Case Study Rating Sheet Perfect SCORE Score 1.) CONTENT 2.) PRESENTATION a. Creativity and integrity b.

Ability to hold the interest of others c. Ability to stimulate group participation 3.) DELIVERY a. Grooming b. Poise c. Voice d. Diction 4.) RESPONSE TO QUESTIONS a. Making sound judgement b. Ability to express self 5.) ATTITUDE a. Attitude towards comments and suggestions TOTAL SCORE GRADE 100 (10) (5) 5 (2) (2) (3) (3) 15 (10) (10) (10) 10 40 30 CDO SCORE DAVAO

LICEO DE CAGAYAN UNIVERSITY

College of Nursing

NCM501203 A Care Study

PATIENT RR

SCHIZOPHRENIA UNDIFFERENTIATED
Submitted to Name of faculty A Partial Requirement for NCM 501203 Submitted by
YAP, ROY D. II LAPURA, JUNILYN P. CAHILES, JOHANNA KHRYSTYNE C. CELIZ, RUFFA CARLA OREJANA, MARICRIS GALLENERO, CHARISSE MAE ABENOJA, EXCELSIOR MAYORDOMO, JC JAMES CREDO, MICHAEL ANGELO SABANDO, RICK PAUL DUCO, ANNACEL

GROUP D4

Table of Contents I. Introduction A. Overview .. B. Objective and Purpose of the Study .. C. Scope and Limitation .. D. Spot Map .. E. Patients Profile ... II. Anamnesis A. Maternal and Paternal Lineage B. Parents C. Subject

III. Course in the Hospital A. Mental Status Exam B. Progress Notes IV. Psychodynamics V. Laboratory Exam and Results Of Psychological Test A. Neuropsychological Test B. Laboratory test if any VI. Diagnosis VII. Multi-Axial Diagnosis VIII. Nursing Management IX. Medical Management X. Prognosis and Recommendation XI. Bibliography

I. INTRODUCTION

D I.

INTRODUCTION

A. Overview Schizophrenia is a disease affecting the brain that causes distorted and bizarre thoughts, perceptions, emotions, movements and behavior (Videbeck, 2001). Schizophrenia usually is diagnosed in late adolescence or early adulthood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women (APA, 2000). There are 5 types of schizophrenia:

The paranoid type, disorganized type, catatonic type, undifferentiated type, and the residual type. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. It cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome or disease process with many different varieties and symptoms, much like the varieties of cancer. For decades, the public vastly misunderstood schizophrenia, fearing it as a dangerous and uncontrollable and causing wild disturbances and violent outburst. Many people believed that those with schizophrenia needed to be locked away from society and institutionalized. No laboratory test is for schizophrenia currently exists. Although schizophrenia affects men and women with equal frequency, the disorder often appears earlier in men, usually in the late teens or early twenties, than in women, who are generally affected in the twenties to early thirties. Available treatments can relieve many symptoms, but most people with schizophrenia continue to suffer some symptoms throughout their lives; it has been estimated that no more than one five individuals recovers completely. Schizophrenia affects about 24 million people worldwide. Schizophrenia is a treatable disorder, treatment being more effective in its initial stages. More than 50% of persons with schizophrenia are not receiving appropriate care and 90% of these are in developing countries. Care of persons with schizophrenia can be provided at community level, with active family and community involvement. In the Philippines alone, out of 86, 241, 697 population, the extrapolated prevalence is 697,543 about .5% to 1% of the population as of 2004. Schizophrenia still ranks among the top causes of disability in the country; however there are some variations in terms of incidence and outcomes for different groups of people. In Northern Mindanao, out of 2, 283, 272 population as of 2005, there is an estimated number of schizophrenic patient, in every 1000 persons there are 12 cases of schizophrenia.(Philippines Mental Health Country Profile).

In this study, the main focus will be on Schizophrenia, Undifferentiated Type; a type characterized by mixed schizophrenic symptoms along with disturbances of thought, affect and behavior (Videbeck 2004). Atypical symptoms present do not meet the criteria for the subtypes of paranoid, catatonic, or disorganized schizophrenia. The client may be observed to exhibit both positive and negative symptoms; odd behavior, delusions, hallucinations and incoherence (Shives and Isaac 2002). B. Objective and Purpose of the Study The objectives of the study are as follows: y y Develop a good working relationship with the client and her family. Assess and determine the possible precipitating and predisposing factors that contribute to the development of the disorder. y Assess the client with psychiatric disorder allowing the students to identify the different abnormal behaviour under Schizophrenia Undifferentiated Type. y Design a nursing care plan and implement nursing interventions appropriate to the condition of the client.

