Schizophrenia Case Study

I.

INTRODUCTION

Psychiatr Psychiatric ic disorders disorders place a substantia substantiall burden and suffering suffering on clients, clients, their families, families, society, and the healthcare system. Caring for clients with psychiatric problems is complex and requir requires es and underst understandi anding ng of neurob neurobiol iologi ogical cal,, cognit cognitive ive,, and psychos psychosoci ocial al underpi underpinni nnings ngs associated with specific psychiatric conditions. 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. Increased dopamine activity in the mesolimbic pathway of the brain is commonly found in  people with schizophrenia. Recent research reveals that schizophrenia may be a result of faulty neur neuron onal al devel develop opme ment nt in the the feta fetall brai brain, n, whic which h deve develo lops ps into into full full-bl -blow own n illn illnes esss in late 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: •

Ambivalence: Holdin Holding g seemin seemingly gly contrad contradict ictory ory belief beliefss or feelin feelings gs about about the same same

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Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of  content)

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Anhedonia: Feeling no joy or pleasure from life or any activities or relationships

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Apathy: Feeling of indifference toward people, activities, and events

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Blurred affect: Restricted range of emotional feeling, tone, or mood

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Psychologi ogical cally ly induced induced immobi immobili lity ty occasi occasional onally ly marked marked by period periodss of  Catatonia: Psychol agitation or excitement; the client seems motionless, as if in a trance

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Flat affect: Absence of any facial expression that would indicate emotions or mood

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Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

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)

•

Named hebephr hebephreni enicc schizo schizophr phreni eniaa in the ICD. ICD. Where Where thought thought Disorganized Disorganized type: Named 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)

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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)

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Residual type: Where positive symptoms are present at a low intensity only. (DSM code

A. Demographic Data Patient name:

Danillo Dimaala

Historian:

JI Raymond AE De Joya

Hospital:

CCMH

Consultant:

Dr. Escaño

Date Interviewed:

8/15/10

B. General Data

This is a case of D.D., a 44 years old right handed male, single, the eldest among his six siblings. Born and currently residing in Nasugbu, Batangas. A High School Graduate and works as water pump tender in a sugar factory in Batangas. He is a Roman Catholic who speaks Tagalog and English, accompanied by his mother to seek consultation to a Psychiatrist for the first time in Cavite Center for Mental Health last August 13, 2010. C. Chief Complaint

Patient complained of “nagugulat pag nakakita ng babae at lalaki” D. Premorbid Personality and Level of Functioning

The patient is a calm and happy person. He loves his family and friends very much. He has lot of friends and works well with his colleagues for 16 years. He has no problems or  conflict among his family, friends and other people. E. History of Present Illness

5 years prior to consultation, the patient had itchiness and soreness around the area of his  penis. There are white-wormy-like rigid structures in his pubic area with erythema and rashes. Patient has black papules present around his body. Patient doesn’t have any history of psychiatric or mental illness. He has a primary love doctor. Patient’s sister died at Diabetes mellitus complications (3rd Sibling). Review of systems: (+) itchiness on penile area G. Family Profile

The Dimaala family is a very kind and supportive family among its household members. They are very supportive among each other. The family members are very supportive on the  patient’s illness and the death of his third sister with the arrangements. Dennis, the youngest among the patient’s sibling is the closest sibling to the patient. Dante, 43 years old male, is the second sibling in the family. He is a kind and gentle person. He has no work and helps the family. Divira, 41 years old female, is a seamstress but died of Dm complications yet she is a very humble person. Dennis, 39 years old male, is a pig caretaker and a very happy  person. Dolor, 37 years old female, is a housewife and a very supportive mother. Darwin, 35 years old male, sells in a sari-sari store near their house and a very funny and disobedient  person at times. H. Genogram

B. Early Childhood He was properly breastfed and bottle-fed. Feeding habits, ea rly development, and toilet training are unremarkable. No tantrums, night tremors, or thumb sucking noted. C. Middle Childhood The patient is cooperative and participative in pre-school activities. He has a lot of  friends and has average academic performance. There is no history of hair pulling, cheating, or lying. D. Late childhood He hates sports and joining extra-curricular activities. He has average academic   performance. He has strong self-esteem and loves helping people. There is no history of  smoking, intake of alcohol, illicit drug use, etc. E. Adulthood Patient doesn’t attend Sunday mass for 5 years and goes to church activities before his illness. Patient has no problems with his work, colleagues, a nd started drinking alcohol when he was 20 years old. He never invited or dated a girl in his life.

IV.

