Undifferentiated Schizophrenia Case Study Sample

A Case Study Presented to the Faculty of The Ateneo de Davao University College of Nursing

A Case Study on Schizophrenia Undifferentiated Submitted to:

Mrs. Anabel Bauzon, RN, MN Clinical Instructor – Panelist of the Case Study

Submitted by: [Group 1]

Abarquez, Eva Rica V. Ampilanon, Rae Maikko M. Ausa, Ryan S. Balboa, Tessa Marie R. Batuhan, Katherene P. Beltran, Maribel S. Bulosan, Von Rainier S. Cabonita, Kristi Ann J. Campaner,Marie Allexis I. BSN-3H

09 February 2010

TABLE OF CONTENTS Acknowledgement…………………………………………………………………..…..3 Introduction…………...……………………………………………………………….…4 Objectives (General & Specific)……………………………..……………………….….6 Personal Data…………………………………………...……………………………….9 Genogram……………………………………………………………………….………11 Anamnesis………………………………………………………………………….…...12 Theories of Development………………………………………………………….....…24 Etiology and Symptomatology….……………………………………………….……44 Psychodynamics………………………………………………………………..………62 Mental Status Exam……………………………………………………………….…..68 Multi Axial Assessment………………………………………………………………..78 Nurse Patient Interaction ……………………………………………………………..81 Complete Diagnosis…………………………………………………………......…….101 Differential Diagnosis……………………………………………………………....…104 Anatomy and Physiology…………………………………………………….…..……115 Doctor’s Order…………………………………………………………...……………126 Drug Study……………………………………………………………………….……130 Nursing Care plan ……………………………………………………………..………149 Prognosis………………………………………………………………..…….......……176 Recommendations………………………………..………………………...…………180 Significance of the Study……………………………………………………...………182 Appendices……………………………………………………..………………...……183 References……………………………………………………...………………...……195 2

ACKNOWLEDGEMENT The group wishes to express their deepest gratitude and warmest appreciation to the following people, who, in any way gave us the possibility making this case study a success: First of all, to the Almighty God, who never cease in loving us and for the continued guidance and protection. To the group’s clinical instructor, Mrs. Apple V. Guiao, R.N,M.N for her guidance and support in the duration of the study and during the psychiatric nursing exposure , whose help, stimulating suggestions and encouragement helped us in all the time of making this case study. To Mrs. Zenaida Lagrosa RN, Mrs. Anabel Bauzon RN and Mr. Richard Cheng,RN for their unlimited patience, guidance and being with us during our psychiatric nursing exposure . Finally to Ms. Melba Irene Gabuya RN for imparting knowledge and learning experience during our lectures on Psychiatric nursing. Without their encouragement and constant guidance, our Psychiatric Nursing exposure would not have been a very meaningful learning experience. The group also wishes to acknowledge the invaluable assistance and cooperation of the staff nurses of the Davao Mental Hospital (DMH), for allowing us to conduct this study, for essential assistance in reviewing the patient files and giving us the opportunity to care for the mentally-ill patients. Special appreciation is extended to the client subjected for this study and other informants for their selfless cooperation, time and entrusting personal information needed for this study. To the group, we would like to show our endless gratitude to each other by specifying our names; Maikz, Eva, Allexis, Kat, Bel, Kitty, Ryan, Tessa and Von; for the understanding, believing in each other, and teamwork. May we continue working hard for future studies.

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And lastly, to our parents who have always been very understanding and supportive both financially and emotionally. INTRODUCTION Schizophrenia (from the Greek roots skhizein ("to split") and phrēn, phren- ("mind")) is a severe mental illness characterized by a variety of symptoms including but not limited to loss of contact with reality. Schizophrenia is not characterized by a changing in personality; it is characterized by a deteriorating personality. Simply stated, schizophrenia is one of the most profoundly disabling illnesses, mental or physical, that the nurse will ever encounter (Keltner, 2007). There are 5 subtypes of schizophrenia naming; paranoid, disorganized, catatonic, undifferentiated, and residual. Schizophrenia undifferentiated is the type of schizophrenia wherein characteristic symptoms (delusions. Hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms) are present, but criteria for paranoid, catatonic, or disorganized subtypes are not met. Schizophrenia is not a terribly common disease but it can be a serious and chronic one. Worldwide about 1 percent of the population is diagnosed with schizophrenia. About 1.5 million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net). Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americans suffer from schizophrenia; fifty percent (50%) experience serious side effects from medications; and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of 86,241,697

of

Filipinos

or

approximately

0.8%

are

suffering

from

schizophrenia

(cureresearch.com). Here in Davao, Dr. Padilla said that the Davao Mental Hospital receives an average of eight to 10 patients a day suffering from schizophrenia, depression and bi-polar illnesses (Positivenewsmedia.net).

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Schizophrenia Ranks among the top 10 causes of disability in developed countries worldwide (World Health Organization, www.who.int) Schizophrenia is a disease that typically begins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophrenia slightly earlier than women; whereas most males become ill between 16 and 25 years old, most females develop symptoms several years later, and the incidence in women is noticeably higher in women after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onset is quite rare for people under 10 years of age, or over 40 years of age (schizophrenia.com). The group 1 of BSN-3H was given opportunity to have a hospital exposure in Davao Mental Hospital last January 19 – 30, 2010 for their psychiatric exposure. It was on that said dates that the group found a creditable case sensible to be presented as case presentation as suggested their Clinical Instructor Apple V. Guiao, R.N. M.N. and was agreed by whole group. The patient, Bob, not his real name, was one of the patients admitted to the Crisis Intervention Unit of Davao Mental Hospital due to Schizophrenia Undifferentiated. The group chose Bob as their subject primarily because his case posed as a very intricate case requiring due understanding and knowledge. Making this case is a good avenue to broaden the proponents’ knowledge about the mental illness involved.

5

OBJECTIVES General Objective: The main goal of the group is to be able to present an extensive and comprehensive case study of our chosen client that would present a comprehensive discussion of Schizophrenia Undifferentiated to yield important information for the case study.

Specific Objectives: In order to meet the general objective, the group aims to: Cognitive: •

interpret the pertinent data gathered from the patient and his significant others;

•

present the anamnesis by thorough gathering of the client’s pertinent personal data, appropriate selection of informants, and familial history tracing;

•

evaluate the developmental stage of the patient according to the theories of Erikson, Freud and Piaget;

•

determine the etiology factors (precipitating and predisposing) of the mental disorder;

•

evaluate the presence or absence of signs and symptoms seen in the patient in relation to the mental disorder;

•

present the psychodynamics of the client’s diagnosis by recognizing its predisposing and precipitating factors with appropriate rationales; To track down the significant events during the client’s developmental stage as shown in the psychodynamics;

•

Interpret and analyze nurse-patient interaction taken through spontaneous and effective use of therapeutic communication; 6

•

thoroughly define the complete diagnosis of the patient;

•

come up with a differential diagnosis with accord to the client’s maladaptive behaviors;

•

discuss thoroughly the Anatomy and Physiology of the involved organs and organ systems in accord to the final diagnosis;

•

present the doctor’s order with its rationalization;

•

formulate effective, specific, measurable, attainable, realistic and time-bounded nursing care plans base on identified actual and potential nursing problems;

•

arrive to a general realistic prognosis drawn from the information gathered and factors affecting the patient’s condition;

•

provide the significance of the case study;

Psychomotor: •

gather pertinent data about the client through detailed chart taking, and effective therapeutic communication and interaction with the client and his significant others;

•

commence the patient with his personal data and present and past health history;

•

trace the health history of the client and family illnesses (past and present) through a genogram;

•

assess client’s mental status thoroughly during the orientation and termination phase as well as the Multi-Axial diagnosis;

• present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, adverse reactions, nursing responsibilities, and importance to the client’s condition; •

render quality nursing care in line with the formulated nursing care plans; 7

•

impart appropriate recommendations to the client, his significant others and community, medical world, and the group as a part of the nurse’s holistic care.

Affective: •

establish rapport to the patient and the patient’s significant others; and

•

establish a trusting nurse-patient relationship with the client and his significant others through provision of holistic care toward the client and use of appropriate verbal and nonverbal therapeutic communication skills with the client and significant others during the data gathering;

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PATIENT’S DATA PERSONAL DATA: CODE NAME: Bob AGE: 40 SEX: Male BIRTHDAY: April 9, 1969 BIRTHPLACE: Cagayan de Oro City ADDRESS: Prk. 1 Rizalian, Bayugan Agusan del Sur Tulip Drive, Matina, Davao city ORDINAL RANK: 1st CIVIL STATUS: Single NATIONALITY: Filipino RELIGION: Catholic EDUCATIONAL ATTAINMENT: 2nd Year College undergraduate OCCUPATION: None NUMBER OF CHILDREN: 0 NUMBER OF BROTHERS: 2

NUMBER OF SISTERS: 2

MOTHER: Aina AGE: 58 EDUCATIONAL ATTAINEMNT: college undergraduate OCCUPATION: Businesswoman FATHER: Danni EDUCAIONAL ATTAINMENT: college undergraduate 9

OCCUPATION: Businessman CLINICAL DATA: WARD/SERVICE: Crisis Intervention Unit/Psychiatry ADMITTING PHYSICIAN: GIOIA FE D. DINGLASAN, M.D ADMITTING DIAGNOSIS: Schizophrenia, undifferentiated PRINCIPAL DIAGNOSIS: Schizophrenia, undifferentiated DATE OF AMISSION: January 19, 2010 DATE OF DISCHARGE: January 21, 2010 INSTITUTION: Davao Mental Hospital

10

11

GENOGRAM Super Lola

Super Lolo Ω †

Angeli ta †

Angelit o†

†

Apolinari o†

as

Gran Ma †

Gran Pa †

Jeorgin o

Legend: L - Male - Female

∞ - schizophrenia Ω - hypertension Ѳ - Diabetes

Aina 58 years old

Fielit aѲ

Bob 40 years old

∞

†

Carmz 31 years old

Ronan aΩ

Dennz 26 years old

Watusi Ω†

Watus a†

Lola Al Ω

Lolo Al †

Ronan

Emman 39 years old

Apolin aria Ω

†

Danni 59 years old

Leo †

Lea

Yose 20 years old

†-deceased 12

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ANAMNESIS A. INTERVIEWS Informant #1 Name: Aina Age: 58 Address: Purok 1, Rizalian, Bayugan, Agusan del Sur Sex: Female Civil Status: Married Relationship to Client: Mother Length of Time Known by the Patient: Since Birth up to Present (40 years) Apparent Understanding of the Present Illness of the Client: According to Aina, her son, Bob, started having the condition when he stopped schooling in late August of 1987 and went back to Agusan because he thought lessons in school are becoming too difficult for him. Bob also verbalized that something is wrong with him and that he needed a psychological check-up. Yet, Aina did not pay attention to what he said; until two days after, Bob’s tongue shrunk, hindering his speech. This event forced Aina to bring Bob to San Pedro Hospital for a check-up. In San Pedro, no diagnoses indicating any mental illness resulted and they were asked to come back for a follow-up check up the following month. On November 1987, Aina brought Bob back to Davao City for a check-up but transferred to Davao Mental Hospital. There, Bob was diagnosed with Schizophrenia Catatonic Type and was admitted for two weeks; after which, he was discharged and was asked to go back to the hospital once a month for psychiatric evaluation and for monthly doses of a depot. Aina says that Bob at times would show extreme hostility and wild behavior. She believes that Bob’s wild behavior which is the reason for his second admission in December 2007 and 14

current admission this January 2010 is due to Bob’s incompliance with the advices of the doctor to stop drinking coke, alcoholic beverages and smoking. The current admission of Bob is already his third admission. Bob and Aina were only at the Davao Mental Hospital to have Bob’s monthly dose of his depot but Bob shouted at the doctor without any apparent reason, exhibiting extreme hostility and wild behavior. This action convinced the doctor that Bob may need a three-day admission at the CIU for observation. After which, he was then discharged Characteristics and Attitude of Informant: Sincerity and concern regarding the condition of the patient is highly evident in the verbal and non verbal cues of the informant during the interview. She looks straight to the eyes and is very cooperative all throughout the interview, trying her best to recall all events that took place in connection to the condition of her son.

Informant #2 Name: Emman Age: 39 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Male Civil Status: Married Relationship to Client: Brother Length of Time Known by the Patient: Since Birth up to Present (39 years) Apparent Understanding of the Present Illness of the Client: Emman said that the illness began when Bob went to Bukidnon in August 1987 to fetch him and go home with him to Agusan. On the night of Bob’s arrival, he started having a convulsion and 15

was given paracetamol. Hours later, Bob was caught eating his own feces and drinking urine from a potty. After the incident, they went home to Agusan. Since then, Bob started to think and talk illogically, displaying disorganized speech and delusions. Weeks later Bob was brought to Davao for a check-up, first as San Pedro then at DMH. Since then, Bob has always been visiting Davao Mental Hospital and was even admitted two times, one in November 1987 then in December 2007, prior to the recent admission. Emman sees Bob’s condition rooted from that convulsion which took place in Bukidnon. As to the reason of the convulsion and the events that took place prior to the convulsion, the brother does not claim any knowledge. Characteristics and Attitude of Informant: Emman was very open and receptive to the group during the interview. He had shown efforts to recollect all salient points regarding the condition of his brother.

Informant #3 Name: Carmz Age: 18 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Female Civil Status: Single Relationship to Client: Sister Length of Time Known by the Patient: Since Birth up to Present (18) Apparent Understanding of the Present Illness of the Client: Mae understands Bob’s condition because she is a student nurse. According to her, Bob’s manifestations are indeed characteristics of schizophrenia. She believes that Bob’s condition will be 16

best improved if Bob follows all medication orders of the doctor and strictly avoid everything that the doctor prohibits him to take. Characteristics and Attitude of Informant: The informant was very responsive in the conversation, showing strong desire to tell the group everything that she knows about the illness of the patient.

Informant #4 Name: Mimi Age: 39 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Female Civil Status: Married Relationship to Client: Sister-in-law Length of Time Known by the Patient: Since Marriage up to Present (20 years) Apparent Understanding of the Present Illness of the Client: According to Mimi , the patient has been isolated and withdrawn since she first met him when she married his brother, Emman wayback in May of 1990, the patient was 21years old by then. She noted that Bob is irritating to the family members at times because there are instances wherein he seems to act like a child. She cited incidents wherein he wakes them up in the midnight because he was hungry and asks them for something to eat or drink. Bob also occasionally asks his mother to sleep with him at night. Taking this information to consideration, the sister-in-law concluded that, somehow, Bob is a burden to their family. She can see that the siblings of Bob have been exhausted in trying to understand him. Yet, in spite this, the family still show their invaluable support and love to Bob. 17

Characteristics of the informant: The informant was open and hospitable to the group. She made ways for the group to contact the family and talk to other members of the family in order to gather data that she could not provide. The warm and welcoming attitude of the informant made it possible for the group to know more about the patient.

Informant #5 Name: Boy Age: 18 Address: 162 Tulip Drive, Matina, Davao City Sex: Male Civil Status: Single Relationship to Client: Nephew Length of Time Known by the Patient: Since Birth up to Present (18) Apparent Understanding of the Present Illness of the Client: Boy says that Bob’s condition was not improving. He said that what Bob’s actions now are the same as what he does in the past. He was always isolated, self-preserved and indifferent with others. He could even go for a whole day without talking to anybody and just watch TV. Boy also says that Bob’s strange actions like talking to the television, flight of ideas and hostile behaviors are not unusual of Bob anymore. Characteristics of the informant: Boy was at the first visit unresponsive to the questions asked by the group. However, on the next home visit, he volunteered to talk about what he knows about his uncle in a warm manner.

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B. FAMILY HISTORY a. Maternal and Paternal Lineage Direct bilateral lineage of the patient show no conditions of mental illness. On the paternal side, prominent family illnesses only concern some members having hypertension. Aside from the condition, no other illnesses run the family. On the maternal line, no illness were reported to run in the family, except one family member having diabetes mellitus type 2, an illness condition occurring singularly to be considered familial. Generally, no mental illness can be traced on both sides of the family. b. Father The father is 59 years old; a known small time businessman in their place at Agusan; owning a small rice mill enough to support the needs of his family. He is a Civil Engineering Undergraduate and was able to finish only until 3rd year of the above course, due to his early fatherly obligation. He impregnated the patient’s mother, when he was only 19 years old, then eloped with her, thwarting him to finish his studies then at the University of Mindanao. As a father, he was lenient in his relationship with his children. Most of his time is spent in their rice mill and would only go home in the afternoon or at night. Moreover, he is a kind of father who would not spank or scold his children and he seldom verbalizes what he feels. He would only speak to his children wherever they do something incorrect.

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c. Mother The mother helps in their small rice mill. Pregnant at the age of 18, she was unable to finish her college education at the University of Mindanao. She was in her second year in college when she dropped out of her Chemical Engineering course. The mother says that she brought her children up in discipline and love; she said she doesn’t spank her children because it does them no good. Like the father, she doesn’t also believe in punishing her children through spanking and the like when they do something wrong. However, as she states, she left her children to the care of nannies when they were young. And put her children in their house in Davao City to pursue their education from elementary school, leaving them, still with a nanny, and visiting them once a week. According to her, this is the best way for her to offer the best education and life to her children and help improve their business in Agusan. d. Siblings The family is composed of five siblings; Bob being the eldest, followed by the second informant, Emman, then by Carmz, Denns and then Yose . His relationship with his siblings is not so good. As a child, although they were the only ones that he would play with, he would still isolate himself when with them. He never shares his thoughts with them. Furthermore, when they grew up and the illness took place, the siblings gradually got irritated with him because of his hostility towards others. 20

III. Personality History a.) Prenatal Being the result of the early pregnancy of his mother, the patient was an unexpected child. Only 18 when she was impregnated, the mother was not ready and did not know what to do, so she eloped with the patient’s father without giving her parents the knowledge as to the reason why she ran away. The mother stayed with the father’s family in Cagayan for the whole duration of her pregnancy. On course of nine months, the mother has adequate prenatal check-ups at a nearby health center. Moreover, she was able to eat adequately because the parents of her husband supported them. They provided her with enough support for her pregnancy. b. Birth Bob was born in the Provincial Hospital in Cagayan de Oro City on the 9th of April 1969 through Normal Spontaneous Vaginal Delivery. No complications took place in the delivery. The mother, Aina, described that her labor was very long, she started having labor pains in the morning and delivered in the afternoon. She did not also breastfeed the patient because she is having pain breastfeeding him and as reported, no breast milk would come out; so instead, she bottle fed the patient with a 21

formula milk in a timed manner. Moreover, she hired a nanny named Nena to look after the baby because she did not have any experience in taking care of a baby, considering her age. c. Infancy and Childhood Characteristics After the birth, in June of 1969 Aina went back to Agusan to talk to her parents. She told them that she ran away because she was pregnant and apologized for everything that she has done. Her parents did accept her apology and welcomed her back. On the August of 1969, Aina and Danni married each other and decided to reside in Agusan. Trying their luck in a new business, the couple got busy with their rice mill that they decided to leave Bob in the care of Nena, Bob’s nanny since birth, while they attend to their business. The nanny was very caring to the child, cuddling him always and looking after him. However, when Bob was almost five months, Nena went home to her province and was replaced by another nanny named Ging-ging. Moreover, Aina instructed her nanny to continue the timed bottle feeding routine every three hours, a routine which continued until the patient was three years old. She instructed to feed the baby every three hours, believing that this would help the nanny attend to other tasks while taking care of the baby. In cases that the baby would cry Ging-ging would just give him a pacifier for him to stop crying. Bob was toilet trained when he was 2 years old. Toilet training was mostly implemented by the nanny Ging-ging, and she is not strict in it. As he had a nanny, Aina instructed the Ging-ging to teach him to urinate and defecate in a potty because 22

it irritates her to find urine and stool just anywhere. Aina is very strict in toilet training. But on instances that Bob would pee or defecate anywhere, Ging-ging would just clean the mess, not correcting Bob. Bob started talking when he was a year old and started walking on that certain age more or less as reported. As to the strategies and the relationship of the nanny to the child, the mother did not exactly describe because according to her, she changed nannies several times. According to her, the relationship of the nanny was not so important to her as long as the needs of her children are met and her children’s safety is not harmed. She carefully instructed the nannies to give to the children everything they want to keep them from having tantrums that could hinder the nanny from doing other household chores. The mother could not remember whether or not the patient’s immunization is complete; but what she does remember is that the patient had measles before he was one year old. d. Psychosexual History The patient’s sexual awareness started when he was 16 years old, on his 4th year in high school. It was on this time that he started having a crush and actually had a girlfriend who after sometime broke up with him. This break-up with his only girlfriend bagged down his self esteem. In addition, his mother also keeps on teasinf him that his girlfriend’s teeth resembles that of a rat which further decreased his self-confidence and esteem as he tried to compare himself with the boys of his age. In his adolescence, he also engages in sexual activities with GROs. 23

e. Play Life Bob does not engage so much in cooperative play and prefers solitary play. He would only sit by himself and play alone in a corner. His playmates were his siblings and would choose to play only in their yard. As a child, he is not talkative, he is uncooperative and becomes aggressive when forced to play with other kids. Furthermore, he likes being a follower in a game rather than a leader. f. School History The patient began preschool in June of 1974, when he was five years old where he was sent to Davao to study at Assumption up to second grade. He stayed in their residence in Davao which is in 162, Interior Tulip Drive, Matina, Davao City. He stayed in Davao together with his brother Emman and their nanny. The first days in school were terrible for Bob, he would cry inside their classroom and would not separate from his nanny. In his third grade, he was transferred to Our Lady of Fatima School, which he did not really approve that he cries in between classes just to be sent home. He is withdrawn from the rest of his classmates and would talk only to a few people. His grades were also affected by his isolation, he did not perform well in school and was not interested in studying. He spent his high school days still at Fatima. In June of 1982, when he is 13 years old, he entered first year highschool, where he formed new set of friends which he grew much attached to. These friends of him were not of good influence because when they started hanging out, he began cutting classes, extorting money from his parents and having low grades. He started drinking and smoking. Also, he started using marijuana.