The purposes of study are as follows: y Enhance the skills of the students involved and their knowledge by understanding the essentials towards promotion of mental health. y It gives opportunity to learn different approaches in establishing a nursepatient relationship. y y Let the family understand the apparent condition of the client. Help client through the application of the nursing process.

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

1. Gather pertinent data about the client through detailed chart taking, and effective therapeutic communication and interaction with the client and his significant others. 2. Commence the patient with his personal data and present and past health history. 3. Assess clients mental status thoroughly using axial diagnosis. 4. Determine the etiology factors (precipitating and predisposing) of the mental disorder. 5. Present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, nursing responsibilities, and importance to the clients condition. 6. Render quality nursing care in line with the formulated nursing care plans; 7. Impart appropriate recommendations to the client, his significant others and community, medical world, and the group as a part of the nurses holistic care. 8. Establish a trusting nurse-patient relationship with the client and his significant others through provision of holistic care toward the client and use of appropriate verbal and non-verbal therapeutic communication skills with the client and significant others during the data gathering.

C. Scope and Limitation This study was conducted at Orochain Village Carmen Cagayan de Oro City, which covers 4 days of visitation. The four days visit includes gathering of the necessary data and interview of a minimum eight informants. The said informants are composed of the patients family, neighbours, and relatives. There were limitations encountered by the group in the conduct of this study. The home visitation covered only four days. The location of the area contributed to the difficulty of the group to properly assess the patient since only a maximum of five persons can enter their house. The patient and her family resides a squatters area. The first 3 days was also limited since

the group needs to conduct the said visit during 9:00-11:00 pm, since her mother is available only during this time because her mother has a mini parlor inside their house, thus a minimum of 2 hour was intended for the interaction of the patient, her family and her neighbours. Information about the clients history of illness will be based only the interview with client, clients mother, her relative, and some of her neighbours. The expected outcomes of the interventions initiated and implemented was dependent upon the cooperation of the patient and her significant others. The point of reference in locating the residence of Mr. RR, is Liceo de Cagayan University located at R.N Pelaez Blvd., Carmen, Cagayan de Oro City. The patients residence is approximately 500 meters and is southwest of the point of reference. In order to reach the area, one has to take a public utility vehicle, with the routed to Carmen Market, Cagayan de Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5 minutes if traffic is not that worse. But during rush hours, it usually takes around 5-10 minutes of commuting time to reach the area. Upon reaching the area, you will see a Gasoline Station (Petron). The patients residence is approximately 30 meters away from the outpost. You need to start walking straight ahead then turn right where you will pass by a mini store. After turning right, you need to walk straight ahead again and turn left pass by 3 houses on the left and on the right theres a wall. After passing these houses on the left side the fourth house from the point of intersection located on your left side is the residence of patient RR. The area where the patient is residing is congested urban since it is described as a squatter area. The main sources of income of the people living in the said area are mini parlor, vendors, by standers, sari-sari stores and laborers to name a few. The houses are made up of wooden structure and are camped up in the area. The peoples past time in the area is gossiping with their neighbours and singing videoke as well as playing cards. The patients residence is made up of combination of concrete and wooden

structure. Their house is composed of two storeys, the upper part is their bed room and the lower part of their house is divided into three parts their kitchen, bathroom, and dining area. D. SPOT MAP The point of reference is Northern Mindanao Medical Center Cagayan de Oro City. The patients reference is approximately half kilometer and is southwest of the point of reference. In order to reach the area, one has to take a public utility vehicle, with the routed to Carmen Market, Cagayan de Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5

minutes if traffic is not that worse. But during rush hours, it usually takes around 5-10 minutes of commuting time to reach the area. Upon reaching the area, you will see a Gasoline Station (Petron). The patients residence is approximately 30 meters away from the outpost. You need to start walking straight ahead then turn right where you will pass by a mini store. After turning right, you need to walk straight ahead again and turn left pass by 3 houses on the left and on the right theres a wall. After passing these houses on the left side the fourth house from the point of intersection located on your left side is the residence of patient RR. The type of community that the patient is residing is an urban squatters area. The main sources of income of the people living in the said area are mini parlor, vendors, by standers, sari-sari stores and laborers to name a few. The houses are made up of wooden structure and are camped up in the area. The peoples past time in the area is gossiping with their neighbours and singing videoke as well as playing cards. The patients residence is made up of combination of concrete and wooden structure. Their house is composed of two storeys, the upper part is their bed room and the lower part of their house is divided into three parts their kitchen, bathroom, and dining area.

