A Case Study On

UNDIFFERENTIATED SCHIZOPHRENIA
In Partial Fulfillment of the Requirements in NCM- RLE
(Psychiatric Exposure)

Submitted to:
Ms. Marie Lyn Al Bayouk, RN
Ms. Evelyn Alba, RN
Ms. Maria Elsie Callueng, RN, MAN
Ms. Mary Jane Guiang, RN
Ms. Maria Delma Mausisa, RN, MAN
Ms. Cecilia Grace Acua, RN
Clinical Instructors

Submitted by:
ANQUE, Joanna Grace Ruby

GARLIT, Irish

ROSALIN, Jeffrey

BACARON, Loumelyn Rose

GONZAGA, Kimberly Anne

SANTOS, Amifaith

BAUTISTA, Ericka

MAGSIPOC, Rubnie Jhum

SENARILLOS, Mary Rose

BUTT, Kanval

OBANDO, Sherilyn

SUCALDITO, April May Anne

CLAVANO, Rock

PUERTO, Angelee

UNTALAN, Benjamin Alejandro

DALHOG, Aaron

REPITO, Desiree

BSN 4B Male Ward Group

Date Submitted:
October 22, 2010

TABLE OF CONTENTS

Table of Contents

I. Introduction
A. Overview
B. Objective
B.1 General Objective
B.2 Specific Objectives.
II. Anamnesis
A. Informants.
B. Maternal and Paternal Lineage..
C. Parents.
D. Siblings
III. Personal History.
IV. Course in the Hospital..

A. Mental Status Examination.

V. Progress Notes.
VI. Psychopathophysiology..
VII. Psychodynamics
A. Tabular Presentation of the Predisposing Factors and Rationale
B. Schematic Diagram.
VIII. Differential Diagnosis.
IX. Multi-Axial Diagnosis DSM-IV TR..

X. Summary..
XI. Nursing Care Plan...
XII. Medical Managements
A. Doctors Order..
B. Psychopharmacotherapy..
XIII. Prognosis and Recommendation
XIV. Discharge Planning
XV. Bibliography
Appendices

A. Spot Map
B. Genogram

INTRODUCTION

OVERVIEW
How human brain works is the most complex toil in the human body. A serious
damage in it can change lives. A change can be on a persons thoughts, perceptions,
behaviors, movements and emotions. These changes can possibly harm a persons
family or worst the community he lives in.
Schizophrenia is not a terribly common disease but it can be a serious and chronic
one. The appearance of its manifestations differs among patients and the duration of
the disorder. The disorder usually begins before the age of 25 and continues
throughout life time. Both patients and their families often suffer from poor care and
social barring.
Early Greek physicians described delusions of grandeur, paranoia, and deterioration
in cognitive functions and personality. It was not until the 19 th century, however that
schizophrenia emerged as a medical condition worthy of study and treatment. Emil
Kraepelin (1856 -1926) and Eugene Bleuler (1857 -1939) are the two major figures in
psychiatry and neurology who studied schizophrenia. Kraepelin first named the
disorder as dementia precox, a term that emphasized the change in cognition and

early onset of the disorder. It was Bleuler who coined the term schizophrenia, which
replaced dementia precox in the literature.
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.
About 90% of schizophrenic patients seek treatment between 18-55 years old. Male
and female equally affected, Symptoms of schizophrenia 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. It is considered to be one of the top
ten causes of long-term disability worldwide.
In the Philippines, a study conducted in three primary health centers situated in an
urban slum in Manila, showed that 17% of adults and 16% of children had mental
disorders. ). According to study done, 697,543 out of 86,241,697 of Filipinos or
approximately 0.8% are suffering from schizophrenia .A study in 1988-1989 in a
barrio in San Jose Del Monte Bulacan, showed the prevalence of adult schizophrenia
to be 12 cases per 1000 persons. 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.
DSM IV TR (Diagnostic and Statistical Manual on Mental Disorders 4 th Text
Revised) classifies the subtypes of schizophrenia as paranoid, catatonic,
undifferentiated, and residual, based predominantly on clinical presentation. Patient
X, admitted in the Crisis Intervention Unit (CIU) of the Davao Mental Hospital, was
diagnosed with undifferentiated schizophrenia. The said disorder is hoped to be
discussed thoroughly in this study.
5

OBJECTIVE
GENERAL OBJECTIVE:
This study aims to discuss the causes and factors that will contribute to the onset
of the condition of the patient.

SPECIFIC OBJECTIVE:

1. Establish a trusting and therapeutic relationship with Patient X and his family.
2. Gather pertinent data from the patient, family, and other informants regarding
patients condition.
3. Identify precipitating and predisposing factors that are possibly involved in the
development of the presented disorder.
4. Determine the family history related to the condition of the patient that is relevant
to the study.
5. Trace the psychopathophysiology of the condition.
6. To learn drug actions, and side effects of medication given to the patient.
7. Formulate Nursing Care Plan suited to the patients condition.
8. Render health teaching to the patient, family and community.

SCOPE AND LIMITATION

This study was accomplished during the Psychiatric Nursing exposure at the Davao
Mental Hospital located at the J.P Laurel Avenue, Davao City last September 28 to
October 15, 2010. This case study focused on a certain patient living at Panabo City. The
patient was diagnosed to have Schizophrenia, undifferentiated and was admitted at Davao
Mental Hospital last September 29, 2010 and discharged from CIU last October 4, 2010.
The group gathered ten informants including his relatives, friends, neighbors, and family
members. The interviewers gathered significant information which is helpful in knowing
the present condition of the patient. The information comprised the familial history and
the patients life.

PATIENTS PROFILE
Name of Hospital: Davao Mental Hospital
Address: J.P. Laurel Avenue, Bajada, Davao City

Patients Name: Patient X

Ward/Room/Bed Service:Crisis Intervention Unit
Address: Guava St. Phase I, Brgy. Cagangohan, Panabo City
Age: 22
Gender: Male
Birth date: January 9, 1987
Civil Status: Single
Nationality: Filipino
Religion: Roman Catholic
Ordinal Position: 5th Child
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Educational Attainment: 3rd Year High School

Fathers Name: Mr. A Sr. (Deceased)

Occupation: Citizenship Advancement Training
Mothers Name: Mrs. A
Occupation: Fruit Vendor
Date of Admission: September 29, 2010
Time of Admission: 10:00 am
Date Discharged: October 4, 2010
No. of Days Admitted: 5 days

Admitting Physician: Dr. Sayon

Type of Admission: New
Principal Diagnosis: Schizophrenia, undifferentiated

ANAMNESIS
INFORMANTS
INFORMANT #1
Name: Mrs. A
Age: 55 years old
Relationship: Mother

VISAYAN VERSION:

According to the informant her son was born in Minda Carmen. They lived at Panabo
province (please refer to the spot map) for 11 years.

