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SCHIZOPRE NIA
A Case Study In Fulfillment of Requirements In Related Learning Experience 105 For the Bachelor of Science in Nursing

Submitted by: BSN III- Group 1 Alot, Menchie V. Caraig, Jessabel B. Duenas, John Luie C. Morales, Elizabeth S. Portes, Jake DC.

Rivera, Anne Mayelle E. Villanueva, Deborah V. Villas, Joyceline S. Submitted to: Dr. Michael B. Espinosa Clinical Instructor

CHAPTER 1
INTRODUCTION Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved the functioning of clients daily life.

CHAPTER II
CLINICAL SUMMARY A. GENERAL DATA Name: Marlene Millebo A.K.A. UW Marlene Gender: Female Age: 28 years old Address: B19, L3, Phase 5, Bagong Silang, Kalookan City Birthday: Nationality: Filipino Religion: Roman Catholic Admitting Time and Date: March 28, 2011 / 12:04pm Admitting Diagnosis: Psychosis, NOS Type of Admission: First

B. CHIEF COMPLAINT The patient was admitted at the National Center for Mental Health Mandaluyong accompanied by a social worker and she was unsure of the reason why. C. HISTORY OF PRESENT ILLNESS

Case of UW Marlyn , female, referred by Social Worker of NCMH Camarin Extension in Caloocan City on March 28, 2011. The patient came in escorted as she was noted loitering in Camarin extension for a month now. She was being fed during mealtime, she established involuntary attempts were due to locate her family but to no avail. Until 1 week PTA, she became descriptive with shouting spells. She ruled on the street and tried to hunt herself. She was apprehended/resumed and was brought to a center.

D. PAST MEDICAL HISTORY Unknown E. FAMILIAL HISTORY Unknown F. SOURCE OF RELIABILITY OF INFORMATION The major source of information was the patient. Further information was obtained from the patients record. Other was based on short and simple assessment done by the student nurses. G. REASON FOR SEEKING CARE The patient was admitted at the National Center for Mental Health with Chief complaint of General Appearance: conscious, inherent, and ambulatory, on March 28, 2011 by Roderick O. Villa. H. PHYSICAL ASSESSMENT

Head to Toe Assessment

Area assessed

Technique used

Normal Findings

Abnormal Findings

Interpretation

 HEAD - shape appearance Inspection and palpation

- consistency HAIR -color -oiliness EYES -eyebrows eyelashes and

-symmetrical and round -smooth and control movements -hard -black

Normal Normal Normal Normal

Inspection

-eyebrows are symmetric in shape -eyelashes are contributed and curled outward

Normal

-round -IRIS AND PUPIL -black -shape -color of iris EARS Inspection and -normal shape -external ears -skin, smooth and -lesions and palpation no lesion discoloration MOUTH Inspection -red -lips NOSE -external Inspection -nose is midline in face -color same as face -clean and neat

Normal

Normal Normal

NAILS -color

Inspection

Normal

SKIN

Inspection

- no masses or lesion upon palpation and inspection

Lesions on the left and right foot

I. GORDONS PATTERNS OF FUNCTIONING

FUNCTIONAL HEALTH PROBLEM

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION (Pre-operative)

ANALYSIS & INTERPRETATION

Health perception health management pattern

The patient sees her health pattern as normal as she suffered from no serious illness before. Whenever she feels pain or something uncommon, she usually takes drugs and consults a physician. The patient stated that she eats 3 times a day and is also fond of eating sweet foods. She likes having meat, fish and vegetables on her meals and she claimed that she has no allergies on foods and drugs. She also stated that she has a good appetite and was able to eat foods that are being served at the table.

Prior and during hospitalization, the client sees herself as a healthy person.

Nutritional and Metabolic Pattern

The patient stated that she eats all foods that are being served to them. She also stated that she can consume 23 cups of rice per meal and eats 3 times a day with merienda given by the student nurses.