E.Patients Profile Initial Name: Address: Date of Birth: Age: Birthplace: Civil Status: Gender: Nationality: Religion: Patient RR Orochain Village Carmen, Cagayan de Oro City January 22, 1982 29 yrs.old Cagayan de Oro City Single Male Filipino Roman Catholic

Educational Attaintment: Grade 1 (West City Central School) Siblings: Name of Mother: Name of Father: Height: Weight: Date of First Check-up: Admitting Diagnosis: Attending Physician: High School : College: One Sister (Ms. M) Mrs. ER Mr. BR 51 50 kgs. March 2008 Schizophrenia Undifferentiated Dr. Eric Boromeo Not Attended Not Attended

Arrest, Court States Probation : None Vital Signs: Blood Pressure : 110/80mmhg Temperature : 36.9 c Respiratory Rate : 20cpm Pulse Rate : 73bpm Date Admitted: None Time Admitted: None Food and drug allergy: (+) chicken Use of street drugs: (+) shabu, Marijuana Use of street alcohol: (+) hard liquors

II. ANAMNESIS

A. INFORMANTS

Informant #1 Name: ER Sex: Female

Age: 50 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: Mother Length of time known to patient: 29 years Apparent understanding of present illness:

Nabuang man na akong anak pag-uli nako. Buotan man na siya na bata kung dili lage mahubog di man jud unta na siya mupalit ug mainom gadaog daogon man gud na siya. Characteristics and attitude of informant: Informant was very willing to answer the questions being asked. She speaks openly about the client and is concern about the clients condition. She is aware of the unusual behaviour that her son has manifested.

Informant # 2

Name: TR

Sex: female Age: 82 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: grandmother Length of time known to patient: 28 years Apparent understanding of present illness:

Nagkadipekto na siya sa pangutok sukad atong giburos pa lang na siya kay iyang mama man gud gainom ug tambal, mao nag kain-ana na siya. Buotan man na siya na bata kay gapatoo na siya pag sugoon. Dili man niya sala nga na in-ana siya, sala jud sa iyang mama.gapanglimpiyo pa gani na siya

Characteristics and attitude of the informant: Shows concern to the client and is aware of the unusual behaviours that his grandson have. She also admits that the patient is very kind and that the patient follows instructions.

Informant # 3 Name: MTC Sex: female

Age: 54 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: neighbor Length of time known to patient: 28 years Apparent understanding of present illness:

ing-ana naman na siya pagbalik sukad pa sa bata pa ginapaskwela gani na siya pero ang problema kay sige siya takas, ug adtong bata pa siya sige lang siya ug hinoktok lang adtong 10 years old pa siya. Characteristics and attitude of the informant: She has known the client well and she is aware of the unusual behaviour that the client manifests though she is confused with what the patients problem.

Informant # 4

Name: W Y

Sex: Female Age: 20 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: Neighbor Length of time known to patient: 14 years

Apparent understanding of present illness: buang man na siya kay mukalit di na siya maka istorya ug tarung unya dili jud na siya. Luoy pa jud kayo na siya kay di na siya kabalo kung piso ba o dili. Buotan kayo na siya na tao kay dali ra kayo masugo.

Characteristics and attitude of the informant: The informant was aware of the unusual behaviors the patient portrays, and was very concern to the clients present condition.

Informant # 5

Name: E A

Sex: male Age: 37 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: neighbor Length of time known to patient: since birth Apparent understanding of present illness:

buang man na siya sukad bata pa kay sige gani na siya hinuktok unya sige takas sa klase. Pero buotan pud kayo na siya na bata kay dali ra jud na nimo masugo. Gakaluoy lagi ko ana niya na. pero grabi jud na siya kabuotan na bata bisan unsaon ba bisan in-ana pa na siya.

Characteristics and attitude of the informant: The informant is very concern to the patient. And he knows much about the patient. And he cooperates with the interview.

Informant # 6 Name: J AS

Sex: Female Age: 58 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: Neighbor Length of time known to patient: since birth Apparent understanding of present illness:

Pagbalik sa iyang mama dani murag nisamot bitaw ang iyang sakit murag in-ana bitaw. Pero grabe jud na siya kabuotan na bata pero dali ra kayo na sugoon kay mulihok jud na siya diretso pero mao pud lage sige lang siya ug daog daogon. Perme na siya kilkilan sa mga tao dani

Characteristics and attitude of informant: Concern about the clients condition and speaks about patients behaviour openly and is cooperative in giving information regarding the clients condition.