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His bad school records started worsening when his girlfriend in his fourth year high school broke up with him, these events pulled his confidence down, that he started isolating himself and increased his use of marijuana, drinking and smoking. Yet he is able to graduate from high school in the March of 1986. Troubles in school were rampant, being evident even when he is already in college. He was occasionally caught brawling with classmates. Furthermore, his mother was once called by the Guidance Office because he threw an eraser to his teacher because the eraser hit him when the teacher threw the eraser at his classmate. He was also suspected of using marijuana during this time but is persistently denying the accusations, although it was really true. Peer pressure can be seen as a great contributing factor in his use of marijuana because his friends would tease him when he refuses to use marijuana.

In his college days, he spent his two years of college education at the University of Mindanao, in the Civil Engineering course. However, he did not have good grades and still continued cutting classes and indulging in his vices. On his second year, he finally decided to stop, claiming that he is already having difficulty catching up with the lessons. g. Religious and Social Adaptability The family is Roman Catholic. However, when he was in college, their family converted to Seventh-day Adventists. However, the patient still follows the Catholic Faith and does not go to Seventh-day Adventist religious celebrations. h. Occupational History 25

When the patient stopped studying during his second year in college, late in the August of 1987, he stayed in Agusan and helped in their rice mill business. There, he would help in the loading and unloading sacks of rice and also in operating the mill. Bob doesn’t get regular salary because what he gets is ten percent of the day’s income. i. Marital History The patient is single. However, he is looking forward to marrying someday. According to his verbalizations, he wants to be married so badly that he would even marry their maid at home. According to him, he already told the maid that he wanted to marry her, but unfortunately, after telling her, the maid ran away. j. Onset of the present illness The recent admission is already the third admission of Bob. Recurrence of hostile behavior is the primary reason why Bob was admitted for three days in the CIU of Davao Mental Hospital. He suddenly shouted at a doctor in the hospital upon having his monthly depot injection and check-up.

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THEORIES OF DEVELOPMENT These are just a few of the fascinating aspects of the field of “human development”: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each theory has its own perspective on the development of man. ERIK ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future.

LIFE STAGE

INDICATORS

INDICATORS

OF POSITIVE

OF NEGATIVE

RESOLUTION RESOLUTION Infancy (birth to Learning how Mistrust, 1 year)

to trust others

Central

task:

Trust

vs.

Mistrust

ASSESSMENT

Mistrust

JUSTIFICATION

Aina, his mother,

withdrawal,

did not breastfeed

estrangement

Bob because she is having

pain

breastfeeding

him

and as reported and no

breast

milk

The first stage,

would come out; so

centers

the

instead, she bottle

basic

fed the patient in a

infant's

on

27

needs being met

timed manner. She

by the parents.

would feed the baby

The

infant

every three hours,

depends on the

believing that this

parents,

would

train

the

baby

to

be

especially

the

mother, for food,

disciplined.

sustenance,

and

Moreover, she hired

comfort.

If the

a Yaya Nena to

parents

expose

look after the baby

the

child

warmth

to and

dependable affection,

because she did not have

any

experience in taking the

care

of

a baby,

infant's view of

considering her age.

the world will be

After 5 months on

one of trust.

the service, Yaya

if

the

Nena left and Yaya

caregivers

are

Ging-ging

neglectful,

the

over her place in

But

took

taking care of Bob.

infant

instead

learns

mistrust-

Because Bob was

that the world is

given not enough

in

attention and left

an

unpredictable

under a care of a

and

nanny he had built a

place.

an

unsafe

sense of mistrust to his parents. He has not been fed well since he’s being fed in a timed manner, he hasn’t feel the 28

sense of comfort since

his

parents

haven’t been there for him to cuddle him

when

he’s

crying or to play with Early Childhood Self(2 to 3 years) Central

without loss of self-discipline

task: self

Autonomy

self-

necessary. Shame and doubt The patient started talking

when

he

was 1 year old and

to willfulness and

started walking on

cooperate

and defiance

caregivers express oneself

encourage

when

–esteem; Or compliance;

vs. ability

Shame & Doubt If

control Compulsive

him

that age as well. The

patient

was

toilet trained when he was 2 years old.

sufficient behavior,

child

As he had a nanny

develops a sense

(Yaya

Ging-ging),

of autonomy- a

the

sense of being

instructed

able to handle

Ging-ging to teach

many things on

him to urinate and

their own. But if

defecate in a potty

caregivers

because it irritates

mother Yaya

too

his mother to find

much too soon,

urine and stool just

refuse

let

anywhere, she was

children perform

too demanding that

tasks of which

the child will learn

they are capable;

how to toilet train

children

may

right away. On the

develop

other hand, Yaya

demand

instead

to

Ging-ging

doesn’t 29

shame and doubt

train him well; she

about

their

has not disciplined

ability to handle

the child well if the

things.

child

pees

anywhere

because

of

unstrict

the

training Yaya Gingging

implemented

on Bob. The child was

unable

to

master this kind of task in this stage, since he developed the sense of shame and doubt in which he was unable to handle

things

because

of

the

different implementation

of

the nanny and his Late

Childhood Learning degree Lack

(4 to 6 years) Central Initiative

of

self Guilt

of assertiveness confidence;

task: and

purpose pessimistic and

vs. influence

Guilt

the over restriction

environment;

of own activity

mother. The client does not engage

much

cooperative

play

and prefers solitary play.

He

would

to this begins stage, the child evaluate one’s learns to take own behavior.

only sit and play

initiative and get

mother and brother,

ready

he’s a silent type of

During

for

alone in a corner. According to his

person,

he’s

not 30

leadership

talkative. He likes

and

goal achievement

playing

roles.

bike and would play

If

together with his

and

siblings.

support

As verbalized by

children’s efforts,

the mother, when

while

also

playing, he was a

helping

them

follower.

make

realistic proper

his

only in their yard

adults

encourage

with

and choices,

children develop initiativeindependence in planning

and

undertaking activities. But if, adults discourage the

search

of

independent activities, children develop guilt about their needs

and

desires. School Age (7 to Developing 12 years) Central Industry Inferiority

sense

Sense of being Inferiority of mediocre;

Task: competence and withdrawal vs. perseverance

He

attended

his

nursery until Grade 2 in Holy Cross of

from peers and

Davao

College.

school.

When he was grade 3, he transferred at 31

stage,

Our Lady of Fatima

are

School. There, he

learn

again developed a

accomplish

separation anxiety,

more

complex

as he needed to

skills:

reading,

leave

At

this

children eager and

to

writing,

telling

his

friends,

old

teachers

and classmates. He

time. If children are encouraged

to

make

do

and

things and are then praised for their accomplishments , they begin to demonstrate industry by being diligent, persevering tasks completed putting

at until and work

before pleasure. If children are instead ridiculed or punished for their efforts or if

was a silent type of person and not very cooperative

and

expressive.

He

withdraws himself with his classmates, he only have few friends due to lack of interaction with them.

He

displays

also poor

performance school

in and

uninterested

with

his studies. He has not

met

the

expectations of his parents from him, which is to do well in his studies.

they find they are incapable

of

meeting

their

teachers'

and 32

parents' expectations, they

develop

feelings

of

inferiority about their capabilities. Adolescence (13 Sense of to 19 years) Central

and

plans

self Feelings

of Role Confusion

to confusion,

Task: actualize one’s hesitancy,

At this stage the client had his first

and

year high school at

Identity vs. Role abilities

possible

Holy Cross College

Confusion

antisocial

of Davao and later

The adolescent is

behavior

on,

they’ve

newly concerned

transferred to Cebu,

with how they

he enrolled himself

appear to others.

to Cebu Avillana

The

of

High School, and

identity

there, due to being a

appears through

shy type, he had not

sexual,

gained new friends.

emotional,

A certain group of

educational,

people make friends

ethnic,

cultural,

with him but they

vocational

were bad influence.

sense

central

and

discovery.

The

adolescent person

He started drinking and

also

smoking

because

of

peer

develops

pressure. Also, he

coherent sense of

started

using

self and plans to

marijuana,

when

actualize

one’s

they

group

abilities.

The

sense of self can

have

sessions

he’s

cutting his class and 33

be confused if a

because of his vices

core

identity

he always got low

does not solidify.

grades. When he

Feelings

was 4th year high

of

confusion, hesitancy,

school and

(16

years

old), he met his first

possible

love and became his

antisocial

girlfriend, but when

behavior also emerge.

may

he brought her at home, her girlfriend was being criticized by his mother to have big front teeth which are similar to a rat, this incident bagged down his self-esteem.

He

spent his two years of college education at the University of Mindanao, in the Civil

Engineering

course.

However,

he did not have good

grades

still

and

continued

cutting classes and indulging vices

and

stopped

in

his

finally studying

when he was in 2nd year

high

school 34

due to difficulty in catching up with his Early Adulthood Intimate

Avoidance

(20 to 34 years)

relationship,

Central

relationship

Task: with

Intimacy

another career

of Isolation

a

sense

the

relationship he had, or

vs. person and has lifestyle

Isolation

lessons. After though

crushing

with other girls, he

of commitments

never

developed

people commitment to and have established work their identities, relationships

another

they are ready to

had

make long-term

intimate

commitments to

relationships

others.

They

friends, though he

become capable

considers people to

of

be his friends, he

Once

intimate

relationship

with

another woman. He

forming

not

form with

intimate,

didn’t trust them

reciprocal

enough. He felt that

relationships and

he’s being envied

willingly

make

by his friends. He

the sacrifices and

continues to isolate

compromises

himself from others.

that

such

relationships require. If people cannot these

form intimate

relationships--a sense of isolation may result. Middle

Working

Lack

of Stagnation

The patient is not so 35

Adulthood ( 35 towards to 65 years)

the productivity;

Central

betterment task: the

During

helping

his

illness.

He’s

society; society to move

being dependent to

forward

his family, though

Generativity vs. being Stagnation

of not

productive due to

productive

generating

small

middle

income for helping

age the primary

in the Rice Mill, but

developmental

still he’s not being

task is one of

productive because

contributing

the little money he

society

to and

earned

is

being

helping to guide

wasted for buying

future

what

generations.

prohibited for him

When a person

to be used, like

makes

marijuana

and

cigarettes

that

a

contribution

is

being

during

this

contributes

in

period,

perhaps

worsening

his

by

raising

family

a or

illness. He has no own

family

to

working toward

support that’s why

the betterment of

he

society, a sense

money for his own

of generativity- a

wants.

sense

of

wasted

When

his

he

productivity and

had free time, he

accomplishment-

went to the plazas

results.

In

or parks to eat or

contrast, a person

drink. He also loves

who

self-

to watch television

and

shows. The client

is

centered

36

unable

or

also adapt to his

unwilling to help

physical changes in

society

his

move

body

and

forward develops

accepted this as part

a

of him, about his

feeling

of

stagnation-

disease, he hasn’t

dissatisfaction

understand

with the relative

fully

lack

further explanation

of

and

this needs

productivity.

for

A person in this

understand. And as

stage

a Filipino citizen,

have

should time

for

him

to

he has done his part

companionship

in becoming a good

and

citizen,

recreation.

he

is

a

He also knows

registered voter and

his

planned to vote for

responsibilities

Noynoy Aquino in

and knows that

the coming election

he is accountable

period, in a way

of

he’s

whatever

actions he takes.

being

productive because he has done his duty

for

the

betterment of the country. But still, he’s not helping the country

to

forward

since he

had

violated

move the

Republic Act 6425 or the Dangerous 37

Drug Act of 1972, Article III, Sec. 8 which is regarding the usage of the prohibited drugs.

SIGMUND FREUD’S PSYCHOSEXUAL THEORY The concept posits that from birth human have intellectual sexual appetites (libido) which unfold in a series of stages. Each stage is characterized by erogenous zone that is the source of libidinal drive during that certain stage. LIFE STAGE CHARACTERISTICS IMPLICATIONS ASSESSMENT Oral (Birth to 1 The center of pleasure Feeding NOT

JUSTIFICATION Though the

1/2 year)

mother,

is the mouth; it is the produces major

source

of pleasure, a sense comfort

Aina,

doesn’t breastfed

pleasure

and of

or

her child because

satisfaction

and ease and safety.

she felt that it is

exploration.

The Feeding

should

painful, still he

child’s primary need be pleasurable, it

feds Bob through

is security or safety.

be

bottle-feeding but

when

in a timed manner

Major

should

conflict: provided

weaning ANAL (1 1/2 The to 3 years)

ACHIEVED

necessary. sources

which is every 3

of Controlling

pleasure are the anus expelling and

the

(sensual

feces ACHIEVED

bladder give pleasure and

satisfaction, sense of comfort.

self control).

Toilet

Major conflict: toilet should training.

and NOT

hours. Toilet

training

was

not

strict.

Bob

was

toilet

trained

by

his

training

nanny which was

be

instructed by his

a

pleasurable

mother to instruct

experience.

him to defecate in 38

a

potty.

nanny,

Her Yaya

Ging-ging not

able

implement

was to well

the instructions of her Ma’am Aina, the Bob,

mother Bob

of was

still urinating and defecating everywhere. Yaya Ging-ging not

able

discipline well

when

was to Bob it

comes to toilet PHALLIC (4-6 The genitals are the The years)

child ACHIEVED

training. At this stage, he

center of gratification. determines

was able to learn

Masturbation

that a boy is for a

offer together with the

pleasure to the child. parent

of

the

Other actions include opposite sex and fantasy,

girl, and a girl is for a boy.

later takes on a

experimentation with love relationship peers, and questioning outside

the

of adults about sexual family. issues

or

sexual

matter. Major conflicts: the Oedipus

Complex

(refers to the male child's attraction for 39

his

mother

unfriendly towards

and

attitudes his

father)

and Electra Complex (refers to the female's attraction

for

her

father and sees her mother as her rival), which resolves when the

child

when

identifies

the

child

identifies with parent of same sex. LATENCY (6 Energy is heading for Encourage child NOT

He started to go

years

to school by this

puberty)

to physical

and with physical and ACHIEVED

intellectual activities. intellectual

time;

Sexual impulses tend pursuits.

gained

to

friends and few

be

repressed. Encourage sports

he

few

Develop relationships and

other

playmates

between peers of the activities

with

because

same sex.

same-sex peers.

had

he

prefers himself to be

alone.

He

isolates himself to his peers. He had not

been

performing

well

to

school

and

uninterested

to

study his lessons. Genital (puberty after)

Energy and toward

is

directed Encourage

NOT

full

sexual separation

from ACHIEVED

independent, until

being

now , he

maturity and function parents,

He

is

not still 40

and development of independent and

lives

skills needed to cope able

parents and being

with the environment.

to

make

with

right and good

dependent

decisions

them,

his to

especially

when it comes to his basic needs and as well as to meet his personal needs to gratify his desires, like asking money to have

sexual

gratification together

with

some GROs and to buy marijuana or cigarettes. He’s not matured when it comes to his sexuality.

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT This theory pertains to the nature and development of human intelligence. LIFE STAGE CHARACTERISTICS ASSESSMENT Sensorimotor Thought • In this stage, inACHIEVED

JUSTIFICATION The client as an infant

(birth-2years)

fants build an un-

was

derstanding of the

breastfed

world by coordi-

mother; he was fed

nating sensory ex-

with the use of the

not

being by

her

41

periences (such as

bottle, when giving

seeing and hear-

the bottle, the infant

ing) with physical,

Bob grasp it as a

motoric actions.

response

Infants gain

hungriness.

knowledge of the

mother, at times, gives

world from the

him a pacifier when

physical actions

the child is crying thus

they perform on

fulfilling the child’s

it. An infant pro-

wants.

of

his The

gresses from reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage. •

Thought derives from sensation and movement.

•

The child learns that he is separated from his environment and that aspects of his environment continues to exist even they may be outside the reach of

Preoperational Thought (2-7 years)

•

his senses. Thinking is still egocentric: has

ACHIEVED

At this age, was fond of

drawing

that 42

•

difficulty taking

represents his ideas.

the point of view

He also draws to show

of others.

what is inside of him,

The children begin

to express his feelings

to represent the

through images that

world with images

he creates.

and words. Symbolic thought goes further than connections of sensory information and physical action. •

Objects are classified in simple ways, especially by significant feature; the child isn’t able to conceptual-

Concrete Operational •

ize abstractly. The child starts to

Thought (7-12 years)

think abstractly

how to arrange his

and conceptualize,

things systematically

forming logical

or in order depending

structures that ex-

on its size, shape or

plains his or her

any

physical experi-

characteristics;

ences.

disorganized when it

Children can exe-

comes to his things.

•

NOT ACHIEVED

Bob does not know

other he’s

cute operations and logical reasoning replaces intuitive thought as 43

long as reasoning can be applied to specific or concrete examples. •

Children show thinking is decentered -they consider multiple aspects of the problem (e.g. understanding the significance of height and width). They focus on the dynamic change in the problem. And, most importantly, they show the reversibility of true

Formal

Operational •

mental operation. The person is ca-

ACHIEVED

During this stage, the

Thought (12 years and

pable of deductive

client was able to

above)

and hypothetical

understand what love

reasoning.

means

The logical quality

about his plans about

of the adolescent's

getting married in the

thought is when

future

children are more

chance;

likely to solve

wanted to marry their

problems in a tri-

helper, according to

al-and-error fash-

him. Though he never

ion.

courted the girl, he

•

.He

if

shared

given he

a

really

44

•

•

•

During this stage

just directly asked her

the young adult is

to marry him but the

able to understand

woman

such things as

answer him and went

love, "shades of

home

gray", logical

hometown.

proofs and values.

In addition to that,

During this stage

when asked, “Kung

the young adult

makakita ka ug pitaka

begins to entertain

na

possibilities for

unsaon man nimo ang

the future and is

pitaka, iuli o gastuhon

fascinated with

ang kwarta?”; he then

what they can be.

replied “Iuli nako, kay

At this stage, they

basig

can also reason

tag-iya ang kwarta.”

logically and draw

He was able to draw

conclusion from

conclusion from the

what information

given

is available.

available.

refused to

punog

to their

kwarta,

kailangan

sa

situation

45

ETIOLOGY AND SYMPTOMATOLOGY A. ETIOLOGY

Predisposing Present/ Absent Factors Family History

Absent

Rationale

Justification

Individuals

with Schizophrenia is not

schizophrenia

seem

to present in any of the

inherit a predisposition to family members of the

disorder

schizophrenia

because the patient in both runs

in paternal and maternal

families. The relatives of lineages. individuals

with

schizophrenia

have

a

greater incidence of the disorder than chance would allow.

Although

an

amazing

amount

of

resources

have

directed genetic

at

finding cause

been the of

schizophrenia, the results are far from specific. In fact,

almost

every 46

chromosome

has

been

linked with schizophrenia. Keltner, Neurostructural

Absent

Anomalies

N.

Psychiatric

Nursing. Chapter 4. The theorists proposed

have The patient’s chart that did not show any

schizophrenia, is a direct laboratory results to effect

of

three confirm the existence

nuerostructural

defects. of such anomalies if

Ventricular brain

enlargement, such are present in

atrophy

dysfunctional blood

and the patient. cerebral

flow.

These

anatomical anomalies in the brain play a major role in the illness. Keltner,

N.

Psychiatric

Nursing. Chapter 4. Precipitating Present/ Absent Factors Intake of drugs, Present

Dopamine is known to be The patient admittedly

substances

or

the neurotransmitter which takes marijuana since

chemicals

which

is prominently affecting he was thirteen. All

increase dopamine.

levels

of

Rationale

the

occurrence

Justification

of informants also concur

schizophrenia. In patients that

the

patient

is 47

with

schizophrenia, indeed

dopamine

levels

using

are marijuana.

invariably high. Therefore, intake or use of drugs, substances and chemicals which

promote

elevation

of

the

dopamine

levels in the brain would trigger

schizophrenia.

Example

of

levodopa,

these

are

ampethamines

and marijuana. Keltner, Perinatal Factors

Absent

N.

Psychiatric

Nursing. Chapter 4. Some researchers believe The mother did not that schizophrenia can be report

any

linked

perinatal abnormalities

and

influenza, complications

during

to

exposure birth

to during

winter, her

pregnancy

and

exposure to lead, minor birth. The mother also malformations during early verbalized no exposure gestation,

exposure

to to

any

infections

viruses from house cats during her pregnancy. and

complications

pregnancy,

of

particularly 48

during labor and delivery. Keltner, Developmental Factors

Present

N.

Psychiatric

Nursing. Chapter 4. Developmental factors There are some stages include

the

internal of

development

reaction of an individual to according to Erikson life stressors or conflicts. that the patient did not Three theorists could be successfully meet. considered here: Meyer, Freud and Erikson. For Meyer, events in early life can cause problems that are

as

severe

as

schizophrenia. For Freud, developmental include

factors

poor

boundaries,

ego

fragile

inadequate

ego, ego

development,

superego

dominance, regressed or id behavior,

ambivalent

relationships and arrested psychosexual development. Furthermore, Erikson

believed

that 49

eight-stage

model

of

human

development

starting from Trust Vs. Mistrust highly influences development condition.

of

the The

accomplishment or failure in the levels affect a person’s

developmental

aspect. Keltner,N. Convulsion

Present

Psychiatric

Nursing. Chapter pp. Convulsion, in medicine, The

patient

had

a

series of involuntary con- convulsion when he tractions of the voluntary was

18

years

muscles. The eyeballs fre- Informants

old. have

quently roll upward or to attested that after the one side during a convul- incident, sion; breathing appears la- started bored, and saliva oozes behavior

the having

patient odd and

from the mouth. The teeth disturbance in thought usually

are

tightly process.

clenched, sometimes causing serious bites to the

50

tongue and the cheeks. Convulsions are a common symptom of epilepsy. They also occur in young children as a part of the reaction of the body to infection.