Patient A starts working as

konductor at the age of 16 at Tres Marias. He only reached 3 rd year high school
because he joined gang and was terminated at school. At the age of 18 he was brought to
Dela Rosa Rehabilitation Center. He keeps on saying to his mother that there are lots of
cigarettes. They found out that he was using marijuana and prohibited drug like shabu.
When he was nineteen years old he became drug dependent. At 21 years old, his uncle
brought him in Baringot Agusan to work. Last May 27, 2010 his father died, the burial
last for fifteen days. At that time he cannot fell to sleep and he kept on hugging his
fathers coffin. He was taking 100mg of Seroquel as maintenance rather 200mg. The
10

informant has 7 children and all of them were delivered via normal spontaneous vaginal
delivery. The informant has spotting of blood while shes pregnant with Patient A. The
informant went to the doctor for checkup and the result was normal. The informant also
has cough during the pregnancy. Patient A has complete immunization and prenatal check
up according to his mother. According to the informant, Patient A loves his siblings so
much and he has close relationship to his father. The informant was smoking during her
third pregnancy. Patient A was breastfed during his infancy. They dont usually cuddle
Patient A. Patient A started walking at 8 months old. He started speaking at the age of 13
months. He started schooling at the age of five. They left him at school during school
hours because he already knows how to go home.
When Patient A was still at the elementary level he really wanted to study, according to
the informant. But when he reached high school level he didnt want to study anymore.
He also received a grade of 76 in English. His favorite subject was mathematics. He had a
lot of friends both male and female. He goes to church once or twice a month. He stays at
home before he was admitted in this hospital. He had a lot of girlfriends before but few
are in serious relationship. One of the girls that he loved went to Dubai and it gave him
the reason to breakup. The woman was widower and has a child. She always went in their
house and Patient A loves her child.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Mrs. A is very cooperative in interactive and very accommodating. She shared
information about his sons life. She was well groomed and her speech was spontaneous.
She responded accordingly to the interviewers questions.
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Informant #2
Name: Mr. JB
Age: 34 years old
Relationship: brother, second to the eldest

Sometimes he became angry right after he left home. He became a konduktor while he
lived with his friend. Right after he went home he talked often, as verbalized by the
informant. The informant said Pag-uli nya sa balay hilomon naman siya, pagkapila ka
adlaw na ing-ana naman sya (pagkatopak). He also becomes wild in our aunts house. We
didnt know that he was using cannabis and methamphetamine. pormal man siya na
pagkatao according to the informant. After a few months when my father died he took
drugs again. He plays basketball when he was a kid, he even plays with other children.
He had a friend and co-worker named Ton-ton, his relationship to his co-workers was
good. He had a girlfriend but I dont know her name. My father is a social drinker, he
smoked but stopped when he was 45 years old. He has hypertension. stroke man to
iyang dahilan pagkamatay, naa pud si tatay ginatumar na tambal

as told by the

informant. He worked at miners as a chef for 2 weeks. Sometimes my mother experiences

shortness of breath. After my fathers death, fruit vending was the source of our income.
Now my mother supports us financially.

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Characteristics and Attitudes of the Informant:

Upon interviewing the informant we have observed that he was answering in all
questions according to his cognitive knowledge although he was in a hurry because he
had work to do. He was well groomed and his speech was spontaneous. He responded
accordingly to the interviewers questions.

Informant #3
Name: Mr. KS
Age: 18 years old
Relationship: Close friend

VISAYAN VERSION:
Ok mana sya kaistorya ug kalit lang muistorya ug lahi lahi ang tubag. Buotan,
musogot suguon, dali istoryahon, daghan amigo, sige dula ug basketball.
Dili siya ( Anthony) hilig magsugal aga-tan-aw lang na siya. Usahay lang naga-inom
ug sigarilyo. Naga-videoke.

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Naay sya barkada sa prutasan kauban niya sa paghit-hit. Bago na siya na-admit
gidakop na siya kay nag-wild ug gi-kulata pud siya sa pulis. Naa tong panahon na
nagtan-aw mi ug basketball human gi-ayo niya ang sound system.
Nag-istorya siya sa tindahan Tindera: Dong asa man ka gikan? Anthony: Nag-adto
ko Baghdad,Iraq. Nag-ingon siya sa usa ka tindera Te, papalita ko ug redhorse isa
ka case kay mag-inom mi sa akong barkada. May sinsilyo ka 25 sa Milyon na gold?
ka yang gibayaran ko niya 25 sentavos. Pagkapatay sa iyang papa kay na-depressed
siya. Kadtong naay vigil sa amo gi-ingnan nya ang mga bisita na mulingkod sa ka
manigarilyo ug mangape. Wala siya pili na barkada kung baga lovable. Kadtong
naa siya gitulis gi-ingnan niya iyang barkada na ihatag n amino ang imong kwarta sa
akoa kay itumba ko na imong motor. Human wala nako ganahi mamasahero kay gihold-up nako niya.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Upon interview we can observed that he is speaking fluently and it is based upon his
knowledge. He had a lot of stories to tell because he was a close friend to Anthony.

INFORMANT #4
Name: Mr. RD
Age: 39 years old
Relationship: Friend, known him for years

14

VISAYAN VERSION:
Dugay name nagkaila. Nagakondoktor siya ug jeep human nikalit lang na torereng
kay napasmohan. Nahibal-an na turiring kay ni-ingon na hayag inyong suga pero
walay andar ang suga. Palapansin sa iyang mga amigo pero sa kalaban masuko.
Kadtong buhi pa iyang papa close sila. ang iyang mga igsoon gikulong siya kay giholdap niya iyang barkada. Ang iyang mama kay nahadlok sa iyang batasan human
nidagan sa pikas balay. Didto sya nagpuyo pila ka simana. Kadtong ulahing tukar
niya kay nanghasi siya sa pulis. Kung mulakaw murag robot.

ENGLISH VERSION:
Ive known him for a long time. He used to be conductor in a jeepney then suddenly
something is ringing in his ear natorereng due to some eating pattern disturbance.
we only knew that he is not in the right condition of his mind when he thought that
our light is bright there is no light switch on.he used to be jolly in his friends but
easily gets angry with his enemy. When his father was still alive they were so bonded.
there was one instance that his brother jailed him because he robbed one of his
friends. His mother fear him because of his behavior he ran off to the other house. his
mother stayed there for a couple of time. last occurrence of his untamed behavior he
robbed a police man. when he walked he seems like a robot.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

15

As we have our interview with him, we sense that he willingly shared all his knowledge with our
patient because he knew him so well.

INFORMANT #5
Name: Mr. PC
Age: 58 years old
Relationship: Friend, known him for 13 years

VISAYAN VERSION:
Nagkasuod mi ani diri na sa lugar. Ang iyang papa kay foreman human naa siya mga
buotan na anak, apil na didto si Anthony. Dili man siya dalo na pagkatao. Naa toy usa
na pagkataon na nag-wild siya sa birthday sa anak sa sarhento nya amigo pajud nya.
Maayo man siya na amigo pero pagmabikil siya kay suko jud siya. Mukalit-kalit lang
baya siya. naa toy usa na nabantayan nako siya na naghit-hit. mayo na siya na bata
pinangga kayo na siya. Dili kayo nako kaila iyang mama. Ang iyang mga amigo parepareha lang ug edad nga puro mga lalaki.

ENGLISH VERSION:
Anthony and I became friend in this area. his father was a foreman he has children
this include Anthny they were behave children. He used to be generous. There was
one time that he became wild at at one event of his friend, a birthday celebration in a

16

sergeants house. He was a good companion and a friend but a fearful one to his
enemy. He suddenly gets irritated. There was one time that I saw him using drugs. He
was loved by many. I dont really knew his mom. He has the same peers almost all of
it is boys.