Informant # 7

Name: D H

Sex: male Age: 48 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: Neighbor Length of time known to patient: since birth

buotan kayo na siya na bata. Dali ran a siya masugo unya di pa jud kabalo mureklamo. Mao raman pud ako nabantayan niya. Pirme man na siya sa liceo dispatcher man na siya.

Characteristics and attitude of informant: The informant was aware that the client has this kind of mental illness based on the unusual behaviour the client has shown but still shows some disregard because he is one of those who keeps on dragging the patient to drink.

Informant # 8

Name: L F

Sex: Female Age: 22 years old Address: Orochain village Carmen Cagayan de Oro City Relation to patient: Neighbor Length of time known to patient: 15 years Apparent understanding of present illness:

wala jud kayo ko kabalo adtong bata pa siya pero karon makiingon jud ko na naa siya daot sa pangutok tungod kay di siya kabalo kung unsa ang piso unya di siya kaistorya ug tarung.

Characteristics and attitude of the informant: Shows willingness and is cooperative in answering the questions, she is aware of the present situation of the client.

III. Course in the Hospital A. Mental Status Examination

D1 I.GENERAL APPEARANCE II.GENERAL MOTILITY Posture Activity Facial expression III.Behavior IV.Patient interaction V.SPEECH Soft Loud Hesitant Slurred Superior Humor Frightened VI.Stream of Talk Spontaneous Deliberate Pressured Blocking VII.Organization of talk Relevant Irrelevant Incoherent Loose Association Flight of Ideas Tangentiality / / / Slouch Purposeful Suspicious Shy nurse Distant Tidy

D2 Tidy

D3 Tidy

D4 Clean

Slouch Purposeful Suspicious Friendly

Slouch Purposeful Happy Friendly

Slouch Purposeful Happy Friendly

Cooperative Cooperative Cooperative

Circumstantiality Perseverance Clang Association Neologism Echolalia Echopraxia VIII.Mood and Affect 1. Mood Euthymic Depressed Euphoric 2.Affect Flat Blunt Angry Elated Anxious Fearful IX.Range of Affective / / / / / / / /

Expression Consistent Labile Anhedonic Appropriate situation verbalized X.Perception Hallucination -auditory -visual / / & to the / / / /

feeling

-olfactory -gustatory -tactile Delusion -grandeur -persecutory -reference -others(specify) Illusion Derealization Depersonalization Identification Thought broadcasting Dj vu Jamais Vu XI.Orientation Memory 1.Identifies correctly 2.Estimate time of the No day 3.Knows where he is 4.Knows the examiner 5.Recalls Yes No Yes No No Yes No Yes Yes No Yes No No No date No No No No and

activities No

done within 24 hours 6.Recalls activities No No No No

done within 1 week XII.Neuro-vegetative functioning Sleep and Rest Pattern

-normal sleep -early awakening -middle awakening -hyper insomnia -difficulty asleep -interrupted sleep -others XIII.Elimination Bowel Bladder XIV.Abstract Ability XV.Judgment in falling night morning

0 2x Thinking Poor

1x 3x Poor

1x 4x Poor

0 3x Poor

Poor

Poor

Poor

Poor

B. Description of MSE Result: First visit (January15, 2011) I. Appearance and Movement During our 1st visit, the client looks neat and clean.His gait was coordinated and smooth. He sat at the doorway and shows slouchiness in his movement.

II.

Speech He was not hesitant to speak. He was able to answer the questions but some portrayed loose association that is why we cant understand some of what he is saying.

III.

Emotional State and Reaction

He was relaxed during the interview

IV.

Thought Control During the first interview, the client cannot recall activities done within 24 hours, he cannot identify the date correctly, and also he cannot estimate the time of the day but he knows where he is. The client wasnt able to know the examiner well. he was able to listen well with our conversation but he cannot maintain eye contact.

V.

Neuro-Vegetative Functioning The client has a normal sleep pattern

Second Visit (January 17, 2011) I. Appearance and Movement On the second day, the client appears to be tidy. His gait was coordinated and smooth but tends to slouch most of the time and doesnt have an eye to eye contact to us all the time. Conversation was done at the same venue and the client was interested to talk with a group and always smiles.

II.

Speech The client talked vividly in soft and low tone. he portrayed loose association.

III.

Emotional State and Reaction He was more relaxed and feels happy when he sees us.

IV.

Thought Control The client still cannot identify the date correctly and cannot estimate the time of the day. But he knows where he is.

V.

Neuro-Vegetative Function The client has a normal sleep pattern.