Such

convulsions,

called febrile convulsions, usually last only a few minutes and are not dangerous. Other causes of convulsions are virus infections; brain tumors or hemorrhages;

toxemias,

such as uremia or lead or cocaine poisoning; chemical disorders, such as hypoglycemia; and acute or chronic alcoholism. A doctor

should

be

notified

whenever a convulsion occurs. Until the arrival of a physician,

emergency

treatment is directed to51

ward protection of the victim from biting or other forms of self-injury. Anticonvulsant drugs include diazepam,

phenobarbital,

and phenytoin. A convulsion may have a significant effect in an individual due to restriction of brain oxygenation in the occurrence of the convulsion. Damage to brain tissues range from mild to severe depending on the type of convulsion and how long. Furthermore, brain cell damage is irreversible. Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

B. SYMPTOMATOLOGY Symptoms

Present/Abse

Rationale

Justification 52

nt

OBJECTIVE SIGNS A. Alterations in Personal Relationships Decreased

Present

attention to

Frequently, patients become less The patient has troubled concerned with their appearance and relationship with other

appearance and

might not bathe without persistent people.

social amenities

prodding. Table manners and other

related to

social skills might diminish to the

introspection and

point that the patient becomes

autism. Inadequate or inappropriate communication

disgusting to others. Present

Keltner, N. Psychiatric Nursing. Patients with schizophrenia have Communication troubled

personal

relationships. of the patient show

Often, these problems develop over a constant long

period,

schizophrenia

well

incoherent

before statements,

is diagnosed,

and circumstantiality,

become more pronounced as the tangentiality illness

skills

progresses.

It

is

and

the

not like which are highly

uncommon to hear that a person was indicative of inadequate asocial, loner or a social misfit and before being diagnosed.

inappropriate

communication.

Keltner, N. Psychiatric Nursing.

53

Hostility

Present

Hostility can also be a common

As the illness progresses

theme, which distances patient from

the hostility became ap-

others.

parent in the patient. The

Keltner, N. Psychiatric Nursing.

patient has tantrums, confronting people with no apparent reason, tumbling tables and chairs and wants to hit people.

Withdrawal

Present

Patients withdraw,

with

schizophrenia

which

further

compromises their ability to engage in meaningful activities. Keltner, N. Psychiatric Nursing

As the informant could remember the patient prefers solitary play in his childhood. Moreover in his adolescence he would hangout with a few friends. Patient has diminished or lost interest in communicating with people.

B.

Alterations in Activity

Psychomotor

Absent

retardation

Catatonic rigidity

Absent

Psychomotor retardation, the markedly slow

The patient did

speech and body movements which occurs

not exhibit this

as a symptom of schizophrenia

symptom.

Keltner, N. Psychiatric Nursing Patients with schizophrenia also display

The patient did

alterations of activity. They may be too

not exhibit this

active or they may be inactive or catatonic.

symptom 54

Keltner, N. Psychiatric Nursing

SUBJECTIVE SIGNS A.

Altered Perception

Hallucinations

Present

Hallucinations

which

Absent

false

Hallucinations, espe-

sensory perceptions, which can be

cially those which are

auditory, visual, tactile, gustatory or

auditory in form is

somatic

are

highly evident in the

by

verbalizations of the

.

Hallucinations

probably

Illusions

are

caused

hyperdopaminergic state in the

patient and also in his

limbic areas.

actions as described by

Keltner, N. Psychiatric Nursing

the informants.

Illusions are misinterpretations of

The patient does not ex-

stimuli.

hibit this symptom.

Like

hallucinations,

illusions also occur as a result of hyperdopaminergic state in limbic areas. books.google.com.ph/books? Paranoid thinking

Present

isbn=0471245313 Suspiciousness of others and their

In connection to perse-

actions also occur as a symptom of

cutory delusions of the

schizophrenia which happens due to

patient, he is becoming

the

suspicious and distrust-

alteration

of

the

normal

perceptual pattern of an individual

ful of people around 55

affected by the condition.

him. He is in deep be-

www.asialink.unimelb.edu.au

lief that people are out there trying to kill him, thus, he becomes paranoid.

B.

Alterations of Thought

Loose associations Present

This is the stringing together of unrelated

Loose associa-

topics with vague connection. This occurs as

tions can be

a result of the altered thought process in

traced in many

individuals with schizophrenia.

of the state-

Keltner, N. Psychiatric Nursing.

ments made by the patient in conversations. Details which do not have anything to do with the topic are being mentioned by the patient.

Retardation

Absent

Retardation is the slowing of mental

This symptom

activity, which is also a direct effect of

is not exhibited

thought process alterations in individuals

by the patient.

affected by schizophrenia. 56

Keltner, N. Psychiatric Nursing.

Blocking

Present

Blocking is the interruption of a thought and

Blocking is ap-

inability to recall it. Blocking may be caused

parent in con-

by the intrusion of hallucinations, delusions

versations with

or emotional factors.

the patient.

Keltner, N. Psychiatric Nursing.

There are several instances wherein he would suddenly stop right in the middle of a conversation.

Ambivalence

Absent

Ambivalence is a state in which two

This symptom

opposite

is not exhibited

strong

feelings

exist

simultaneously. Schizophrenic patients may be

immobilized

by

their

by the patient.

ambivalence

regarding a matter as simple as deciding whether to drink an apple juice or an orange juice. Delusions

Present

Keltner, N. Psychiatric Nursing. Delusions are fixed false beliefs and can

Persecutory

take many forms. Delusions are defined as

delusions are

false belief firmly held by a person even

highly evident 57

though other people recognize the belief as

in the patient’s

obviously untrue. For example, a person

verbalizations

who truly believes he is Napoleon Bonaparte

and actions de-

is delusional. Religious beliefs or popular

scribed by the

conceptions, such as the belief that people

informants.

have been abducted by aliens, are not delusions because they are widely held beliefs. Delusions are a type of psychotic symptom that indicate a person has lost contact with reality (see Psychosis). There are many different types of delusions. A person with a paranoid delusion believes that others—such as the FBI, CIA, or the Mafia—are trying to harm or plot against him or her. A person with a delusion of reference believes that events or people refer specifically to him or her when they do not. For example, a woman with schizophrenia may believe that a television news broadcaster is talking personally to her rather than to the entire viewing audience. A grandiose delusion is a belief that one is extremely famous or that one has special powers, such as

58

the ability to magically heal people Keltner, N. Psychiatric Nursing. en.wikipedia.org/wiki/Delusion Poverty of Speech Absent

Poverty of speech is manifested by the

This is not

inability to formulate and articulate thoughts

manifested by

that are relevant to the discussion at hand.

the patient.

This is also highly connected in the alterations of thought process taking place in individuals with schizophrenia. Ideas of

Absent

Reference

Keltner, N. Psychiatric Nursing. Ideas of reference and delusions of reference

This is not ex-

involve people having a belief or perception

hibited by the

that irrelevant, unrelated or innocuous

patient.

phenomena in the world refer to them directly

or

have

special

personal

significance. In psychiatry, delusions of reference form part of the diagnostic criteria for psychotic illnesses such as schizophrenia during the elevated stages of mania. Autism

Absent

Keltner, N. Psychiatric Nursing. Autism occurs when patients

are

so

This is not

introspective that they are distracted from

manifested by

external

the patient

events.

Patients

become

preoccupied with themselves and may be 59

oblivious to the reality around them.This results in a personalized view of reality. Keltner, N. Psychiatric Nursing. C.

Altered Consciousness Confusion

Present

Confusion is an anxiety-producing symptom

Disorientation

that is associated with psychosis. Keltner, N.

to time is evi-

Psychiatric Nursing.

dent in the patient. The patient is obviously confused as to the time and chronological arrangement of events in his life.

Incoherent Speech

Present

Like confusion, incoherent speech is also a

The patient

direct

displays inco-

effect

of

schizophrenia

in

the

functioning of an affected individual.

herent speech

Keltner, N. Psychiatric Nursing.

as evidenced by the disorganization of thoughts and flight of ideas which are illogical to fol60

low.

D.

Alterations in Affect

Inappropriate,

Absent

Affective

flattening,

inappropriateness,

This is not

blunted, flattened

lability are affective symptoms sometimes

manifested by

or labile

associated with schizophrenia. They often

the patient.

respond to antipsychotic drug. Flat affect is a

cardinal

symptom

of

negative

schizophrenia and may only respond to an atypical antipsychotic drug. Apathy

Absent

Keltner, N. Psychiatric Nursing. Apathy is another symptom associated with

This is not

the affective alterations brought about by

manifested by

schizophrenia. It can be defined as a lack of

the patient.

concern or interest. It is the inability to generate a normal response to people, situations or the environment. Overreaction

Present

Keltner, N. Psychiatric Nursing. Because of emotional limitations,

the

The patient

schizophrenic patients overreact to normal

overreacts to

events to overcome mental and social

normal situa-

inertia. Keltner, N. Psychiatric Nursing.

tions. The informants verbalized that the 61

patient overreacts even in simple television shows. Anhedonia

Absent

Anhedonia is the inability to experience

This is not

pleasure which is highly associated with the

manifested by

detrimental effects of schizophrenia in the

the patient.

affect

of

individuals

schizophrenia.

Keltner,

suffering N.

from

Psychiatric

Nursing.

62

PSYCHODYNAMICS

63

NARRATIVE PSYCHODYNAMICS Bob’s parents, Aina and Danni, eloped at the age of 18 and 19 respectively. They ran away to Cagayan because Aina got pregnant. They lived together with Danni’s parents there while Aina’s parents did not know about anything. Anxiety, guilt and shame caused emotional distress in both of them in this stage. Both undergraduates in their courses, Aina and Danni, stopped studying and were dependent to Danni’s parents to support them in Aina’s pregnancy. Danni’s parents, supportive of their child, provided a jeepney for Bob to use as a temporary means of income for them to use in the course of Aina’s pregnancy. In the course of her pregnancy, Aina had adequate prenatal check-ups at a nearby heath center. Young for pregnancy and emotionally anxious, Aina’s situation puts her child, Bob at high risk of fetal abnormalities. In the prenatal stage, the mother’s pregnancy is highly affecting the baby. According to researches, the mother’s emotional state during pregnancy may bring about long term effects in the fetus. This is so because stress-induced changes in the endocrine system of a woman during pregnancy is said to cross the placental barrier, thereby, affecting the fetal environment. Researches in low income African American populations in 2002 made by Mulder, et. Al., presented that depressed and anxious mothers during pregnancy were more likely to have negative consequences to the baby which extend far beyond the events of childbirth. During birth, the mother may experience complications, premature labor and delivery and even spontaneous abortion. Depression during pregnancy may also induce immunologic and neurological anomalies in growing fetus. Cognitive impairment, together with motor retardation may also be possible. 9th of April 1969. Aina felt labor pains early in the morning, unfortunately, Danni was out making a living, and it was some time before Danni was successfully called by a neighbor that his wife was already in labor. Aina was rushed to Cagayan de Oro Provincial Hospital. There, she 64

delivered Bob through NSVD without any complication. However, according to her labor was rather long and extremely painful. From birth, Bob was left in the care of a nanny named Nena. Aina entrusted Bob to Nena because she did not have enough skills in tending a child. Furthermore, she also has to go home to Agusan in order to talk to her parents. Bob was not breastfed because Aina felt pain when she attempted to breastfeed Bob. So she decided to feed him with formula milk in a timed manner every three hours. Bob being left to the care of a nanny and the limited presence of his parents, started building the sense of mistrust in the part of Bob as a baby. Furthermore, as Bob was not able to be breastfed, he was unable to absorb significant nutrients from his mother, together with oxytocin and colustrum, which directly contributes to poor mother-child bonding. In the August of 1969, Aina and Danni married each other in Agusan and moved there, starting a rice mill business. Trying their luck on their new business, the couple got busy in their rice mill and left Bob to the care of Nena. They would only go home at night and has poor bonding with the child. As a result feelings of Mistrust formed in the child’s psyche.

Moving on, in Bob’s toddlerhood, the core conflict in this stage, according to Erikson is Autonomy Vs. Shame and Doubt. And in the resolution of this conflict, the child must learn to imitate. Imitation being the core process involved in the resolution of the conflict in this stage, Bob is not at all fortunate. His parents’ availability was limited and the attitude of his mother and nanny were very variable. Thus, Bob developed a sense of confusion and inability to identify to any of his parents. Bob was unable to master skills such as eliminating and dressing up because everything was just handed to him readily by the nanny. Although this “spoiling” of the nanny to Bob may

65

contribute to his sense of autonomy, his lack of figures of attachment bringing about confusion and inability to master certain tasks further outweighs his derived autonomy. Thus, Bob gained doubt. During his play age, Bob was a loner. He would want to be in solitary play. He would only play with his siblings and would only play inside their yard. He was not open to other children. In this stage, the core conflict is Initiative Vs. Guilt. Initiative is the inquiry of the child to the world. The child begins to explore and uncover the wonders of the world around him and use his senses to perceive the order of things. In this stage the child learns to adapt and resolve the conflict thru education. However, Bob was a loner, withdrawing from other people in play. Furthermore, first signs of hostility were noted on Bob at this stage, because he would become hostile whenever asked or forced to join other kids in their play. Bob is also a good follower rather than a leader in games. During this stage, he did not accomplish the developmental task of forming initiative but instead formed sense of guilt. In school age, Bob was as withdrawn as he is in his past developmental stage. He has a difficulty in relating to others and as a result, his school performance is highly affected. He consistently has separation anxiety and cries inside the classroom every time his nanny would be out of his sight. Because of this, Bob was unable to form meaningful relationships with others and thus formed inferiority. In his adolescence, Bob entered high school at the age of 13 in the June of 1982. Bob became attached to a certain group of friends who doesn’t seem to be a good influence to him. As a shy person, Bob didn’t have many friends, so when this small group of people asked him to hang out with them, Bob was overwhelmed, believing that they could provide belongingness and acceptance. Bob treasured this small group of friends because this is all that he has. Bob was easily affected by peer pressure. Fearing rejection if he does not do what his friends would want him to do.

66

So when his friends asked him to join them in their vices, Bob also joined in. Bob started drinking alcoholic beverages and smoking. Worse, Bob also began using marijuana. During his fourth year in high school, Bob was 16 years of age, he met a girl named Rowena and courted her. Rowena became Bob’s only girlfriend. There was actually a time wherein Bob brought Rowena home, but his mother disapproved of her because she said her teeth looks like rat teeth. This created anger and insecurity in Bob. Later on, Rowena broke up with him for an unknown reason. This break up bagged down Bob’s self esteem. He started isolating himself again and increased his use of marijuana, drinking and smoking. In this stage, Bob is obviously not in control of his life. His decisions were affected by the people around him. Even his role in the society and the people that he chooses to be with are dictated by peer pressure and the ideas of his mother. Bob therefore has role confusion. Entering college at 17, Bob went to the University of Mindanao for Civil Engineering course. However, due to his constant to constant absences and tardiness, Bob’s academic performance trampled. Coupled with his consistent use of marijuana, cigarettes and alcohol, Bob’s life was greatly affected. Behavioral changes emerged, his hostility grown so large that he already fights with teachers and brawls with classmates. He was also called in by the Guidance Counselor regarding his behavior. With this in mind, Bob therefore failed to achieve this stage of development and formed isolation. It was also in this stage that the first onset of the illness happened. Bob was 18 back then when Bob stopped studying, he went back to Agusan with his brother. Prior to going to Agusan, he had a convulsion in a trip to Bukidnon in the August of 1987, there he ate his own stool and drank urine from a potty. First persecutory delusion also emerged there. After the incident, Bob was never the same again. He is already having flight of ideas, disorganized speech, hallucinations and extreme hostility. Because of this and his verbalization that there is something wrong with him, he 67

was brought to Davao City for a psychological chec-up. In San Pedro Hospital, no mental illness was diagnosed, but upon their return the next month and transferred to DMH, Bob was diagnosed with schizophrenia catatonic type. After then, Bob constantly visits DMH for his depot. At first, control of symptoms were at its best, but as the years progressed, he was again admitted in the December of 2007 because of the recurrence of symptoms of hostile behavior. The following admission, which is on the 19th of January 2010 was also due to his hostile behavior.

68

MENTAL STATUS EXAMINATION INITIAL Name: Bob

Diagnosis: Schizophrenia Undifferentiated

Age: 40 years old

Physician: Gioia Fe D, Dinglasan, MD

Ward: Crisis Intervention Unit

Date of Examination: January 21, 2009

I.

PRESENTATION A. General Apperance The patient appears to be younger than his real age which is 40. During the interview at Crisis Intervention Unit in Davao Mental Hospital, he wore a green polo shirt, denim shorts, and a pair of slippers and is seated on bed with his mother and sister-in-law. The patient appears to be untidy. He has dirty clothing, unkempt hair, long fingernails and toenails with traces of dirt evidently seen on both. At the time of the interview, the patient was alert and responsive. B. General Mobility a. Posture and Gait – The patient slouches when seated but holds himself erect when standing and walking. His mannerisms include manually hyper extending his fingers and scratching his head. b. Activity – The patient’s movement are organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity. c. Facial Expression – The patient’s facial expressions are very much appropriate to his verbal responses during the interview. He was composed and receptive to whatever the group asks him. 69

C. Behavior The patient was friendly and warm to us during the interview. He was sitting on bed calmly. He interacts well with the group and as what we had observed; he has a good relationship with his mother and his sister-in-law who were present at that time. D. Attitude towards the Examiner The patient accepted the group warmly. He entertained our questions and answered almost all of them. However, his eye contact was poor. He often looks down. II.

STREAM OF TALK A. Characteristic of Talk – During our conversation with the patient, we noticed that he is spontaneous most of the time. However, there are times in which blocking is evident in between his speech. His articulation words were clear but the content is slightly vague. B. Organization of Talk – The patient was eager to talk with the group. He tries to answer every question the group asks him however, in his answers, we apparently observe succession of circumstantiality and tangentiality. He provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesn’t arrive at the answer at all.

III.

EMOTIONAL STATES AND REACTION A. Mood – At the course of the interview, the patient’s mood was euthymic. His feelings were appropriate to the situations as he relays his answers to the group.

70

His mood was just appropriate and basing from his gestures and other nonverbal cues, his mood is fitting to the situation. B. Affect – The patient’s affect is appropriate as well. There is a marked harmony

between thought content, emotional response, and expressiveness. When asked, “Unsa may nabati nimu kadtong nagka-uyab mo?”, he replied, “Lipay kaayo ui. Alangan. Kaw gud daw magka uyab.” with a smile. IV.

THOUGHT CONTROL A. Perceptions – Throughout the interview, the group observed manifestations of illusions and hallucinations. When the patient was asked if he experiences any of the two, he told us that there are times that he hears someone whispering to him. “Naa may gahong-hong sa ako usahay na mag wild daw ko.”, as claimed by the patient. He denied that he had any visual hallucinations however, the mother and the sister-in-law attested that during tantrums, the patient verbalizes that he sees someone whom they cannot see. B. Delusion – There are several types of delusions that are present in the patient as claimed by the patient himself, and confirmed by the mother who witnessed them all. First, the patient claimed that there is some sort of outside force controlling his thought, compelling him into the belief that somebody has aa plan to kill him – which is a clear sign of persecutory delusion. He also has a feeling that others, especially his friends, hate him because they are jealous of him.

V.

NEUROVEGETATIVE STATE A. Sleep The patient usually sleeps at 12 in the midnight and usually wakes up at 5am getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and in71

stead, he just spends his time watching television until he falls asleep. Five in the morning for the patient is too early for him to wake up that is why he attempts to go back to sleep, but then, he is unable to do such. This is a manifestation of late or terminal insomnia. B. Appetite The patient has increased appetite. He eats a lot however, he is choosy in his food. “Ganahan man gud ko mukaon samot na kung lami ang sud-an.”, reported by the patient. “Kusog kaayo mukaon nang bataa na, pero pili-an lang jud ug sud-an.”, as verbalized by his mother. C. Diurnal Variation The patient’s mood varies during the day. He is usually fine in the morning and gets, uneasy, restless, and irritable as the day progresses. Other times, his day starts out worse in the morning and feels better later on. VI.

GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation The patient is well oriented of the time, place and person. When asked during the interview if what date and time was it, he answered correctly. However, as the conversation progressed, we noticed that he is confused and not well oriented with the time. When asked, when did he last used marijuana, he answered, “Two months ago. Mga 2008.” The group finds this statement confusing since two months ago, basing on the date of the interview, is around November of last year (2009). The patient is also oriented with the situation since he knows that he is the Davao Mental Hospital for his treatment. B. Memory 72

The patient has difficulty recalling remote memories. When asked what his age when he went to Bukidnon was, he replied; “Ambot lang. Wala ko kahinumdom.” On the other hand, the patient has a good memory when it comes to remembering recent and immediate memories. C. Calculation The patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and the like. He was able to answer all of them but there we long pauses before he can finally give the answer. D. General Information The patient knows basic general information like the current president of the Philippines and even of the United States. He know the capital of some Philippine provinces and he was able to name the national hero of the country. E. Abstract Thinking, Judgement and Reasoning The patient was given a maxim translated in Visaya to evaluate his reasoning and abstract thinking. He was asked to explain the quote Try and try until you succeed. He was able to explain it but not profoundly. He said, “Maningkamot gud.” And when asked to elaborate, he refused to. He was also given a situation wherein someone left her wallet, and he was asked what he should do. He replied, “Akong i-uli. Di man na akoa so dapat nako i-uli.” VII.

INSIGHTS The patient understands that he needs to go to the hospital for his treatment. Since he was 18, he knew that there is a problem in him and he even asked his mother to bring him to the doctor. However, he does not have concrete understanding of what his illness

73

is. He believes that there is a lube (grasa) in his brain that is why he is acting differently, thus, he has a fair insight.

