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INTRODUCTION
Psychiatric disorders place a substantial burden and suffering on clients, their families,
society, and the healthcare system. Caring for clients with psychiatric problems is complex and
requires and understanding of neurobiological, cognitive, and psychosocial underpinnings
associated with specific psychiatric conditions.
Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and
behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process
with many different varieties and symptoms. It is usually diagnosed in late adolescence or early
adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of
age for men and 25 to 35 years of age for women.
• Paranoid type: Where delusions and hallucinations are present but thought disorder,
disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code
F20.0)
• Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought
disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1)
• Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless
movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code
295.2/ICD code F20.2)
• Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid,
disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)
• Residual type: Where positive symptoms are present at a low intensity only. (DSM code
295.6/ICD code F20.5)
Families and society are affected by schizophrenia too. Many people with schizophrenia
have difficulty holding a job or caring for them, so they rely on others for help. Treatment helps
relieve many symptoms of schizophrenia, but most people who have the disorder cope with
symptoms throughout their lives. However, many people with schizophrenia can lead rewarding
and meaningful lives in their communities. Researchers are developing more effective
medications and using new research tools to understand the causes of schizophrenia. In the years
to come, this work may help prevent and better treat the illness.
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A. Demographic Data
Patient name: Danillo Dimaala
Historian: JI Raymond AE De Joya
Hospital: CCMH
Consultant: Dr. Escaño
Date Interviewed: 8/15/10
B. General Data
This is a case of D.D., a 44 years old right handed male, single, the eldest among his six
siblings. Born and currently residing in Nasugbu, Batangas. A High School Graduate and
works as water pump tender in a sugar factory in Batangas. He is a Roman Catholic who
speaks Tagalog and English, accompanied by his mother to seek consultation to a
Psychiatrist for the first time in Cavite Center for Mental Health last August 13, 2010.
C. Chief Complaint
The patient is a calm and happy person. He loves his family and friends very much. He
has lot of friends and works well with his colleagues for 16 years. He has no problems or
conflict among his family, friends and other people.
5 years prior to consultation, when the patient fees or meets an individual, he gets
nervous, vision gets blurred, dizzy(slight) and starts to have palpitations. He thinks that
people around him, talk about him, and sometimes likes to hurt or threaten him. He hears
voices inside his head, whether he is alone or not, that tells his unclear or vague commands.
He ignores it and he claims that the voices get mad if he ignores them. Hearing the voices
happens anytime of the day. He is unable to sleep and ends up restless. He claims that people
call him “manyakis”. He consulted to a psychiatrist from nasugbu and prescribed him
medications such as Prozac, Vitamin B Complex, and Rintril. His sleep pattern improved
after taking these medications. After 3 months, he refused to follow-up on his check-up. He
stated to have visual perception of moving shadows and red lights telling him unclear
comments. He claims to have fewer friends at work and accuses his work colleagues of
spreading rumors about him. He plans to resign at work. He usually stays at home after work
and watches TV.
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5 years prior to consultation, the patient had itchiness and soreness around the area of his
penis. There are white-wormy-like rigid structures in his pubic area with erythema and
rashes. Patient has black papules present around his body.
Patient doesn’t have any history of psychiatric or mental illness. He has a primary love
doctor. Patient’s sister died at Diabetes mellitus complications (3rd Sibling).
G. Family Profile
The Dimaala family is a very kind and supportive family among its household members.
They are very supportive among each other. The family members are very supportive on the
patient’s illness and the death of his third sister with the arrangements. Dennis, the youngest
among the patient’s sibling is the closest sibling to the patient. Dante, 43 years old male, is
the second sibling in the family. He is a kind and gentle person. He has no work and helps
the family. Divira, 41 years old female, is a seamstress but died of Dm complications yet she
is a very humble person. Dennis, 39 years old male, is a pig caretaker and a very happy
person. Dolor, 37 years old female, is a housewife and a very supportive mother. Darwin, 35
years old male, sells in a sari-sari store near their house and a very funny and disobedient
person at times.
H. Genogram
III. ANAMNESIS
A. Pre-natal and perinatal history
Patient is a planned pregnancy, no pregnant complications noted. No mental or emotional
problems noted. No alcohol or drug taken.
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B. Early Childhood
He was properly breastfed and bottle-fed. Feeding habits, early development, and toilet
training are unremarkable. No tantrums, night tremors, or thumb sucking noted.
C. Middle Childhood
The patient is cooperative and participative in pre-school activities. He has a lot of
friends and has average academic performance. There is no history of hair pulling, cheating,
or lying.
D. Late childhood
He hates sports and joining extra-curricular activities. He has average academic
performance. He has strong self-esteem and loves helping people. There is no history of
smoking, intake of alcohol, illicit drug use, etc.
E. Adulthood
Patient doesn’t attend Sunday mass for 5 years and goes to church activities before his
illness. Patient has no problems with his work, colleagues, and started drinking alcohol when
he was 20 years old. He never invited or dated a girl in his life.
B. Speech:
He is quiet, moderate in late of production and in moderate volume. He does not interrupt
the examiner in the interview. He has no monotonous speech.
D. Perception:
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He has no auditory and visual hallucinations, illusions, derealization or
depersonalization.
H. Judgment:
He has intact judgment by helping a victim of pick pocketing.
I. Insight:
The patient is fully aware of the illness and accepts it.
J. Reliability:
He has established good rapport to the examiner.