CHARACTERICTICS AND ATTITUDES OF THE INFORMANT

Our informant known him for more than 10 years, he speaks fluently and confidently.

Informant #6
Name: Mr. P
Relation: Neighbor/ Friend of patients father
Known patient since 1997. When asked about the patient, informant said But-an, pero
pag mabikil kusgan jud ng bata na na. When asked about his most memorable violent
incident with the patient, informant said kalit kalit magbunal bato sa video karera.
Informant attested that patient used cannabis in his home. In terms of cigarette smoking,
patient used to smoke 1 pack of cigarettes per day. When informant was asked about the
patients father, he said he died because of hypertension and that he was very strict. When
asked about the patients mother, he said that the mother was always not home because
she had to go to the market to sell fruits. Informant observed that the patient had friends
of the same age and same sex. He goes to church, but not with the whole family.
Informant observed that the patient is his parents favorite child. Patient used to bring
food to his family after work. The last incident that happened between the informant and
17

the patient was when the patient went to his home, unable to recognize him as a close
family friend.

Informant #7
Name: Mrs. M
Relation: Neighbor
Known patient since 1995. When asked what she can say about the patient, she said
Maayo man siya, pero pag mabikil magalit. Patient brings food to family. He also has
lots of friends. When asked about his most memorable violent incident with the patient,
informant said that the patient once threw a stone that broke their window. Informant also
shared another incident with the patient. He once brought a lot of orchids from his
mothers garden to his neighbors houses without his mothers permission.

Informant # 8
Name: Mrs. G
Address:
Relationship: Aunt
Length of time known to patient: 23 years

Apparent Understanding of Present Illness to the Patient:

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Mrs. G verbalized, buotan mana na bata si Anthony, bright gane na siya naundang lang
na siya ug eskwela mao to nag konduktor na siya jeep pa davao. Murag na pasmuhan
man gud na siya unya katong nag konduktor na siya nakasaksi na siya nga nay gibaril sa
iyang atubangan mao tong na shock siya didto na nagsugod iya sakit unya namatay
iyahang papa nisamut iyahang sakit. Sa side pud sa mama ni Anthony naa siya pagumangkon nga naa sakit sa utok, napasmuhan pud to siya sa bukid man to nahitabu kay
nag-uma man to siya didto, pero step sister lang man to sa mama ni Anthony basin dili
pud to konektado sa Iyahang sakit.
Characteristics and Attitude of the Informant:
Mrs. G is willing to share information regarding her nephews condition, she response
accordingly to our question.

Informant # 9
Name: Mrs. E
Address:
Relationship: Neighbor
Length of time known to patient: 2 years

Apparent Understanding of Present Illness to the Patient:

Mrs. E verbalized, ay sa barkada-barkada mana siya basig na impluwensiyahan na siya
mag take ug bawal na gamut, bugoy man gud na iya mga barkada. Pero dili ko sure ana
19

kay bag-o lng pud baya me dire unya mahadluk jud ko ana niya kay mututok man na siya
sa balay,last week lang gani to sya nag-wild.
Characteristics and Attitude of the Informant:
As we interview Mrs. E, she was very sociable and readily answers our question
regarding the patients condition.

Informant # 10
Name: Mrs. F
Address:
Relationship: neighbor
Length of time known to patient: 1 year

Apparent Understanding of Present Illness to the Patient:

Mrs. F verbalized, ang pagkabalu nako bag-o lang na siya na kagawas ug mental pero
wala jud ko kabalo sa iyahang sakit. Mahadluk lang mi sa iyaha kay lain man gud na siya
mutan-aw mao na naga pan lock me sa gate namu.
Characteristics and Attitude of the Informant:
Mrs. F is hesitant to give information due to the fear that the patient will be agitated and
harm their family.

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MATERNAL AND PATERNAL LINEAGE

PARENTS
Father
Mr. A Senior grew up in Panabo City. He is an employee at a private company for 6 years
then he became a commandant for the high school subject CAT (Citizenship
Advancement Training) at Panabo National High School. He wass a good provider to his
family and was generally described as a good person. In the family, he was known to be a
strict disciplinarian. Among his children, the patient was his favorite. In terms of religious
practices, he seldom attends mass. Mr. A Seniors activities includes singing in a videoke
machine and occassional drinking session of alcoholic beverage with his colleagues. The
late Mr. A believed that discipline is a key to have a harmonious relationship among each
family member.

Mother
Mrs. A also grew up in Panabo City. She was a fruit vendor at the public market. She was
described by the informants to be a good and kindhearted person. In terms of discipline,
an informant told the interviewers that he witnessed the mother spanking her kids
whenever they did something wrong. She had a good relationship with her husband but

21

was said that she was a very busy person that sometimes she lacks time to spend with her
family.

22

SIBLINGS
Joe, 36 years old, is the eldest in the family. He was already married for 7years with
two daughters. He was able to finish first year high school and stopped then after.
This was due to his extreme attachment to his friends and vices. Currently, he resides
at Panabo City and is working at TADECO Company. He was described as a very
sociable person in the entire family.
Jov, 30years old, is the second in the family. He was also married for 5 years with 2
kids. He was the only one in the siblings who was able to reach first year college
level. He was not able to finish schooling due to financial constraints. He was
described as a silent and shy type of person.
Fred, 29 years old, is the third in the family. He was able to graduate in High School.
He is still single and is currently working at the Panabo Port. He was also a shy type
of person and only opens up to those who are very close to him.
Vidi, 27 years old, is the fourth in the family. He also graduated in High School. He is
single and is currently working as a waiter at a local restaurant nearby their residence.
He was described as a simple guy and a very thrifty person.
Anthony is the fifth in the family. He is 23 years of age. He reached 3rd year High
School and was not able to pursue his education due to his vices and recurrent
admission to the psychiatric institution. He was described as a silent type of person
before his sickness but his behavior drastically changed right after he was admitted.

23

He became aggressive and anxious most of the time but he calms down when his
mother starts to threat him that she will call the police officers. Anthony starts
working at 18 years old when he became a konduktor (helper) in the jeepney that
travels from Panabo City to Davao City. Currently, he is still staying in their residence
and is still under observation for possible recurrence of aggression that he exhibits a
week prior to admission.
Vani age 22 is a high school graduate. He is the sixth in the family and is working as a
school janitor. He is still single and helps in the familys finances especially now that
their father is gone. He was described by the neighbor informants to be budotsbudots (quirky clothing style) due to his fashion statement. He was also known to be
a member of a gang who was said to be involved in some violent activities.
Vens age 18 is the youngest in the family. He is a high school graduate. He is
currently helping his mother in selling fruits and vegetables in the market. He was
known to be a good person in their community.

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PERSONAL HISTORY
Mrs. A has a poor prenatal check up. She doesnt have any supplements and she rarely
eats nutritious foods. She also lacks exercise. She verbalized that she took
paracetamol when she have headache or fever when she was pregnant.
BIRTH
She delivered all her children via normal spontaneous vaginal delivery. The first five
children were delivered at home wherein a midwife facilitated the delivery. The two
younger siblings were delivered at the hospital. As for Anthony, he was born on
January 9, 1987

and there were no complications noted upon delivery.