C. Progress Notes Day 1: January 15, 2011 Specific Objectives: 1. To locate the area 2. To establish trust and rapport with the client and her family. 3. To have a verbal contract and consent both client and family. 4. To make initial assessment. 5. Arrange for the next schedule visit

It was on a Saturday morning when the group went to Orochain Carmen CDOC to find for a potential client for our care study. We went to the outpost of the baranggay to ask for any potential client and fortunately we were given one. Before we arrived to our clients house we planned what we do, including the most important assessment. We conducted a mental status examination. The consent was obtained from the mother and the client as they permitted the group to conduct series of interviews with them. The clients name was patient RR and her mother was Mrs. ER. We gained the necessary datas that we needed from the client, her mother and relatives. We gather the clients profile and some other important information regarding the client. A verbal contract was made about the number of days we were going to conduct the interview, health teaching, nursing intervention and length of time of our visit.

Day 2: January 17, 2011 Specific Objectives: 1. Continue establishing rapport to the client. 2. Continue with the mental status exam. 3. Determine the factor that causes the clients disorder. 4. Trace the client history. 5. Ask the clients neighbor for some relevant information.

During the second visit, the group continued the mental status exam. The client cooperates with the group by answering questions being asked from her although she speaks in a low tone. The group was able to get some information regarding the clients condition. Her mother is also very approachable and friendly to us and never hesitates to answer all our questions about her son.

IV. PSYCHODYNAMICS a. Tabular presentation of Predisposing Factors.

FACTORS A. GENETICS

PRESENT There were no traces of mental illness on the patients maternal side. On the paternal side however, it is unknown due to separation of patients parents and the patients mother does not have knowledge on whether or not the patients father has any family history of being mentally challenged.

RATIONALE Videbeck (2001) stated stated that several theories and studies seem to indicate that several disorders may be limited to a specific gene or a combination of both genes. According to Colleen Sullivan, suite 101.com; close relatives of individual who have disorders are at high risk. If you have a parent, sibling, or a child with a disorder, there is a 7-10% chance that you may develop the same disorder and 810% to develop depression.

B. SEX

Patient is an adult male.

Sex determines the communitys expectation of a person.

C. AGE

The patient exhibited mild Age of onset seems to be an onset of illness during his early childhood. The worse part of his condition was clearly observed when he was in his mid-twenties, during which his mother was not able to personally care for him as she worked abroad and the patient important factor in how well the client fares. Those who develop the illness earlier have worse outcomes than those who developed it later. (Buchaman and Carpenter, 2000) According to Hagop S. Akistol M.D. are higher in younger age groups especially in the stage

was left to relatives who didnt really looked after his needs.

because of having role confusion and identity crisis.

b. Tabular presentation of Precipitating Factors FACTORS A. ENVIRONMENTAL FACTORS  Lower socioeconomic status  Living in large cities PRESENT RATIONALE

Mother is the breadwinner and only income earner in the family.

When a person is insufficiently provided with his basic needs, his chances of getting Schizophrenia increases. People living in high-density urban areas are 50 percent more likely to develop the disease than people in rural areas, and economic factors such as homelessness, unemployment and poverty also contribute to the chances of having the disease.

 Stressful events during childhood

Patients parents separated when he was still young. During his parents marriage, his parents always quarreled which led to separation.

Studies show that children growing up in abusive or otherwise dysfunctional families are six times more likely to develop schizophrenia than their normal counterparts.

Prohibited drugs such as cocaine have effects similar to the positive symptoms of During his mothers absence, the patient was schizophrenia. These drugs can also trigger schizophrenia.

left in the care of relatives There is an increasing amount who didnt really looked  Drug and alcohol intake after him and just allowed him to go anywhere and anytime he desires. He abused this liberty by alcohol intake and drug abuse. of evidence that cannabis damages the brain and can lead to schizophrenia. It is thought that cannabis doubles a person's risk of schizophrenia. Alcohol is the substance most often abused by people with schizophrenia. While alcohol can cause a relapse of symptoms, there is no evidence to suggest that alcohol use causes schizophrenia. B. LIFESTYLE C.  Skipping of Meals The patient started to skip meals when his mother went to work abroad. Because he had the freedom to do anything he wanted, he spent his time loitering around the city and According to Stuart and Sundeem (1995). Poverty and society could abuse Schizophrenic or some individuals choose to be Schizophrenic to cope the insanity of mother world.

getting drunk.

V. Laboratory Exam and results of Psychological Test Our client has not undergone laboratory exam and psychological testing.