74

FINAL

Name: Bob

Diagnosis: Schizophrenia Undifferentiated

Age: 40 years old

Physician: Gioia Fe D, Dinglasan, MD

Place of Interview: 162, Interior Tulip Drive, D.C. Date of Examination: January 23, 2009

I.

PRESENTATION A. General Apperance During the home visit the group did, the patient was wearing a blue shirt and denim pants. Again, Bob looked younger that his age which is 40. He was properly groomed and looked like he had just taken a bath. He was actually getting himself ready to go back to Agusan. His fingernails and toenails are still long and dirty. During the interview, the patient was again warm and yet a little aloof to us. He looked happy to see us again for the second time. B. General Mobility a. Posture and Gait – The patient still slouches when seated but holds himself erect when standing and walking. His mannerisms are still present and evident throughout the interview. b. Activity – During the interview, the patient was able to sit straight and fo-

cus on answering the questions asked to him. There is no overactivity or underactivity nor impulsiveness noted. He was very calm and composed along the interview.

75

c. Facial Expression – The patient was able to exhibit appropriate facial expression towards a certain topic. C. Behavior/Attitude towards the examiner The patient was still accommodating to the group but we noticed that he is a little shy this time. He seated on one corner and has minimal eye contact. II.

STREAM OF TALK A. Characteristic of Talk – He speaks in a loud tone and his words were very clear to us. Blocking was still evident especially when we bring in the discussion on his use of marijuana. He maintains limited eye contact this time and prefers to look down and do his mannerisms. His attention was still in the conversation though. B. Organization of Talk –Most of his statements were not comprehensible this time. Circumstantiality and Tangentiality still surfaced during the interview. He still cooperates with the discussion and still, he tries to answer the questions we gave him.

III.

EMOTIONAL STATES AND REACTION A. Mood – The patient was able to maintain a normal mood all through the home visit. He was responding well to the conversation and his mood was appropriate for the discussion. B. Affect – The patient’s affect was still appropriate as well. His statements jive very well with his facial expressions and gestures.

IV.

THOUGHT CONTROL A. Perceptions – Throughout the interview, the group did not observe any manifestations of illusions or hallucinations. He was very calm and composed. 76

B. Delusion –Delusion of paranoia was present. He believes that his friends were very much jealous of him since his family owns a rice mill. When he was asked why did he say so, he answered, “Dugay ra ko gaduda ana nila. Maka ingon jud ko na na sina ni sila nako kay din a muduol nako.” This is a manifestation of delusion of paranoia. He was also asked about his illness. “Naa man koy grasa sa utok. Murag gud ug makina. Madaot.” This is a manifestation of a somatic delusion. V.

NEUROVEGETATIVE STATE A. Sleep The patient said that he had a good sleep the night before the interview. According to his sister-in-law, he slept at around 11pm and woke up at around 5am. He said that he did not have any difficulty sleeping at night. “Na injectionan man gud ko gahapon mao nang maayo akong tulog.” B. Appetite The patient had a good appetite. He was eating his breakfast well and was able to consume a moderate amount of rice and viand. C. Diurnal Variation It was around 7:30am when we conducted the home visit and so far, he was relaxed and comfortable. He did not have any feeling of discomfort or uneasiness during the interview.

VI.

GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation

77

The patient is well oriented of the time, place and person. He was still able to recognize our group after two days of not seeing each other. He is aware of the time and the place as well.

B. Memory Most of our questions to him were about his adolescent life and we can say that he has difficulty remembering details. Long pauses before answering indicate that he was trying to retain information for him to come up with the answer. The nurse asked, “Pila man imong edad gasugod kag gamit ug marijuana?”. He replied “Ambot lang” and “Dili ko sigurado.” C. Calculation The patient was given again given mathematical equations. Still, he was able to answer all of them correctly and quickly. D. General Information The patient was asked to enumerate the presidentiables he knows for this upcoming election in May 2010. He was able to name Villar, Aquino, Estrada, and Gordon. He said that he would vote for Aquino since his mother was a good example to everyone. “Si Noynoy jud akong iboto kay maayo nang tao, liwat sa iyang mama.”, said with calm emotion by the client. E. Abstract Thinking, Judgement and Reasoning The patient was given another set of situations and questions to evaluate him. He was asked to tell the group the meaning of certain idiomatic expressions like parang basing sisiw. He was them each correctly but with limited words. When asked if he would cheat on a quiz if the teacher is not around, he insistently an78

swered NO. “Dili mana maayo nang manikas ka. Maski wala pa gatan-aw ang teacher, gatan-aw man ang Ginoo.” He explained.

VII.

INSIGHTS The patient still had the same understanding of his illness. Manifestation This time, he insists his false belief that marijuana is not harmful to him and even claimed that it is therapeutic for him. Delusions were more evident this time. He also insists that his vices especially smoking and drinking Coke, which the doctor prohibited, are helpful to him. With these statements, we can say that he has a poor insight.

79

MULTIAXIAL ASSESSMENT Axis I- Schizophrenia Undifferentiated This type of schizophrenia is manifested by pronounced delusions, hallucinations, and disorganized thought processes and behavior, but criteria for other types of schizophrenia are not met (Antai-Otong, 2003). Axis II Schizotypal Personality Disorder Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, odd behavior and thinking, and often unconventional beliefs. These people tend to turn inward rather than interact with others, and experience extreme anxiety in social situations. People with schizotypal personality disorder often have trouble engaging with others and appear emotionally distant. They find their social isolation painful, and eventually develop distorted perceptions about how interpersonal relationships form. (Psychiatric Nursing: contemporary practice. Mary Ann Boyd. 2007) Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 80

2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity

     

and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder

Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid) 6÷10 ×100 =60% Axis III- Axis 3 is not applicable to the client. Axis IV- inability to go back to school, unemployment Napoleon was unable to finish his schooling. He was a 2nd-year undergraduate at the University of Mindanao with a course of Civil Engineering. The reason for stopping school 81

was due o the onset of his illness. As a result of the patient’s mental illness, he has not landed a permanent job and is currently unemployed. The patient’s educational attainment also made him unable to land a job. The patient is currently living with his parents and depends on them for his basic needs. Axis V- Global Assessment of Functioning a) Initial Assessment (51-60) Moderate symptoms or moderate difficulty in social, occupational, or school functioning. According to the patient, he finds it hard to sleep at night. He usually sleeps at around 12am and wakes around 5am. Circumstantial and tangential speech is also noted since he provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesn’t arrive at the answer at all. According to Bob, he has very few friends. Also, he is quite withdrawn to people around him like the workers of his parents’ business. b) Final Assessment (51-60) Moderate symptoms or moderate difficulty in social, occupational, or school functioning. During the final assessment, circumstantiality and tangentiality is still noted in his speech. He was also quite aloof to the group, when the interview and assessment was being conducted.

82

NURSE-PATIENT INTERACTION Name: Bob

Diagnosis: Schizophrenia Undifferentiated

Age: 40 years old

Physician: Gioia Fe D. Dinglasan, MD

Ward: Crisis Intervention Unit

Date: January 21, 2009 – 1:40 pm FIRST NURSE-PATIENT INTERACTION

NURSE Verbal Maayong buntag!

PATIENT

ANALYSIS

Nonverbal Verbal Nonverbal Greets the Maayong buntag Looks at the Nurse: Gives the patient and his Greetings

Kami patient

diay

INTERPRETATION

client’s

pud. Unsa diay student nurses family a warm greeting to create presence as well as creating a good

mga with

estudyanteng

acknowledge

a inyong

and smiles

smile and pangutana?

a

positive

atmosphere

and start

Looks curious establish a good rapport upon

de

the purpose of acknowledges the nurses with a Fundamentals

University. Naa introduce

the interview

lang miy pipila the group

Greets

knowing

client’s

disposition.

nars sa Ateneo uses hand Davao gestures to

asking Patient:

and

back of

Nursing

by

smile and shows interest and Kozier, B. p. 430 curiosity

ka pangutana sa members imo. Ok ra ba nimu? Kumusta

man Looks

at Ok ra man. Laay Scratches head N:

ka? Unsa man the patient lang kaayo akong and imong

pamati and smiles

karong adlawa?

Starts

paminaw

to Gusto

establish a muuli.

dire. down na

ko

Tries

to

open

up

a Broad openings make explicit that

looks conversation by using questions the client has the lead in the that encourages patient to talk interaction. For the client who is and share

hesitant

about

talking,

broad

P: Exhibits boredom over his openings may stimulate him or her 83

good

hospital stay and expresses wish to take the initiative.

rapport

to go home

Psychiatric Mental Health Nursing by Frisch p 185

Kanus-a pa man Looks diay ka diri?

at Tulo na kaadlaw. Changes into a N: Asks a question to seek viable Seeking information is used to

the patient

Pero pirmi man comfortable

information

mi dire sige balik sitting position

P:

balik.

communicates his interest to to make clear that which is not

His

change

know more about client’s feelings, of

position thoughts and ideas. It is also used

participate in the conversation

meaningful or vague. Psychiatric Mental Health Nursing

Ah. Kabalo pd Continues

by Frisch p 185 Kabalo ui. Naa Makes an eye N: Attempt to evaluate patient’s Exploring is delving further into a

ka nganong naa to

may

ka diri karon ug maintain

hong

gahong- contact sa

ako the nurse

kung

ngano eye contact usahay na mag gabalik balik mo wild daw ko. dire? Magpatambal man

ko.

injection

with understanding and perception of subject or idea. This can help his own illness

patient

examine

the

issue

N: Reports understanding that he morefully. Any problem or concern needs to be treated and evaluated can once in a while by a doctor

be

explored.

better If

understood

patient

if

expresses

Pa

unwillingness to share, the nurse

ba.

must respect his or her wishes.

Tapos naa na pud

Mental Health and Psychiatric

nang

Nursing by Ann Isaacs p.197

mga sa

Auditory hallucinations are false

doctor nga balik

sensory impression heard by the

balik.

patient, usually, commanding in

pangutana

nature.

84

Mental Health and Psychiatric Magpatambal ka?

Nursing by Ann Isaacs p.197 O. Magpatambal Scratches head N: Repeats the statement made Clarification is putting into words

Moves

Ngano? closer

to ko. Kani man gud and

looks by the client to seek clarification. vague ideas or unclear thoughts of

Unsa diay sakit the patient

akong utok, naa down again

Asks further questions to delve in the client. Purpose is to help nurse

nimu?

niy grasa. Murag

to what the patient has said.

gud ug makina.

P: Explains his understanding of explain.

Kunga

his illness. Patient has a false idea Mental Health and Psychiatric

maguba,

understand, or invite the client to

kaylangan

that his brain had some sort of a Nursing by Ann Isaacs p.197

ayuhon.

lubricant.

His belief that there is a lube (grasa)

in

his

brain

is

a

manifestation of Somatic delusion. This type of delusion is a false notion or belief concerning body image or body function. Psychiatric Nursing by Keltner, N Ngano

naka Looks

at Mailhan

man Manually

Chap 9 pp.112-113 N: Attempts to focus and bring in Focusing is concentrating on a

ingon man ka na the patient

nako.

naay

mulain na akong his fingers in a P: Verbalizes his thought about topics or cues given by the client.

grasa

imong utok?

paminaw.

Basta hyperextending the discussion into a single topic

single point; Picking up on central

repetitive

what he believes towards his The nurse encourages the client to

manner

illness.

Starts

mannerisms.

to

show

his concentrate his energies on a sing le point, which may prevent a multitude of factors or problems from overwhelming the client.

85

Mental Health and Psychiatric Unsa diay imung Looks mga gipangbati?

at Naay mag hung Manually

the patient

Nursing by Ann Isaacs p.197 N: Asks question to open and Encouraging description

hung sa ako nga hyperextending explore a certain topic.

of

perceptions is asking the client to

mag wild daw ko his fingers in a P: Retells what he experiences verbalize what he or she perceives. ug Usahay

maglagot. repetitive

whenever his illness recurs. The To understand the client, the nurse

(pause) manner

pause in between his lines is a must see things from client’s

pud kay mu ana

manifestation of blocking speech.

perspective. Encouraging the client

nga patyon daw

to describe fully may relieve the

ko sa usa ka tao.

tension the client is feeling, and he might be less likely to take action on ideas that are harmful or frightening. Psychiatric Nursing by Keltner, N

Unya, unsa pud Looks imung

at Usahay

kay Looks

buhaton the patient tuohan man nako and

anang ga hung and hung nimo?

uses kay

hand

mura

pud head

bitaw ug tinuod.

Chap 9 p 233 down N: Evaluates how the patient Exploring is delving further into a scratches reacts to such stimulus

subject or idea. This can help

P: Patient has the tendency to patient examine the issue more heed to whatever this stimulus is fully. Any problem or concern can

gestures to

saying. Scratching his head is be better understood if explored. If

convey

another mannerism evident in the patient expresses unwillingness to

message

patient.

share, the nurse must respect his or her wishes. Mental Health and Psychiatric Nursing by Ann Isaacs p.197

86

Panan-aw nimu, Continues

Wala man. Nikalit Looks at the N: Tries to stimulate the patient Seeking information is used to

nganong nasakit eye cotact

ra man ni. Pero nurse

to recall past events of his life know more about client’s feelings,

man ka? Naay ba

kabalo ko na naay

that could have contributed to his thoughts and ideas. It is also used

kay

jud lain mao to

present illness.

mahinumduman

gusto

P: Patient cannot remember any meaningful or vague.

ngano

padoktor.

nagka

ingon ana ka? Ah… Kumusta Maintains man

Okay

pd

ra

ko

significant event which he thinks Psychiatric Mental Health Nursing is a contributing factor. by Frisch p 185 man. Looks at his N: Assesses patients relationship Focusing is concentrating on a

relasyon eye contact Palangga man ko mother

nimo sa imong and

and towards his family

nila. Samot na ni smiles

mama ug papa? presents a mama. Imung

mga conveying

igsuon?

to make clear that which is not

looks

single point; Picking up on central

then P: Expresses seriousness in his topics or cues given by the client. at

the tone of voice

The nurse encourages the client to

Suod pud mi sa nurse again

Tells the nurse how close he is to concentrate his energies on a sing

hand

akong

his family

gesture

manghud.

The

Kamaguwangan

statement

(pause) man ko.

manifestation of blocking speech.

Suod

mga

ming

pause

le point, which may prevent a in

between

is

again,

his multitude of factors or problems a from overwhelming the client. Mental Health and Psychiatric Nursing by Ann Isaacs p.197

Emman. Kadtong

Blocking is usually caused by

nagsunod sa ako.

affectively delusional

charged thoughts

topics, or

preoccupations. Psychiatric Nursing by Keltner, N Ah! Kung mag Looks away

mo

Chap 9 p 233 at Wala uy! Okay Looks at the N: Asks question to look at the General leads indicate that the

sa the patient

kaayo

among nurse with a current topic being discussed for nurse is listening and following

87

imung isgsuon

mga ug

imong

pamilya. I-agi ra face that tries further assessment

sa mga

what the client is saying without

gud sa storya. Di to convince

P: Strongly denies any presence taking away the initiative for the

man

of

kinhanglan

domestic

violence.

Seeks interaction.

They also encourage

ginikanan, naka

magsinakitay

affirmation from the nurse by the client to continue if he is

sinakitay mo?

diba?

asking “Diba”.

hesitant or uncomfortable about the topic. Mental Health and Psychiatric

Tama

pud

Maayo ingon

no. Maintains

Naa

gud.

Dula Scratches head

nang eye contact dula. Pero di man

Nursing by Ann Isaacs p.191 N: Commends the patient for the Giving recognition good insight given.

acknowledging

and

is

indicating

ana.

ko malingaw sa

Assess the patient’s childhood to appraisal to the client’s actions.

Kadtong bata pa

ilang mga (pause)

get viable information

ba ka, daghan ba

dulay usahay mao

P: Expresses gloom through fall esteem.

kag kadula?

nang ako na lang

of voice tone. Blocking of speech Mental Health and Psychiatric

isa madula sulod

is evident.

Nursing by Ann Isaacs p.197

sa balay. Nganong di man Sits on bed Dagan

dagan. Manually

pud

kaayo hyperextending allow patient to explain

malingaw?

ka and maintains

Lami

This helps elevate client’s self

N: Uses open-ended questions to Questioning

is

communication

a

therapeutic

technique

using

magdagan dagan. his fingers in a P: Restricted facial expression open-ended questions to achieve

eye contact Dili ko ganahan repetitive

and inconsistency of eye contact relevance and depth discussion.

sa ilang mga dula. manner

show that the patient is not Psychiatric Nursing by Keltner, N

Daghan

interested

kaayo

sila. Samukan ko.

on

the

topic. Chap 9 p 93

Circumstantiality is evident on If in response to a direct question, his

speech

as

he

provides the patient provides and excessive

irrelevant data before answering amount of irrelevant details before

88

the question.

finally answering the question, the condition

is

called

circumstantiality. Psychiatric Nursing by Keltner, N Kadtong

Looks the Ok

elementary

ug patient

ra

gud. Uses

Chap 9 p 113 hand N: Changes the topic since the Questioning is

Barkada barkada. gestures as he patient

started

to

exhibit communication

a

therapeutic

technique

using

high school ka,

Bugoy

bugoy talks

disinterest in the conversation

kumusta

man

kadali.

Bisyo

P: Is interested again in the relevance and depth discussion.

imong

pag

bisyo.

skwela?

Mura

gud

ra

conversation as his vocal tone Psychiatric Nursing by Keltner, N

ug

rises and as he gestured while Chap 9 p 93

ordinaryong Bisyo? Unsa pud Maintains na nga bisyo?

talking

studyante. Sigarilyo ug Coke Does his finger N:

eye contact jud ako (pause) mannerisms ganahan,

open-ended questions to achieve

inom- again

Tries

to

explore

and Exploring is delving further into a

encourage the patient to recall his subject or idea. This can help vices

patient examine the issue more

inom, chiks chiks.

P: Blocking is evident in his fully. Any problem or concern can

Ana lang gud.

speech as he enumerates his vices

be better understood if explored. If patient expresses unwillingness to share, the nurse must respect his or her wishes. Mental Health and Psychiatric

Ah.

Ganahan Looks

diay kag Coke?

patient

Nursing by Ann Isaacs p.197 at Ganahan mo lang. Looks up at the N: Focuses the topic on a Focusing is concentrating on a Kadtong

New ceiling

particular subject

single point; Picking up on central

89

Year, halos isa ka

P: Retells a particular event topics or cues given by the client.

case ako nahurot.

where his craving for Coke was The nurse encourages the client to

Boring man gud

evident.

concentrate his energies on a sing

maghulat ug alas

le point, which may prevent a

dose.

multitude of factors or problems from overwhelming the client. Mental Health and Psychiatric

Wala

pud

nitisting

ka Maintains

Droga??? Shabu? Looks

anang eye contact Wala

droga droga?

ui. and

down N:

Explores

for

Nursing by Ann Isaacs p.197 further Seeking information is used to

scratches significant details

know more about client’s feelings,

Marijuana

nuon. head

P: has a delusion marijuana is not thoughts and ideas. It is also used

Pero

mana

an prohibited and dangerous drug

di

droga.

to make clear that which is not meaningful or vague. Psychiatric Mental Health Nursing

Nagagamit marijuana? Sukad pa?

Oo ui. Kadtong Smirks

by Frisch p 185 N: Uses restatement to verify The nurse repeats what the client

high school pa ko.

acquired information

Uso mana didto sa

P: Smiked when the topic on his the same words the client has used.

expression

agro. Kami tanan

peers and their marijuana use was This restatement lets the client

while

sa among barkada

brought in

kag Conveys curious

kanus-a facial

keeping an gagamit

Unsa

ana.

has said in approximately or nearly

know that he or she communicated the idea effectively.

eye contact Ganahan man gud

Mental Health and Psychiatric

with

Nursing by Ann Isaacs p.197

patient diay Looks

ko sa feeling ba. at Lami

kaayo

sa Smiles

and N: Seeks significant information Exploring is delving further into a

90

mabati-an nimu the patient

paminaw ui. Mura looks

kung mugamit ka

kag galutaw sa nurse

patient

ana?

hangin

P: Shows elated response as he fully. Any problem or concern can

patient examine the issue more

Walay problema.

smiles and verbalized how he be better understood if explored.

Mag sige lang kag

enjoys marijuana

Mental Health and Psychiatric

Tistingi

ra

Nursing by Ann Isaacs p.197

gud,

maganahan ka. at Dili mana Shakes

makadaot

ng the patient

makadaot.

marijuana

sa

Makatambal

imo?

the on the effect of marijuana to the subject or idea. This can help

pero.

katawa.

Kabalo ba kang Looks

at

head N:

and frowns pa

Gives

information

and When it is obvious that the client is

presents reality to patient that misinterpreting reality, the nurse marijuana use is not good neither can indicate what is real. The nurse

man gani na. Si

beneficial

mama,

P: Shows disagreement as he expressing the nurse’s perceptions

sige

kasab-an

ko

bahin

does this by calmly and quietly

shook his head and frowned

or the facts not by way of arguing

ana kay di lage

with the client or belittling h is

daw maayo.

experience. Mental Health and Psychiatric

Unsa pud imu Looks ginabuhat

at Muhilom

kung the patient

lang. Scratches head N:

Pero di man ko and

Explores

on

the

Nursing by Ann Isaacs p.199 topic Exploring is delving further into a

looks discussed to get more information subject or idea. This can help

kasab-an ka sa

mutuo niya. Wa down

P: Insists his belief that marijuana patient examine the issue more

imong mama.

man ko nadaot.

is not harmful

fully. Any problem or concern can be better understood if explored. Mental Health and Psychiatric Nursing by Ann Isaacs p.197

91

Panan-aw nimu? Stands up Ang

babae Shakes

Dili kaha mao from

ganina,

wala and

nang

nikaon.