Prior to hospitalization, the patient seems to have a good appetite but have a high amount of sweet food intake . During hospitalization, there were inadequacy on her nutritional and metabolic pattern due to the limited nutritious foods served in the hospital

The patient stated that she Doesnt feel any difficulty in defacating and urinating.

Elimination Pattern
The patient stated that she is not practicing typical exercises and her household chores serves as her exercise for the whole day.

The patient stated that nothing change on her bowel and bladder function.

Prior and during hospitalization, patient claimed to have a normal bowel and bladder function.

Activity and Exercise Pattern

The patient stated she was involved in exercise given by the student nurses.

Prior to hospitalization, the patient doesnt have any regular exercise except for household chores and during hospitalization she enjoyed all activities

given by the student nurses. The patient stated that she usually wakes up at 7:00 am and sleeps at 9:00 pm. The patient stated that she has adapted her sleeping pattern to the activities in the hospital. She usually wakes up at 5:00 am to wash clothes and clean their hallway and sleeps at 8:00 pm. The patient claimed that she understands what the nurses and doctors are asking of her to do. The patient had changes in her sleeping pattern during hospitalization.

Sleep and Rest pattern

Cognitive Pattern

The patient stated that she has a good vision, hearing and she was able to smell, taste and touch. She also claimed that she can communicate appropriately.

During hospitalization, though there is no alteration on patients five senses and she felt nothing has changed.

Self Perceptual/Self -Concern Pattern

The patient perceives her self as a believer of God but didnt recall any feelings toward her family.

Patient claims that she still a believer of God and now misses her family.

Prior and during hospitalization, the patients perception regarding her self changed and missing her family caused her anxiety. Because of years of confinement in the NCMH, her relationship with family and community was somehow changed and altered by anxiety and just successfully made her adjustments through the help of staff nurses, new friends and student nurses. Nothing changed in her sexuality/reproductive pattern

Role/Relationship Pattern

The patient claimed that she has a good relationship with her family and her friends. She only relies on her family when it comes to financial status because she never worked.

The client verbalized that her relationship with family changed from since hospitalization because they dont see each other for long time. She only built her relationship with her friends inside the ward and treats the staff nurses as their elder siblings.

Sexuality/Reprodu ctive Pattern

The patient denied of being sexually active.

The patient denied of being sexually active.

Coping/Stress Tolerance Pattern

The patient claimed that she doesnt have problems in dealing with stress.

The patient verbalized that she copes up with the situation. Still, she exclaimed that she is sometimes feeling anxious about her familys whereabouts

The patient claims she has a good stress coping pattern but experiences anxiety about her family.

Values/Belief Pattern

The patient stated that she is a Roman Catholic. She has a strong faith in God and their whole family usually goes to church during Sundays.

The patient stated that she knows God and sometimes Priest visits them and thats the only time they were able to attend mass.

Prior and during hospitalization, the patient knows God and still practices praying when asked by the situation like every before meal.

J. LABORATORY AND DIAGNOSTIC EXAM December 22, 2011 Urinalysis Protein RBC WBC December 22, 2011 Hematology Hematocrit Lymphocytes Ref Value F 0.36 0.42 0.20-0.35 Result 0.43 0.40 Positive (++) 2-4/hpf 18-22/hpf

March 29, 2011 Exam desired Pregnancy Test March 31, 2011 Electrolytes Determination Result Negative

Sodium, Potassium and Lithium are all normal

April 11, 2011 Blood Chemistry Examination Glucose, BUN, Creatinine, Uric Acid , SGPT (ALT), SGOT are all normal

January 09, 2012 Urinalysis Color Transparency Specific Gravity Ph Protein Sugar Yellow Slightly Turbid 1.010 Acidic Negative Negative Microscopic Findings WBC RBC Epithelial cells Mucus treads Amorphorous Urates 0-2 /hpf 0-2 /hpf moderate few moderate

Radiological Report Part examined: Chest Tentative Diagnosis: Kochs Chest There are few small nodular densities on the (R) supraclavicular area The rest of the lungs are clear The heart ,diaphragm and cestophrenic sinuses are normal. Impression:

Impression

PTB, minimal (R) activity undetermined

CHAPTER III.
CLINICAL DISCUSSION OF THE DISEASE A. Anatomy and Physiology Structure and function of the nervous system I. Structures A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord. 2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up

of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia. B. The brain is covered by three membranes. 1. The dura matter is a fibrous, connective tissue structure containing several blood vessels. 2. The arachnoid membrane is a delicate serous membrane. 3. The pia matter is a vascular membrane. C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral. D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid membrane.