MENTAL HEALTH EXAMINATION

A. General Description:

He has no auditory and visual hallucinations, illusions, derealization or  depersonalization. E. Thought & Process: He has paucity of ideas, no looseness of association, clang association, word salad or neologism. He has flight of ideas, tangential sometimes. He has no echolalia or   perseveration. F. Thought & Content: He has delusion of reference and persecutory delusions, but no obsessions. G. Sensorium and Cognition: Patient is alert and conscious. He is oriented to the time place and person. He has intact remote, recent past, resent and immediate recall memory. He has intact concentration. He was having hard time subtracting 7 from 100, 7 from 93 and so on. He was able to spell LIKHA forward and backward. He can write a complete sentence. He can draw a clock hanging on a wall from an actual wall clock. He knows the current President and Vice-president of the Philippines. H. Judgment: He has intact judgment by helping a victim of pick pocketing. I. Insight: The patient is fully aware of the illness and accepts it.

The major parts of the basal ganglia consist of the caudate nucleus, the putamen and the globus  pallidus. The basal ganglia is involved in the control of movement. The nucleus accumbens contains neurons that are part of the basal ganglia. Thus, this structure may play a role in the regulation of  movement, including the control of complex motor  activity and the cognitive aspects of motor control. In addition, this structure has been found to   possibly be the area that becomes activated in situations that involve reward and punishment. The

nucleus accumbens is a nucleus of the basal forebrain. It receives dopamine-secreting terminal  buttons from neurons of the ventral tegmental area (VTA) and is thought to be involved in reinforcement and attention.

The limbic system has been implicated in learning and memory and emotions. The implication in emotions involves feelings and expressions of emotions, emotional memories and recognition of emotions in other people. TEGMENTUM

The tegmentum consists of an area of the midbrain. It includes the bottom end of the reticular  formation, the periaqueductal gray matter, the red nucleus, the substantia nigra and the ventral tegmental area.

The reticular formation is a large structure consisting of many nuclei. It is also characterized by a diffuse, interconnected network of neurons with complex dendritic and axonal processes. The reticular formation receives sensory information and projects axons to the cerebral cortex, thalamus and spinal cord.

NEURONS

other neurons. This vast interconnectedness allows simple neuronal activity to translate into complex neuronal messages creating human behavior.

NEUROTRANSMISSION •

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The basic structure of a neuron includes a cell body (soma), dendrites, axon and axon terminal.  Neurotransmission is an electrochemical message that allows neurons to communicate information with one another neuron.

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Electrochemical messages pass from the dendrites (projections from the cell body)

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Through the soma or cell body

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Down the axon (long extended structures)

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And across the synapses (gaps between cells)

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To the dendrites of the next neuron

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After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase

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These neurotransmitters are necessary in just the right proportions to relay messages across synapses

GABA

GABA is the most common inhibitory neurotransmitter in the nervous system and is found throughout the body. Produce calming effects and are target sites for benzodiazepines. Glutamate

Glutamate is an excitatory neurotransmitter that is involved in learning and memory. Alterations in production may play a role in the underpinnings of neurodegenerative disorders, such as Alzheimer’s disease and schizophrenia.

Acetylcholine

Acetylcholine is responsible for muscular movement and has  been shown to have a role in memory formation. It was the first neurotransmitter to be discovered, and thus is the best known.

Dopamine

Dopamine has been implicated in numerous functions within the body, including movement, attention, learning, and the reward and reinforcement. Schizophrenia and other psychotic disorders are associated with increased or  dysregulation of dopamine

VII.

PSYCHOPATHOPHYSIOLOGY

VIII. Drug Name

Generic Name: Haloperidol Brand Name: Haldol Classification : Antipsychotic

Action

A butyrophenone that probably exerts antipsychotic effects by blocking postsynaptic dopamine receptors in the brain.

Indication

psychotic disorders 

chronic psychosis requiring prolonged therapy 

nonpsychoti c behavior disorders 

DRUGSTUDY Contraindicatio n Hypersens itivity to drug, tartrazine, sesame oil or benzyl alcohol 

Adverse Reaction

CNS: confusion, drowsiness, restlessness, sedation, lethargy, insomnia, vertigo, dyskinesia, seizures, neuroleptic, malignant syndrome 

CV: hypotension, hypertension 

 Tourette syndrome 



Delirium

Nsg Consideration



Monitor CNS status closely, cardiovascular status and respiratory status 

Advice patient to minimize GI upset by eating frequent small serving of meal 

Instruct patient to report signs and symptoms of serious adverse reaction

EENT: blurred vision, dry eyes 

GI: constipation, drymouth, anorexia 

GU: urinary retention, menstrual irregularities, gynecomastia 

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HEMATOLOGIC : anemia 

RESPIRATORY: dyspnea 

Drug Name

Action

Indication

Contraindicatio n

Adverse Reaction

Nsg Consideration

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Generic Name: Clozapine Brand Name: Leponex Classification : Antipsychotic

