Universidad De Manila

(Formerly City College of Manila)

COLLEGE OF NURSING

A case study of Schizophrenia, Undifferentiated type

Submitted To: Mrs. Connie Castro RN

Clinical Instructor

Submitted By: Rachel V. Sorilla NR42 Group 4

Introduction

Schizophrenia is a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life, and by disintegration of personality expressed as order of feeling, thought, perception and behaviour (MW. 2006). Schizophrenia is usually diagnosed in the late adolescence or early adulthood. Rarely does it manifest in childhood. The peak of incidence of onset is 15 to 25 years old for men and 25 to 35 year old for women (American Psychiatric Association, 2000). It is thought that these disorders are the end result of a combination of genetic, neurobiological, and environmental causes. A leading

neurobiological hypothesis looks at the connection between the disease and excessive levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The genetic factor in schizophrenia has been underscored by recent findings that first-degree biological relatives of schizophrenics are ten times as likely to develop the disorder as are members of the general population. The prevalence of schizophrenia is thought to be about 1% of the population around the world. Thus, it is more common than diabetes, Alzheimer's disease, or multiple sclerosis. Male and female equally affected. Symptoms appear earlier in males. More than 1/2 of all male schizophrenic patients and 1/3 of all female patients are first admitted to psychiatric hospitals before 25.The disorder is considered to be one of the top ten causes of long-term disability worldwide. There are 697,543 cases of schizophrenia in the Philippines, 75% are males and the rest are females (2010). And 51 million people worldwide suffer from schizophrenia in which males have the most number of percent. This statistics shows that males have the greater risk to develop psychiatric disorder such as schizophrenia because of their lifestyle and keeping their emotions.

The DSM-IV-TR(APA, 2000) classified schizophrenia into four types: Schizophrenia, paranoid type; Schizophrenia, disorganized type; Schizophrenia, catatonic type; Schizophrenia, undifferentiated type and Schizophrenia, residual type. The diagnosis is made according to the clients predominant symptoms. Undifferentiated schizophrenia is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect and behaviour (Videbeck, 2006). It is often defined as a form in which enough symptoms for a diagnosis are present, but the patient does not fall into the catatonic, disorganized, or paranoid subcategories. Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic negative symptoms of schizophrenia without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behaviour, manifest as a marked loss of interest, idleness, and social withdrawal. There are no known single causes. One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is incomplete understanding of their causes.

GENERAL OBJECTIVE: At the end of the case analysis, I, a fourth year nursing student, will be able to share the knowledge that I have gained about undifferentiated schizophrenia acute, the skills required to manage the patient and the attitude that I must obtain to become an effective and efficient nurse to the patient that I may encounter in the future.

SPECIFIC OBJECTIVE: After researching the case analysis. I will specifically: * Determine the patients psychiatric health history * Enumerate the different signs and symptoms manifested by the patient * Determine the factors that cause the disease. * Trace the psychopathology of the disorder * Formulate Nursing care Plan utilizing the nursing process * Know the actions and side effects of the medication prescribed by the physician and understand why the drugs are given.

Patients Profile

Name: Age: Birth date: Birthplace: Address: Gender: Civil Status: Nationality: Religion: Educatonal Attaiment: Date of Admission: Time of Admission: Admitting Diagnosis: Final Diagnosis:
Chief Complaints:

39 yrs/old October 7, 1972 Leyte Manila Male Single Filipino Roman Catholic High School Graduate July 22, 2012 2:40 PM Undifferentiated Schizophrenia, Disturbed Undifferentiated Schizophrenia, Paranoid type

According to the mother, the client was hostile and showing untoward behaviors. He began to be assaultive to his mother and father. Tried to burn their house and he would be seen talking and laughing to self
History of present illness

The client has been showing untoward behaviors for 12 years, it all started when his business went into bankruptcy. He was unable to sleep and eat. His illness worsen when his live-in partner leave him.
PAST medical history:

Unknown
Family Health history

(+)Hypertension

(+)Diabetes

PHYSICAL AND MENTAL ASSESSMENT

A. GENERAL APPEARANCE The client appears stated with his age of 39 years old, wearing a blue shirt and short, well groomed. Hes taking a bath everyday with a good daily routine. The client has a good posture, gait and coordination. During interaction, he has a good eye to eye contact. He was well oriented with time, place, date and reality. The client considered the interview as a normal thing and he was guided accordingly with no harsh or offending questions thrown to him during the interview. He was cooperative with consistency of speech and behavior. B. GENERAL BEHAVIOR AND ACTIVITY The client sometimes lethargic and catatonic stupor during interactions. There are also times that he was restless where he cant remain still. He has also knee tremors which were involuntary, purposeless rhythmic movements. C. ORIENTATION The client was well oriented on date, time, place and reality. He can relate to past experiences and able to organized ideas and thoughts related to his present condition. He know and aware that he was at the National Center for Mental Health. D. AFFECT AND MOOD The client show appropriate affect with regards to a certain situation. But sometimes, he suddenly change in expression of mood and this makes hard to identify whether he was on stated condition and willing to cooperate and interested with the interaction. Sometimes, there was an alteration of the affective state of the client which was inappropriate and contrary to his feelings and emotions. E. THOUGHT PROCESS AND CONTENT Even the client was at the center, he has a normal and logical thought process. What he uttered was meaningful and with sense. He didnt use confabulation nor circumstantial. He can easily catch up what the interviewee mean and answer relevant to the questions. F. MEMORY, PRESENT AND REMOTE The client good memory but sometimes he had lapses. He can recall and remember his past experiences and important events and people in his life. What were discussed in the previous days were recalled which were integrated on the present scenario on the interaction.

G. JUDGMENT The condition of the client only started when he was on his early adulthood. Therefore, it doesnt mean that he cannot make decisions on its own. He can formulate and think of other alternatives which later beneficial for solving his own problems. H. INSIGHT The client was knowledgeable and aware of his condition that he was at the national center for mental health. He knows the state of his illness being manageable and how was the progression with regards to his rehabilitation and in response to medication regimen and psychotherapies. He was able to respond of what was going on and can comprehend appropriately. I. INTELLECT He has a good sense of reasoning but it was limited. He was able to pinpoint and defend his answers but if asked for the main reason why he was at the center, he cant answer directly. J. COPING MECHANISMS The client has good pattern in handling stressors that arises in his life. Since he was able to formulate ideas and alternatives in order to divert his attention his problems, he just did his responsibilities at the center and just enjoyed the therapies. K.DEFENSE MECHANISM In the case of my client, he used denial as a defense mechanism. In the reason why he was at the center, he elaborated that he only wanted to rest because she was already tired and exhausted, but in fact, hes been hostile and doing unacceptable manner.

Laboratory and diagnostic examination

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

Radiological Report

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

Impression PTB, minimal (R) activity undetermined

CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

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

II. Function

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

ii The temporal lobe is the center for taste, hearing and smell, and in the brains dominant hemisphere, the center for interpreting spoken language.

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

e The brain stem, which includes the mesencephalon, pons, and medulla oblongata, relays nerve impulses between the brain and spinal cord. 2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do not involve brain control. B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord. C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS contains two divisions. 1. The sympathetic nervous system serves as an emergency preparedness system, the flight-for-fight response. Sympathetic impulses increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic stimuli are mediated by norepinephrine. 2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic impulses are mediated by acetylcholine. III. Differences in nervous system response. The nervous system is one of the first systems to form in utero, but one of the last systems to develop during childhood. A. Accuracy and completeness of the neurologic assessment is limited by the childs development. B. The childs brain constantly undergoes organization in function and myelinization. Therefore, the full impact of insult may not be immediately apparent and may take years to manifest.

C. The peripheral nerves are not fully myelinated at birth. As myelinization progresses, so does the childs fine motor control and coordination. D. Early signs of increased intracranial pressure (ICP) may not be apparent in infants because open sutures and fontanelles compensate to a limited extent. E. The development of handedness before 1 year of age may signify a neurologic lesion. F. Several primitive reflexes are present at birth, disappearing by 1 year of age. Absence, persistence, or asymmetry of reflexes may indicate pathology. G. The spinal cord ends at 13 in the neonate, instead of L1-L2 where it terminates in the adult. This affects the site of lumbar puncture. H. Children have 65 to 140 ml of CSF compared to 90 to 150 ml in the adult.