VI. Diagnosis Schizophrenia, Undifferentiated Type

VII. MULTI-AXIAL DIAGNOSIS

AXIS I SCHIZOPHRENIA, UNDFFERENTIATED TYPE Schizophrenia is characterized with the following 1. anger 2. disorganized speech 3. inability to take care of personal needs 4. incoherence 5. hallucinations

Our client Mr. RR manifested negative symptoms which is inability to take care of personal needs and auditory hallucination, which is also a manifestation of undifferentiated schizophrenia.

AXIS II BORDERLINE PERSONALITY DISORDER A persistent pattern of instability in interpersonal relationship and affects. 1. Frantic effort to avoid real or imaged abandonment. (di sya ganahan nga pasagdan ra sya, kay katong naa pa ko dubai, gnapasagdan ra man sya iya mga uncle ug ante, murag wala ra sila pakialam sa iya as verbalized by the mother.) 2. Impulsivity in or at least two areas that are self damaging such as cigarette smoking and substance abuse. 3. Affective instability due to marked reactivity (easily got mad and hitting others with anything he gets to) 4. Inappropriate, intense anger or difficulty controlling anger (gawild gapamunal ug kahoyas verbalized by the mother) 5. transient, stress-related paranoid ideation or severe dissociative symptoms ( feeling niya gainterviewhon siya sa tanang tao pag mangutana sa iya as verbalized by the mother)

AXIS III FOR GENERAL MEDICAL CONDITIONS NONE AXIS IV PROBLEM RELATED TO SOCIAL ENVIRONMENT RVR has difficulty making friends due to his condition since birth AXIS V GLOBAL ASSESSMENT OF FUNCTIONING The GAF scaling of RVR. is 51-60

Moderate symptoms RVR has inability to take care of personal needs Moderate difficulty in social functioning RVR has only few friends

Substance induce psychotic disorder A. prominent hallucination or delusion. Note: Do not include hallucination if the persons has insight that they are substance induced. B. there is evidence from the history, physical examination or laboratory findings of : y the symptoms in criterion a developed during or within a month of substance Intoxication or withdrawal y medication is etiologically related to disturbance C. The disturbance is not better accounted for by a psychotic disorder that is not substance induce. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induce might include the following: y The precede the onset of the of the substance use ( medication use) y The symptoms persist for substantial period of time (about a month)

After the cessation of acute withdrawal or severe intoxication, or are substantial in excess of what would be expected to be given the type or amount of the substance used or duration of use: or there is other evidence that suggest the existence of independent non-substance-induce Psychotic disorder D. the disturbance does not occur exclusively during the course of delirium Note:this diagnosis should be made instead of diagnosis of substance Intoxication or substance withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficient severe to warrant independent clinical attention.

VIII. NURSING MANAGEMENT A. IDEAL NURSING MANAGEMENT 1.) Disturbed thought processes related to physiologic changes due to substance abuse INTERVENTION: RATIONALE

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks.

Delusional client are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions. Broken promises reinforce clients mistrust to others.

Do not make promises that you cannot keep.

Encourage client to talk with you but do not pry for information.

Probing increases the client suspicion and interferes with the therapeutic relationship. Recognizing the client perceptions can help you understand the feelings shes experiencing.

Recognize the client delusion as the clients perception of the environment.

Initially, do not argue with the client or try to convince the client that delusions are false or unreal.

Logical argument does not dispel delusional ideas and can interfere with the development of trust.

Interact with the client on the basis of Interacting about reality is healthy for the client. real things; Do not dwell on the delusional materials.

2.) Ineffective Family Coping related to exhausted supportive capability of family members

INTERVENTION:  Assess family history; explore roles of family members, circumstances involving drug use, strengths, and areas for growth.  Explore hoe the significant

RATIONALE Determines areas for focus, potential for change.

Co-dependent also suffers from the

others has coped with the addicts habit, e.g denial, repression, rationalization, hurt, loneliness, projection  Determine understanding of current situation and previous method of coping with lifes problems  Assess current level of functioning of family members  Determine extent of Enabling behaviours being evidenced by family members, explore with patient

same feelings as the patient (e.g anxiety, self-hatred, helplessness, low self-worth, and guilt) and needs help in learning new effective coping skills. Provides information on which to base present plan of care

 Provide information about enabling behavior, addictive disease characteristics for both user and non-user co-dependent  Provide factual information to the patient and family about the effects of addictive behavior on the family and what to expect after discharge.  Encourage significant others to be aware of their own feelings, look at the situation with perspective and objectivity. They can ask themselves. am I being conned? am I acting out of fear, shame, guilt or anger? Do I have a need to control?