Unclear. Thought to interfere with dopamine binding in limbic system of CNS, with high affinity for dopamine receptors

Schizophre nia in patient unresponsive to other therapies 

hypersensi tivity to drugs 

uncontroll ed seizure 

severe CNS depression or coma 

CNS: sedation, drowsiness, dizziness, vertigo, insomnia, disturbed sleep, nightmares, restlessness 

CV: tachycardia, hypotension, hypertension, chest pain 

EENT: visual disturbances 

GI: dry mouth, constipation, nausea, vomiting, excessive salivation 

GU: urinary frequency or urgency, urine retention 

Respi: repiratory arrest 

Patient monitoring 1. Monitor wbc count weekly for 6 months 2. Monitorecg and liver function test 3. If drug must be withdrawn abruptly, monitor patient for psychosis and cholinergic rebound (head ache, nausea, vomiting and diarrhea) 

Patient teachings 1. Tell patient to allow orally disintegrating tablet to dissolve in mouth 2. Advise patient to immediately report of new onset of  lethargy, weakness, fever, sore throat. Malaise, mucous membrane ulcers, or other signs and symptoms of  infections 

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Drug Name

Action

Generic Name: Diphenhydrami de

Interferes with histamine effects at h1 receptors site; prevents but doesn’t reverse histaminemediate response.

Brand Name: Celestamine Classification : Antihistamine

Indication

Contraindicatio n

Allergy sypmtoms caused by histamine release

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nausea and vertigo, cough







dyskinesia; parkinsons disease

hypersensi tivity to drug Alcohol intolerance 

Acute asthma attacks



mild nighttime sedation 

MAO inhibitor use within past 14 days 



Breastfeed

ing Neonates, premature infants

Adverse Reaction

 CNS:

Drowsiness, dizziness, headache, paradoxical stimulation (especially in children)

 CV:

Hypotension, palpitations, tachycardia

 EENT:

Blurred vision, tinnitus

 GI:

Diarrhea, constipation, dry mouth



Nsg Consideration

Patient monitoring: monitor cardiovascular status  Patient teaching: 1. Advise patient to avoid alcohol 2.Caution patient to avoid driving and other hazardous activities until he knows the drug effects 3.Review all significant adverse reaction 

 GU:

Dysuria, urinary frequency or retention

 Skin:

Photosensitivity  Other:

decreased appetite, pain at I.M. injection site

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Drug Name

Generic Name: Clonazepam Brand Name: Rivotril Classification : Anticonvulsant

Action

May enhance activity of  gamma-amino butyric acid, and inhibitory neurotransmitter in CNS

Indication

Contraindicatio n

Nsg Consideration

CNS: fatigue, drowsiness, behavioral changes, depression and reduced intellectual ability

Paient monitoring 1. Monitor patient for respiratory depression 2. Monitor hematologic and liver function test results

LennoxGastaut syndrome, atypical absence seizures, akinetic and myoclonic seizures

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

severe hepatic disease

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Panic disorder

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

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Acute manic episodes of  bipolar disorder 

Adjunct treatment for schizophrenia

hypersensi tivity to drug or benzodiazepin es

Adverse Reaction



acute angle-closure glaucoma

CV: palpitations EENT:, blurred vision, diplopia, nystagmus, sinusitis, rhinitis, pharyngitis, 

GI: constipation, diarrhea, hypersalivation





Periodic leg movements during sleep

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Caution: tell patient not to stop taking drug abruptly, advise patient not to drink alcohol which may increase drowsiness, dizziness, and risk for seizures 

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Parkinsonia n dysarthria 



Neuralgias

GU: dysuria, nocturia, urinary retention, dysmenorrhea, delayed ejaculation, erectile 18

dysfunction Respi: respiratory depression, shortness of  breath Adverse Reaction 

Drug Name

Generic Name: Akineton Brand Name: Biperiden Classification : Antiparkinsonian

Action

Synthetic anticholinergic drug, blocks cholinergic responses in the CNS

Indication

Parkinsonia n syndrome especially to counteract muscular rigidity and tremor, extrapyramidal symptoms 

Contraindicatio n narrow angle glaucoma 

mechanica l stenoses in gastrointestina l and mega colon, prostatic adenoma and diseases leading to perilous tachycardia 

hypersensi tivity to bipereden. 

skin rashes dyskinesia ataxia  twitching  impaired  speech micturation  difficulties fatigue  dizziness at  higher doses restlessness  agitation  anxiety  confusion  

Nsg Consideration



Document indication for therapy, onset of signs and symptoms and other  agents tried in outcome of therapy  Assess for   parkinsonism or EPS, shuffling gait, muscle rigidity, involuntary movement, pill rolling, muscle spasm, drooling before and during treatment 

Assess for mental status: affect mood CNS depression worsening of mental symptoms during early therapy 

Monitor for  constipation cramping  pain in the abdomen, 19

and abdominal distension. Increase fluids, add fiber to diet and exercise

Drug Name

Generic Name: Vitamin B complex Brand Name: Crystamine Classification : Vitamins

Action

A coenzyme that stimulates metabolic function and is needed for cell replication, hematopoiesis and nucleoprotein and myelin synthesis.