INFANCY AND CHILDHOOD

Anthony was breastfed for 9months. His eruption of teeth occurred at around
4months. At 8 months, he was able to take his first steps. He was able to baby talk at
1year and 1month. The patient was toilet trained at 3years old. At 4 years old an
unexpected incident occurred wherein he fell down 3steps in the stairs and resulted to
few bruises and lesions but there were no any neurologic deficit noted.

PSYCHOSEXUAL HISTORY

25

Anthony verbalized that he was already oriented on his sex as a male since he was a
child. He was circumcised at age 8. He had his first girlfriend at age 15. He had 2
succeeding relationships thereafter. He verbalized that he had a serious relationship
with a woman and he got her impregnated but the woman decided to abort the child
and that made him devastated because he wanted a child.

PLAYLIFE
The patient was given toys appropriate for his age. His mother verbalized, Ay,wala
jud nay problema nang bata-a nah. Grabeh jud nah siya makadula. Daghan pud nah
siya ug amigo.

SCHOOL HISTORY
At 6years old, he started schooling as a kindergarten student. He received an award at
the end of the school year as a fifth with honors. In elementary years, Anthony was
really eager to excel in school but when he reached high school he became too
involved with his friends and was influenced with their bad habits thats why he
flanked his English subject.

MARITAL HISTORY
Patient is still single.

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ONSET OF PRESENT ILLNESS

Upon stopping school at age 16 he became a konduktor (helper) of the jeep. The
work was very tedious and he skips meals often. He also became influenced to take
illegal drugs and he became addicted to it. He was rehabilitated three times at De La
Rosa rehabilitation Center yet he still continued his vices after discharge. Last May
2010, his father died which precipitated his aggression towards other people which
includes his robbery case. He was then placed by his mother and his siblings on
restrain because he could no longer control his anger. This prompted the family to
seek consult at DMH (Davao Mental Hospital).

27

COURSE IN THE HOPITAL

MENTAL STATUS EXAMINATION
Patients Name: Patient A

Age: 23 years old

Address: Niceville Subdivision, Cagangohan, Panabo City

CIU Visit September 30, 2010

I. Presentation
A. General Appearance: Fairly Groomed with Good eye contact; akathesia
noted
B. General Mobility:
1. Posture and Gait: () Appropriate

( ) Inappropriate

Describe: Normal_____________________________________

2. Activity
( )Normoactive
( ) Psychomotor Retardation
() Restless

28

( ) Agitated

3. Facial Expression () Appropriate

( ) Inappropriate

Quality:
()Smiling

() Worried

( ) Angry

()Happy

( ) Tensed

( ) Suspicious

( ) Ecstatic

( ) Sad

( ) Frightened

( ) Tearful

( ) Distant

C. Behavior: Restless and anxious

D. Nurse- Patient Interaction
()Cooperative

( ) Uncooperative

( ) Initially Only

() Throughout interview

E. Quality
( ) Warm

( ) Distant

( ) Suspicious

()Talkative

( ) Hostile

( ) Others:_________

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II. STREAM OF TALK

A. Character of Talk

() Spontaneous

( ) Deliberate

( ) Relevant

( ) Irrelevant

( ) Incoherent

() Circumstantial

( ) Looseness of Association

( ) Tangential

() Flight of Ideas

B. Organizational of Talk

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood

() Euthymic ( ) Depression

( ) Euphoria

( ) Others:_____________________________________________

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B. Affect:

() Appropriate

Quality: ( ) Flat

( ) Blunted

( ) Inappropriate

( ) Hostile

( ) Labile

C. Depersonalization and Derealization

( ) Present

D. Suicidal Potential

( ) Present

() Absent

E. Homicidal Potential

( ) Present

() Absent

( ) Elated

() Absent

IV- Thought
A. Delusion
Type: auditory

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First Home Visit October 06, 2010

I- Presentation
A. General Appearance: Clean clothing, good eye contact, hurried speech

B. General Mobility:
1. Posture and Gait: () Appropriate

( ) Inappropriate

Description: Normal_______

2. Activity

() Normoactive
( ) Psychomotor Retardation
( ) Restless
( ) Agitated

3. Facial Expression () Appropriate

( ) Inappropriate

Quality:
()Smiling

( ) Worried

( ) Angry

()Happy

( ) Tensed

( ) Suspicious

( ) Ecstatic

( ) Sad

( ) Frightened

( ) Tearful

( ) Distant

32

C. Behavior: Normal
D. Nurse- Patient Interaction
()Cooperative

( ) Uncooperative

( ) Initially Only

()Throughout interview

E. Quality
( ) Warm

( ) Distant

( )Suspicious

()Talkative

( ) Hostile

( )Others:_________

II. STREAM OF TALK

A. Character of Talk

() Spontaneous

( ) Deliberate

() Relevant

( ) Irrelevant

( ) Incoherent

( ) Circumstantial

( ) Looseness of Association

( ) Tangential

( ) Flight of Ideas

B. Organizational of Talk

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood

() Euthymic ( ) Depression

( )Euphoria

( ) Others:_____________________________________________

33

B. Affect:

() Appropriate

Quality: ( ) Flat

( ) Blunted

( ) Inappropriate

( )Hostile

( )Labile

C. Depersonalization and Derealization

( ) Present

D. Suicidal Potential

( ) Present

()Absent

E. Homicidal Potential

( ) Present

()Absent

( )Elated

()Absent

IV- Thought
A. Delusion
Type: absent

34

Second Home Visit October 06, 2010

I- Presentation
A. General Appearance: Clean clothing, good eye contact, hurried speech

B. General Mobility:
1. Posture and Gait: () Appropriate

( ) Inappropriate

Description: Normal_______

2. Activity

() Normoactive
( ) Psychomotor Retardation
( ) Restless
( ) Agitated

3. Facial Expression () Appropriate

( ) Inappropriate

Quality:
()Smiling

( ) Worried

( ) Angry

()Happy

( ) Tensed

( ) Suspicious

( ) Ecstatic

( ) Sad

( ) Frightened

( ) Tearful

( ) Distant

35

C. Behavior: Normal
D. Nurse- Patient Interaction
()Cooperative

( ) Uncooperative

( ) Initially Only

() Throughout interview

E. Quality
( ) Warm

( ) Distant

( ) Suspicious

()Talkative

( ) Hostile

( ) Others:_________

II. STREAM OF TALK

A. Character of Talk

() Spontaneous

( ) Deliberate

() Relevant

( ) Irrelevant

( ) Incoherent

( ) Circumstantial

( ) Looseness of Association

( ) Tangential

( ) Flight of Ideas

B. Organizational of Talk

( ) Others:___________________________________________________

III- Emotional State and Reactions

A. Mood

() Euthymic ( ) Depression

( ) Euphoric

( ) Others:_____________________________________________

36

B. Affect:

() Appropriate

Quality: ( ) Flat

( ) Blunted

( ) Inappropriate

( )Hostile

( )Labile

C. Depersonalization and Derealization

( ) Present

D. Suicidal Potential

( ) Present

()Absent

E. Homicidal Potential

( ) Present

()Absent

( )Elated

()Absent

IV- Thought
A. Delusion
Type: absent

37

PROGRESS NOTES
Progress Notes
Admission
Date: October 6, 2010

Oriented on time and place

poor sleep
poorly groomed
conversant with good eye contact
positive audiovisual hallucination

Analysis: Undifferentiated Schizophrenia

Planning: For Discharge
Brief History: September of 2005 patient was caught taking drugs and was admitted
to Dela Rosa for rehabilitation, he lasted there for 1 month. On October of the same
year he was admitted again, on the second day of his stay he tried to escape but was
captured, he was rehabilitated for 6 months. on 2006 mid year the patient took drugs
again, became violent and often goes amok. the patient was again admitted at Dela
rossa for 7 months. 2007-2010 before the death of his father his mother claimed that
he was normal. after the death of his father he took drugs again and was admitted at
Davao Mental Hospital after he stole money from his friend including previous
violent behaviour in their community.
Admitting Impression: Undifferentiated Schizophrenia

38

Medication:

Fluphenazine
Trifluoperazine
Chlorpromazine
Perphenazine
Thioridazine

Procedure: CBC
Recommendations: Continue Meds

39

PSYCHOPATHOPHYSIOLOGY

40

PSYCHODYNAMICS
TABULAR PRESENTATION OF THE PREDISPOSING
FACTORS AND RATIONALE

Predisposing factors
Factors

Present

Rationale

Sex

The patient is male.

