients often believe others are discussing them, and secretive behaviors reinforce the paranoid feelings.

mistrust. LTOE: Long term goals were met. After 3 days of nurse-client interactions, the client appropriately interacted and cooperated with staff and SN in therapeutic community setting.

-Be honest and keep all promises.

- Honesty and dependability promote a trusting relationship.

- Activities should never include anything competitive.

- Activities that encourage a oneto-one relationship with the nurse or therapist are best. Competitive activities are very threatening to suspicious clients.

- Encourage client to verbalize true feelings. The nurse should avoid becoming defensive when angry feelings are directed at him or her.

- Verbalization of feelings in a non-threatening environment may help client come to terms with long-unresolved issues.

- An assertive, matter-of-fact, yet genuine approach is least threatening and most therapeutic.

- A suspicious person does not have the capacity to relate to an overly friendly, overly cheerful attitude.

Psychoparmacology: - Mouth checks may be necessary following medication administration to verify whether client is swallowing the tablets or capsules.
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-Suspicious clients may believe they are being poisoned with their medication and attempt to discard the pills.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 105-106

Name of patient: Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Implementation Date:

Shift: Ward: References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 319

Nursing Diagnosis: Self-care deficit r/t withdrawal into the self Cause Analysis: Because of apathy or lack of energy over the course of the illness, poor personal hygiene can be a problem for clients who are experiencing psychotic symptoms as well as for all clients with schizophrenia. Cues Subjective: Objective: - Refusal to take a bath - lack of interest in maintaining appearance at a satisfactory level Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will verbalize a desire to perform ADLs. LTO: Within 4 days of nurseclient interactions, the client will be able to perform ADLs in an independent manner and demonstrate a willingness to do so by time of discharge from treatment. Intervention Nurse Patients Relationship: - Encourage client to perform normal ADLs to his or her level of ability. - Encourage independence, but intervene when client is unable to perform. - Offer recognition and positive reinforcement for independent accomplishments. - Show client, on concrete level, how to perform activities with which he or she is having difficulty. - Keep strict records of food and fluid intake. Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.
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Rationale - Successful performance of independent activities enhances self-esteem. - Client comfort and safety are nursing priorities. - Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. - Because concrete thinking prevails, explanations must be provided at the clients concrete level of comprehension. - This information is necessary to acquire an accurate nutritional assessment. - The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client. STOE:

Evaluation

Short term goals were met. After 4 hours of nurse-client interaction, the client was able to take a bath, change clothing and brush teeth. LTOE: Long term goals were met. After 4 days of nurse-client interactions, the client maintained optimal level of personal hygiene by bathing daily and carrying out essential toileting procedures without assistance.

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 111-112

Name of patient: Diagnosis: Schizophrenia, Undifferentiated Type

Admission Date: Implementation Date:

Shift: Ward: References Videbeck, Shiela L. (2004). Psychiatric Mental Health nd Nursing, 2 ed. p. 314 Evaluation STOE: - It is important to communicate to the client that you do not accept the delusion as reality. Short term goals were met. After 4 hours of nurse-client interaction, the verbalized reflect thinking processes oriented in reality. LTOE: Long term goals were met. On the day of the discharge, was able to maintain activities of daily living (ADLs) to his maximal ability and refrained from responding to delusional thoughts.

Nursing Diagnosis: Disturbed thought process r/t delusional thinking /possible hereditary factors Cause Analysis: The client (with schizophrenia) experiencing delusions utterly believes them and cannot be convinced that they are false or untrue. Such delusions powerfully influence the clients behavior. Cues Subjective: Objective:
- Inappropriate non-

Nursing Outcomes STO: Within 4 hours of nurse-client interactions, the client will verbalize that false ideas occur at times of increased anxiety. LTO: By time of discharge from treatment, client will experience (verbalize evidence of) no delusional thoughts and will be able to differentiate between delusional thinking and reality.