Affects individuals ability to cope with the situation Enabling is doing for the patient what he needs to do for self. People want to be helpful and do not want to feel powerless to help their loved one to stop drinking and change to behaviour that is so destructive. However, the substance abuser relies on others to cover up own inability to cope with daily responsibilities. Awareness and knowledge provide opportunity for individuals to begin the progress of change. Many patients/ significant others are not aware of the nature of the addiction. If the patient is using legally obtained drugs, may believe this does not constitute abuse. For self awareness of the significant others, to be able for them to handle situations involving the patient.

3.) Sleep pattern disturbances related to psychological stress

INTERVENTION:  Consult psychiatrist in arranging medication regimen - to maximize night time and minimize day time sedation

 Give sleep medication as needed. Teach relaxation technique  Encourage day time activity and discourage day time naps.  Determine normal sleep habit and changes that are occurring  Obtain comfortable bedding, provide some of own possessions ex. Pillow  Establish sleep routine suitable to old pattern and new environment  Encourage some light physical activity during the day, make sure patient stops activity several hours before bedtime  Provide warm bath and massage, warm milk, wine or brandy at bedtime

- Provide rest.

- This will exhaust the patient during the day time which will give them the opportunity to rest well at night. -assesses need for and identifies appropriate interventions -increases comfort for sleep as well as physiologic/ psychologic support -when new routine contains as many aspects of old habits as possible, stress and related anxiety maybe reduced. -daytime activity can help patient expend energy and be ready for night time sleep. However, continuation of activity close to bedtime may act as a stimulant, delaying sleep -promotes a relaxing soothing effect. Note; milk has no prolific qualities, enhancing synthesis, and neurotransmitter that helps patient fall asleep faster and sleep longer.

B. ACTUAL NURSING MANAGEMENT

Oo gamata-mata ko pag tungang gabii kay naa koy makit-an na tigulang ug bata as verbalized by the client.     Weak & Drowsy Inattentive, irritable Midnight awakening Less than 8 hours of sleep

Sleep Pattern Disturbance related to psychological stress as evidenced by visual hallucination

Short term: At the end of 1 hour, the client will be able to express the feeling of being well rested. P Long term: At the end of 4 days, the client will specify the number of hours of sleep without interruption.

Independent: 1) Discouraged naps during the day 2) Instructed to restrict intake of caffeine (eg. coffee, tea, cocoa, cola drinks) 3) Encouraged to engag in physical activities/exercise during morning and afternoon. Instructed to restrict activity in the evening prior to bedtime 4) Allowed the client to identify the circumstances that interrupted her sleep and frequency 5) Evaluated level of stress/orientation as day progresses.

Rationale  Not to alter the sleep pattern at night  May stimulate CNS, interfering with relaxation and ability to sleep

 Enhances sense of fatigue and promotes sleep/rest, evening activity may actually stimulate client and interfere with/delay sleep

 To evaluate sleep pattern and dysfunctions

 Increasing confusion, disorientation, and uncooperative behaviors may interfere with restful sleep pattern

At the end of 4 days, the client was able to establish adequate normal sleeping pattern.

S O A

Gi- kapoy na gyud ko og ayo. Kadugayan naluoy na cguro siya sa ako, kadugayan miingon siya nga-higti nlng ko ma para di ka kapoyan. As verbalized by the mother.  Financial instability Ineffective Family coping related to exhausted supportive capability of family members Short term: At the end of 1 hour, the clients family will be able to identify resources within themselves deal with the situation.

Long term: at the end of 4 days, the clients family will be able to visit regularly and participate positively in care of the client, within limits of abilities.

Independent: 1) Had established rapport and acknowledged difficulty of the situation for the family. 2) Determined current knowledge of the situation.

3) Discussed underlying reasons for the clients behavior with the family during visit. 4) Encouraged the family members / SO to provide support through visitations.

Rationale  May assist family to accept what is happening and be willing to share problems with caregivers.  Lack of information or unrealistic perceptions can interfere with family members/ clients response to illness.  When family members know why client is behaving in different ways, it helps them understand and accept/ deal with situation.  It provides the family opportunity to talk with the client, thus, reducing the anxiety and allows expression, as well as opportunity to make future plans and share support. 

Dependent 1) Refer to appropriate resources for assistance as indicated (e.g., counselling, spiritual support)

May need additional assistance in resolving family issues.

At the end of 4 days, the family expresses more realistic understanding and expectations of the client Maligo raman siya kung ganahan pero ang gasabonan ra kay ulo ug abaga. Pero ako jud magligo niya. As verbalized by the mother. y Inability to keep body clean Inability to dress appropriately Poorly combed hair

y y

Self-care deficit related to perceptual and cognitive impairment as A evidenced by difficulty keeping body clean and dressing

appropriately.

