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1 INTRODUCTION Schizophrenia is considered the most common disabling of psychotic disorder.

It is a sever mental illness characterized by persistent defects in the perception or expression of reality. It is defined as split personality they mean something akin to a Jekyll and Hyde experiencing untreated schizophrenia typically demonstrates grossly disorganized thinking, and may also experience delusions or auditory hallucinations. Although this illness primarily affects cognition, it can also contribute to chronic problems with behavior or emotions. The student chose schizophrenia because it is one of the most profoundly disabling illnesses, mental or physical, the student encountered. Its not only for the partial requirement of the course but because it is the most common and major cause of rehabilitation in the Vicente Sotto Memorial Medical Center-. This study is very interesting and it answers to the students curiosity about the illness. Because of this study, the students want to gain more knowledge on this illness. It also helps the students to know on how to deal and handle a client with schizophrenia. Through this, the students can help the client improve his condition as well as his self-esteem through the rendering of proper nursing management. And be able to impart the necessary, accurate nursing management and treatment for patients with this illness. And they expect to increase and broaden their knowledge about schizophrenia. The student nurses expect from this case study to know more about the patients mental disorder which is Schizophrenia. They also expect to obtain more information on the patients profile and his history prior to his admission.

2 OBJECTIVES: General Objectives: After two weeks of student nurse-patient interaction, the student nurse will be able to gain more knowledge and enhances skills in managing a patient with mental disorder (schizophrenia). Specific Objectives: After two weeks of student nurse-patient interaction, the student nurse will be able to: 1. introduce self to the patient. 2. establish rapport with the client. 3. develop trust to the patient. 4. gather information regarding significant events that causes patients admission. 5. identify the personal, social, and familial history of the patient. 6. encourage the client to cooperate with care measures and psycho logic therapies. 7. enumerate the classical signs and symptoms of schizophrenia. 8. impart health teaching to the patient and level of understanding. 9. interact through therapeutic communication. 10. provide health teaching regarding activities of daily living (Self-Care).

Patient-Centered Objective General Objectives: After two weeks of student nurse-patient interaction, the patient will be able to gain more knowledge, demonstrate beginning skills and gain positive attitude in performing of activities of daily living. Specific Objectives: After two weeks of student nurse-patient interaction, the patient will be able to: 1. state the name of the student nurse. 2. establish rapport and trust with the student nurse. 3. re-orient self as to proper date, time and place of interaction. 4. participate during interaction and maintain good manners and right conduct. 5. exhibit compliance medication management. 6. verbalize his needs. 7. exhibit compliance with medication management. 8. state coping skills such as opening up his problems. 9. show positive attitude toward the student nurse. 10. gain knowledge and skills regarding activities of daily living.

4 II. NURSING ASSESSMENT 1. 1.1 Personal History Patients Profile Name: Barrero, Roberto Age: 41 years old Sex: Male Civil Status: Married Religion: Roman Catholic Case Number: 496465 Date of Admission: August 11, 2004 Ward No.: Ward XII Psychiatric Male Ward Diagnosis: Schizophrenia Physician: Dr. Yozar 1.2 Patients Information, Social and Health History A case of Mr. Roberto Barrero, Roman Catholic, once a resident from Bogo, Cebu was brought to Vicente Sotto Medical Center for the first time last August 11, 2004. Patients records show that hours prior to admission, patient was transported to the emergency room at surgery department due to lacerated wound at left and right temporal area. Policeman suspected that the patient was possibly mauled. After treating, the patient was cleared from neuro department, he was reffered to psychiatric department for transfer of service because patient was seen by Dr. Sanchez (PGI) at emergency room wearing disposable diaper, strapped to bed, patient was unresponsive.

5 Level of Growth Development Level of Growth Development Middle-aged Adults (40-65 years old) Source: Fundamentals of Nursing by Kozier page 398 The middle years, from 40 to 65, have been called the years of stability and consolidation. For most people, it is a time when children have grown and moved away or are moving away from home. Thus partners have more time for and with each other and time to pursue interests they may have deferred for years. Physical Development Both men and women experience decreasing hormonal production during the middle years. The menopause refers to the so-called change of life in women, when menstruation ceases. It is said to have occurred when a woman has not had a menstrual period within a year. The menopause usually occurs anywhere between ages 40 to 55. The average is about 47. years. At this timr, ovarian activity declines until ovulation ceases. Common symptoms are hot flushes, chilliness, a tendency of the breasts to become smaller and flabby, and a tendency to gain weight. Insomnia and headaches also occur with relative frequency. Psychologically, the menopause can be an anxiety producing time, especially if the ability to bear children is an integral part of the womans self-concept. Psychosocial development Robert Peck believes that although physical capabilities and functions decrease with age, mental and social capabilities tend to increase in the later part of life. The middle aged person looks older and feels older. People usually accept the fact that they are aging; however, a few try to defy the years by changing their dress and even their actions. Some men and women have extramarital affairs and marry younger partners. A new freedom to be independent and follow ones individual interests arises. Gail Sheehy suggests that the transition into middle life is critical. She outlines characteristics of the midlife crises and calls the decade between the ages 35 to 45 the