Intervention Nurse Patients Relationship: - Convey your acceptance of clients need for the false belief, while letting him or her know that you do not share the belief. - Do not argue or deny the belief. Use reasonable doubt as a therapeutic technique: I find that hard to believe.

Rationale

reality-based thinking - Delusional thinking (false ideas) - Short attention span distractibility

- Arguing with the client or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded. - If the client can learn to interrupt escalating anxiety, delusional thinking may be prevented.

- Help client try to connect the false beliefs to times of increased anxiety. Discuss techniques that could be used to control anxiety (e.g., deep breathing exercises, other relaxation exercises, thought stopping techniques). - Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people.

- Discussions that focus on the false ideas are purposeless and useless, and may even aggravate the psychosis.

- Assist and support client in his or

- Verbalization of feelings in a nonthreatening environment may

her attempt to verbalize feelings of anxiety, fear, or insecurity. Psychoparmacology: - Administer medications as ordered by physician such as: a. Risperidone 2mg/tab, 1 tab BID b. Biperiden 2mg/tab, tab - Monitor medication for its effectiveness and for any adverse side effects.

help client come to terms with long unresolved issues. The avenue of the least restrictive alternative must be selected when planning interventions for a psychiatric client

References: Townsend, Mary C. (2008). Nursing Diagnosis in Psychiatric Nursing, 7 ed. p. 108-109

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PSYCHOTHERAPIES
DEFINITION Music therapy Forms of music therapy generally are based around cognitive/behavioral, humanistic or psychoanalytic frameworks or a mixture of approaches. There are usually both active and receptive parts of the therapy, meaning that at times music is listened to and at other times there is the use of musical improvisation or creation. INDICATION NURSING RESPONSIBILITIES MECHANICS

Is the most frequently used to help the mentally or physical disabled. It can help people to express feelings by making musical sounds and music .

-Stimulate patient to think about something and talk about himself. -Gives him reason to value himself and increase his selfrespect. -music is selected which evoke the clients long term memory processes and stimulates reminiscence.

Use of music as an addition to relaxation therapy in psychotherapy to elicit expression of suppressed emotion by promoting patients to dance, out, laugh or crazy in response.

Dance therapy

A method of psychological treatment in which movement and dance are used to express and deal with feelings and experiences, both positive and negative. Also called movement therapy

is based on the premise that the body and mind are interrelated. Dance therapist believes that mental and emotional problems are often held in the body in the form of muscle tension and constrained movement patterns. Conversely, they believe that the state in the body can affect attitudes and feelings, both positively and negatively.

-Remain calm and state limits on behavior in a firm manner. Be truthful but not judgmental. -provide protection in the environment by constant observation and removal of objects that could harm self/ others.

Promote healing in a number of ways. Moving in a group brings people out of isolation, creates powerful social and emotional bonds. And generates those good feelings that come from being others. Moving rhythmically eases muscle rigidity, diminishes anxiety, and increases energy

Art therapy

Promote healing in a number of ways. Moving in a group brings people out of isolation, creates powerful social and emotional bonds. And generates those good feelings that come from being others. Moving rhythmically eases

Practice is based on knowledge of human developmental and psychological theories which are implemented in the full spectrum of models of assessment and treatment including

-Ensures that appropriate materials and space are available for the client-artist, as well as an adequate amount of time for the session.

As human service profession that uses art media, images, the creative process, and patient/client responses to the created products as reflections of individuals development, abilities, personality, interest, concerns and conflicts.

-provide protection in the

muscle rigidity, diminishes anxiety, and increases energy

educational, psychodynamic, cognitive, transpersonal, and other therapeutic means of reconciling emotional conflicts, foster selfawareness, developing social skills, managing behavior, solving problems , reducing anxiety, and increasing self esteem.

environment by constant observation and removal of objects that could harm self/ others.

Exercise therapy

Prescription of bodily movement to correct impairment, improves musculoskeletal function, or maintains a state of wellbeing.