Schizophrenia affects
both male and female
with equal frequency.

Age

The patient is 23 years

Schizophrenia is

old.

usually diagnosed in
late adolescence or
early adulthood. Peak
incidence of onset is
15-25 years of age for
men and 25-35 years of
age for women.
(Videbeck p. 297, 2nd
edition)

Genetics/Hereditary

The patients first

The genetic or
41

cousin from the

hereditary

mother side has a

predisposition theory

psychiatric problem

suggests that the risk of

brought by starvation.

inheriting
Schizophrenia is 10%
in those who have one
immediate family
member with the
disease. (Psychiatric
Mental Health Nursing,
5th edition. By Shrives,
p.263).

Characteristics/Personality

Stressed

An interpersonal

Depressed

approach to the
etiology of
schizophrenia is based
on the theory that there
exist a pre-disposition
of the personality under
high level of stress.

Precipitating Factors
Factors

Present

Rationale
42

Peer Influence

The patient started using

According Horrocks and

marijuana and shabu

Benirnoff, the peer group

when he worked as a

is the adolescences real

bus conductor at the age

world, providing a stage

of 16.

upon to which to try

himself and others.

Family

The father and his

Lack of loving and

brothers are occasional

nurturing caregivers, one

drinkers. His mother

of many other factors, is

spends most of her time

thought to be responsible

in the market where she

for mental problems in

works. The patient and

later life. (psychiatric

his siblings are always

nursing 3rd edition,

left at home to tend to

Keltner).

themselves. The
patients father died
early this year.
Vices

The patient is a smoker

Teenagers tend to have

and alcoholic drinker.

vices due to peer

The patient also uses

pressure. Cannabis and

cannabis and shabu.

shabu increases
dopamine levels in the

43

brain. An increase in
dopamine level in the
brain is possibly linked
to schizophrenia.
Emotional Trouble

The patient was

According to Manfreda

depressed when he

and Krapmitz, drives

broke up with his

may be expressed in an

girlfriend, Loch. He

individuals behavior

claims to have fallen

reaction to everyday

over heels for her.

incidents such as
disappointments,
rejections, deprivations,
marital difficulties,
failure in one ambition,
inferiorities, and
economic reverses.

Low Socio-Economic

The patient now belongs

Social causation

Status

to a low income family

hypothesis proposes that

because his father, the

stresses experienced by

breadwinner, died early

members of low socio-

this year. Before that,

economic group

the patient lived an

contribute to the

easier life, but was still

development of

44

prompted to work as a

Schizophrenia. (Synopsis

bus conductor.

of Psychiatry by
Kapplan, p. 462)

45

SCHEMATIC DIAGRAM
Trust vs. Mistrust
(Infants, 0 to 18 months)
Mother
Experienced vaginal
spotting during
pregnancy for 2
months bit was able to
continue pregnancy
until full term
Optimal care was not
given due to lack of
attention because she
still had 4 older
children to take care of
Needed to attend
family business in the
market, thus, limiting
time with the patient
Bottle-fed with
mothers milk

Father
Rarely have time with the
patient due to work conflicts

Patient
Limited attention and care
Limited feelings of security and
belongingness
Attachment to the mother not very
well developed

Task Achieved: Mistrust

46

Autonomy vs. Shame & Doubt

(Toddlers, 18 months to 3 years)

Mother
Doesnt personally supervised
the patients activities
Had 4 other children at home
Allows her children to play with
others
Able to toilet train the patient

Toilet Train
Age 3- able to go to
the bathroom when
has the urge to urinate
or defecate
If unable to go the
bathroom on time,
mother punishes
patient through
spanking

Father
Preoccupied with his work as an
employee at TADECO (private
company)

Patient
Loves to play logical
games with different
colors and shapes

Task Achieved: Autonomy

47

Initiative vs. Guilt

(Preschool, 4 to 6 years)
Siblings
Initiate play with
younger brother

Father
Disciplinarian father

Mother
Had another baby
boy
Has limited time to
her other children

Patient
Loves to play outside with friends
Plays shatong, tumba lata, etc.
Shy type but energetic as well as thoughtful child
Inadequate maternal support and guidance
But developed sense of initiative through the
people surrounding him (e.g. nanny)

Task Achieved: Initiative

48

Industry vs. Inferiority

(Childhood, 7 to 12 years)
Mother
Arrived home late and
sometimes never slept in
their house due to work
conflicts
Less time spent with her
family

Father
Very strict and implements
discipline within the family
Among his children, patient
was his favorite

Patient
Age 9- started smoking
Age 10- started drinking alcoholic
beverages
Became a varsity player in running, 1
km dash, as verbalized by the patient
Awarded Athlete of the Year

Task Achieved: Industry

49

Identity vs. Role Confusion

(Adolescents, 13 to 18 years)
Mother
Less supervision
Preoccupied with her work

Father
Worked as a CAT
Commandant at Panabo
National High School
Spent less time with the
family

Friends
Influenced patient to join
fraternities
Most were males
Interested in girls
Influenced patient to take
prohibited drugs such as
shabu, marijuana, etc.

Patient
Heavy drinker
Had a girlfriend for
the first time but for
a short period
Joined in different
fraternities for
comfort and security
Age17- influenced
to take prohibited
drugs such as
marijuana, shabu,
etc.

Task Achieved: Identity

50

Intimacy vs. Isolation

(Young Adults, 19 to 34 years)
Mother
Out of house to work

Father
Very strict when at home
Seldom spends time with his
family

Siblings
Not supportive with his lovelife
Social drinkers
Busy with their own
relatioonship

Miss Wa
Last girlfriend of the patient
Impregnated by the patient but
aborted the child
Broke up with the patient
because of the involvement of a
third party

Patient
Deeply in love with Miss Wa
Wanted to have a baby
Impregnated with Miss Wa but was
disappointed for the child has been aborted
Broke up with Miss Wa
Depressed because of his fathers death
Took prohibited drugs (shabu, marijuana, etc.)leads to being hostile, hallucinations, delusions

Task Achieved: Isolation

51

DIAGNOSIS
COMPLETE DEFINITION OF DIAGNOSIS

Definition of the complete Diagnosis

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.
Source: Keltner, et. al, Psychiatric Nursing (p. 351).3rd Edition (1999) Philippines: C&E Publishing Inc.