6 deadline decade. According to Sheehy, most women pass through the midlife crises, which occurs when individuals recognize that they have reached the halfway mark of life. Youthfullness and physical strength can no longer be taken for granted. Middle age can be viewed by the individual as either a crises or a transition from youth to later maturity. In this stage generativity refers to the adult's ability to care for another person. The most important event in this stage is parenting. Does the adult havethe ability to care and guide the next generation? Generativity has a broadermeaning then just having children. Each adult must have some way to satisfy and support the next generation. According to Erikson, "A person does best at this time to put aside thoughts of death and balance its certainty with the only happiness that is lasting: to increase, by whatever is yours to give, the goodwill and higher order in your sector of the world"(Erikson, 1974). Cognitive Development The middle-aged adults cognitive and intellectual abilities change very little. Cognitive processes include reaction time, memory, perception, learning, problem solving, and creativity. Reaction time during the middle years stays much the same or diminishes during the latter part of the middle years. Memory and problem solving are maintained through middle adulthood. Learning continues and can be enhanced by increased motivation at this time in life. Moral development According to Kohlberg, the adult can move beyond the conventional level to the post conventional level. Kohlberg believes that extensive experience of personal moral choice and responsibility is required before people can reach the post conventional level. Kohlberg found that few of this subjects achieved the highest level of moral reasoning. In the middle age, people tend to be less dogmatic, about religious beliefs, and religion often offers more comfort to the middle-aged persons that it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death and injury.

7 1.2 The Ill Person at This Stage: Schizophrenia is a behavior disease that disrupts perceptions, thinking, feelings, and behavior. It can cause distortions of reality, false beliefs, hallucinations and changes in speech patterns, mood and behaviors. It disrupts the persons ability to function, socialize and work. Many middle-aged adults remain healthy; however, the risk of developing a health problem is greater than that of the young adult. Leading causes of death in this age group include motor vehicle and occupational accidents, chronic disease such as cancer and cardiovascular disease. Mr. Barrero has a Schizophrenia disorder which is a mental illness, it is very difficult to trace the cause of his present condition because of many theories involved. In the case of the client, continuous monitoring of the client and proper interventions most especially his medication regimen and an environment conducive for his recovery as soon as possible.

8 Patient: Robert, Barrero Diagnosis: Schizophrenia Mental Status Examination Patient is wearing white t-shirt, brown pants and red slippers. His hair was cut short, teeth with full of dental carries. He has a smiling face during the interaction. Nails were uncut. He often bows down his head and he walk slowly. He has difficulty in raising his hand due to bone dislocation at the left elbow. Roberto responds slowly to the questions asked by the student nurse. Roberto usually holds of the student nurses hand always, shy sometimes, tremors were sometimes observed. Patient speaks slowly and slurring of speech was observed. He has flight of ideas and cannot remember the words that he speaks. He usually talks to other student nurses. He usually alters the specific word often. Roberto is always happy and calm. Feeling of sadness is not irritable even if the student nurses were asking him so many questions. Patient is disoriented to time, place, date and environment. Poor memory retention; cannot verbalize events in detail. Patient is able to understand simple words at a time. Date: September 3, 2008 Sex: Male

9 Anatomy and Physiology of the Brain

A. Cerebrum it is composed of 2 hemispheres that are incompletely separated by the great longitudinal fissure. The sulcus separates the right and left hemispheres. The fissure by the corpus callosum. The cerebral hemispheres are divided into parts; frontal, parietal, temporal and occipital lobe. 1 FRONTAL - the largest lobe, the area controls concentration, abstract thought information storage and motor function. It is also responsible for affect, judgment, personality and inhibitions. 2 PARIETAL - a predominantly sensory lobe, contains primary sensory cortex, which analyzes sensory information and relays interpretation. It also essential to an individuals awareness of the body in space.

10 3 TEMPORAL - contains auditory receptive areas, contains a vital area called the interpreting area provides integration of somatization, visual and auditory areas. 4 OCCIPITAL - responsible for visual interpretation.