V. FINAL DIAGNOSIS
Undifferentiated Schizophrenia
It is characterized by mixed schizophrenic symptoms (of other types) along with disturbances
of thought, affect and behavior.
VI. ANATOMY & PHYSIOLOGY IN SCHIZOPHRENIA
THE BRAIN
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Structures of the brain that are implicated in schizophrenia focus on three systems
in the brain: the Basal Ganglia, Limbic System and Tegmentum.
BASAL GANGLIA
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The major parts of the basal ganglia consist of the
caudate nucleus, the putamen and the globus
pallidus.
The
LIMBIC SYSTEM
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The limbic system has been implicated in learning and memory and emotions. The implication
in emotions involves feelings and expressions of emotions, emotional memories and recognition
of emotions in other people.
TEGMENTUM
The tegmentum consists of an area of the midbrain. It includes the bottom end of the reticular
formation, the periaqueductal gray matter, the red nucleus, the substantia nigra and the ventral
tegmental area.
NEURONS
Cells in the nervous system are called neurons. The neuron is an information processing and
transmitting cell that undermines all bodily functions. It is estimated that the human brain
contains over 100 billion neurons, with each neuron potentially communicating with hundreds of
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other neurons. This vast interconnectedness allows simple neuronal activity to translate into
complex neuronal messages creating human behavior.
NEUROTRANSMISSION
• The basic structure of a neuron includes a cell body (soma), dendrites, axon and axon
terminal.
• Electrochemical messages pass from the dendrites (projections from the cell body)
NEUROTRANSMITTERS
• Neurotransmitters are the chemical substances manufactured in the neuron that aid in the
transmission of information throughout the body. They either excite or stimulate an
action in the cells (excitatory) or inhibit or stop an action (inhibitory).
• These neurotransmitters fit into specific receptor cells embedded in the membrane of the
dendrite.
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• After neurotransmitters are released into the synapse and relay the message to the
receptor cells, they are either transported back for later use (reuptake) or are metabolized
and inactivated by enzymes, primarily monoamine oxidase
• These neurotransmitters are necessary in just the right proportions to relay messages
across synapses
GABA
Glutamate
Acetylcholine
Serotonin
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Dopamine
VII. PSYCHOPATHOPHYSIOLOGY
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VIII. DRUGSTUDY
Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n
GI:
constipation,
drymouth,
anorexia
GU: urinary
retention,
menstrual
irregularities,
gynecomastia
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HEMATOLOGIC
: anemia
RESPIRATORY:
dyspnea
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Generic Unclear. Thought Schizophre hypersensi CNS: sedation, Patient
Name: to interfere with nia in patient tivity to drugs drowsiness, monitoring
Clozapine dopamine unresponsive to dizziness, vertigo, 1. Monitor wbc
binding in limbic other therapies uncontroll insomnia, count weekly for 6
Brand Name: system of CNS, ed seizure disturbed sleep, months
Leponex with high affinity nightmares, 2. Monitorecg
for dopamine severe restlessness and liver function
Classification: receptors CNS test
Antipsychotic depression or CV: 3. If drug must
coma tachycardia, be withdrawn
hypotension, abruptly, monitor
hypertension, patient for psychosis
chest pain and cholinergic
rebound (head ache,
EENT: visual nausea, vomiting and
disturbances diarrhea)
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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n
Skin:
Photosensitivity
Other: decreased
appetite, pain at
I.M. injection site
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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n
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dysfunction
Respi:
respiratory
depression,
shortness of
breath
Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n
Monitor for
constipation cramping
pain in the abdomen,
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and abdominal
distension. Increase
fluids, add fiber to diet
and exercise
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Drug Name Action Indication Contraindicatio Adverse Reaction Nsg Consideration
n
To prevent
vit C deficiency
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in patients with
poor nutritional
habits or
increase
requirements
To acidify
urine
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IX. NURSING CARE PLAN
ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues: Disturbed thought After 2 weeks of Be sincere and To establish a Goal met:
“Nagugulat ako pag processes related nursing honest when trusting relationship After 2 weeks of nursing
nakakakita ng babae to presence of interventions the communicating interventions the client
at lalaki” psychological client will be able with the client was able to:
conflicts as to:
Objective cues: evidenced by Interact Do not make Broken promises Socialize with others in
Auditory delusions and and respond to promises that you reinforce the client’s reality-based
hallucinations hallucinations reality-based cannot keep mistrust of others conversations through
Visual interactions verbal and nonverbal
hallucinations initiated by Explain procedures The client feel behavior
Insomnia others and be sure the less likely that he or
Restlessness client understands she is being tricked
Ramus mood Demonstrat the procedures
with full affect e reality based before carrying
Paucity of thinking in them out
ideas verbal and
nonverbal Interventions for
Tangential at
behavior Delusions:
times
Ideas of Give positive Enhances the
reference feedback for client’s sense of well-
client’s success being and helps to
Persecutory
delusions make nondelusional
reality a more
Flight of ideas
positive situation
Has a hard
time subtracting
Interact with the Interacting about
7 from 100, 7
client on the basis reality is healthy for
from 93 and so
of real things, do the client
on
not dwell on the
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delusional material
Interventions for
Hallucinations:
Elicit description of To protect the
hallucination client and others.
Understanding the
hallucination will
provide ways to calm
or reassure the client
Help present or
maintain reality by To maintain
frequent contact and reality orientation
communication
with the client
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