Indication

RDA for cyanocobalamin 

Vit B12 deficiency from inadequate diet, subtotal gastrectomy 

Contraindicatio n hypersensi tivity to Vit B12 or cobalt and in those with early Leber’s disease



use cautiously in anemic patient with coexisting cardiac, pulmonary or hypertensive disease







Pernicious anemia or vit B12 malabsorption 

Methylmalo nic acid uria 

Adverse Reaction

CV: peripheral vascular thrombosis, heart failure GI: transient diarrhea 

Nsg Consideration



Determine hematocrit, iron, and Vit B levels before   beginning therapy 

Obtain a sensitivity test history  before administration

Respi: pulmonary edema



Skin: itching, urticaria





Don’t give large oral doses routinely Monitor patient for  hypokalemia for first 48 hours 

Teach patient using intranasal form how to administer drug 

Instruct patient not to take folic acid as a replacement for  vitamin B12 20

Drug Name

Generic Name: Vitamin C (Ascorbic Acid) Brand Name: Vita-C Classification : Vitamins

Action

Stimulates collagen formation and tissue repair; involved in oxidationreduction reactions.

Indication

Increases protection mechanism of  the immune system 

 Treatment and prevention of vitamin C deficiency, including a condition called scurvy 

Extensive burns, delayed fracture or wound healing, severe febrile or chronic diseases states 

Contraindicatio n

Adverse Reaction



Allergy to tartrazine sulfites





Large doses in pregnant patients



GI: diarrhea, heartburn, nausea, vomiting





CNS: faintness, dizziness

Nsg Consideration

GU: gastric urine, renal calculi 

When giving for  urine acidification, check urine pH to ensure efficacy If using IM, explain that this route may promote better  use of the vit by the  body 

Inform patient or  relatives that vitamin is readily absorbed from citrus fruits, tomatoes,  potatoes and leafy vegetables 

Advise smokers to increase intake of  vitamin

 To prevent vit C deficiency 

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in patients with poor nutritional habits or increase requirements  To acidify urine 

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IX. ASSESMENT Subjective cues: “Nagugulat ako pag nakakakita ng babae at lalaki” Objective cues:  Auditory hallucinations  Visual hallucinations  Insomnia  Restlessness  Ramus mood with full affect  Paucity of  ideas  Tangential at times  Ideas of  reference  Persecutory delusions  Flight of ideas  Has a hard time subtracting 7 from 100, 7 from 93 and so on

DIAGNOSIS

Disturbed thought  processes related to presence of   psychological conflicts as evidenced by delusions and hallucinations

NURSING CARE PLAN

PLANNING

After 2 weeks of  nursing interventions the client will be able to: Interact  and respond to reality-based interactions initiated by others Demonstrat e reality based thinking in verbal and nonverbal  behavior 

INTERVENTION 

Be sincere and honest when communicating with the client

RATIONALE 

To establish a trusting relationship



Do not make  promises that you cannot keep





Explain procedures and be sure the client understands the procedures  before carrying them out

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

Interventions for Delusions:  Give positive feedback for  client’s success



Interact with the client on the basis of real things, do not dwell on the

Broken promises reinforce the client’s mistrust of others The client feel less likely that he or  she is being tricked

EVALUATION

Goal met: After 2 weeks of nursing interventions the client was able to: Socialize with others in reality-based conversations through verbal and nonverbal  behavior 



Enhances the client’s sense of well being and helps to make nondelusional reality a more  positive situation 

Interacting about reality is healthy for  the client 23

delusional material 

Directly interject doubt regarding delusions if client seems ready to accept reality

Interventions for Hallucinations:  Elicit description of  hallucination



Engage client in reality-based activities such as card playing, occupational therapy, or listening to music



Help present or  maintain reality by frequent contact and communication with the client

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As the client trust you, he or she may be willing to doubt the delusion if you express your doubt

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To protect the client and others. Understanding the hallucination will  provide ways to calm or reassure the client 

To limit or  decrease the recurrences of  hallucinations



To maintain reality orientation

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