Hypothalamus is located anterior and inferior to the thalamus. It is the site of hunger center and is involved in appetite control. it houses centers that regulate the sleep-wake cycle, blood pressure, aggressive and sexual behavior and emotional responses.

B. Brain Stem -the brain stem consists of the midbrain, pons and the medulla oblongata 1. MIDBRAIN - contains sensory and motor pathways and serves as a center for auditory and visual reflexes. 2. PONS - situated in front of the cerebellum between the midbrain and the medulla. Cranial nerve V and VII connected to the brain in the pons. The pons contains motor and sensory pathways. Portions of the pons also control the heart, respiration and blood pressure. 3. MEDULLA OBLONGATA transmits motor fibers from the brain to the spinal cord to the brain.

C. Cerebellum is separated from the cerebral hemispheres by a fold of dura mater, the tentorium cerebelli. The cerebellum has both excitatory and inhibitory action and is largely responsible in coordination of movements. It also

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11 controls fine movement, balance, position, sense and integration of sensory output. Major Neurotransmitters: 1. ACETYLCHOLINE it is found in many areas of the brain; autonomic nervous system. Its action is usually excitatory, parasympathetic effects sometimes inhibitory. 2. SEROTONIN it is found in the brain stem. Hypothalamus and the dorsal horn of the spinal cord. It functions are inhibitory, helps control mood and sleep; exhibits pain pathways. 3. NOREPINEPHRINE sympathetic nervous found in the brain stem.

Hypothalamus and the post gangrionic neurons of the system. Its action is usually excitatory, affects mood and overall activity. 4. DOPAMINE found in the substantia nigra and basal ganglia. Its action are usually inhibitory, affects behavior and fine movements. 5. GAMMA AMINOBUTYRIC ACID (GABA) found in the spinal cord, cerebellum, basal ganglia and some cortical areas. Its actions are inhibitory, muscle and nerve stimulation. 6. ENCEPHALINS and ENDORPHINS found in the nerve terminals in the spine, brainstem, thalamus, and hypothalamus and pituitary gland. Its action are excitatory, pleasurable sensations, inhibits pain transmissions.

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12 * BASAL GANGLIA involves in movement and emotions and in integrating sensory information. Abnormal functioning in schizophrenia is thought to contribute to paranoia and hallucinations. (Excessive blockage of dopamine receptors in the basal ganglia by traditional anti-psychotic medicines leads to motor side effects). * AUDITORY SYSTEM enables human to hear and understand speech. Schizophrenia, over activity of the speech area (called Wenickes area) can create auditory hallucinations, illusion that internally generated thoughts are real voices coming from outside. * OCCIPITAL LOBE process information about the visual world. People with schizophrenia rarely have full-blown visual hallucinations, but disturbances in this area contribute to such difficulties as interpreting complex images, recognizing motion and reading emotions on others faces. * FRONTAL LOBE critical problem solving, insight and other high level reasoning. Perturbations in schizophrenia lead to difficulty in planning actions and organizing thoughts. * LIMBIC SYSTEM involved in emotion. Disturbances are thought to contribute to the agitation frequently seen in schizophrenia. * HIPPOCAMPUS mediates learning and memory formation. Intertwined functions that are impaired in schizophrenia.

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Psychopathology of Schizophrenia (Schematic Diagram)

Predisposing Factors Factors Genetic Risk relationships Neuroanatomy: decreased brain volume & abnormal brain function in frontal and temporal areas Neurochemical/alterartions in neurotransmitters system parenting (dopamine and serotonin) substance abuse Exposure to virus system Stress

Precipitating Dysfunctional

Poor nutrition Dysfunctional Tobacco, alcohol, Altered immune in

Infections

pregnant women Children born in crowded areas cold weather Conditions that are hospitable respiratory ailments Brain trauma mechanisms Poor coping to and

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14 Patient always seen happy in mood and interacts well with other persons especially student nurses. This interaction to other person is his coping mechanism whenever he feels bad in mood or feels alone. Patient has no more support coming from his family. Only the student nurses and institutional workers in VSMMC are his support system. Prior to admission; patient shows signs of schizophrenia like flight of ideas, disorganized thinking and hallucination. Schizophrenia

Positive Signs of Schizophrenia Schizophrenia Hallucination Delusion Flight of Ideas Echopraxia Ambivalence Associative looseness

Negative Signs of Lack of Volition Flat Affect Catatonia Apathy Alogia Anhedonia Blunted Affect

Nursing Interventions Treatment Promoting safety to client & others group therapy Establishing therapeutic relationship and Implementing interventions for