Sayang down

rason sitting

nganong nasakit position ka?

head N: Assesses patient’s perception To understand the client, the nurse looks on how marijuana affected his must see things from client’s

ang pagkaon ba.

illness

perspective. Encouraging the client

P: Provided irrelevant answers to describe fully may relieve the

Continues

and never arrived to the real tension the client is feeling, and he

to

answer – a manifestation of might be less likely to take action

maintain

tangentiality.

on ideas that are harmful or

eye contact

frightening. Mental Health and Psychiatric Nursing by Ann Isaacs p.192 Tangentiality is when patient gets lost in unnecessary and irrelevant details and never answers the question. Psychiatric Nursing by Keltner, N

Bob, naa koy ipa Smiles

Dapat

explain

muundang

Unsa

nimu. imo

dili Looks down

skwela.

ug Sige

ka

ug

N: Evaluates the abstract thinking of the patient of the client P: Uses self as example. Looking

pagsabot sa try

dapat

and try until you

skwela

para

disappointment.

succeed?

maabot

ang

Has concrete understanding of

pangarap

ba.

the the quotation given.

Dapat

dili

musundog nako.

down

could

indicate

Chap 9 p 93 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

92

2.

3.

4.

5.

in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container. 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. 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. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself. Reward positive behav93

ior 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 oth94

ers 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 physical contact 95

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 evaluate 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 96

syndrome. Make sure you document and report such effects promptly. Psychiatric Nursing by Keltner, N Chap 9 p 93 Testing the abstract thinking ability is a test to note the congruence between the patient’s economic status and his abstracting abilities. Mental Health and Psychiatric Aw.

lang sa mi kutob patient’s

Okay ra kaayo ui. waves hand

and

sa

Adto mog balay

scheduled meeting

pagpangutana.

ha? Kita kita ta

Recognizes effort of the patient thanking

Bisitahun ra ka

didto

who was accommodating to the participation

namu

Sabado.

among back

unya

sa

inyong

balay

karong

Sabado

para

magstorya

Sige

sa panahon.

sige. Smiles

Nursing by Ann Isaacs p.194 and N: Terminates the conversation The nurse gives recognition in a

Diay ba? Dire Taps

karong Salamat inyong

orients

group

patient

on

the nonjudgmental way. The nurse then terminates

throughout

the the

interaction client and

for

by his

cooperation

the during the whole interview.

conversation

Fundamentals

of

Nursing

by

Shows gratitude to patient for the Kozier, B. p 470 time he and his family spared for

na pd ta. Ayos ba

us.

na? Salamat sa

P:

imung panahon.

cooperation

Shows

understanding by

and

responding

positively to nurse’s statement

97

SECOND NURSE-PATIENT INTERACTION Place of Interview: 162, Interior Tulip Drive, Davao City (Patient’s City Address)

NURSE

PATIENT

Date: January 23, 2009 – 7:30 pm

INTERPRETATION

ANALYSIS

Verbal Nonverbal Verbal Nonverbal Maayong buntag Smiles and Nindot kaayo ang Stares blankly Nurse: Greets the patient to The nurse greets the patient Bob! Kumusta man looks at the adlaw.

Lami and

looks create a positive environment and upon seeing each other and

ang imong tulog patient

manglaba karon kay down

establish

kagabii?

init.

conversation

Ok

lang

man.

opening.

rapport. using

Starts uses broad openings to start a

broad their

conversation.

Broad

openings lead or invite the

Nakatulog man kog

Patient: Able to answer the client to explore thoughts or

tarong. Sayo sayo

question but circumstantiality is feelings.

gani ko kamata.

evident and poor eye contact was questions specify only the noted.

Open-ended

topic to be discussed and invite answers that are longer than one or two words. Circumstantiality is when in a response to a direct question, the

patient

excessive

provides amount

an of

irrelevant detail before finally answering the question.

98

Kozier, B. Fundamentals of Nursing. Chapter 26, p. 469.

Ah. Maayo. Mao Smiles

Aw. Kani? Mubalik Touches

pud diay sayo ka

na man gud ming and smiles

to

nakaligo no? Asa

mama sa Agusan.

presentable during the interview.

diay

Excited na gani ko.

P:

ron? Nindot man

Gikapoy

enthusiasm

lage kag suot?

gud ko didto sa

with the nurse and expresses his communication.

hospital ba.

feelings regarding his stay in the Acknowledgment

ka

muadto

na

man

shirt N: Acknowledges patient’s effort Giving groom Shows

self

and

excitement while

hospital.

recognition,

in

a

look nonjudgmental way, of a change in behavior, an effort

and the client has made, or a

conversing contribution

with

to

or

a

may

be

without

understanding,

verbal

or

nonverbal. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. Diay ba? Abi nako Smiles and Ang among bugasan Looks at the N: Asks a question to explore a Questioning uses open-ended naay kay pormahan establishes

sa

karong

kaayo ug kita.

adlawa? eye contact

Nagkauyab ba ka?

Oo.

Agusan Ka-usa

Kadtong

kusog nurse smiles ra.

and certain topic.

questions

to

P: Shares his experiences and relevance

and

opinions

about

his

achieve depth

in

previous discussion (not closed/yes-no

high

relationship in a comical manner. questions). The nurse ask

school pa ko. Pero

Irrelevant details are provided questions to explore and gain

dili naman mi uyab

before arriving to answer – a information from a new topic.

99

karon. man

Pangit gud

na

manifestation

siya.

of Circumstantiality is when in a

circumstantiality.

response to a direct question,

Ngipon niya murag

the

patient

ngipon sa ilaga.

excessive

provides

an

amount

of

irrelevant detail before finally answering the question. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter Unsa may pangalan Maintains

7, p. 93. Ah. Kadto siya? Si Points finger at N: Focuses on the topic to gather Focusing is helping the client

ato? Nagdugay pud eye contact

Rowena. Taga dinha the

mo ato?

ra man to sa una oh! direction

his past experiences.

Namalhin na man

P: Shares information about his important for the nurse to

siguro

experience

to

specified more information and look into expand on and develop a

sila.

with

topic of importance. It is a

former wait until the client finishes

Dugay dugay pud.

girlfriend. Patient is trying to stating the main concerns

Mga pipila ka bulan.

remember

Pero wa ni abot ug

relationship lasted.

how

long

their before attempting to focus. The focus may be an idea or

tuig.

feeling. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. and N: Inquires about the history on Questioning uses open-ended

Ah! Gi unsa nimu Smiles

Wala na uy! Ning Giggles

pagka uyab sa iya?

ngisi ra man to siya scratches head

how the relationship with her questions

Gi ligawan pa ba

nako. Naka crush

former girlfriend started.

nimu siya?

siguro ba. Ni ngisi

P: Narrates their story in an discussion (not closed/yes-no

ra pud kog balik.

amusing

manner

relevance as

he questions).

to and

achieve depth

The

in

nurse

100

Mao to. Uyab na

remembered

what

dayon mi.

between them.

happened questions or inquires about the client’s past history. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter

Kuyawa ba.Gwapo Laughs and Wala na. Wala na Laughs diay kaayo ka no continues to man

koy continues

ka yang babae man look at the nagustuhan. ni-una. Pagkahuman

patient sa

iya? Wala na kay

7, p. 93. and N: Actively listens to client and Active listening pays close

Mga scratch head

to compliments on his physical attention attributes by giving recognition. nonverbal

to

verbal

and

communications,

pangit na man ang

The nurse then resumes focusing patterns of thinking, feelings

uban uy. Bati ug

on the previous topic by asking and behaviors and the nurse

nawong.

questions.

na uyab?

gives a positive recognition as

P: Shares to the nurse his lack of a response to the patient’s interest in having a relationship statement. and

his

perceptions

about Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter

women. Pero sa edad nimu Conveys

a Gusto

uy! gani

Gusto Manually

N:

Explores

on

7, p. 93. patient’s The nurse assists the client to

ron, gusto pa ka more

man

nako hyperextending perceptions and thoughts about explore thoughts and feelings

magminyo?

serious

minyoon

facial

katabang

expression

pangit. Pero kataw- manner

married and his intention of tries to assess the client’s

an ra man ko nila

marrying their helper. Patient perceptions to the questions

man pag ako silang

tells the nurse the reaction of his asked.

ingnon.

family about his decision of Kozier, B. Fundamentals of

among his fingers in a getting married at his age. bahalag repetitive

and acquires understanding

P: States his interest in getting from the client. The nurse

marrying their helper.

Nursing. Chapter 26, p. 473.

101

Ngano gusto man Maintains

Wala namay lain. Smiles

pud nimu minyoon eye contact

Kadto na lang. Wala looks down

statement on his objective of making the client’s broad

inyo katabang nga

na may lain. Pero di

marrying their helper, even if, overall

pangitan man diay

man

according to him is unattractive.

ka?

mama. Di na jud

P: Replies to question with understandable. To clarify the

siguro ko maminyo

noticeable desperation. Shows message, the nurse can restate

ani.

that he is no longer interested the basic message or confess

musugot

and N:

si

Clarifies

the

patient’s Clarification is a method o

with the topic.

meaning

of

message

the more

confusion and ask the client to

repeat

or

restate

the

message. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. Unya Bob, karong Looks at the Ambot ato nila ui. Looks at the N: Shifts topic to explore on The nurse assists the client to pag-uli

Nasina man to sila nurse

another subject that may have explore thoughts and feelings

magkita na pud mo

nako kay ako tig

significance

sa

operate sa rice mill

illness.

unya sila kay driver

P: Shares insights about his tries

lang. Di na lang ko

friends back in his hometown and patient’s perceptions on the

muduol nila kay lain

his views about them.

imong

nimu, patient mga

barkada?

with

his

mental and acquires understanding from the client. The nurse still

pagkabalo

nimu Maintains nga eye contact

nasina sila nimu?

Mabati-an nako.

on

the

Kozier, B. Fundamentals of Nursing. Chapter 26, p. 473. gyud Looks at the N: Focuses on the topic and seeks Focusing is helping the client

nako. Sige silag tan- nurse aw

explore

question asked.

naman sila. Giunsa

to

and an

Sigeg scratches head

panabis. Di na ko

understanding

from

the expand on and develop a

patient’s feelings towards his topic friends.

of

importance.

The

focus may be an idea or

102

ganahan

mustorya

nila.

P: Relates his thoughts and feeling. The nurse then seeks feelings about his friends and understanding after focusing how

they

respond

to

him, on the topic.

according to his observations. Wala

pud

ka Maintains

Wala na uy! Klaro Looks

Kozier, B. Fundamentals of

Nursing. Chapter 26, p. 470. away N: Seeks more information, by The nurse seeks informing by

nitisting ug duol eye contact

na kaayo sa TB TB from the nurse asking questions regarding the asking questions about the

nila

na lain jud ilang and

unya

mangutana?

shakes topic, from the patient to further topic. Questioning uses open-

buot sa ako. Bahala head

understand his situation with his ended questions to achieve

gud sila.

friends.

relevance

and

depth

in

P: Responded according to what discussion (not closed/yes-no he felt and from his viewpoint questions). about his friends. Lack of interest Keltner, et. al, Psychiatric was observed when asked to Nursing, 5th Edition. Chapter Bob, kung kita ka Looks at the Daghan ug

pitaka,

baligya sa gawas ba. nurse

from the given situation.

nabilin sa tag-iya.

Akong

P: Answers accordingly from the meaning or importance of

Unsa

Alangan. Dili man

given

na ako.

appropriate behavior.

man

buhaton?

unya patient

approach his friends. 7, p. 93. pitaka Looks at the N: Evaluates patient’s judgment Encouraging evaluation asks

imu

I-uli.

situation

that

for patient’s views of the showed something. Circumstantiality is when in a response to a direct question, the patient provides an excessive amount of irrelevant detail before finally

answering

the

question.

103

Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, p. 93. head N: Further evaluates patient’s The nurse is trying to evaluate

Dili pud kaha nimu Maintains

Dili uy. Dili man na Shakes

kuhaon? Kwarta na eye contact

ako. Kung wala koy and looks at judgment

gud

na.

kwarta, magayo ra the nurse

situation and how he would further.

Makatabang

na

gud ko. Dili jud

respond from it.

nako na hilabtan.

P: Explained his intention of views of the meaning or

nimu.

from

the

given on

the

client’s

judgment

Encouraging

evaluation asks for patient’s

returning the money that showed importance

of

something.

a correct behavior from the given Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter

situation. Wow! Maayo no Smiles and Daghan kaayo ug Looks at the N: kay i-uli jud nimu maintains

kawatan

ang

silingan. Samot na

positive behavior in the given an effort the client has made,

kung

situation.

pitaka eye contact

magkina-unsa man.

dira

sa nurse

7, p. 93. affirmative The nurse gives recognition

Provides

gabii.

reinforcement to the patient’s on the client’s behavior and

Masakpan pa gani

P:

nako usahay

irrelevant

or

Responded from

to

the their

Tangentiality was noted.

a

contribution

to

a

nurse communication. topic. Acknowledgment with

may

or

understanding, nonverbal.

be

without verbal

or

Tangentiality

differs from circumstantiality in that the patient gets lost in unnecessary and irrelevant detail

and

never

directly

104

answers the question. Kozier, B. Fundamentals of Bob,

unsa

Nursing. Chapter 26, p. 470. ba Looks at the Math. Mao ganing Looks at the N: Asks a question to explore on The nurse asks a new

paborito nimu nga patient

nag

Civil nurse

subject?

Engineering ko.

and a new topic.

smiles

question to the client to delve

P: Answered appropriately to the in a new topic. Questioning question asked. Relates it to his uses open-ended questions to reason of taking up his course.

achieve relevance and depth in discussion (not closed/yesno questions). Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter

Sige daw bi.

Moves

Laughs

1+1?

closer to the 2 uy.

looks

7+2?

patient

ceiling

9.

7, p. 93. and N: Evaluates the client’s skill in The nurse is evaluating as at

the calculation. P:

Answered

well as exploring on the most

of

the client’s

ability

to

solve

40-7?

33. Grabe pud.

calculations asked to him to solve mathematical solutions.

6x8?

Ahmm.. 48!

on his own. Took time answering Videbeck. Psychiatric-Mental

25/5?

5

questions that were quite hard to Health Nursing. Chapter 6.

100-7? Tama!

(pause) 97? Paborito Smiles and Sige. Kay excited na Smiles

solve. p.107. N: Provides a positive feedback The nurse gives recognition

nimu siguro ang maintains

pud ko muuli. Si

to the client’s skill in calculation in a nonjudgmental way. The

math.

papa lang man gud

and shows acknowledgment by nurse then terminates the

Murag mulakaw na

isa

balay.

giving recognition. Establishes interaction by thanking the

jud

Gikapoy na pud ko

information that the nurse is client for his participation and

Sige mo

Bob. eye contact kay

sa

105

naghulat Mama

na

si

dire. Salamat pud sa

leaving and wishes him well cooperation during the whole

nimu.

pag storya storya

upon

nako.

Terminates

Mulakaw na lang

their

next

encounter. interview. nurse-client Kozier, B. Fundamentals of

pud mi ug una.

relationship.

Salamat! Hangtod

P: Responds appropriately and

sa atong sunod na

shows an eagerness to go back

pagkita. Pamansin

home and see his father.

Nursing. Chapter 26, p. 470.

ha?

106

107

DEFINITION OF COMPLETE DIAGNOSIS SCHIZOPHRENIA UNDIFFERENTIATED SCHIZOPHRENIA Schizophrenia is one of the most common causes of psychosis. It is not characterized by a changing personality; it is characterized by a deteriorating personality. Simply, schizophrenia is one of the most profoundly disabling illnesses, mental or physical. It is a diagnostic term used by mental health professional to describe a major psychotic disorder. It is characterized by disturbances in thought and sensory perception (hallucinations, delusions), thought disorders, and by deterioration in psychosocial functioning. Keltner, et. al, Psychiatric Nursing (p. 351).3rd Edition (1999) Philippines: C&E Publishing Inc. Schizophrenia is a disorder associated with a variety of a complex combination of symptoms, including hallucinations, delusions, disorganized speech, disorganization, flat affect, alogia, and avolition (APA, 2000; Bleuler, 1950). Persons experiencing an earlier onset of schizophrenia usually have more problems with movement from adolescence into adulthood and development of inappropriate social relationships and interactions.The course of the disease may be different for each person, depending on when the disorder manifests itself and if symptoms of the schizophrenia are compounded by a person’s use of alcohol or other substance (Brunette and Drake, 1998). Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 347). Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).

Refers to a group of psychotic disorders in which there are certain characteristic disorders like disturbances in reality testing, hallucinations, delusions, withdrawal from society, etc. 108

Schizophrenia is a major mental disorder having a characteristic set of symptoms. It is most closely approximate what most of us think as “craziness.” Schizophrenia ranges from mild to intense. It is the label given to a group of psychoses in which deterioration of functioning is marked by severe distortion of thought, perception and mood, by bizarre behaviour and by social withdrawal. Jafar Mahmud. Abnormal Psychology (p. 186). APH Publishing Corp. (2002)

Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the world. People with schizophrenia have an altered perception of reality, often a significantloss of contact with reality. They may see or hear things that don’t exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched. With such a blurred line between the real and the imaginary, schizophrenia makes it difficult—even frightening—to negotiate the activities of daily life. In response, people with schizophrenia may withdraw from the outside world or act out in confusion and fear. Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing, Quezon City, Phils. (2004)

UNDIFFERENTIATED TYPE Undifferentiated schizophrenia is manifested by pronounced delusions, hallucinations, and disorganized thought processes and behavior. Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 348). Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).

109

Subtype in which the clients clearly meet the general criteria of schizophrenia, yet do not fit into any of the other three subtypes. James Hansen & Lisa Damour. Abnormal Psychology (p. 406). Hobeken, N.J.: Wiley (2005). Clients with diagnosis of undifferentiated schizophrenia display forbid psychotic symptoms (delusions, hallucinations, incoherence, disorganized behavior) that do not clearly fit under any other category. Forti Nash & Holoday Worret. Psychiatric Nursing Care Plans (p. 113). 4th Edition. Mosby Inc., St. Louis, Missouri. The essential feature of undifferentiated schizophrenia is that it cannot be classified in any category listed or that meet the criteria for more than one of the other mentioned schizophrenic disorders. Jafar Mahmud. Abnormal Psychology (p. 188). APH Publishing Corp. (2002) This type is characterized by some symptoms seen in all of the other types but not enough of any one of them to define it a particular type of schizophrenia. Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing, Quezon City, Phils. (2004)

110

DIFFERENTIAL DIAGNOSIS SCHIZOPHRENIA Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the clinical picture that occasioned the most recent evaluation or admission to clinical care and may therefore change over time. They are defined by their symptomatology. The disorder lasts for at least 6 months and includes at least one month of the active phase symptoms namely two or more of the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The subtypes are: 295.30 Paranoid Type 295.10 Disorganized Type 295.20 Catatonic Type 295.90 Undifferentiated Type 295.60 Residual Type

Diagnostic Criteria for Schizophrenia A. Characteristic symptoms. Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):



(1) delusions (2) hallucinations (3) disorganized speech (e.g. frequent derailment or incoherence)

 

(4) grossly disorganized or catatonic behavior (5) negative symptoms (i.e. affective flattening, alogia or avolition) 111

Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. 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 selfcare are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) C. Duration



Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.) D. Schizoaffective and Mood Disorder exclusion:



Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, Or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance



(e.g. a drug of abuse, a medication) or a general medical condition F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated. Total

7÷10×100= 70% 112

295.30 Schizophrenia Paranoid Type The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent. Delusions are typically persecutory or grandiose or both but delusions with other themes may also occur. Hallucinations are also typically related to the content of the delusional theme. Diagnostic criteria for 295.30 Paranoid Type A. Preoccupation with one or more delusions or frequent auditory hallucinations B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. TOTAL



1÷2×100 = 50%

295.10 Schizophrenia Disorganized Type The essential features of the Disorganized Type of Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not organized into a coherent theme. Diagnostic criteria for 295.10 Disorganized Type A. All of the following are prominent 1. disorganized speech 2. disorganized behavior 3. flat or inappropriate affect B. The criteria are not met for catatonic type TOTAL



 1÷4×100 = 50%

113

295.20 Schizophrenia Catatonic Type The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include stereotypes, mannerisms, and automatic obedience or mimicry. Diagnostic criteria for 295.20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor 2. excessive motor activity (that is apparently purposeless and not influence by external stimuli) 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism 4. peculiarities of voluntary movement as evidenced by posturing √ (voluntary assumption of inappropriate bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing 5. echolalia or echopraxia TOTAL

1÷5×100 =20%

295. 90 Schizophrenia Undifferentiated Type Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly fit under any category. 114

Diagnostic criteria for 295.90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type TOTAL

 1÷1×100 = 100%

295.60 Schizophrenia Residual Type The Residual Type of Schizophrenia should be used when there has been at least one episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing evidence of the disturbance as indicated by the presence of negative symptoms or two or more attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and are not accompanied by strong affect. Diagnostic criteria for 295.60 Residual Type A. Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of



negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experience) TOTAL

1÷2×100 = 50%

301.22 Schizotypal Personality Disorder Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute 115

discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity

     

and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid) 6÷10 ×100 =60% Schizoid Personality Disorder Individuals with schizoid personality disorder are emotionally detached and prefer to be left alone. Diagnostic criteria for 301.20 Schizoid Personality Disorder 116

A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. neither desires nor enjoys close relationship, including being a part of a family 2. almost always chooses solitary activities 3. has little, if any, interest in having sexual experiences with



another person 4. takes pleasure in few, if any , activities 5. lacks close friends or confidants other than first degree

 

relatives 6. appears indifferent to the praise or criticism of others 7. shows emotional coldness, detachment, or flattened activity  B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizoid Personality Disorder (Premorbid)” TOTAL

4÷8 ×100 =50%

297.1 Delusional Disorder The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not prominent. Tactile or olfactory hallucinations may be present if they are related to delusional themes. Diagnostic Criteria for 297.1 Delusional Disorder A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or 117

lover, or having a disease) of at least 1 month’s duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not



markedly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. TOTAL

 2÷5×100 =40%

Substance-Induced Psychotic Disorder The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations or delusions that are judged to be due to the direct physiological effects of a substance. Hallucinations that the individual realizes are substance induced are not included here and instead would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic symptoms occur only during the course of delirium. Diagnostic criteria for Substance-Induced Psychotic Disorder A. Prominent hallucinations or delusions.