Short term: At the end 30 minutes, the client will be able to demonstrate proper hygiene.

Long term: At the end of 4 days, the client will be able to perform selfcare and ADLs at highest level of adaptive functioning possible.

1. Identified presence/severity factors that of affect

1. Impairment in these areas can alter clients ability/readiness self-care. 2. Appearance personal affects for

clients capacity for selfcare. 2. Discussed I

how the client sees self. A rundown,

appearance/grooming and dressing colors, encouraged in bright attractive

disheveled appearance conveys a sense of low self-

clothes. Gave positive feedback for efforts.

worth,

whereas

an

attractive, together conveys

well-putappearance a positive

3. Assisted client with care of fingernails and

sense of self to the client as well as to others.

toenails as required. 4. Encouraged client to

3. To promote sense of well-being

perform minimal oralfacial hygiene after

rising as possible. 5. Encouraged comb client to 4. To promote sense of well-being

own

hair,

suggested hair styles that are low

maintenance. 5. client to autonomy possible. for as This enables the

maintain long as

The goal was partially met since the client was able to perform selfE care and ADLs at level of adaptive functioning possible.

IX. Medical Management Drug Study Brand Name: Largactil Generic Name of Ordered Drug: Chlorpromazine Hydrochloride Classification: Antipsychotic Date Ordered: April 2, 2007 Dose/ Frequency/ Route : 100mg/tab/PO/OD Mechanism of Action: Blocks the post synaptic dopamine receptors in the brain. Specific Indication: To prevent occurrence of psychosis, mania. Contraindications: Hypersensitivity to drugs in those with CNS depression, bone marrow suppression or subcortical damage. Side effects/ Toxic Effects: y CNS: Seizures, Nueroleptic Malignant Syndrome y G.I: Dry Mouth, Constipation y HEMATOLOGIC: Aplastic Anemia

Nursing Precaution: y Largactil can pass into the breast milk and cause drowsiness and unusual muscle movements in the baby. Therefore, it is not recommended for nursing mothers. y This medicine should not be given to patients diagnosed with Parkinsons disease, narrowangle glaucoma, cardiovascular disease and epilepsy. y It should not be used concomitantly with other drugs that can cause sedation. y Largactil should not be taken if you are hypersensitive to it.

IX. PROGNOSIS CRITERIA a. ONSET OF ILLNESS b. DURATION OF ILLNESS c. PRECIPITATING FACTORS d. MOOD and AFFECT e. ATTITUDE AND WILLINGNESS TO TAKE X GOOD PROGNOSIS POOR PROGNOSIS X X

X X

MEDICATION AND TREATMENT f. ANY DEPRESSED FEATURES g. FAMILY SUPPORT X X

On the criteria listed above, six out of seven criteria shows that our client represents a poor prognosis. His onset of illness is early that is when he is 20 years old. The duration is persistent / recurring whenever client cant take his medication or triggered by other depressant factors such as family problems, and lack of financial support. There are some precipitating factors identified that contributes to his condition such as poor guidance and family support. His mood is inappropriate with flat affect evidenced by absence of facial expression that would indicate emotions. He religiously takes his medications and participates in minimal therapeutic conversations.

RECOMMENDATION

The group recommends that the client should stay inside their home and family should provide emotional support and guidance to alleviate clients misconceptions regarding his environment, this would provide a therapeutic outcome to possibly lessen the stressor that would trigger clients condition. Support from family members in addition is a huge factor that will encourage client to take his medications and to provide security to the client. Peer group can also help client feel as part of the community and as a functioning individual.

Lastly, providing small tasks to the client to divert clients attention to any factors that may trigger his condition.

XI. Bibliography y Videbeck Sheila L., Psychiatric Mental Health Nursing 2nd Edition, Lippincott Williams and Wilkins, 2001, pp 297 301 y Deglin, Judith H. Davis Drug Guide for nurses, 9th Edition, 2005 by F.A Davis company, Philadelphia y Doesnges, Marilyn E., Nursing Care Plan, Guidelines for individualizing Patient Care, 6th edition, 2002 by F.A Davis Company Philadelphia y F.A Davis, Tabers Encclopedia Medical Dictionary, 20th Edition, 2005 by Lippincott Williams and Wilkins, Philadephia. y Keltner et. Al, Psychiatric Nursing 3dr edition 1999.

y y

Nursing Drug Handbook. 27th edition 2007 Sparks, Sheila M, Nursing Diagnosis Reference manual, 5th edition, 2001 by Springhouse Corporation, Pennsylvannia. The Lippincott Manual of Nursing practice. 7th Edition. Vol.2