Improve muscle strength and maintain maximal voluntary contractile force. Improve exercise performance and functional capacity (endurance). Improve circulation and respiratory capacity.

-Accept the client manipulative behaviorism such as anger without reacting an emotional basis. -Remain calm and state limits on behavior in a firm manner. Be truthful but not judgmental. -provide protection in the environment by constant observation and removal of objects that could harm self/ others.

A climate or warm friendliness and acceptance are essential, reading, poetry and current events from bridge to reality, props are used to promote discussion of topics.

PSYCHOPHARMACOLOGY
Indications Generic Name: risperidone Trade Names: Risperdal Classification: Therapeutic: Antipsychotics, mood stabilizers Pharmacologic: Benzisoxazoles Schizophrenia in adults and adolescents age. Antagonizes serotonin2 and dopamine2 receptors in CNS. Also binds to alpha1and alpha2 adrenergic receptors and histamine H1 receptors. Oral: 2mg/tab, 1 tab BID CNS: aggressive behavior, dizziness, drowsiness, extrapyramidal reactions, headache, increased dreams, longer sleep periods, insomnia, sedation, fatigue, nervousness, agitation, anxiety, tardive dyskinesia, hyperkinesia, akathisia, transient ischemic attack (TIA), cerebrovascular accident (CVA), neuroleptic malignant syndrome CV: orthostatic hypotension, chest pain, tachycardia, arrhythmias EENT: vision disturbances, rhinitis, sinusitis, pharyngitis GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, dry mouth, increased salivation, anorexia GU: difficulty urinating, polyuria, galactorrhea, dysmenorrhea, menorrhagia, decreased libido Musculoskeletal: joint or back pain Respiratory: cough, Drug-drug Antihistamines, opioids, sedative hypnotics: additive CNS depression Carbamazepine: increased metabolism and decreased efficacy of risperidone Clozapine: decreased metabolism and increased effects of risperidone Levodopa, other dopamine agonists: decreased antiparkinsonian effects of these drugs Drug-behaviors Alcohol use: increased CNS depression Sun exposure: increased risk of photosensitivity Patient Monitoring
Closely monitor

Mechanism of Action

Route, Frequency, Dosage

Adverse Reactions, Side Effects

Interactions

Nursing Implications

neurologic status, especially for neuroleptic malignant syndrome (high fever, sweating, unstable blood pressure, stupor, muscle rigidity, and autonomic dysfunction), extrapyramidal reactions, TIA, CVA, and tardive dyskinesia. Monitor blood pressure, particularly for orthostatic hypotension. Assess body temperature. Check for fever and other signs and symptoms of infection. Patient Teaching
Instruct patient to

remove orally disintegrating tablet from blister pack, place on tongue immediately, and swallow as tablet dissolves. Tell patient to mix oral solution with water, coffee, orange juice, or low-fat milk. Tell him solution isnt compatible with cola or tea. Advise patient to use effective bedtime routine to avoid sleep disorders. Teach patient to

dyspnea, upper respiratory tract infection Skin: pruritus, diaphoresis, rash, dry skin, seborrhea, increased pigmentation, photosensitivity Other: toothache, fever, impaired temperature regulation, weight changes

recognize and immediately report signs and symptoms of serious adverse reactions, including tardive dyskinesia and neuroleptic malignant syndrome. Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease. Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of lightheadedness (especially in hot weather). Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Advise female patient to tell prescriber if she is or plans to become pregnant. Caution her not to breastfeed during therapy. Advise patient not to drink alcohol. As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above.

Generic Name: Biperiden Trade Name: Akineton Classifications: Anticholinergic, Antidyskenitic Pharmachologic: Anti-parkinsonian

Relief of symptoms of extrapyramidal disorders that accompany phenothiazine therapy.

Blocks acetylcholines action at cholinergic receptor sites. This action restores the brains normal dopamine and acetylcholine balance, which relaxes muscle movement and decreases rigidity and tremors. Biperidenalso may inhibit dopamine reuptake and storage, which prolongs dopamines action.