Note: Do not include hallucinations if the person has insight that they are substance induced B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms of Criterion A developed during or within a month of, Substance intoxication or Withdrawal 2. Medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a 118

Psychotic Disorder that is not a substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance –induced Psychotic Disorder (e.g., a history of recurrent non-substance related episodes. D. The disturbance does not occur exclusively during the course of delirium. Note: This diagnosis should be made instead of a diagnosis of Substance intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. 1÷5×100 TOTAL

= 20%

295.70b Schizoaffective Disorder Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some time in the absence of any mood syndrome.

Diagnostic criteria for 295.70b Schizoaffective Disorder A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet criterion A for Schizophrenia. Note: The Major Depressive Episode must include criterion A1: depressed mood. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. 119

D. The disturbance is not due to the direct physiological effects of a substance (e.g.,



a drug of abuse, a medication) or a general medication. 1÷4×100 = 25% Substance Intoxication Delirium Diagnostic criteria for Substance Intoxication Delirium A. Disturbance in consciousness(i.e., reduced clarity of awareness of the



environment) with reduced ability to focus, sustain or shift attention B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia C. The disturbance develops over a short period of time (usually hours to days) and



tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) Criteria Present 1. the symptoms in Criteria A and B developed during Substance Intoxication 2. medication use is etiologically related to the disturbance* 2÷5×100 =40% INITIAL SUMMARY Schizophrenia

70%

Paranoid Type

50%

Disorganized Type

50%

Catatonic Type

20%

Undifferentiated Type

100%

Residual Type

0%

Schizotypal Personality Disorder

60% 120

Schizoid Personality Disorder

50%

Delusional Disorder

40%

Schizophreniform Disorder

50%

Substance-Induced Psychotic Disorder

20%

Schizoaffective Disorder

25%

Substance Intoxication Delirium

40% ANATOMY AND PHYSIOLOGY

The nervous system is an intricate, highly organized network of billions of neurons and neuroglia. The structures that make up the nervous system include the brain, cranial nerves, spinal nerves, ganglia, enteric plexuses and sensory receptors. The two main subdivisions of the nervous system are the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and spinal cord. The brain is the center for registering sensations, correlating them with one another and with stored information, making decisions and taking actions. It also is the center for the intellect, emotions, behavior, and memory. The major parts of the brain include: the brain stem, cerebellum, diencephalon, and cerebrum. The spinal cord is connected to a section of the brain called the brainstem and runs through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both sides of the body. The spinal cord carries signals (messages) back and forth between the brain and the peripheral nerves.

121

The brain stem is continuous with the spinal cord and consists of the medulla oblongata, pons, and midbrain. The medulla oblongata forms the inferior part of the brain stem. The medulla contains the cardiac, respiratory, vomiting and vasomotor centers and deals with breathing, heart rate and blood pressure. The pons is a bridge that connects parts of the brain with one another. The midbrain extends from the pons to the diencephalon. The midbrain is a short section of the brain stem between the diencephalon and the pons. Posterior to the brain stem is the cerebellum. Traditionally, the cerebellum has been known to control equilibrium and coordination and contributes to the generation of muscle tone. It has more recently become evident, however, that the cerebellum plays more diverse roles such as participating in some types of memory and exerting a complex influence on musical and mathematical skills. Superior to the brain stem is the diencephalon, which consists of the thalamus, hypothalamus, and epithalamus. The thalamus acts a relay center for all sensory impulses, except smell, to the cerebral cortex. The hypothalamus is involved in the acceleration or deceleration of the 122

heart. Impulses from the posterior hypothalamus produce a rise in arterial blood pressure and an increase of the heart rate. Impulses from the anterior portion have the opposite effect. The hypothalamus is also involved in body-temperature regulation. If the arterial blood flowing through the anterior portion of the hypothalamus is above normal level, the hypothalamus initiates impulses that cause heat loss through sweating and vasodilation of cutaneous vessels of the skin. A belownormal blood temperature causes the hypothalamus to relay impulses that result in heat production and retention through the initiation of shivering, the contraction of cutaneous blood vessels. The hypothalamus is also involved in the regulation of hunger and control of gastrointestinal activity. Low levels of blood glucose, fatty acids and amino acids are partially responsible for the sensation of hunger elicited from the hypothalamus. When sufficient amounts of food have been ingested, the hypothalamus inhibits the feeding center. It also regulates sleeping and wakefulness. A specialized sexual center in the hypothalamus responds to sexual stimulation of the tactile receptors within the genital organs. Also, the hypothalamus is associated with specific emotional responses, such as anger, fear, pain and pleasure. The hypothalamus produces neurosecretory chemicals that stimulate the anterior pituitary gland to release various hormones. The epithalamus is the posterior portion of the diencephalon. Supported on the diencephalon and brain stem is the cerebrum, which is the largest part of the brain. The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body, 123

and the left hemisphere controls voluntary limb movements on the right side of the body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas, which are interconnected.

The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory. The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They process sensory information such as temperature, pain, taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of one’s body parts, the space around one’s body, and one's relationship to this space. The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions. The occipital lobes are located at the back of the brain. They receive and process visual information.

124

Neurotransmitters are chemicals which relay, amplify, and modulate signals between a neuron and another cell. Some neurotransmitters are commonly described as "excitatory" or "inhibitory". The only direct effect of a neurotransmitter is to activate one or more types of receptors. Examples of neurotransmitters are acetylcholine, dopamine, gamma-aminobutyric acid, dopamine, glutamate, aspartate, and serotonin. The chemical compound acetylcholine (often abbreviated ACh) is a neurotransmitter in both the peripheral nervous system (PNS) and central nervous system (CNS) in many organisms including humans. In the peripheral nervous system, acetylcholine activates muscles, and is a major neurotransmitter in the autonomic nervous system. In the central nervous system, acetylcholine and the associated neurons form a neurotransmitter system, the cholinergic system, which tends to cause excitatory actions. Gamma-Aminobutyric acid (GABA) is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating neuronal excitability throughout the nervous system. In humans, GABA is also directly responsible for the regulation of muscle tone. Dopamine has many functions in the brain, including important roles in behavior and cognition, voluntary movement, motivation, punishment and reward, inhibition of prolactin production (involved in lactation and sexual gratification), sleep, mood, attention, working memory, and learning. In the frontal lobes, dopamine controls the flow of information from other areas of the brain. Dopamine disorders in this region of the brain can cause a decline in neurocognitive functions, especially memory, attention, and problem-solving. Reduced dopamine concentrations in the prefrontal cortex are thought to contribute to attention deficit disorder. Dopamine is commonly associated with the pleasure system of the brain, providing feelings of enjoyment and reinforcement to motivate a person proactively to perform certain activities. Dopamine is released (particularly in areas such as the nucleus accumbens and prefrontal cortex) by naturally rewarding experiences such as food, sex, drugs, and neutral stimuli that become associated with them. Recent studies indicate 125

that aggression may also stimulate the release of dopamine in this way. This theory is often discussed in terms of drugs such as cocaine, nicotine, and amphetamines, which directly or indirectly lead to an increase of dopamine in the mesolimbic reward pathway of the brain, and in relation to neurobiological theories of chemical addiction (not to be confused with psychological dependence), arguing that this dopamine pathway is pathologically altered in addicted persons. Projection neurons that produce dopamine are found in the diencephalon and the brainstem. In the diencephalon, dopamine cell bodies give rise to tuberopophysial dopamine projections, e which inhibit the release of prolactin and melanocyte-stimulating hormone from the anterior and intermediate lobes of the pituitary, respectively, and the incertohypothalamic projections, which connect the zona incerta in the posterodorsal diencephalon with the anterior hypothalamus and septal area. A third dopamine projection system arises from neurons scattered along the ventricular system in the periaqueductal gray, the dorsal motor of the nucleus of the vagus, and the nucleus solitarius. The preventricular system provides terminals in the gray matter along the course of the ventricles. Longer dopamine projection systems arise from the substantia nigra and the ventral tegmental area (VTA) of the midbrain. The former, the nigrostriatal dopamine system, is particularly important in the control of motor function. The function of the VTA’s dopamine projections to the forebrain, called the mesolimbic and mesocortical systems, has been linked to the complex group of disease we refer to as schizophrenia. Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor-binding is found in people with social anxiety. Traits common to negative schizophrenia (social withdrawal, apathy, anhedonia) are thought to be related to a hypodopaminergic state in certain areas of the brain. In instances of bipolar disorder, manic subjects can become hypersocial, as well as hypersexual. This is credited to an increase in dopamine, because mania can be reduced by dopamine-blocking anti-psychotics.

126

The locus ceruleus at the rostal end of the floor of the fourth ventricle on each side marks the position of a nucleus with a rich vascular supply and consisting of neurons containing melanin pigment. The nucleus (also known as nucleus pigmentosus) is partly in the pons and partly in the midbrain, lying dorsolateral to the oral pontine reticular nucleus. The locus ceruleus is the largest of about a dozen nuclei I the brainstem that produce cathecolamines. Most produce norepinephrine, but some of those in the medulla produce epinephrine. A third catecholamine is dopamine, a transmitter used by the large neurons of the substantia nigra and ventral tegmental area, and by certain nuclei of the hypothalamus. Serotonin or 5-Hydroxytryptamine (5-HT) is a monoamine neurotransmitter that is primarily found in the gastrointestinal (GI) tract and central nervous system (CNS) of humans and animals. Approximately 80 percent of the human body's total serotonin is located in the enterochromaffin cells in the gut, where it is used to regulate intestinal movements.[1][2] The remainder is synthesized in serotonergic neurons in the CNS where it has various functions, including the regulation of mood, appetite, sleep, muscle contraction, and some cognitive functions including memory and learning. Modulation of serotonin at synapses is a thought to be a major action of several classes of pharmacological antidepressants. Serotonin secreted from the enterochromaffin cells eventually finds its way out of tissues into the blood. There, it is actively taken up by blood platelets, which store it. When the platelets bind to a clot, they disgorge serotonin, where it serves as a vasoconstrictor and helps to regulate hemostasis and blood clotting. Serotonin also is a growth factor for some types of cells, which may give it a role in wound healing. Serotonin is eventually metabolized to 5-HIAA by the liver, and excreted by the kidneys. One type of tumor, called carcinoid, sometimes secretes large amounts of serotonin into the blood, which 127

causes various forms of the carcinoid syndrome of flushing, diarrhea, and heart problems. Due to serotonin's growth promoting effect on cardiac myocytes, persons with serotinin-secreting carcinoid may suffer a right heart (tricuspid) valve disease syndrome, caused by proliferation of myocytes onto the valve. Glutamate is the most abundant excitatory neurotransmitter in the vertebrate nervous system. At chemical synapses, glutamate is stored in vesicles. Nerve impulses trigger release of glutamate from the pre-synaptic cell. In the opposing post-synaptic cell, glutamate receptors, such as the NMDA receptor, bind glutamate and are activated. Because of its role in synaptic plasticity, glutamate is involved in cognitive functions like learning and memory in the brain. CRANIAL NERVES

Cranial nerves are nerves that emerge directly from the brain stem, in contrast to spinal nerves which emerge from segments of the spinal cord. There are 12 pairs cranial nerves emerging from the brain, and these are:

Cranial nerve number

Sensory, Name

Motor

Function

or Both 128

I

Olfactory nerve

Purely Sensory

II

Optic nerve

Purely Sensory

Transmits the sense of smell; Located in olfactory foramina of ethmoid Transmits visual information to the brain; Located in optic canal Innervates levator palpebrae superioris, superior

III

Oculomotor nerve

Mainly Motor

rectus, medial rectus,inferior rectus, and inferior oblique, which collectively perform most eye movements; Located in superior orbital fissure Innervates the superior oblique muscle, which

IV

Trochlear nerve

Mainly Motor

depresses, rotates laterally (around the optic axis), and intorts the eyeball; Located insuperior orbital fissure

V

Trigeminal nerve

VI

Abducens nerve

Both Sensory

Receives sensation from the face and innervates

and Motor

the muscles of mastication

Mainly Motor

Innervates the lateral rectus, which abducts the eye; Located insuperior orbital fissure Provides motor innervation to the muscles of facial expression, posterior belly of the digastric muscle, and stapedius muscle, receives the special sense of

VII

Facial nerve

Both Sensory and Motor

taste from the anterior 2/3 of the tongue, and provides secretomotor innervation to the salivary glands (except parotid) and the lacrimal gland; Located and runs through internal acoustic canal to facial canal and exits at stylomastoid foramen

VIII

IX

Vestibulocochlear

Senses sound, rotation and gravity (essential for

nerve (or auditory-

balance & movement). More specifically. the

vestibular

Mostly sensory vestibular branch carries impulses for equilibrium

nerveor statoacoustic

and the cochlear branch carries impulses for

nerve)

hearing.; Located in internal acoustic canal

Glossopharyngeal

Both Sensory

Receives taste from the posterior 1/3 of the tongue,

nerve

and Motor

provides secretomotor innervation to the parotid gland, and provides motor innervation to 129

the stylopharyngeus (essential for tactile, pain, and thermal sensation. Some sensation is also relayed to the brain from the palatine tonsils. Sensation is relayed to opposite thalamus and some hypothalamic nuclei. Located in jugular foramen Supplies branchiomotor innervations to most laryngeal and all pharyngeal muscles (except the stylopharyngeus, which is innervated by the glossopharyngeal); provides parasympathetic fibers to nearly all thoracic and abdominal viscera down X

Vagus nerve

Both Sensory

to the splenic flexure; and receives the special sense

and Motor

of taste from the epiglottis. A major function: controls muscles for voice and resonance and the soft palate. Symptoms of damage: dysphagia (swallowing problems),velopharyngeal insufficiency. Located in jugular foramen Controls sternocleidomastoid and trapezius

Accessory nerve XI

(or cranial accessory nerve or spinal

muscles, overlaps with functions of the vagus. Mainly Motor

Examples of symptoms of damage: inability to shrug, weak head movement; Located in jugular

accessory nerve)

foramen Provides motor innervation to the muscles of the

XII

Hypoglossal nerve

Mainly Motor

tongue and other glossal muscles. Important for swallowing (bolus formation) and speech articulation. Located in hypoglossal canal

130

DOCTOR’S ORDER Date 01/19/10

Order

Rationale

Please admit to CIU.

2:40pm

Remarks

For close monitoring of the patient Admitted and proper management of his condition. The crisis intervention unit is a special unit operating on a 24-hour basis, which serves as a receiving and action center for walk-in referred, and rescued individuals

Secure

consent

care.

and families in crisis situation. to This is done to ensure that the Secured. client or significant others has been

adequately

informed

of

significant information concerning treatment

processes

and

procedures. When persons, due to age or mental status, are legally incapable

of

giving

informed

consent, doctors obtain informed permission

from

authorized

person,

substitute

consent

a

legally if

is

such legally

permissible. To secure the consent of the client is important for legal purposes. DAT with aspiration This is done to give appropriate Done precaution.

and adequate nourishment with the prevention or minimization of risk factors in the patient at risk for 131

aspiration. Monitor

vsq6

and Vital signs are important for Taken

record please

baseline

assessment

and

and

to recorded.

monitor patients condition which evaluates the whole treatment course, especially the medications he receives that could be a contributing factor in the variation results of the vital signs. Meds:

Given

Haloperidol

5mg Haloperidol is an older 1amp IM now then antipsychotic used in the treatment q12

of schizophrenia.

Flupentixol dec 20mg 1ampule now then q monthly

Flupentixol injection weekly

is

given to

a

long

two

or

people

acting three with

schizophrenia who have a poor compliance with medication and suffer frequent relapses of illness.

Hcl Biperiden is commonly used to 2mg/tab 1 tab BID improve parkinsonian signs and symptoms related to antipsychotic PRN for EPS Biperiden

drug therapy. Homicidal

and This is ordered so that the patient Done

suicidal

tendencies will be monitored closely and to

escape

precaution avoid the harming of patient's life

please

or others.

Restrain patient when Psychiatric facilities often use Done necessary.

medical interventions in the form of restraints to reduce safety risks posed by violent patients and to 132

prevent patients from harming themselves and others. Refer accordingly

This may create a collaborative Referred treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client.

01/20/10 11:40am Hold Haloperidol IM To change to chlorpromazine. Start Chlorpromazine This is given as a substitute for

Done Given

decanoate 200 mg/tab Haloperidol. This is an atypical ½ tab in am, 1 tab at drug and is considered to have less HS. 01/21/10 07:40 AM CONTINUE MEDS

EPS side effects. To promote the patient's well Done

For possible discharge being. MGH:

The patient’s psychotic episodes

Done

have diminished. The patient is advised to go home so the patient may go back to his normal life.. Home meds:

This is ordered as patient's mainte-

1. Chlorpromazine

nance medications for his condi-

200mg 1tab, ½ in AM

tion.

2. Biperiden HCL 2g/tab 1tab BID 3. Flupentixol dec 20mg/1amp IM qmonthly (last dose 1/1910) >Follow up at OPD This is ordered for patient's reafter 1 month.

assessment and constant monitoring. 133

134

DRUG STUDY

Generic Name:

Haloperidol

Brand Name: Aloperidin, Bioperidolo, Brotopon, Dozic, Duraperidol (Germany), Einalon

S, Eukystol,

Haldol, Halosten, Keselan, Linton, Peluces, Serenace, Serenase, and Sigaperidol Classification(s):

Typical Antipsychotic

Suggested Dose: Individualized dose depends on indication and response. AVAILABLE FORMS: Haloperidol: Tablets – 0.5 mg, 1 mg, 2 mg, 5mg, 10 mg, 20 mg. Haloperidol decanoate: Injection – 50mg/ml, 100 mg/ml Haloperidol lactate: Injection – 5mg/ml. Oral concentration: 2 mg/ml. Ordered dose: Mode of Action:

Haloperidol 5 mg 1 amp IM now then q 12 (January 19, 2010) Unknown. A butyrophenone that probably exerts antipsychotic effects by blocking postsynaptic dopamine receptors in the brain.

ROUTE

ONSET

PEAK

DURATION

P.O.

Unknown

3-6 hr

Unknown

I.V.

Unknown

Unknown

Unknown 135

I.M.

Unknown

3-9 days

Unknown

(decanoate) I.M. (lactate) Unknown

10-20 min

Unknown

Indications: ♂

Psychotic disorders (Adults and children older than age 12: Dosage varies for each patient. Initially, 0.5 to 5 mg P.O. b.i.d. or t.i.d. Or, 2 to 5 mg I.M. haldol lactate q 4 to 8 hours, although hourly administration may be needed until control is obtained.)

♂

Chronic psychosis requiring prolong therapy (Adults: 50 to 100 mg I.M. haloperidol decanoate q 4 weeks.)

♂

Tourette Syndrome (Adults: 0.5 to 5 mg P.O. b.i.d., t.i.d., or p.r.n.)

Contraindications: ♂ In patients hypersensitive to drug and in those with parkinsonism, coma, CNS depression. ♂ Use cautiously in elderly and deliberated patients; in patients with history of seizures or EEG abnormalities, severe CV disorders, allergies, glaucoma, or urine retention; and in those and those taking anticonvulsants anticoagulants, antiparkinsonians, or lithium. Drug Interaction: Drug – Drug ♂

Anticholinergics: May increase anticholinergic effect and glaucoma. Azole antifungals, buspirone, macrolides: May increase haloperidol level. Carbamazepine: May increase haloperidol level. CNS depressants: May increase CNS depression. Lithium: May cause 136

lethargy and confusion after high doses. Methyldopa: May cause dementia. Rifampin: May decrease haloperidol level. Drug – Lifestyle ♂

Alcohol use: May increase CNS depression.

Side Effects: ♂ CNS: severe extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, lethargy, headache, insomnia, confusion, vertigo. ♂ CV: tachycardia, hypotension, hypertension, ECG changes ♂ EENT: blurred vision. ♂ GI: dry mouth, anorexia, constipation, diarrhea, nausea, vomiting, dyspepsia. ♂ GU: urine retention, menstrual irregularities, priapism. ♂ Hematologic: leukocytosis. ♂ Hepatic: Jaundice. ♂ Skin: rash, other skin reactions, diaphoresis. ♂ Other: gynecomastia. Adverse Effects: ♂ CNS: seizures and neuroleptic malignant syndrome. ♂ CV: torsades de pointes, with I.V. use. ♂ Hematologic: Leukopenia Nursing Responsibilities: ♂ Although drug is least sedating of the antipsychotics, warn patient to avoid activities that require alertness and good coordination until effects of the drugs are known. ♂ Educate patient that drowsiness and dizziness usually subside after a few weeks. 137

♂ Inform patient to avoid alcohol while taking this drug. ♂ Tell patient to relieve dry mouth with sugarless gum or hard candy. ♂ Always remember, don’t give deconate form IV. ♂ Monitor the client for signs of tardive dyskinesia which may occur after prolonged use. It may not appear until months or years later and may disappear spontaneously or persist for life, despite ending drug. ♂ Watch out for signs and symptoms of neuroleptic malignant syndrome, which is rare but fatal. ♂ Inform patient to do not withdraw the drug abruptly unless required by severe adverse reactions. ♂ Remind patient to always protect the drug from light. Slight yellowing injection or concentrate is common and doesn’t affect potency. Discard the drug if there is a markedly discolorations in the solutions. ♂

Stop taking haloperidol and check the patient with their doctor right away if they have any of the following symptoms while using haloperidol: convulsions (seizures); difficulty with breathing; a fast heartbeat; a high fever; high or low blood pressure; increased sweating; loss of bladder control; severe muscle stiffness; unusually pale skin; or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome (NMS).