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 significant
loss of contact with reality. They may see or hear things that dont exist, speak in strange
or confusing ways, believe that others are trying to harm them, or feel like theyre being
constantly watched. With such a blurred line between the real and the imaginary,
52

schizophrenia makes it difficulteven frighteningto negotiate the activities of daily

life. In response, people with schizophrenia may withdraw from the outside world or act
out in confusion and fear.
Source: Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing,
Quezon City, Phils. (2004)

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 persons use
of alcohol or other substance (Brunette and Drake, 1998).
Source: Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 347). Australia; Clifton
Park, NY: Thomson/ Delmar Learning (2003).

Undifferentiated

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.
Source: Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing,
Quezon City, Phils. (2004)

53

Undifferentiated schizophrenia is manifested by pronounced delusions, hallucinations,

and disorganized thought processes and behavior.
Source: Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 348). Australia; Clifton
Park, NY: Thomson/ Delmar Learning (2003).

Undifferentiated Schizophrenia usually is a characterized by atypical symptoms that do

not meet the criteria for the subtypes of paranoid, catatonic, or disorganized
schizophrenia. The client may exhibit both positive and negative symptoms. Odd
behavior, delusions, hallucinations, and incoherence may occur. Prognosis is favorable if
the onset of symptoms is acute or sudden.
Source: Psychiatric Nursing: biological & behavioural concepts (Deborah Antai-Drong)thomson/Delmar learning;c
2003.

54

DIFFERENTIAL DIAGNOSIS
DSM IV TR identifies five subtypes of schizophrenia: paranoid, catatonic, disorganized,
undifferentiated, and residual (American Psychiatric Association, 2000).
Paranoid Type
Clients exhibiting paranoid schizophrenia tend to experience persecutory or grandiose
delusions and auditory hallucinations. They also may exhibit behavioral changes such as
anger, hostility, or violent behavior. Prognosis is more favorable for this subtype of
schizophrenia than for the other subtypes of schizophrenia.
Patient exhibits grandiose delusion, auditory hallucinations, anger, hostility, and violent
behavior. Patient do not exhibit persecutory delusions.
Catatonic Type
Psychomotor disturbances, such as stupor, rigidity, excitement, or posturing, are the
prominent feature of catatonic schizophrenia. Echolalia and echopraxia are also features
of catatonic schizophrenia. Clients are at risk medically because of extreme withdrawal.
Patient do not exhibit stupor, rigidity, echolalia, echopraxia, and extreme withdrawal.
Instead, patient demonstates anxious movements of the hands and feet and was open to
the student nurses during interview.
Disorganized Type
The client experiences a disintegration of personality and is withdrawn. Speech may be
incoherent. Behavior is uninhabited. Prognosis is poor.

55

Patient do not exhibit social withdrawal and poor hygiene. Patient sometimes exhibit
incoherent speech.
Residual Type
Residual schizophrenia is the subtype used to describe clients experiencing negative
symptoms following at least one acute episode of schizophrenia.
Patient do not exhibit negative symptoms.

56

MULTI-AXIAL DIAGNOSIS DSM-IV TR CRITERIA FOR

DIFFERENTIAL DIAGNOSIS

Characteristic Symptoms: two or more of the following present for a significant portion
of the time during a month period:
1.
2.
3.
4.
5.

Delusions
Hallucinations
Disorganized Speech
Grossly Disorganized or Catatonic Behavior
Negative Symptoms

[ ]
[ ]
[ ]
[ X]
[X ]

A. Social / Occupative Dysfunction:

1. Work, Interpersonal Relations, or self care is markedly below the Level [ ]
Achieved prior to onset.
2. Duration: Continuous signs of the disturbance persist for at least
[ ]
6 months.
3. Schizoaffective and mood disorder with Psychotic features have been
ruled out.
4. Exclusion of substance abuse and general medical condition.

[ X]
[ X]

TOTAL: 5 / 9 X 100 = 55.55%

57

POSITIVE SYMPTOMS

Anxiety
Bizarre Behavior
Delusions
Hallucinations
Agitation
Aggressiveness
Hostility
Somatic Complaints
Suspiciousness
Cognitive Disorganization: Looseness Association and Tangentiality
Speech Disturbances
Inappropriate affect

[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ X]
[ ]
[ ]
[ ]
[ X]

TOTAL: 10 / 12 X 100 = 83.33%

NEGATIVE SYMPTOMS

Motor Retardation
Absence of Pleasure
Intellectual Impairment
Social Withdrawal and Isolation
Depressed Mood
Apathy and Disinterest
Poor grooming and Self Care
Lack of Thoughts
Lack of Goal Directed Behavior
Blunted Affect

[ X]
[ X]
[ X]
[ X]
[ X]
[ X]
[ X]
[ X]
[ X]
[ X]
TOTAL: 0 / 10 X 100 = 0%

A. CATATONIC
Extreme Psychomotor Retardation and Posturing
Catatonic Excitement
Extreme Psychomotor Agitation
Purposeless Movements which may harm self or others
Negativism
Waxy Flexibility

[ X]
[ X]
[ ]
[ X]
[ ]
[ X]
58

Stupor
Echolalia
Echopraxia
Delusions
Extreme Withdrawal
Selective Mutism

[ X]
[ X]
[ X]
[ ]
[ X]
[ X]
TOTAL: 3 / 12 X 100 = 25%

B. PARANOID
Delusions
Hostile
Argumentative
Aggressive
Hallucinations
Suspicious
Social Impairment
Regression Behavior
Anger
Violent Behavior
Threat to safety of self or others

[ ]
[ ]
[ X]
[ X]
[ ]
[ ]
[ ]
[ X]
[ X]
[ ]
[ ]
TOTAL: 7 / 11 X 100 = 63.63%

C. DISORGANIZED
Flat or inappropriate affect
Bizarre Behavior
Social impairment
Flight of ideas
Incoherent Speech
Disintegration of personality
Withdrawn
Poor personal hygiene and grooming

[ X]
[ X]
[ ]
[ ]
[ ]
[ ]
[ X]
[ X]
59

TOTAL: 4 / 8 X 100 = 50%

D. UNDIFFERENTIATED
Odd Behavior
Delusions
Hallucinations
Incoherence

[ ]
[ ]
[ ]
[ ]
TOTAL: 4 / 4 X 100 = 100%

E. RESIDUAL
History of at least a previous episode of Schizoprenia with prominent
psychotic symptoms
[ ]
Shy
[ X]
Easily Irritated
[ ]
Perceived as Peculiar
[ X]
Emotional blunting
[ X]
Illogical thinking
[ ]
Disorganized behavior
[ ]
Absence of prominent delusions and hallucinations
[ X]
TOTAL: 4 / 8 X 100 = 50%

I.
SCHIZOAFFECTIVE DISORDER
Has strong element of either Depression or Euphoria effect
May be Depressed, Retarded or Suicidal
Expressed observed delusions of persecution, complains of being
controlled by outside forces

[ X]
[ X]
[ X]

TOTAL: 0 / 3 X 100 = 0%
II.