Oral: 2m/tab 1 tab/day

CNS: Disorientation, confusion, psychoses, agitation, nervousness, delusions, delirium, paranoia, euphoria, excitement, lightheadedness,dizziness, depression, drowsiness, weakness, giddiness, paresthesia, heaviness of the limbs (centrally acting anticholinergic effects). CV: tachycardia, palpitations, hypotension, orthostatic hypotension (peripheral anticholinergic effects). Dermatologic: Rash, urticaria, other 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 maintatining an erction. OTHER: flushing, deacreased sweating, elevated temperature, muscular weakness, muscular cramping.

Interactions: Drug- drug : Paralytic ileus, sometimes fatal, with other anticholinergics,with drugs that have anticholinergic properties (phenothiazines, TCAs) Additive adverse CNS effects (toxic psychosis) with drugs that have CNS anticholinergic properties (phenothiazines, TCAs). Possible masking of extrapyramidal symptoms , tardive dyskinesia, in long term therapy with antipsychotics (phenothiazines, haloperidol), possibly due to central antagonism.

NURSING INTERVENTIONS:
Decrease dosage or

discontinue temporarily if dry mouth makes swallowing or speaking difficult. WARNING:

Give with caution, and

reduce dosage in hot weather. Drug inerferes with sweating and ability of body to maintain heat equilibrium; anhidrosis and fatal hyperthermia have occurred. Give with meals ig GI upset occurs; give before meals to patients with dry mouth; give after meals if drooling or nausea occurs. Ensure that patient voids just before receiving each dose of drug if urinary retention is a problem. Patient Teaching:
Take this drug exactly as

prescribed.
Avoid the use of alcohol,

sedative, and over the counter drugs (can cause dangerous effects) You may experience these side effects;drowsiness, dizziness, confusion, blurred vision (avoid driving or engaging in activities that require alertness and visual acuity);nausea (eat frequent small meals); dry mouth (suck sugarless lozenges or

ice chips ); painful or difficult urination (empty the bladder immediately before each those);constipation (maintain adequate fluid intake and exercise regularly); use caution in hot weather (you are susciptible to heat prostration). Report difficult or painful urination;constipation; rapid or pounding heartbeat; confusion,eye pain, or rash.

DISCHARGE PLAN MEDICATIONS Medications

Biperiden

Dosage/Frequency
2mg/tab, once a day

Nursing Instructions
Take this drug exactly prescribed. Avoid the use of alcoholism ,sedative and over the counter drugs(can cause dangerous effect) You may experience these side effects: drowsiness, dizziness, confusion, blurred vision, nausea, dry mouth, difficulty urination, constipation. Report difficult Or painful urination, constipation, rapid or pounding heartbeat, confusion, eye pain, rashes

risperidone

2mg/tab,once a day

Instruct patient to remove orally disintegrating tablet from blister pack, place on tongue immediately, and swallow as tablet dissolves. Tell patient to mix oral solution with water, coffee, orange juice, or low-fat milk. Tell him solution isnt compatible with cola or tea. Advise patient to use effective bedtime routine to avoid sleep disorders. Teach patient to recognize and immediately report signs and symptoms of serious adverse reactions, including tardive dyskinesia and neuroleptic malignant syndrome. Instruct patient to move slowly when sitting up or standing, to avoid dizziness from sudden blood pressure decrease. Tell patient that excessive fluid loss (as from sweating, vomiting, or diarrhea) and inadequate fluid intake increase risk of lightheadedness (especially in hot weather).

Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness. Advise patient not to drink alcohol. As appropriate, review all other significant and lifethreatening adverse reactions and interactions, especially those related to the drugs and behaviors mentioned above.