BIBLIOGRAPHY:

26th Edition Nursing 2006 Drug Handbook by Lippincott Williams

and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition. 138

Generic Name:

Flupentixol

Brand Name:

Fluanxol; Depixol; Depixol Low Volume; Depixol-Conc

Classification(s): Ordered dose:

Typical Antipsychotics Flupentixol decanoate 20 mg 1 amp now then q monthly (January 19,

2010) Mode of Action:

Flupenthixol is a type of thioxanthene drug and acts by antagonism of D1 and D2 dopamine receptors (as well as serotonin). Side effects are similar to 139

many other typical antipsychotics, namely extrapyramidal symptoms of akathisia, parkinsonian tremor and rigidity. However, anticholinergic adverse effects are low. The typical antipsychotics are less commonly used now that the atypical antipsychotics are available (with less side effects). Indications: ♂ Schizophrenia and other psychoses Dose: oral (rarely used) - initially 3-9mg twice daily, max. dose 18mg/day Depot antipsychotic (Depixol) (brand name: Fluanxol Depot in Australia) o test dose of 20mg IM, o if tolerated, further dose of 20-40mg after 7 days, o usual interval 2-4 weeks between doses, o usual maintenance dose between 50mg every 4 weeks and 300mg every 2 weeks, o max. 400mg IM weekly. ♂ Depression Dose: o initially 1mg/day, increased after 1 week to 2mg/day, o use half above doses in the elderly, o max 3mg/day (2mg in the elderly), o doses above 2mg (1mg in the elderly) should be gived as divided doses.

140

Contraindications: ♂ If patient is allergic to flupentixol or any other medicine of this class. ♂ If patient is allergic to any other medicine including preservative and dyes. ♂ Elderly people should be prescribed flupentixol with caution. ♂ If patient has history of kidney problem, liver problem or epilepsy. ♂ If patient has a problem of heart disease, high blood pressure or diabetes. ♂ If patient has a problem of enlarged prostate, thyroid problem or Parkinson’s disease. ♂

If two drugs are taken together, they may interact with each other. If patient is taking any prescribed or non-prescribed, food supplements or herbal medicine.

♂ If patient is pregnant, or plan to become pregnant.

Drug Interaction: ♂

Prescription and nonprescription medications, especially those that may cause drowsiness such as: sedatives, narcotic pain relievers (e.g., codeine), anti-anxiety agents (e.g., diazepam), antidepressants or other psychiatric medicine, dopamine-type drugs (e.g., cabergoline, pergolide, bromocriptine, pramipexole), muscle relaxants (e.g., cyclobenzaprine), drowsiness-causing antihistamines (e.g., diphenhydramine), atropinelike drugs, anti- seizure drugs.

♂

Many cough-and-cold products contain ingredients that may add a drowsiness effect.

Side Effects:

141

•

Nausea, drowsiness, dizziness, diarrhea, constipation, blurred vision, insomnia, urine problem, tremor, weakness, vomiting, and difficulty in breathing, slow heart rate, irregular blood pressure and convulsions.

•

Less common side effects of flupentixol include skin rashes, muscle problem, dizziness while rising from bed, sore throat, dark urine, increased sweating, yellowness of skin and eyes, decreased sex drive and painful erection, chest pain and muscle spasms.

Nursing Responsibilities: ♂ Educate patient that Flupentixol can cause drowsiness, dizziness and blurred vision. ♂ Remind client that alcohol will increase feelings of drowsiness. ♂ Remind patient that before having any surgery, including dental or emergency treatment, tell the surgeon, doctor or dentist that you are taking flupentixol. ♂ Inform client that Flupentixol can occasionally cause a dry mouth. If patient experiences this, try chewing sugar-free gum, sucking sugar-free sweets or pieces of ice. ♂ Flupentixol can cause some people's skin to become more sensitive to sunlight than it usually is. Avoid strong sunlight and sunbeds until you know how your skin reacts and use a suncream higher than factor 15. ♂ If client experience 'flu like' symptoms such as stiffness, high temperature, abnormal paleness, leaking bladder and a racing heartbeat contact their doctor or go to the accident and emergency department of your local hospital immediately. ♂ Educate the patient that the symptoms of overdose may include seizers, muscle spasms, weakness, fast heartbeat, fever, difficult breathing, severe dizziness, drowsiness, convulsions, irregular heartbeat, disturbed concentration, constipation and coma. 142

♂ Inform patient to take the medicine with a full glass of water. ♂ Remind the patient that the medicine can be taken with or without food. ♂ Instruct to the patient that he can swallow the medicine as whole. Don’t cut or chew the medicine. BIBLIOGRAPHY:

26th Edition Nursing 2006 Drug Handbook by Lippincott Williams

and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.

Generic Name:

Biperiden

Brand Name:

Akineton, Benzum 2, Berofin, Biperen, Bipiden, Desiperiden

Classification(s):

Anti-Parkinson's Agent, Anticholinergic

Suggested Dose: Adults: 143

Parkinsonism: 2 mg 3-4 times/day Extrapyramidal: 2 mg 1-3 times/day Elderly: Initial: 2 mg 1-2 times/day Ordered dose: Mode of Action:

Biperiden Hcl 2 mg / tab 1 tab B.I.D. prn for EPS (January 19, 2010) Biperiden is a weak peripheral anticholinergic agent with nicotinolytic activity. The beneficial effects in Parkinson's disease and neuroleptic-induced extrapyramidal symptoms are believed to be due to the inhibition of striatal cholinergic receptors.

Indications: ♂ Adjunctive treatment of all forms of Parkinson's disease (postencephalitic, idiopathic, and arteriosclerotic). ♂ Improve parkinsonian signs and symptoms related to antipsychotic drug therapy. ♂ Relieves muscle rigidity, reduces abnormal sweating and salivation, improves abnormal gait, and to lesser extent, tremor. Contraindications: ♂ Hypersensitivity to biperiden or any component of the formulation ♂ Narrow-angle glaucoma ♂ Bowel obstruction, megacolon ♂ Myasthenia gravis

144

♂

Caution in patients with obstructive diseases of the urogenital tract, patients with a known history of seizures and those with potentially dangerous tachycardia.

Drug Interaction: Drug – Drug ♂ Amantadine, rimantadine: Central and/or peripheral anticholinergic syndrome can occur when administered with amantadine or rimantadine. ♂ Anticholinergic agents: Central and/or peripheral anticholinergic syndrome can occur when administered with opioid analgesics, phenothiazines and other antipsychotics (especially with high anticholinergic activity), tricyclic antidepressants, quinidine and some other antiarrhythmics, and antihistamines. ♂ Atenolol: Anticholinergics may increase the bioavailability of atenolol (and possibly other beta-blockers); monitor for increased effect. ♂ Cholinergic agents: Anticholinergics may antagonize the therapeutic effect of cholinergic agents; includes tacrine and donepezil. ♂ Digoxin: Anticholinergics may decrease gastric degradation and increase the amount of digoxin absorbed by delaying gastric emptying. ♂ Levodopa: Anticholinergics may increase gastric degradation and decrease the amount of levodopa absorbed by delaying gastric emptying. ♂ Neuroleptics: Anticholinergics may antagonize the therapeutic effects of neuroleptics. Side Effects: 145

♂

CNS : Drowsiness, vertigo, headache,

and dizziness are

frequent.

With

high

doses

nervousness, agitation, anxiety, delirium, and confusion. Biperiden may lower the seizurethreshold. ♂ Peripheral side effects : Blurred vision, dry mouth, impaired sweating, abdominal discomfort, and obstipation are frequent. Tachycardia may be noted. Allergic skin reactions may occur. ♂ Eyes : Biperiden causes mydriasis with or without photophobia. It may precipitate narrow angle glaucoma. Adverse Effects: ♂ Cardiovascular: Orthostatic hypotension, bradycardia ♂ Central nervous system: Drowsiness, euphoria, disorientation, agitation, sleep disorder (decreased REM sleep and increased REM latency) ♂ Gastrointestinal: Constipation, xerostomia, dry throat, nasal dryness ♂ Genitourinary: Urinary retention ♂ Neuromuscular & skeletal: Choreic movements ♂ Ocular: Blurred vision Nursing Responsibilities: ♂

Instruct patient to use caution when driving, operating machinery, or performing other hazardous activities. Biperiden may cause dizziness or blurred vision. If patient experience dizziness or blurred vision, avoid these activities. 146

♂

Remind patient to use alcohol cautiously. Alcohol may increase drowsiness and dizziness while client is taking biperiden.

♂

Remind client to avoid becoming overheated. Biperiden may cause decreased sweating. This could lead to heat stroke in hot weather or with vigorous exercise.

♂

Educate client to take each dose with a full glass of water.

♂

Educate patient to take biperiden after a meal if it upsets his stomach.

♂

Remind the patient to store biperiden at room temperature away from moisture and heat.

♂

This medication decreases saliva production, an effect that can increase gum and tooth problems (e.g., cavities, gum disease). Instruct client to take special care with their dental hygiene (e.g., brushing, flossing) and have regular dental check-ups.

♂

If client experiences signs of hyperthermia such as mental/mood changes, headache, or dizziness, promptly seek cool or air-conditioned shelter and/or stop exercising, and seek immediate medical attention.

♂

Remind patient to not share the medication to others.

♂

If patient misses a dose, remind them to take it as soon as they remember. If it is near the time of the next dose, skip the missed dose and resume their usual dosing schedule. Do not double the dose to catch up.

BIBLIOGRAPHY:

26th Edition Nursing 2006 Drug Handbook by Lippincott Williams

and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition

147

Generic Name:

Chlorpromazine Hydrochloride

Brand Name:

Chlorpromanyl, Largactil, Novo-Chlorpromazin, Thorazine

Classification(s):

Typical Antipsychotic

Suggested Dose: Individualized dose depends on indication and response. AVAILABLE FORMS: Capsules (extended release): 200 mg, 300 mg. Injections: 25 mg/ml Oral concentrate: 30 mg/ml, 100 mg/ml Suppositories: 25 mg, 100 mg Syrup: 10 mg/5ml Tablets: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg Ordered dose: Mode of Action:

Chlorpromazine 200g/tab (January 20, 2010) Unknown. A piperidine phenothiazine that probably blocks postsynaptic dopamine receptors in the brain.

ROUTE

ONSET

P.O.

30-60min

I.M., I.V.

Unknown

PEAK Unknown

Unknown

DURATION 4-6hr

Unknown 148

P.R.

>1hr

Unknown

3-4 hr

Indications: ♂

Psychosis, mania (Adults: for hospitalized patients with acute disease, 25 mg I.M.)

♂

Nausea and vomiting (Adults: 10 to 25 mg PO q 4 to 6 hours, p.r.n. Or, 25 mg IM initially.)

♂

Acute intermittent porphyria, intractable hiccups (Adults: 25 to 50 mg PO t.i.d. or q.i.d.)

♂

Tetanus (Adults: 25 to 50 mg IV or IM t.i.d. or q.i.d.)

Contraindications: ♂ In patients hypersensitive to drug; in those with CNS depression, bone marrow suppression, or subcortical damage, and in those in coma. ♂ Use cautiously in elderly and deliberated patients and in patients with hepatic or renal disease, severe CV disease, respiratory disorders, hypocalcemia, glaucoma, pr prostatic hyperplasia. ♂ Use cautiously in acutely ill or dehydrated children. Drug Interaction: Drug – Drug ♂

Antacids: May inhibit absorption of oral phenothiazines. Anticholinergics such as

tricyclic antidepressants, antiparkinsonians: May increase anticholinergic activity, aggravated parkinsonian symptoms. Anticonvulsants: May lower seizure threshold. Barbiturates, lithium: May decrease phenothiazine effect. Centrally acting anthypertensives: May decrease 149

antihypertensive effect. CSN depressants: May increase CNS depression. Electroconvulsive therapy, insulin: may cause severe reactions. Lithium: May increase neurologic effects. Meperidine: May cause excessive sedation and hypotension. Propanolol: May increase levels of both propanolol and chlorpromazine. Warfarin: May decrease effect of oral anticoagulants. Drug – Lifestyle ♂

Alcohol use: May increase CNS depression, particularly psychomotor skills.

Side Effects: ♂ CNS: extra pyramidal reactions, sedation, tardive dyskinesia, pseudoparkinsonism. ♂ CV: orthostatic hypotension ♂ GI: dry mouth, constipation ♂ GU: urine retention ♂ Skin: mild photosensitivity reactions, pain at IM injection site Adverse Effects: ♂ CNS: Seizures and neuroleptic malignant syndrome. ♂ Hematologic: Leukopenia, agranulocytosis, aplastic anemia, thrombocytopenia Nursing Responsibilities: ♂ Obtain baseline blood pressure measurements before starting therapy, and monitor regularly. Watch client for orthostatic hypotension. ♂ Monitor client for tardive dyskinesia, which may occur after prolonged use. ♂ Warn patient to avoid activities that require alertness or good coordination until effects of drug are known. ♂ Remind client that drowsiness and dizziness usually subside after a few weeks.

150

♂ Advise patient not to crush, chew, or break extended release capsule form before swallowing. ♂ Educate patient to avoid alcohol while taking the drug. ♂ Have the patient to report signs of urine retention or constipation. ♂ Remind patient to use sunblock and to wear protective clothing to avoid oversensitivity to the sun. ♂ Advise client to relieve dry mouth with sugarless gum or hard candy. ♂ Withhold dose and notify prescriber if jaundice, symptoms of blood dyscrasia, or persistent extrapyramidal reactions develop.

BIBLIOGRAPHY:

26th Edition Nursing 2006 Drug Handbook by Lippincott Williams

and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.

SCIENTIFIC NAME:

Cannabis sativa L.

BRAND/STREET NAME:

Marijuana, Marihuana, Hemp, Hashish

CLASSIFICATION:

Psychoactive drug; stimulant; depressant; hallucinogen

ROUTE OF ADMINISTRATION: Inhaled smoke, screened bowls, bubblers (small pipes with water chambers), bongs, one-hitters, chillums, paper-wrapped joints and tobacco-leaf-wrapped blunts, tea, and orally. 151

CHEMICAL CONSTITUENTS: Cannabis chemical constituents including about 100 compounds responsible for its characteristic aroma. These are mainly volatile terpenes and sesquiterpenes. INDICATIONS: •

Amelioration of nausea and vomiting

•

Stimulation of hunger in chemotherapy and AIDS patients

•

Lowers intraocular eye pressure (shown to be effective for treating glaucoma)

•

General analgesic effects (pain reliever)

CONTRAINDICATIONS: •

Hypersensitivity to cannabis

•

Pregnant women, or planning to get pregnant

DRUG INTERACTIONS: •

Alcohol: Make both drugs stronger.

•

Amphetamines

•

Cocaine: (Uppers and downers)

•

Ecstasy: Extends and expands the experience of ecstasy.

•

Heroin: Complimentary effects.

•

Ketamine: Increases cannabis effects.

SIDE EFFECTS: •

General sense of well being and relaxation, giggliness and euphoria

•

Eyes: Reddening, decreased intraocular pressure.

•

Dreaminess, increased appreciation of music, sleepiness and time distortion

•

Dryness of the mouth 152

•

Increase heart rate

•

Muscle relaxation

•

Low blood pressure

•

Impairment of short-term episodic memory, working memory, psychomotor coordination, and concentration

•

Anxiety, panic, paranoia and feelings of impending doom

ADVERSE EFFECTS: •

Lung cancer

•

Chronic fungal infections

•

Paranoia

•

Confusion

•

Long-lasting toxic psychosis

NURSING RESPONSIBILITIES: •

Reassure client that anxiety attacks are common side effects of the drug and will disappear within hours.

•

Provide a supportive environment for the client when experiencing feelings of paranoia and anxiety.

•

Remind client to avoid strenuous activities like driving or operating machinery until the effects of the drug diminishes.

•

Educate client that effects at first can be subtle, first time users usually detect little or no effect at all.

•

Inform the client that if he is possibly experiencing marijuana OD symptoms, it is recommended that he calls the local emergency line. 153

•

Educate client that if he is a regular cannabis smoker (every day) and stopped smoking, he will experience some of the following withdrawal symptoms: restlessness, irritability, mild agitation, insomnia, nausea, sleep disturbance, sweats, and intense dreams.

154

155

NURSING CARE PLAN TIME

CUES

NEED

AND

GOAL OF CARE

INTERVENTIONS

EVALUATION

DIAGNOSIS

DATE Januar SUBJECTIVE: y

NURSING

21, “Naay

C

nagahung- O

Disturbed sensory At the end of 2 perception related hours

of nursing

build trust with the @ 2:30 PM

the

client

2009

hung sa akoa usahay G

to alteration in care,

@

nga mag-wild daw ko N

function of brain will be able to

12:30

ug

tissue

P.M.

verbalized

maglagot” by

as I

•

•

® The client must trust

orientation to ®It is the change

time,

V

in the amount or

person,

E

patterning

circumstances

Disoriented

-

incoming stimuli

for

to time

P

accompanied by a

period

Auditory and E

diminished,

time;

visual hallu- R

exaggerated,

• demonstrate

of

and

specified of

about hallucinations and other sensory-perceptual alterations

•

The pa-

tient was able to maintain orientation to time,

2. Continuously

orient

the client to actual environmental events or activities in a nonchal-

place, person and situation. “Huwebes karon. Mga

C

distorted,

Misinterprets

E

impaired

ception of the

response to such

environment

®Brief, frequent ori-

sa Mental hos-

stimuli.

by responding

entation

pital para mag-

appropriately

present reality to the

Schultz,

to stimuli in

client with sensory-

M.J.;Videback,

the surround-

perception disturbance

S.L.; Lippincott’s

ings; and

others

of P T

to U make simple A L decisions

or

place,

the nurse before talking

cinations actions •

GOAL UNMET

I

OBJECTIVE •

patient

• maintain

the T

patient

1. Establish rapport and January 21, 2009

Inability

accurate per-

udto na man

lenging way.

siguro. Naa ko helps

to

pacheck-up” •

However,

the client was not able to

156

•

Inappropriate responses

P A T T E R N

Manual

of

Psychiatric Nursing

• lessen visual and audi-

Care

Plans 7th edition

tory

halluci-

nations

demonstrate ac3. Reinforce and focus on reality. Talk about real events and real people. Use real situations and events to divert client from long, tedious, repetitive verbalizations

of

false

ideas

tion of the environment as evidenced by the presence of delusion and hallucination •

Presence

of auditory hal-

® Working with reality

curate percep-

lessens

patient’s

lucination is still evident.

initiation of his hallucinations. 4. Correct

client's

de-

scription of inaccurate perception, and describe the situation as it exists in reality ® Explanation of, and participation in, real situations and real activities

interferes

157

with the ability to respond to hallucinations. 5. Observe

for

verbal

and nonverbal behaviors associated with hallucinations ® Early recognition of sensory-perceptual disturbance promotes timely

interventions

and alleviation of the client’s symptoms. 6. Describe the hallucinatory behaviors to the client. ® The client may be unable to disclose perceptions and the nurse can openly facilitate disclosure by reflect-

158

ing on observations of the client’s behaviors, which helps the client engage in more open discussion with the nurse, which in itself brings relief. 7. Explore the content of hallucinations to determine the possibility to harm self, others or the environment ® Exploring the content of the hallucination helps the nurse identify if the sensoryperceptual disturbance is threatening or dangerous to the client, such as a command type of hallucination that may be telling the

159

client to harm or kill the client or others. The nurse can then reinforce treatment and safety precautions. 8. Use clear, direct, verbal

communication

rather than unclear or nonverbal gestures ®Unclear or

directions

instructions

can

confuse the client and promote distorted perceptions or misinterpretations of reality. 9. Modify the client’s environment to decrease situations that provoke anxiety ®Decreased

anxiety

can reduce the occur-

160

rence

of

hallucina-

tions 10. Reassure

the

client

(frequently if necessary) that the client is safe and will not be harmed ®Alleviation of fear is necessary

for

the

client to begin to trust the environment and to feel safe.

161

TIME

CUES

NEED

AND DATE Januar y

NURSING

GOAL OF CARE

INTERVENTIONS

EVALUATION

DIAGNOSIS SUBJECTIVE

C

21, “Magpatambal ko. Kani O

Disturbed

At the end of 2

thought process hours of nursing

est when communi- @ 12:30 PM cating

2009

man gud akong utok, naa G

related

@

niy grasa.” as verbalized N

disintegration

7:00

by the patient

thinking.

I

A.M OBJECTIVE • •

Thought insertion

R

•

Incoherent speech

C

•

Demonstrates

tory hallucinations

GOAL PARTIALLY

Maintain

Demon-

•

Presence of audi-

client.

tremely

E

•

•

the

entation;

noia

sleep pattern

will be able to

with

I

-

in

patient

®Clients are ex- MET

Delusion of para- P

disturbance

the

reality ori-

Delusion of perse- E

a

to care,

T V

cution

1. Be sincere and hon- January 21, 2009

E P T U A L

®It

is

disruption

the in

•

cognitive operations

and

activities. Cognitive

by

which knowledge

is

acquired. These mental

about others and

client

was

strate reali-

can recognize insin-

able

ty

cerity. Evasive re-

maintain re-

thinking in

marks

ality orien-

verbal and

mistrust.

based

reinforce

•

to

tation. He is oriented

2. Assess client’s non-

behavior;

those

mental processes

The

nonverbal

processes include

•

sensitive

when

and

verbal

Demon-

such as gestures, fa-

day

it

is.

cial expression and

But

he

is

posture.

still

preoc-

strate

the

ability

to

behavior,

time

to

cupied with

abstract, conceptual-

asked what

®This

assessment

his

delu-

may help to meet

162

P

processes

ize, reason

the client’s needs

sions about

A

include

and calcu-

that cannot be con-

his

T

orientation,

late consis-

veyed

jealous

T

comprehension,

tent

speech.