Drug Study

GENERIC/ BRAND NAME Chlorpromazine

CLASSIFICATION

Antipsychotic

MECHANISM OF ACTION A piperidone phenothiazine that may block post synaptic dopamine receptors in the brain.

CONTRAINDICATION Hypersensitivity to drug and those with Parkinsonism, coma or CNS depression

SIDE & ADVERSE EFFECT CNS: severe extra pyramidal reactions, dyskinesia, dizziness, drowsiness CV: tachycardia GI: nausea constipation, dry mouth

Nursing Implication
-Monitor blood pressure regularly. - Watch for orthostatic hypotension -Monitor for tardice dyskinesia -Watch for signs and symptoms of neurolyptic malignant syndrome -Advise client not to chew extended release capsule before swallowing

DOSAGE 100 mg capsule once a day

INDICATION Psychotic Disorders

THERAPEUTIC EFFECTS Exerts antipsychotic effects to the client

PRECAUTION Use cautiously in elderly clients, those with history of seizures, CV disorders and respiratory disorders

GENERIC/ BRAND NAME Haloperidol/ Haldol

CLASSIFICATION

Antipsychotic

MECHANISM OF ACTION A butyrophenone that probably exerts antipsychotic effects by blocking post synaptic dopamine receptors in the brain.

CONTRAINDICATION Hypersensitivity to drug and those with Parkinsonism, coma or CNS depression

SIDE & ADVERSE EFFECT CNS: severe extra pyramidal reactions, dyskinesia, seizures, lethargy CV: hypotension, tachycardia GI: anorexia, constipation, dry mouth

Nursing Implication
- Monitor patient for tardive dyskinesia which may occur after prolong use. - Watch for signs and symptoms of extra pyramidal effects - Tell client to relieve dry mouth with sugarless candy

DOSAGE 5 mg tablet once a day

INDICATION Psychotic Disorders

THERAPEUTIC EFFECTS Exerts antipsychotic effects to the client

PRECAUTION Use cautiously in elderly clients, those with history of seizures, CV disorders and those using lithium.

Nursing care plan

ASSESSMENT BACKGROUND KNOWLEDGE Aloneness experienced by the individual are perceived as imposed by others and as a negative or threatening state. PATIENTS PROBLEM Social Isolation related to sadness, poor eye contact at times, absent of significant others and isolation of self in room most of the time. OBJECTIVE OF INTERVENTIONS After nursing interventions, the client will be able to engage self in all social activities actively and verbalize willingness to social interactions. NURSING ACTIONS AND RATIONALE >Provide therapeutic Environment _To gain clients trust > Provide a positive reinforcement when client makes moves towards others. _It encourages continuation of efforts. >Promote participation in activities. _This facilitates socialization >Engage other client to interact with the client _this promotes social skills in a safe setting. >Help the client seek out clients to socialize with who have similar interest. _Shared common interest promote more enjoyable socialization which may be repeated. >Praise the client for attempts to seek out others for activities and interactions _Praises promotes repeated positive social behavior.

SUBJECTIVE: >Malungkot dito kapag walang student nurse.

OBJECTIVE: >sadness > poor eye contact at times >absent of significant others >isolates self in room most of the time

Discharge Planning

Medication Instruct the family of the client to strictly follow the doctors prescribed medication . Medication education should also be documented, along with instructions about dosage, times and any special instructions such as the need to take the drugs with food or milk Instruct the family of the client importance of compliance to medication as discontinuing antipsychotic medications is a frequent cause of relapse and rehospitalization. Exercise Instruct the family of the client to continue the light exercise and avoid the strenuous activity because to prevent seizure Treatment Strictly follow Physicians treatment order. Health teaching Inform the family of the patient to always orient the patient to time, place, date and current events Inform the family of the patient to use therapeutic communication while talking to the patient Inform the family of the patient to do different therapeutic activity like occupational, remotivational, movie analysis and health teaching. Inform the family of the client that good communication is a big contributing factor for the recovery of the patient. Out-patient follow up Inform the family of the client that the appointment or follow up with the psychiatrist is very much needed for the patient with schizophrenia to promote continues recovery Advise the family of the client to go back to hospital If they observe any unnecessary action of the patient aside from the one explained by the psychiatrist.