EXERCISE -Stretching exercise -Deep breathing exercises involves inhaling slowly and deeply through the nose, holding the breath for a few seconds, then exhaling slowly through the mouth pursing the lips. THERAPY -Group Therapy A form of psychological treatment in which a number of clients meet together with a therapist for purposes of sharing gaining personal insight and improving interpersonal coping strategies. HEALTH TEACHINGS -Avoid smoking and drinking alcoholic beverages. -Do not skip doses of medications. -Be aware of the common side effect that may because by your medications. -Do not stop prescription medications without taking to your doctor. -Encourage client to perform independently as many activities as possible. (independent accomplishment and positive reinforcement enhance self-esteem and promote repetition of desirable behaviors). -Ensuring that client continues to get treatment after hospitalizations. -Encourage client to regain his/her activities, abilities. It is important that goals be attainable, since the patient feels paranoid and/ repeatedly criticized by others will probably experience irritation that may worsen the symptoms. OPD VISITS/REFERRALS -Follow check-up after one to two weeks of discharge, especially for medication relapse cases and when patient is combative.

DIET 1 cup rice 3 ounce of salmon 1 boiled egg serving of bas-uy 1 glass of milk and water SPIRITUAL CARE -Encourage the patient to pray and ask for help to our heavenly father to give him more strength, in order to cope with his problems as well as for faster recovery from his condition. Encourage to participate in bible studies.

PROGNOSIS
Prognosis Onset of Illness Acute - Good Document Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, and loss of interest in school or work, and neglected hygiene. (videbeck rd 3 ed., p. 277) Coping with schizophrenia is a major adjustment for both clients and their families. Understanding the illness, the need for continuing medication and follow-up, issues. Clients and families need help to cope with the emotional upheaval that schizophrenia causes. rd (videbeck 3 ed., p. 296) Pattern of depressive cognitions and behaviors in a variety of contexts is absent. rd (videbeck 3 ed., p. 351) Clients with schizophrenia report and demonstrate wide variances in mood and affect. They often are described as having flat affect (no facial expression) or blunted affect (few observable facial rd expressions). (videbeck 3 ed., p. 286) Maintaining the medication regimen is vital to a successful outcome for clients with schizophrenia. Failing to take medications as prescribed is one of the most frequent reasons for recurrence of psychotic symptoms and hospital admission. (Kane and Marder, 2005)

Family Support

Strong - Good

Depression Feature

Absent - Good

Mood and Affect Appropriate

Good

Willingness to take medication

Schizophrenia Treatment Recommendations Medication advice Since the last PORT review, two large clinical trials have compared efficacy of first- and second-generation antipsychotics: the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS). Based on the findings of these studies, the PORT reviewers noted that in many cases, first- and secondgeneration antipsychotics are equally effective for treating schizophrenia. First-episode of Psychosis. The PORT review recommends using any antipsychotic except clozapine (Clozaril) and olanzapine (Zyprexa), because these drugs are most likely to cause significant weight gain and other metabolic side effects. Because patients experiencing psychosis for the first time are both more responsive to medications and more likely to have side effects, antipsychotics should be prescribed at doses that are lower generally about half compared with those recommended for patients with chronic schizophrenia. Relapse. Patients who initially responded to medication but suffer a relapse of symptoms have several options. The PORT team recommends any first- or second-generation antipsychotic other than clozapine, and stipulates that medication be prescribed at the lowest effective doses to reduce side effects. Choice of which antipsychotic to use depends on patient preference, past medication response, side effects, and medical history. Maintenance therapy. Studies that have followed patients with first-episode or chronic schizophrenia for one to two years have concluded that continuous maintenance antipsychotic treatment reduces risk of relapse. The PORT review recommends that intermittent maintenance therapy a strategy of stopping antipsychotics until symptoms reappear or worsen be reserved only for patients who refuse to continue taking an antipsychotic or for those who cannot tolerate the side effects.