E

awareness, and

ability to

R

judgment.

A

3. Encourage

N

disruption

in

client

reality

these

with

through

being to

him the

to

express

•

The

client

was

mental

feelings and do not

not able to

may

pry cross examine

demonstrate

for information

reality-

processes lead

to

inaccurate

based think-

interpretations

®Probing increases

ing in ver-

of

client’s

bal and non-

the

suspicion

environment

and interferes with

verbal

and may result

the therapeutic rela-

sponses. His

in an inability to

tionship

mannerism

evaluate reality accurately. Alterations

is 4. Show empathy to

in

thought

the

client’s

feel-

re-

largely

observed and

he

ings, reassure the

wasn’t able

client of your pres-

to establish

not limited to

ence

eye contact

any

tance

processes one

are age

group,

gender,

or

clinical

and

accep-

with any of the

inter-

®The client’s ex-

163

problem. (http://www1.us .elsevierhealth.c om/MERLIN/G ulanick/Constru

periences can be

viewer.

distressing. Empa-

•

thy conveys accep-

wever,

tance of the client

was able to

your caring and in-

exhibit

terest.

positive ab-

ctor/index.cfm? plan=53.01)

Ho he a

stract, 5. Avoid

laughing,

son,

reajudg-

whispering, or talk-

ment

ing quietly where

calculation

client can see but

abilities.

and

not hear what is being said. ®Suspicious clients often believe others are

discussing

them, and secretive behaviors reinforce the paranoid feelings. 6. Give simple directions using short words and simple

164

sentences. ® Giving simple directions lessen or prevent

confusion

of the patient 7. Never convey to the client that his delusions and hallucinations are real ®The delusion or hallucination would be reinforce if it’s accepted. 8. Maintain oriented

reality relation-

ship and environment ® Maintaining reality based relationship and environ-

165

ment lets the patient know that the relationship is temporary and prevents separation anxiety 9. Give positive feedbacks and acknowledge the client ®Positive feedback enhances sense of well-being

and

makes a more positive situation for the client. 10. Do not judge or belittle

client’s

be-

liefs. ®What the client feels or thinks is not funny for him. The client may feel

166

rejected

if

ap-

proached

by

at-

tempts of humor.

167

TIME

CUES

NEED

AND SUBJECTIVE:

Januar

“Maulaw man gyud ko E

21, basta ing-ana”

S

Situational low At the end of 2 self-esteem

L

related

2010

F

cognitive

@ 12 OBJECTIVE:

-

impairment

:30

GOAL OF CARE

INTERVENTIONS

EVALUATION

DIAGNOSIS

DATE . y

NURSING

•

PM

•

E

Lack social inter- R C

the

patient

will: •

@ 2:30 PM

ings in relation to GOAL UNMET •

Verbalize

knowledge pain of

It is the state in

understand-

loss. Support client

was unable to

which

ing

through process of

verbalize under-

grieving.

standing

an

of

Has little interest E P in activities

previously

had

precipitate

self-

current sit-

Talks only when T I asked

esteem

N

January 21, 2010

of functioning. Ac-

things that

O

express honest feelloss of prior level

individual who

action •

to care,

Lacking eye con- P tact

•

hours of nursing

1. Encourage client to

positive

uation; and

experience

a

negative feeling towards self due to

a

certain

situation

•

strate

haviors that show positive self-esteem

Handbook

of

Nursing Diagnosis

be-

by

of

things that lead ® Client may be fixed in anger stage of grieving process,

Demon-

The patient

which

is

turned

inward on the self, resulting diminished

in self-

esteem. 2. Devise methods for assisting client to

to current situation •

The patient

was unable to demonstrate behaviors show

that positive

self-esteem

as

evidenced

by

inability to have

168

Lynda CarpenitoMuyet

Juall

an express

feelings

properly..

eye-contact

as well as looking

® To explore the feelings

of the

client

thereby

down

at

during the interview.

allowing him to acknowledge his own strength and weakness. 3. Encourage

client's

attempts to communicate. If verbalizations are not understandable,

express

to client what you think he or she intended to say. It may be necessary to reorient client frequently. ® The ability to communicate

169

effectively

with

others may enhance self-esteem.

4. Encourage reminiscence and discussion of life review. Also

discuss

present-day events. Sharing picture albums, if possible, is especially good. ® Reminiscence

and

life review help the client resume progression

through

the grief process associated with disappointing life events and increase selfesteem as successes are reviewed. 5. Encourage participation in group ac-

170

tivities.

Caregiver

may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication. ®

Positive

feedback

from

group members will increase

self-

esteem. 6. Offer support and empathy client

when expresses

embarrassment

at

inability to remember people, events, and places. ® Focus on accomplish-

171

ments to lift self-esteem. 7. Encourage client to be as independent as possible in selfcare activities. ® The ability to perform independently preserves

self-

esteem. 8. Listen to patient’s concerns and verbalizations without comment or judgment. ®It

enables

the

client to develop trust and thereby establish communication

172

9. Provide feedback to client’s

negative

feelings. ®To

allow

the

client experience a different view.

173

TIME

CUES

NEED

AND

NURSING

GOAL OF CARE

INTERVENTIONS

EVALUATION

DIAGNOSIS

DATE January

SUBJECTIVE:

21,

The

2010

exactly

@12:30 PM

clarified

C

At the end of 3 day

1. Provide opportuni- January 21, 2010

memory related nursing care, the

ties

to neurological patient will be able

cence or recall past

months he was referring N

disturbances

events

about his last used of I

®Impaired

marijuana, he verbalized T

memory

“Kadtong 2007 man to, I aw 2008 diay”

was

when O

Impaired

the

OBHECTIVE: •

•

®Long-term mem-

awareness

ory may persist af-

was able to

directly related

of memory

ter loss of recent

verbalize

V

to

problems;

memory. Reminis-

awareness

E

general medical

and

cence is usually an

of memory

-

condition

Accept lim-

enjoyable

problems

ongoing effects

itations

for the client.

of

current

E

effects

is of or

substance.

•

of

activity

The patient

as he verbalized

Depending o n

rience of forget- C

the areas of the

client to use written

gyud

E

brain, the client

cues such as calen-

makalimot

are

dars or notebooks

na ko”

his P head when he is T unable to recall U Scratches

information •

•

GOAL MET

Observed expe- R ting

•

to:

reminis- @ 2:30 PM

Verbalize

Disorientation to P time

•

2 G

for

A

Inability to de- L

unable

to

condition

2. Encourage

the

“Usahay

recall

®Written cues de-

information,

crease the client’s

was able to

either remote or

need to recall activ-

verbalize

recent.

The

ities, plans and so

acceptance

client

may

on from memory.

•

The patient

174

termine if a be-

confabulate

to

3. Encourage ventila-

of his limi-

havior

fill in those lost

tion of feelings of

tations due

memories.

frustration,

to his con-

forme

is

per-

lessness,

helpand

so

ditions

forth. Refocus attention to areas of focus and progress. ®To lessen feelings of powerlessness/hope lessness 4. Provide for proper pacing of activities and having appropriate rest ®To avoid fatigue 5. Allow the client to do tasks on his own, but do not rush him to do it. Make the client feel that he can still do things independently. ®It is important to

175

maximize independent function, assist the

client

when

memory has deteriorated further. 6. Assist

the

client

deal with functional limitations

and

identify resources. ®To meet individual needs, maximizing independence. 7. Provide single step instructions

when

instructions

are

needed. ®Client with memory

impairment

cannot multistep

remember instruc-

tions 8. Do not contradict the client who experiences an illusion. Instead, sim-

176

ply explain reality, and find some practical solutions to the problem ®Therapeutic

re-

sponses promote reality while offering solutions that help enhances

the

client’s sense and may reduce fear, anxiety, and confusion. 9. Monitor client’s behavior and assist in use of stress-management techniques ®To reduce frustration 10. Determine client’s response to medication

medications

prescribe prove

to

im-

attention,

concentration,

177

memory

process

and to lift spirits and modify emotional responses. ®Helpful in deciding whether quality of life is improved when

using

medications TIME

CUES

NEED

AND

NURSING

GOAL OF CARE

the pre-

scribed. INTERVENTIONS

EVALUATION

DIAGNOSIS

DATE January

SUBJECTIVE: “Makatamad usahay 21, maligo. Wala pa gani ko 2010 @ ligo ron. Kapoy pud manlimpyo ug kuko”, as 12:30 verbalized by the P.M. patient. OBJECTIVE: Unkempt hair noted food stains visible on clothing untrimmed fingernails and toenails with visible dirt noted

A C T I V I T Y E X E

Self care deficit: After 2 hours of nursing care, the bathing / client will be able hygiene related to: a) verto lack of balize self motivation care need ® The patient b) De has an impaired monstrate ability to techniques provide self care to meet requisites due to self-care environmental needs and

1.

Establish

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

January 21, 2009 @ 2:30 PM GOAL PARTIALLY MET

Identify

After 2 hours of reason for nursing care, the client was able to: difficulty in selfa) ver balize self care. care need R: underlying cause afb) but fects choice of inwas unable to demonterventions/ strate-

178

R

psychological

gies.

C

factors.

3.

Determine

I

hygienic needs and

S

provide assistance

E

as

needed

strate techniques to meet selfcare needs.

with

activities like care P

of

A

brushing teeth.

T

R: basic hygienic needs may be forgotten.

T E R N

4.

nails

and

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 selfcare like various toiletries. R: increases the client’s awareness of different materials for

179

self-care. 6.

Let the pa-

tient 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

180

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.

181

182

PROGNOSIS GOOD FAIR POOR Onset of the

☻

illness

JUSTIFICATION Bob first experiences the signs and symptoms of schizophrenia when he was 18 years old and now he is 40 years old. The first signs that Bob showed was when he ate feces and since then people who are close to him noticed that he has illogical speech and flight of ideas. It was until after two months, November 1987 that they decided to bring Bob to the hospital for check-up when Bob’s tongue shrunk. The onset of illness was poor since the family waited that the situation of Bob worsened and did not immediately seek medical advice immediately when there was changes in his behavior like when he ate stool and showed illogical speech

Duration of illness

☻

and flight of ideas. The client has been diagnosed with schizophrenia catatonic 22 years ago. The patient went to the Davao Medical Hospital for his third admission last January 19, 2010 and was diagnosed with schizophrenia undifferentiated. As we can see, the duration of illness has been very long since it was years ago since he was mentally sick thus rating him with poor prognosis.

183

Precipitating

☻

factors

Intake of drugs, substances or chemicals which increase levels of dopamine and developmental factors are the present precipitating factors seen in Bob. The proponents rated this area as poor since Bob is abusing substances like marijuana, alcohol, cigarette and soft drinks. In his development, Bob developed mistrust,

shame and doubt, guilt,

inferiority, role confusion, and isolation which rated him poor. Mood and Affect

☻

During the interview, Bob has appropriate mood and affect therefore rating him with good prognosis.

Family Support

☻

During the interview the mother and the sister-inlaw was with the patient. As the interview progresses the student nurses observed that the family is supporting the patient. The patient is receiving appropriate family support since his family is doing all they can to help him recover. They are helping him financially as well as emotionally. The family understood what he is undergoing and giving him the support he need for

Willingness to

☻

his recovery. Bob was brought to the hospital for check-up

take medications

because he demanded to his parents saying that

and treatment

something is wrong with him. Bob submits himself properly to the medication without missing any single dose. He may be taking the proper regimen, however, he is not listening to the advice of the doctor to stop alcohol, smoking, taking marijuana and even drinking soft drinks. For a person to be treated he must not only take the drugs prescribed but also to stop things that are contraindicated for him for his treatment. Because of this, Bob was 184

rated with prognosis with the willingness to take the Depressive

medication and treatment. During the interview, the patient does not show any

☻

features

depressive features. Bob knew that something is wrong with him and he need medical attention. Even though he is aware that something is wrong with him, he is still not depressed with this fact. He didn’t finish college but he is not depressed with this fact. Not getting the things he wants won’t make him depress but instead, Bob goes wild and becomes hostile. Computation:

Total

3

1

3

 Poor: (3*1)/7

= 3/7

 Fair:

(1*2)/7

= 2/7

 Good: (3*3)/7

= 9/7

Total:

2.00

General Prognosis: 1-1.6

= POOR

1.7-2.3 = FAIR 2.4-3.0 = GOOD Rationale for Fair Prognosis: Bob has a fair prognosis therefore he has small chance, according to the calculation, of recovering from his illness. The onset of illness was 22 years ago. He was not immediately brought to the hospital but they waited 2 months and decided to bring him to the hospital because of shrinking of his tongue and he demanded so. The duration of illness is long since it was last November 1987 that he was first diagnosed of Catatonic Schizophrenia and just this last January 19, 2010 that he was diagnosed of Schizophrenia undifferentiated. He also abused many substances like marijuana, alcohol, cigarette and soft drinks. And during his development, he developed mistrust, shame and doubt, guilt, inferiority, role confusion, and isolation which rated him poor. 185

In addition to that, he didn’t listen to the advice of the doctor to stop alcohol, smoking, taking marijuana and drinking soft drinks. However, he submits himself to the regimen, taking the medications promptly even going to the hospital every month for his medication. Furthermore, during the interview, Bob has appropriate mood and affect therefore rating him with good prognosis. He has good family support as evidenced by the support of his mother and sister-in-law while he is in the hospital. His father is supporting him financially but is not able to go with him because of his work back in Agusan. The family understood what he is undergoing and giving him the support he need for his recovery. Lastly, the patient does not show any depressive features. Bob knew that something is wrong with him and he need medical attention. Even though he is aware that something is wrong with him, he is still not depressed with this fact. He didn’t finish college but he is not depressed with this fact. Not getting the things he wants won’t make him depress but instead, Bob goes wild and becomes hostile.

186

RECOMMENDATION The group 1 of section 3H would like to recommend the following:

To the patient: 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. To the patient’s family: The patient’s family plays an important role in the patient’s mental illness and recovery. The family should make themselves physically present so that the patient would feel their support and concern. They are encouraged to continue interacting with the patient so that ideas of violence towards self and others will be diverted. In addition, it is of prime importance that they are oriented and educated regarding the patient’s mental illness so that they will understand him even better and assist him in his daily activities.

To the Ateneo de Davao University- College of Nursing: The faculty and staff are encouraged to continue improving the standards of the Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be equipped with the knowledge and skill that they may impart to student nurses. They are challenged to not just teach but impart to us as well nursing experiences that we may apply in the course of caring for our future patients.

To the Davao Mental Hospital: 187

The group recommends that they should improve their facilities in treating the mentally-ill patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the patients and staff. Address the needs of each patient by first assessing the level of severity of the patient’s condition; let every patient be submitted for history and physical examination and be evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend that the psychiatric team would work together in order to provide mental health care service that promotes rehabilitation of the patient. Also they are recommended to know the latest trends in improving therapeutic communication between them and the patients.

To the student nurses: Even if nursing students find it difficult to establish therapeutic relationships with mentallyill patients because of the relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to our 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.

188

SIGNIFICANCE OF THE STUDY

This study will be a significant undertaking in depth understanding the reason behind our subject’s mental illness. This study will also be beneficial to the students and clinical instructors in College of Nursing in making use of different concepts taught inside the classroom related to psychiatric nursing.

This case study will give us better understanding regarding mentally-ill patients; provide recommendations on how to deal with them in the future. It will give us better grasp why certain people experience being mentally unstable by looking deeper into the history, physiology, brain chemistry; development of physical, emotional and cognitive; and social relations of the patient.

Some of the mentally ill patients remain undiagnosed and untreated because they never sought medical attention due to old stigmas and societal attitudes towards mental illness. Stigmas results in the social exclusion of people with a mental illness and is detrimental to the part of the family. Moreover, this study will be helpful to aid the family in caring their mentally-ill member; giving them more understanding, acceptance, and how to deal with the illness and issues concerning it.

189

APPENDICES DIAGNOSTIC STATISTICAL MANUAL CRITERIA FOR DIFFRENTIAL DIAGNOSIS Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the clinical picture that occasioned the most recent evaluation or admission to clinical care and may therefore change over time. They are defined by their symptomatology. The disorder lasts for at least 6 months and includes at least one month of the active phase symptoms namely two or more of the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The subtypes are: 295.30 Paranoid Type 295.10 Disorganized Type 295.20 Catatonic Type 295.90 Undifferentiated Type 295.60 Residual Type Diagnostic Criteria for Schizophrenia G. Characteristic symptoms. Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (6) delusions (7) hallucinations (8) disorganized speech (e.g. frequent derailment or incoherence) (9) grossly disorganized or catatonic behavior (10)

negative symptoms (i.e. affective flattening, alogia or avolition)

Only one Criterion A symptom is required if delusions are bizarre or 190

hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. H. 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 selfcare are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) I. Duration Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.) J. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, Or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. K. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition L. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated. Total

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295.30 Schizophrenia Paranoid Type The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent. Delusions are typically persecutory or grandiose or both but delusions with other themes may also occur. Hallucinations are also typically related to the content of the delusional theme. Diagnostic criteria for 295.30 Paranoid Type A. Preoccupation with one or more delusions or frequent auditory hallucinations B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. TOTAL 295.10 Schizophrenia Disorganized Type The essential features of the Disorganized Type of Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not organized into a coherent theme. Diagnostic criteria for 295.10 Disorganized Type A. All of the following are prominent 1. disorganized speech 2. disorganized behavior 3. flat or inappropriate affect B. The criteria are not met for catatonic type TOTAL

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295.20 Schizophrenia Catatonic Type The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include stereotypes, mannerisms, and automatic obedience or mimicry. Diagnostic criteria for 295.20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor 2. excessive motor activity (that is apparently purposeless and not influence by external stimuli) 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism 4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing 5. echolalia or echopraxia TOTAL 295. 90 Schizophrenia Undifferentiated Type Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly fit under any category. Diagnostic criteria for 295.90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type TOTAL 295.60 Schizophrenia Residual Type

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The Residual Type of Schizophrenia should be used when there has been at least one episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing evidence of the disturbance as indicated by the presence of negative symptoms or two or more attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and are not accompanied by strong affect. Diagnostic criteria for 295.60 Residual Type A. Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experience) TOTAL 301.22 Schizotypal Personality Disorder Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 194

7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid)

Schizoid Personality Disorder Individuals with schizoid personality disorder are emotionally detached and prefer to be left alone. Diagnostic criteria for 301.20 Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. neither desires nor enjoys close relationship, including being a part of a family 2. almost always chooses solitary activities 3. has little, if any, interest in having sexual experiences with another person 4. takes pleasure in few, if any , activities 5. lacks close friends or confidants other than first degree relatives 6. appears indifferent to the praise or criticism of others 7. shows emotional coldness, detachment, or flattened activity B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a 195

general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizoid Personality Disorder (Premorbid)” TOTAL

301.0 Paranoid Personality Disorder People with paranoid personality disorder are distrustful and suspicious and anticipate harm and betrayal. Diagnostic Criteria for 301.0 Paranoid Personality Disorder A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her 2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her 4. reads hidden demeaning or threatening meanings into benign remarks or events 5. persistently bear grudges , i.e., is unforgiving of insults, injuries, or slights 6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Paranoid Personality Disorder (Premorbid)” 196

TOTAL 298.8 Brief Psychotic Disorder The essential feature of Brief Psychotic Disorder is a disturbance that involves the sudden onset at least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized speech or grossly disorganized or catatonic behavior Diagnostic Criteria for 298.8 Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms 1. delusion 2. hallucination 3. disorganized speech 4. grossly disorganized catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features , Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition TOTAL 297.1 Delusional Disorder The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not prominent. Tactile or olfactory hallucinations may be present if they are related to delusional themes. Diagnostic Criteria for 297.1 Delusional Disorder A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month’s duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. 197

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. TOTAL 295.40 Schizophreniform Disorder The essential features of Schizophreniform Disorder are identical to those of Schizophrenia (Criteria A) except for two differences: the total duration of the illness (including prodromal, active, and residual phases) is at least 1 month but less than 6 months and impaired social or occupational functioning during some part of the illnesses not require although it may occur. Diagnostic Criteria for 295.40 Schizophreniform Disorder A. Criteria A, D, and E of Schizophrenia are met B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as “Provisional.”) TOTAL Substance-Induced Psychotic Disorder The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations or delusions that are judged to be due to the direct physiological effects of a substance. Hallucinations that the individual realizes are substance induced are not included here and instead would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic symptoms occur only during the course of delirium. Diagnostic criteria for Substance-Induced Psychotic Disorder A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms of Criterion A developed during or within a month of, Substance intoxication or Withdrawal 2. Medication use is etiologically related to the disturbance 198

C. The disturbance is not better accounted for by a Psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not a substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance –induced Psychotic Disorder (e.g., a history of recurrent non-substance related episodes. D. The disturbance does not occur exclusively during the course of delirium. Note: This diagnosis should be made instead of a diagnosis of Substance intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. TOTAL 293.xx Psychotic Disorder Due to General Medical Condition Diagnostic criteria for 293.xx Psychotic Disorder Due to General Medical Condition A. Prominent hallucination or delusions B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. TOTAL 295.70b Schizoaffective Disorder Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some time in the absence of any mood syndrome.

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Diagnostic criteria for 295.70b Schizoaffective Disorder A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet criterion A for Schizophrenia. Note: The Major Depressive Episode must include criterion A1: depressed mood. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medication.

Substance Intoxication Delirium Diagnostic criteria for Substance Intoxication Delirium A. Disturbance in consciousness(i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) Criteria Present 1. the symptoms in Criteria A and B developed during Substance Intoxication 2. medication use is etiologically related to the disturbance*

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