MAJOR DEPRESSIVE DISORDER

Sexual Disinterest
Suicidal or Homicidal Ideations
Affect, Sadness, Anger, Irritability
Decrease in Personal hygiene
Tearfulness, Crying, melancholy
Self Destructive Behavior
Difficulty Concentrating

[ X]
[ X]
[ ]
[ X]
[ X]
[ X]
[ ]
60

Loss of Energy or Restlessness

Anhedonia ( Loss of Pleasure )
Gain or Loss of Weight
Anger: Self Directed
Psychomotor retardation or Agitation
Insomnia or Hypersomnia
Feeling of Hopelessness, Worthlessness, Helplessness

[ ]
[ X]
[ ]
[ X]
[ X]
[ ]
[ X]

TOTAL: 5 / 14 X 100 = 35.71%

III.
SUBSTANCE ABUSE DISORDER
Failure to fulfill major role obligations at work, school or home
Recurrent substance use in hazardous situations
Recurrent substance related legal problems
Continued substance use despite problems

[ ]
[ ]
[ ]
[ ]

TOTAL: 4 / 4 X 100 = 100%

61

SUMMARY
Percentage:
1. Characteristic Symptoms shows Delusions, Hallucinations and Disorganized
2.
3.
4.
5.

Speech
Social / Occupative Dysfunction
Positive Symptoms
Negative Symptoms
DSM IV Criteria for Schizophrenia Subtypes
A. Catatonic
B. Paranoid

C. Disorganized
D. Undifferentiated
E. Residual
6. Schizoaffective Disorder
7. Major Depressive Disorder
8. Substance Abuse Disorder

30%
83.33%
0%
25%
63.63%
50%
100%
50%
0%
35.71%
100%

This DSM IV criterion has been used by the group during the first interview of
Anthony.
Using the DSM IV criteria, Anthony showed signs and symptoms of Schizophrenia.
During our interview with Anthony, he manifests Undifferentiated Schizophrenia with the
percentage of 100% that was related to his diagnosis. We are able to communicate and
interact with him.
On the other Disorders, Schizoaffective Disorder is 0%, Major Depressive
Disorder is 35.71% and Substance Abuse Disorder is 100%.
Therefore, based on the results of the DSM IV criteria, the group concluded that
Anthony suffers from Undifferentiated Schizophrenia like his diagnosis.

62

NURSING CARE PLAN

63

MEDICAL MANAGEMENTS
DOCTORS ORDER
Nursing/Pharmacological Diagnostic Examination
H E M A T O L O G Y

HEMOGLOBIN

150

g/dL

Male: 140-170
Female: 120150

CLINICAL
SIGNIFICANCE

FUNCTION/S

Sex: Male

REFERENCE

Room: CIU

UNIT

Date: 09-22-10

RESULT

Age: 23 yrs old

TEST

Name: Patient X

= anemia, liver and

Hemoglobin is

kidney disease.

responsible for binding

= primary and secondary

polycythemia, COPD, CHF,
burns.

oxygen in the lungs and

in transporting the
bound oxygen
throughout the body
where it is used in
aerobic metabolic
pathways.

ERYTHROCYTES

4.40

10^12/L

4.0 6.0

= anemia, acute and

RBCs transport oxygen

64

(RBCs)

chronic haemorrhage,

bound to hemoglobin;

leukemia, and chronic

also transports small

infection

amount of carbon

= primary and secondary

dioxide.

polycythemia,
erythropoietin-secreting
tumors, and renal disorders
LEUKOCYTES
(WBCs)

10.95

10^9 /L

5.0 10.0

(H)

= leucopenia viral

Leukocytes function as

infections, bone marrow

phagocytes of bacteria,

depression due to drugs,

fungi, and viruses,

irradiation, and primary

detoxification of toxic

bone marrow disorders.

proteins that may result

= leukocytosis acute
infection (degree depends
on the severity of infection,

from allergic reactions

and cellular injury, and
immune system cells.

age, resistance, and

presence of trauma, tissue
necrosis or inflammation
and haemorrhage)
Differential Count

Segmenters

.77

eg. Neutrophils

(H)

0.45 - 0.65

= neutropenia

Neutrophils are active

in acute bacterial

phagocytes; number

infection, viral

increases rapidly during

infection, some

short-term or acute

parasitic, blood,

infections.

aplastic, and
pernicious anemia,
anaphylactic shock,
and renal disease.

65

 = neutrophilia
in acute localized
and general
bacterial
infections, gout
and uremia, acute
hemorrhage, and
hemolysis of
RBCs,
myelogenous
leukemia and tissue
necrosis
Lymphocytes

.13
(L)

0.20 - 0.35

=
lymphocytopenia /

Lymphocytes are part of

immune system; one

lymphopenia

group (B cells)

gastrointestinal

produces antibodies;

tract and in aplastic

other group (T cells)

anemia, immune

involved in graft

system

rejection, fighting

dysfunction, and

tumors and viruses, and

severe or

activating B

debilitating disease

lymphocytes.

of any kind.
= lymphocytosis
occurs in certain
chronic diseases
and during
convalescence
from acute
infection

66

Monocytes

.09

0.02 0.06

(H)

= monocytopenia

Monocytes are active

occurs in HIV,

phagocytes; number

hairy cell leukemia

increases rapidly during

and overwhelming

short-term or acute

infection

infections.

= monocytosis in monocytic and

other leukemia,
myoproliferative
disorders, and other
lymphomas,
recovering state of
acute infections
HEMATOCRIT

.38

Female: 0.38 -0.4

(L)

Male: 0.4-0.60

= anemia or

Hematocrit is a measure

hemodilution.

of the proportion of

= dehydration,
polycythemia or

blood volume that is

occupied by RBCs.

hemoconcentratio
n.

67

PSYCHOPHARMACOTHERAPY
Pharmacologic Studies

Generic Name: Fluphenazine

Brand Name: Modecate, Prolixin Decanoate, Modecate Concentrate
Indication: Acute and Chronic Psychoses
Action: Alter the effects of Dopamine in the CNS. Possess anticholenergic and alphaadrenergic blocking activity.
Contraindicated in: Hypersensitivity. Cross sensitivity with other phenothiazines
may exist. Narrow angle glaucoma. Bone marrow depression. Severe liver or
cardiovascular disease and Hypersensitivity to sesame oil.
Adverse reactions/Side effects: Extrapyramidal reactions, sedation, tardive
dyskinesia, blurred vision, hypotension, tachycardia, photosensitivity and
agranulocytosis.
Interactions:
Pimozide: may have additive adverse caridiovascular effects.
antihypertensive: additive hypotension.

68

CNS depressants, antihistamines, MAO inhibitors, general anesthetics and

opioids: additive CNS depression
Phenobarbital: may increase metabolism and decrease effectiveness.
epinephrine and norepinephrine: decrease vasopressor response
Amphetamines: decrease pharmacologic effects.
Route/dosage
IM/ subcut (adults): 12.5-25mg initially, may be repeated q 1-4 wk. dosage
may not exceed 100mg/dose.
IM/subcut (Children): 6.25-18.75mg initially, may be repeated q 1-3 wk.
Nursing Consideration:
Assess patients mental status (orientation, mood, behaviour) before and
periodically throughout therapy.
Monitor VS especially BP and RR including ECG. May cause q- wave and Twave changes in ECG.
Dilute concentrate just before administration in 100cc-240cc of water, milk,
carbonated beverages or fruit juices. Do not mix with caffeine products
(coffee, cola), tannics (tea), or pectinates (apple juice).