Psychopharamacology Chlorpromazine Maintenance therapy: - Biperiden

Psychosocial Individual and Family therapy education

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15 The Disease Process and its Effect on Different Organ / System Schizophrenia is a disabling disease characterized by disturbed thinking, disorganized speech and in many cases, odd sometimes frightening behavior. Comprising a group of disorders, Schizophrenia can be classified according to its 5 subtypes: catatonic, paranoid, disorganized, residual, and undifferentiated. A patients subtype may change over time. The patients overall disability depends mainly on the severity of cognitive impairment. May impair the patients ability to hold a job, stay in school, maintain relationships, and even perform self-care. In some cases, leaves the patient unemployable, socially isolated, and estranged from family and friends. Approximately 10% of Schizophrenics commit suicide, typically within the first 10 years of illness. Symptoms of Schizophrenia usually arise gradually, but in some patients. They emerge over just a few days or one week. The most common age of onset in late adolescence although earlier and later onsets arent usual. In males: typically starts in the late teens or early twenties. In females: may start in the mid twenties or early thirties. Between periods of exacerbation, some patients have no disability, while others need continuous institutional care. With each acute episode, the prognosis worsens. Few Schizophrenics experience just a single psychotic episode. Only about one in five recovers completely. Most continue to suffer at least some lifelong symptoms. Common causes of Schizophrenia are precisely unknown. Probably results from interplay of genetic, biochemical, structural brain abnormalities, developmental, and other factors. Behaviors and functional deficiencies seen in schizophrenia vary widely among patients. The signs and symptoms of Schizophrenia are typically categorized into three groups: positive, negative, and disorganized. Symptom cluster may vary throughout the course of illness; however, a single symptom cluster usually predominates at any time. Positive symptoms are deviant symptoms symptoms that are present but should be absent. These positive symptoms are hallucinations and delusions. Negative (deficit) symptoms reflect the absence of normal characteristics.

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CLASSICAL SYPTOM Apathy

CLINICAL SYPTOM

RATIONALE

Not manifested

-lack of concern or interest, is the inability to generate a normal response to people, situations or the environment. This is due to the kinds of feelings manifested, which seems to be out of keeping with the ideas being expressed or amount of emotions. (psychiatric Nursing 10th ed. By: Manfreeda pp. 148 and Psychiatric Nursing by: Keltner 3rd. ed. Pp. 360 )

Aggressive

Not manifested

-anger

is

universal

emotion

perhaps one of the most difficult for people whether it is ones own or someone else angry or aggressive impulses. Anger and aggression are the last stages of response that begins with feeling vulnerable and then uneasiness. ( Psychiatric Clinical Guide by: Varcolis pp. 371 ) Depression Not manifested -this is due to failure of the individual to function successfully in preserving internal emotional

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17 equilibrium. ( Psychiatric Nursing by: Manfreeda pp. 390 ) Hallucination Manifested own that are not there -hallucination is a false sensory stimuli (e.g. seeing things that are not there ) ( Psychiatric Nursing by: Keltner 3rd ed. pp. 360 ) Suspiciousness Not manifested -suspicious refers to lack of trust. This could be due to anxiety, over stress. This is also due to a lesion of the amygdale region, which is also manifest fearfulness. ( Behavioral Science by: Faden pp. 208 ) Echopraxia Not manifested -it is characterized by repetitive, meaningless movement. It is the limitation of someone or something a person is observing, it does involve the element the loose ego boundaries. ( Psychiatric Mental Nursing by: Townsend pp. 655 )

-patient see things on his perception unrelated to external

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CLASSICAL SYPTOM Word Salad

CLINICAL SYMPTOM

RATIONALE

Manifested -sometimes conversation to

-it is randomized set of words patient without logical connections. Also the known as Wernickes aphasia. This language system in schizophrenia. ( Psychiatric Nursing by: Videbeck pp. 290)

student nurse does not is a manifestation of a distorted connect with the topic.

Echolalia

Manifested heard.

-repetition of words heard. This is disordered Wenickes and Bocas area which is responsible for the perception, encoding of stimuli of the language system. (Psychiatric Nursing by: Videbeck pp. 290 and Psychiatric Mental Health Nursing by: Pownseus pp. 25 )

-patient repeat the words correlation of schizophrenic with

Clang Association

Not manifested

-schizophrenic

persons

characteristically exhibit a blunter flat affect, in contrast to the healthy conveys a feeling that is indicative of this personal, emotional status which is augment of saying this is due to compromise ability of the ego to inhibit, impulses in the

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19 expression of feeling . ( Psychiatric Nursing 10th ed. by: Manfreeda pp.148 ) