Case Study of Undifferentiated Schizophrenia

Introduction Mr. Apo a 49yr old male single patient in dorm two was born on March 12, 1960. He weight 74 pounds and height of 5’10. He lived at barrio matalaba lingayen. He has a Filipino nationality and his religion is Roman catholic. His educational a ttainment was a 2nd year college only. He was admitted at NCMH on August 13,1960, involuntarily and accompanied by his relatives especially his sister Arlene. His sister decided to admit Mr. Apo due to unwanted behavioral changes like restlessness and Sleeping disturbance. He was diagnosed as undifferentiated schizophrenia and now his current diagnosis was undifferentiated schizophrenia.

Undifferentiated schizophrenia is a menta mentall disor disorder  der wh whic ich h is part part of the the fami family ly of diso disord rder erss broa broadl dly y know known n as “schiz “schizoph ophren renia. ia.”” There There are a number number of subcat subcatego egorie riess of schizo schizophr phreni eniaa includ including ing  paranoid schizophrenia, catat catatonic onic schiz schizophreni ophreniaa, disorganized schizophrenia, residual schizophrenia,, schizophrenia

and sch schizo izoaff affecti ective ve

disord dis order  er ; undifferent undifferentiated iated schizophreni schizophreniaa is

often

defined as a form in which enough symptoms for a diagnosis are present, but the patient does not fall into the catatonic, disorganized, or paranoid subcategories. Schizophrenia is characterized by a lack of grounding in reality, known as psychosis as psychosis.. People in a state of psychosis can experience hallucinations hallucinations,, delusions delusions,, and other events in which they break from reality. Individuals with schizophrenia experience psychosis and can also develop symptoms such as disorganized speech, lack of interest in social

interactions, a flat affect, affect, inappropriate emotional responses to situations, confusion, and disorganized thinking. Patients Patients with undifferenti undifferentiated ated schizophreni schizophreniaa do not experience experience the paranoia the paranoia associated with

para aranoid oid schizophr phrenia nia,

the

catatonic

state

seen

in

patients

with

catatonic schizophrenia, or the disorganized thought and expression observed in patients with disorganized schizophrenia. However, they do experience psychosis and a variety of  other symptoms associated with schizophrenia, including behavioral changes which may  be noticeable to family and friend.

Psychopathology Causes One of the reasons for the ongoing o ngoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes. It is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading neurobiological hypothesis looks at the connection between the disease and excessive levels of dopamine, a chemical che mical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been bee n underscored by recent findings that first-degree  biological relatives of schizophrenics are ten times as likely to dev elop the disorder as are members of the general population. Prior to recent findings of abnormalities in the brain structure of schizophrenic patients, several generations of psychotherapists advanced a n umber of psychoanalytic and sociological theories about the origins of schizophrenia. These theories ranged from

hypotheses about the patient's problems with anxiety or aggression to theories about stress reactions or interactions with disturbed parents. Psychosocial factors are now thought to influence the expression or severity of  schizophrenia rather than cause it directly. As of 2004, migration is a social factor that is known to influence people's susceptibility to psychosis. Psychiatrists in Europe have noted the increasing rate of schizophrenia and other   psychotic disorders among immigrants to almost all Western European countries. Black  immigrants from Africa or the Caribbean appear to be especially vulnerable. The stresses involved in migration include family breakup, the need to adjust to living in large urban areas, and social inequalities in the new country. Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the hippocampus, a part of the brain that processes sense perceptions. Damage to the hippocampus would account for schizophrenic patients' vulnerability to sensory overload. As of 2004, researchers are focusing on the possible role of the herpes simplex virus (HSV) in schizophrenia, as well as human end ogenous retroviruses (HERVs). The  possibility that HERVs may be associated with schizophrenia has to do with the fact that antibodies to these retroviruses are found more frequently in the blood serum of patients with schizophrenia than in serum from control subjects.

Symptoms Patients with a possible diagnosis of schizophrenia are evaluated on the basis of a set or  constellation of symptoms; there is no single symptom that is unique to schizophrenia. In 1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank  symptoms, which he regarded as diagnostic of the disorder. These symptoms include:

•

delusions

•

somatic

•

hallucinations

•

hearing voices commenting on the patient's behavior 

•

thought insertion or thought withdrawal

Somatic hallucinations refer to sensations or perceptions concerning body organs that have no known medical cause or reason, such as the notion that one's brain is radioactive. Thought insertion and/or withdrawal refer to delusions that an outside force (for example, the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove them.

History The patient diagnosed as undifferentiated schizophrenia and current undifferentiated schizophrenia. He has lesions in legs, arms, back of the body and knee. He does not undergo in any surgery. His medications are only for his mental illness. His previous medications are Nozinan and haloperidol. His current medications are nozinan, haloperidol and chlorpromazine.

 Nursing physical assessment Apo was alert and oriented to person, place and time. The patient’s temperature 36.0 Celsius, pulse rate was 80, respiratory rate 20, blood p ressure was 120/90. The patient has no skeletal deformities. The skin of the patient was dry with scar. The musculoskeletal status of the patient are weakness and tremors. The patient scars was located at leg, arms, and at the back of the body. The patient stated her pain level. The bowel sounds of the  patient is good. The color of urinalysis is light yellow, transparency was slightly turbid. The patient was on regular diet. The fasting blood sugar of the patient is 5.31 and specific 1.010. The weight of Apo is 74 pounds. Apo was regular exercise everday.

Related Treatment

Mr. Apo is now receiving a Haloperidol 1mg tablet, which an typical antipsychotic medication. It works by changing the effects of chemicals in the brain. It is used to treat undifferentiated schizophrenia. Haloperidol 10mg/capsule it is used in the treatment of  schizophrenia and is also used in the management of pain, distress, nausea and vomiting associated with terminal illness. Nozinan 10mg/ capsule it is used in the treatment of  schizophrenia and is also used in the management of pain, distress, nausea and vomiting associated with terminal illness. Chlorpromazine is used to treat the symptoms of  schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and other psychotic disorders (conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real) and to treat the symptoms of mania (frenzied, abnormally excited mood) in people who have bipolar disorder (manic depressive disorder; a condition that causes episodes of mania, episodes of depression, and other abnormal moods).

 Nursing care plan  Nursing Diagnosing & Patient Goal A doctor must make a diagnosis of schizophrenia on the basis of a standardized list of  outwardly observable symptoms, not on the basis of internal psychological processes. There are no specific laboratory tests that can be used to diagnose schizophrenia. Researchers have, however, discovered that patients with schizophrenia have certain

abnormalities in the structure and functioning of the brain compared to normal test subjects. These discoveries have been made with the help of imaging techniques such as computed tomography scans (CT scans). When a psychiatrist assesses a patient for schizophrenia, he or she will begin by excluding physical conditions that can cause abnormal thinking and some other behaviors associated with schizophrenia. These conditions include organic brain disorders (including traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, prion diseases, Huntington's chorea, and encephalitis. The doctor will also need to rule out heavy metal poisoning and substance abuse disorders, especially amphetamine use. After ruling out organic disorders, the clinician will consider other psychiatric conditions that may include psychotic symptoms or symptoms resembling psychosis. These disorders include mood disorders with psychotic features; delusional disorder; dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder ; schizotypal, schizoid, or paranoid personality disorders; and atypical reactive disorders. In the past, many individuals were incorrectly diagnosed as schizophrenic. Some patients who were diagnosed prior to the changes in categorization should have their diagnoses, and treatment, reevaluated. In children, the doctor must distinguish between psychotic symptoms and a vivid fantasy life, and also identify learning problems or disorders. After  other conditions have been ruled out, the patient must meet a set of criteria specified:

•

the patient must have two (or more) of the following symptoms during a onemonth period: delusions; hallucinations; disorganized speech; disorganized or  catatonic behavior; negative symptoms

•

decline in social, interpersonal, or occupational functioning, including

self-care •

the disturbed behavior must last for at least six months

•

mood disorders, substance abuse disorders, medical conditions, and

developmental disorders have been ruled out.

 Nursing intervention 1. Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container. 2. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others. 3. Adopt an accepting and consistent approach with the patient. Don't avoid or  overwhelm him. Keep in mind that short, repeated contacts are best until trust has  been established. 4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself. 5. Reward positive behavior to help the patient improve his level of functioning. 6. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide

reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate  behavior. 7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the  patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject. 8. Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor. 9. Don't touch the patient without telling him first exactly what you're going to do. For  example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require ph ysical contact with facility personnel until the patient is less suspicious or agitated. 10. Remember, institutionalization may produce new symptoms and handicaps in the  patient that aren't part of his diagnosed illness, so eva luate symptoms carefully. 11. Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills. 12. Encourage compliance with the medication regimen to prevent relapse. Also monitor  the patient carefully for adverse effects of drug therapy, including drug-induced

 parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.

Evaluation The client was able to maintain reality orientation. He is oriented to time when asked what day it is. The patient was demonstrate behaviors that show positive self esteem as evidenced by inability to have an eye contact.

Recommendation He is advised to take part in complying with the treatment; the medication and therapeutic regimen designed for his rehabilitation. He should realize the importance of  complying with his medication and the benefits this practice would bring to the improvement of his well-being. Even if nursing students find it difficult to establish therapeutic relationships with mentally-ill patients because of the relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to o ur   patients; and improve our therapeutic technique in caring for our patients; that we may  play a part in the rehabilitation of our mentally-ill patients.

A case study Presented to the faculty of  Our lady of Fatima University College of Nursing

A Case Study on Undifferentiated Schizophrenia Submitted to: Ms. Leyden Dela cruz RN Clinical instructor 

Submitted by Belardo, Gillian abegail F. Group A

 Nursing care plan Assessment Subjective “Sobrang lamig ng tubig nakakatamad maligo, ay ang haba pala ng kuko ko” as verbalized by the patient

Objective Untrimmed fingernails and toenails with visible dirt noted

Diagnosis Self care deficit bathing/ hygiene related to lack of motivation. The patient has an impaired ability to provide self care requisites due to env ironmental and psychological factors.

Planning After 2 hours of nusing care, the client will be able to a) Verbalize self care need b) Demonstrate techniques to meet self care needs

Interventions 1.

Establish rapport.

R: to gain client’s trust and facilitate a good working relationship. 2.

Identify reason for difficulty in self-care.

R: underlying cause affects choice of interventions/ strategies. 3.

Determine hygienic needs and provide assistance as needed with activities

like care of nails and brushing teeth. R: basic hygienic needs may be forgotten. 4.

Discuss on importance of hygiene.

R: makes client aware of how hygiene is vital in caring for oneself. 5.

Orient client to different equipment for self-care like various toiletries.

R: increases the client’s awareness of different materials for self-care. 6.

Let the patient enumerate his ideas on the importance of hygiene.

R: Encourages the patient to understand the need for hygiene. 7.

Discuss the possible negative implications of not taking a bath such as

infections and odor. R: Broadens the patient’s idea about the problem and encourages him to meet the need. 8.

Encourage client to perform self-care to the maximum of ability as defined

 by the client. Do not rush client. R: promotes independence and sense of control, may decrease feelings of  helplessness. 9.

Allot plenty of time to perform tasks.

R: cognitive impairment may interfere with ability to manage even simple activities. 10.

Assist with dressing neatly or provide colorful clothes.

R: Enhances esteem and convey aliveness.

Evaluation GOAL PARTIALLY MET After 2 hours of nursing care, the client was able to: a)

verbalize self care need

 b)

but was unable to demonstrate techniques to meet self-care needs.

 Nursing care plan Assessment Subjective “Hindi ako masyado makatulog sa gabi” as verbalized by the patient Objective 

restlessness



dark circles under eyes

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irritability

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frequent change of mood

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V/S taken as follows

T: 36.5˚C P: 54 R: 12 BP: 110/ 80

Diagnosis Disturbed Sleep Pattern related to hyperactivity

Planning After 8 Hours, Patient will be able to report feeling rested and show improvement in sleep/rest  pattern.

Intervention I NDEPENDENT

1. Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth, length, positions, aids, and interfering agents.

2. Document nursing or caregiver observations of sleeping and wakeful behaviors. Record number of sleep hours. Note physical (e.g., noise, pain or discomfort, urinary frequency) and/or psychological (e.g., fear, anxiety) circumstances that interrupt sleep. 3. Instruct patient to follow as consistent a daily schedule for retiring and arising as  possible. 4. Avoid including in the meal alcohol or caffeine as well as heavy meal 5. Increase daytime physical activities as indicated. 6. Recommend an environment conducive to sleep or rest (e.g., quiet, comfortable temperature, ventilation, darkness, closed door). COLLABORATIVE 

Administer sedatives as ordered.

Evaluation After 8 hours of Nursing Interventions, the patient was able to show improvement in his sleeping pattern.

 Nursing care plan Assessment Subjective “Ang aking mga sugat ay nangangati” as verbalized by the patient

Objective 

(pain)



Localized erythema



Disruption of the skin

Diagnosis Impaired skin integrity related to inflammatory response secondary to infection.

Planning Following a 3-day nursing intervention, the client will be able to display improvement in wound healing as evidenced by:

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

Intact skin or minimized presence of wound.

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Absence of redness or erythema.

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Absence of purulent discharge.

Absence of itchiness.

Intervention 

Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes.



Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.



Instructed family to maintain clean, dry clothes, preferably cotton fabric (any Tshirt).



Emphasized importance of adequate nutrition and fluid intake.



Demonstrated to the family members on how to make a guava decoction to apply to the wound as alternative disinfectant.



Instructed family to clip and file nails regularly.



Provided and applied wound dressings carefully.

Evaluation At the end of the 3-day nursing intervention, the client was able to display improvement in wound healing as evidenced by:





Minimized presence of wounds.



Several wounds have dried up.



Minimized erythema.



Minimized purulent discharge.



(Continue cleaning the wound with disinfectant)

Presence of itchiness (Continue instructing client to avoid scratching the wound)

 Nursing process Recording Mr. Apo drawn a heart and uses a red crayon to make it. He described the drawing as a symbol love and passion. He also said that symbolizes people who love each other. My  patient thinks of love and the way people express it, and show it, in the way that people can appreciate the true meaning of LOVE. Why do people fall in love and what is it for. Is it important to people to love in able to attain peace or to unite people and be happy

with their special someone. The answer is clear and the only thing that makes people happy is because of LOVE.