II. Function

A. CNS 1. Brain a The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and right) and four lobes, each with specific functions. i The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses. ii The temporal lobe is the center for taste, hearing and smell, and in the brains dominant hemisphere, the center for interpreting spoken language.

iii The parietal lobe coordinates and interprets sensory information from the opposite side of the body. iv The occipital lobe interprets visual stimuli. b The thalamus further organizes cerebral function by transmitting impulses to and from the cerebrum. It also is responsible for primitive emotional responses, such as fear, and for distinguishing between pleasant and unpleasant stimuli. c Lying beneath the thalamus, the hypothalamus is an automatic center that regulates blood pressure, temperature, libido, appetite, breathing, sleeping patterns, and peripheral nerve discharges associated with certain behavior and emotional expression. It also helps control pituitary secretion and stress reactions. d The cerebellum or hindbrain, controls smooth muscle movements, coordinates sensory impulses with muscle activity, and maintains muscle tone and equilibrium.

e The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord. 2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control. B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord.

C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions. 1. The sympathetic nervous system serves as an emergency preparedness system, the flight-for-fight response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine. 2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine. III. Differences in nervous system response. The nervous system is one of the first systems to form in utero, but one of the last systems to develop during childhood. A. Accuracy and completeness of the neurologic assessment is limited by the childs development. B. The childs brain constantly undergoes organization in function and myelinization. Therefore, the full impact of insult may not be immediately apparent and may take years to manifest. C. The peripheral nerves are not fully myelinated at birth. As myelinization progresses, so does the childs fine motor control and coordination. D. Early signs of increased intracranial pressure (ICP) may not be apparent in infants because open sutures and fontanelles compensate to a limited extent. E. The development of handedness before 1 year of age may signify a neurologic lesion. F. Several primitive reflexes are present at birth, disappearing by 1 year of age. Absence, persistence, or asymmetry of reflexes may indicate pathology. G. The spinal cord ends at 13 in the neonate, instead of L1-L2 where it terminates in the adult. This affects the site of lumbar puncture. H. Children have 65 to 140 ml of CSF compared to 90 to 150 ml in the adult.

D. Discharge Planning

Medication
Instruct the family of the client to strictly follow the doctors prescribed medication

. Medication education should also be documented, along with instructions about dosage, times and any special instructions such as the need to take the drugs with food or milk
Instruct the family of the client importance of compliance to medication as

discontinuing antipsychotic medications is a frequent cause of relapse and rehospitalization. Exercise

strenuous activity because to prevent seizure Treatment Strictly follow Physicians treatment order.

Health teaching Inform the family of the patient to always orient the patient to time, place, date and current events Inform the family of the patient to use therapeutic communication while talking to the patient
Inform the family of the patient to do different therapeutic activity like

occupational, remotivational, movie analysis and health teaching.

for the recovery of the patient. Out-patient follow up Inform the family of the client that the appointment or follow up with the psychiatrist is very much needed for the patient with schizophrenia to promote continues recovery
Advise the family of the client to go back to hospital If they observe any

unnecessary action of the patient aside from the one explained by the psychiatrist.

Diet
Advise the family of the client give the patient nutritious foods rich in vitamins and

minerals
Advise the family of the client to give the patient 6 to 8 glasses of water a day.

Spiritual counseling
Advise the family of the client to continue spiritual preference together with the

client.