Instruct patient to take medication exactly as directed and not to skip doses or
double up on missed doses. If a dose is missed, take after 1 hr or skip dose and

return to regular schedule if taking 1 dose/day.

Inform patient of possible extrapyramidal symptoms and tardive dyskenesia.
Inform patient that this drug may turn urine pink or reddish brown.
69

Phenothiazides
Generic Names with Trade names: trifluoperazine (etrafon, trilafon),
Chlorpromazine (Emetil, Megatil, Emetil plus), Perphenazine (Siquil,
Orap, Neurap), Thioridazine (Mellaril, Novoridazine, Thioril).
Indications: Treatment of acute and chronic psychosesparticularly when
accompanied by increased psychomotor activity.
Actions: Block dopamine receptors in the brain. also alter dopamine release and
turnover. Peripheral effects include anticholinergic properties and anti
adrenergic blockade.
Contraindications: Hypersensitivity, Should not be used on patients with CNS
depression. Severe liver impairment.
Interactions:
Alcohol, antihypertensive and nitrates: additive hypotension effect.
Antacids: may decrease absorption
Phenobarbital: increase metabolism and decrease effectiveness.
CNS depression: additive CNS depression
Lithium: decrease blood levels and effectiveness of phenothiazides.
Levodopa: decrease therapeutic response.
Antithyroid agents: increase risk of agranulocytosis.

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Adverse Reactions: agranulocytosis, akathisia, aplastic anemia, apnea, blurred

vision, confusion, constipation, contact dermatitis, diaphoresis, dizziness,
drowsinesss, dystonic reaction, ejaculation dysfunction, headache,
hypotension, hypothermia, neuroleptic malignant syndrome, orthostatic
hypotension, photosensitivity, pseudoparkinsonism, respiratory
depression, sinus tachycardia, tardive dyskinesia, visual impairment.
Nursing Consideration:

Assess patients mental status during and throughout therapy

Monitor BP, pulse and respiratory rate before and frequently during dosage

adjustments
Observe patient carefully to ensure that drugs are taken and not hoarded.
Monitor patient for onset of akathesia, extrapyramidal effects, dystonia and

parkinsonianeffects.
Monitor for tardive dyskenesia.
Monitor for Neuroleptic Malignant Syndrome- fever respiratory distress,
tachycardia, convulsions, diaphoresis, hypotension or hypertension, pallor,

tiredness, severe muscle stiffness and loss of bladder control.

Administer PO with a full glass of water or milk to decrease gastric irritation.
Dilute most concentrate in 120ml of distilled or acidified water or fruit juice

just before administration.

Instruct patient to take medication exactly as directed Instruct patient to

slowly change position to prevent orthostatic hypotension.

Medications may cause drowsiness. Caution patient to avoid drinking or other
activities requiring alertness until response to medication is known.

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PROGNOSIS AND RECOMMENDATION

Criteria
Onset of illness
Duration of

Poor

Fair

Good

Justification
chronic
The patient has been in and out in the

illness

rehabilitation center for the past 5

years. The patient had shown sign of

Precipitating

improvement but has relapses.

The precipitating factors include peer

factors

influences, family, vices, socioeconomic status, and emotional

problem. As of now patient has
withdrawn from peers and has been
avoiding cigarette smoking, but there

Mood and affect

is a risk of relapses.
Patient has labile mood at first
encounter but he gradually improves
by the time of second visit wherein
he already had appropriate emotional
response. The patient verbalized that
he is willing to take the medication,
now he is comfortable with the
treatment regimen as evidenced by

Any Depressive
features

improved sleep.
The patients have bouts of depression
when the topics of love discussed.
This just related to the break up with

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the formal girlfriend and the recent

Family support

death of his father.

The family, especially the elder
brother expresses that they are
willing to give their emotional and
financial support but as of now the
family is economically depressed.

Computation:
Poor 4 x 1 = 4
Fair 2 x 2 = 4
Good 0 x 3 = 0

Total: 8/6 = 1.33%

The prognosis of the patient is poor having the score of 1.33 based on the computation
and justification. The family of the patient is willing to support the patient but they lack
of financial resources. Also there is possibility of relapses because of non adherence of
the treatment regimen.

DISCHARGE PLANNING

Medication
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 Instruct the patient to comply the treatment regimen

To conform to pharmacological regimen and to attain full coarse of prescribed
treatment
Encourage and instruct the family members to always seek medication advice and
prescription.
To prevent further complication and for further information.
Inform the patient about the effect of the drug
To know what to expect when symptoms occur and to have knowledge about the
drug.
Instruct the patient, do not discontinue the drug and avoid over the counter drug.
To avoid drug resistance
Encourage patient to verbalize concerns regarding the drug and inform the physician if
side effects are occurring.
To address patient apprehension and prevent underlying factors.

Exercise
Encourage the client to do daily exercise
to practice range of motion and to enhance musculoskeletal strength
Encourage adequate rest and sleeping periods.
to promote comfort and prevent fatigue
Encourage deep breathing exercise.
to enhance breathing pattern

74

 Instructed to void every 2 to 3 hours during the day and completely empty the bladder.
This prevents over distention of the bladder and compromised blood supply to the
bladder wall
Maintained good environment free from pollution and stress provoking environment.
An environment free from pollution may facilitate fast recovery and prevent
recurrence of the disease influenced by unhealthy environment.

Treatment
Instructed the patient to comply the treatment regimen
to achieve the effectiveness and expected outcome

Encouraged the patient to participate diligently in the treatment modalities

advised to him by the physician.

To hasten the improvement of her health status

Encouraged the patient to verbalize honest information to the physician and

other

health care provider.

To aid accurate detection of a disease and early medical intervention

Tell the family that they should take part on the treatment of the patient.

To strengthen the support system of the client

Treatment should be taken in a timely manner

To ensure proper timing of treatment regimen

75

Hygiene
Encourage daily bathing and use clean clothing
to promote proper hygiene and promote proper circulation
Instruct patient to take care of wounds and do proper wound dressing.
to prevent infection and prevent the spread of microorganism
Instruct the patient to do oral hygiene and use soft bristle brush
to avoid bleeding of the oral mucosa
Encourage the patient to do the proper hand washing at all times.
to deter the spread of microorganism
Instruct the patient to do proper grooming and always trim nails
to prevent harbor of microorganism in a certain area

Outpatient
Emphasize to patient the importance of follow up check-up
to assess the effectiveness of therapy given
Reiterated health teaching regarding diet and hygiene
to provide health information and awareness
Sighted any symptoms other than the usual that may indicate infection and report it
immediately to the physician.
To note any unusualities and address it promptly before complications occur
Instructed significant others to change wound dressing daily, if there is wound.
To reduce bacterial colonization

76

Diet
Encourage patient to eat nutritious food at the right time and right amount.
to enhance balance diet and avoid malnutrition
Encourage to drink at least 6-8 glasses of water a day.
to ensure proper intake of fluids
Inform the patient to avoid alcohol and cigarette smoking
to prevent occurrence of symptoms and to prevent alteration in the effectiveness of
the drug
Inform patient to avoid eating food which is high in tyramine such as cheese and
process meat.
to avoid alteration in the effectiveness of the drug.

77

APPENDICES
SPOT MAP

78

GENOGRAM

79

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