For patients with chronic schizophrenia, both first- and second-generation antipsychotics are equally effective at preventing relapse. During maintenance therapy, first-generation drugs may be used at lower doses than those required to treat the initial (acute) episode, while second-generation drugs can be prescribed at whatever dose was effective in the initial phase. Long-acting injectable antipsychotics provide another option in maintenance therapy, especially for patients who have trouble taking medication. The PORT review concluded that it is unclear whether injectable medications are any more effective than pills at preventing relapse, mainly because of a lack of randomized controlled studies. Treatment resistance. The PORT review recommends that patients who have not responded adequately to two previous antipsychotics try clozapine for at least eight weeks. If this does not alleviate a patient's symptoms, a blood test may be useful to determine whether the medication has reached a therapeutic level (defined as blood levels above 350 nanograms per milliliter). Some patients require higher doses of clozapine to achieve this blood level. Smoking cessation. As many as nine in 10 patients with schizophrenia smoke cigarettes. The PORT team recommends that patients who want to stop smoking take bupropion (Wellbutrin) twice a day for 10 to 12 weeks, either with or without nicotine replacement therapy, and supplement it with a support group or some type of psychosocial intervention. The report notes that this approach may help patients to quit at least temporarily, but long-term success remains unclear. Other challenges. The PORT review also offers advice about clinical situations that are less common. For example, clozapine is an option for patients with schizophrenia who are hostile or persistently violent, as well as for patients who are at risk for suicide. Patients who become agitated may respond to oral or injectable antipsychotics, alone or combined with a rapid-acting benzodiazepine. Patients who continue to experience auditory hallucinations in spite of antipsychotic treatment may respond to low-frequency transcranial magnetic stimulation.

GLOSSARY
Ambivalence holding seemingly contraindicating beliefs of feelings about the same persons or event or situation. Anergia lack of energy; inactivity. Anhedonia feeling of no joy or pleasure from life or any activities or relationships. Antipsychotic are used primarily to treat most dorms of psychosis such as schizophrenia, schizoaafective disorder and others. Apathy lack of emotion. Delusion a false fixed belief or opinion. Dementia deterioration of intellectual faculties, such as memory, concentration, and judgment, resulting from an organic disease or a disorder of the brain. Denial failure to admit the reality. Echolalia the immediate and voluntary repetition of words or phrases just spoken by others, often a symptom of autism or some types of schizophrenia. Echopraxia imitation of posture of others. Flat affect absence or near absence of any signs of affective responses. Hallucinations perception of visual, auditory, tactile, olfactory, or gustatory experiences without an external stimulus and with a compelling sense of their reality, usually resulting from a mental disorder or as response to a drug. Illusions the condition of being deceived by a false perception or belief. Paranoia in psychology, a term denoting persistent, unalterable, systematized, logically reasoned delusions, or false beliefs, usually of persecution or grandeur. Schizophernia a severe mental disorder characterized by delusion, hallucinations, incoherence and physical agitations. Schizoparanoid is the presence of auditory hallucinations or prominent delusional thoughts about persecution agitations. Schizodisorganized there is impairment of the emotional processes of the individual. Social isolation persons spends most of the day alone or only with close friend. Thought blocking sudden stop in train of thought. Thought content - is the specific meaning expressed in the patients communication. It refers to the what of the patients thinking.

BIBLIOGRAPHY
BOOKS Videbeck, Sheila L. (2004) Psychitric Mental Health Nursing, 2rd Edition Shives, Louise R. (2008) Psychiatric-Mental Health Nursin, 7th edition Townsend, Mary C. (2008) Nursing Diagnoses in Psychiatric Nursing, 7th Edition Schull, P. D. (2010) Nursing Spectrum Drug Handbook, 5th Edition. Deglin, J. H. (2008) Davis Drug Guide, 11th Edition Nicoll, Diana et. al. (2001) Pocket Guide to Diagnostic Test, 3rd Edition Wilson, Denise D. (2008) Manual of Laboratory & Diagnostic Tests

ELECTRONIC SOURCES www.search.ebscohost.com www.mentalhelp.net/poc/view_doc.php?type=doc&id=8806