B. Drug Study
drug halope ridol dosage 10 mg classification antipsychotics action -Alters the effects of dopamine in the CNS -Also has anticholinergic and alphaadrenergic blocking activity. -Diminished signs and symptoms of psychoses indication -Organic Psychoses -acute psychotic symptoms -Relieve hallucinations, delusions, disorganized thinking -severe anxiety -seizures contraindication -seizure disorder -glaucoma -elderly clients Adverse effect -CNS: extrapyramidal symptom such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures -CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension. -EENT: blurred vision, glaucoma -GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain. -GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia -Hematologic: anemia, leucopenia, agranulocytosis -Skin: rash, dermatitis, phtosensitivity Nursing responsibilities Assess mental status prior to and periodically during therapy. Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration. Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK. Advise patient to take medication as directed. Take missed doses as soon as remembered, witih remaining doses evenly spaced through out the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care

professional. Abrupt withdrawal may cause dizziness, nausea, vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.

drug Bi pe riden

dosage 2 mg

classification Anticholinegic drug

action Synthetic anticholinergic drug, blocks cholinergic responses in the CNS.

indication Parkinsonian syndrome especially to counteract muscular rigidity and tremor; extrapyramidal symptoms.

contraindication Untreated narrow angle glaucoma, intestinal stenosis or obstruction, mega colon, prostatic hypertrophy, life threatening tachycardia.

Adverse effect CNS and peripheral effects, skin rashes, dyskinesia, ataxia, twitching, impaired speech, micturition difficulties. Fatigue, dizziness, at higher doses, restlessness, agitation, anxiety, confusion.

Nursing responsibilities -Assess for Parkinsonism, EPS. -Assess for mental Status . -Assess patient response if anticholinergics are given. -Assess for tolerance over long term therapy, dosage may have to be increased or changed . -Avoid activities that require alertness, may cause dizziness, drowsiness and blurring of vision.

drug dipenhydramine

dosage 50 mg

classification Antiparkinsonian drug

action Antagonizes the effect of histamine at H1 receptor sites; does not bind or inactivate histamine

indication parkinsonism or druginduced extrapyramidal effects

contraindication -cardiac disease or hypertension -glaucoma - gastric or duodenal ulcers

Adverse effects -CNS: headache, fatigue, anxiety, tremors, vertigo, confusion, depression, seizures, hallucinations -CV: tachycardia, palpitations, orthostaic hypotension, heart failure -EENT: blurred vision - GI: dry mouth, nausea, vomiting, constipation, flatulence -GU: urinary hesitancy or frequency, urine retention - Hematologic: leukopenia -Skin: photosensitivity, dermatitis

Nursing responsibilities Caution the client that the medication may cause drowsiness, creating difficulties or hazards or other activities that require alertness. Tell the client to take the medication with food to decrease GI upset. Explain to the client that arising quickly form a lying or sitting position may cause orthostatic hypotension. When taking these medications, the client needs to have blood cells counts, renal function, hepatic function, and blood pressure monitored. Adverse effects of these drugs occur more commonly in elderly clients. Explain to the client that use of these drugs in warm weather may increase the likelihood of heatstroke.

drug chlorpromazine

dosage 100 mg

classification antipsychotics

action -Block dopamine receptors in the brain; also alter dopamine release and turnover. -Prevention of seizures

indication -Acute and chronic psychoses, particularly when accompanied by increased psychomotor activity. Nausea and vomiting. -Also used in the treatment of intractable hiccups

contraindication -Hypersensitivity. -Cross-sensitivity may exist among phenothiazines. Should not be used in narrowangle glaucoma. -Should not be used in patients who have CNS depression.

Adverse effects -CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reactions, tardive dyskinesia -CV: hypotension (increased with IM, IV) -EENT: blurred vision, dry eyes, lens opacities -GI: constipation, dry mouth, anorexia, hepatitis, ileus -GU: urinary retention -Hematologic: agranulocytosis, leucopenia -Skin: photosensitivity, pigment changes, rashes

Nursing responsibilities Assess mental status prior to and periodically during therapy. Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG. Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded. Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration. Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately.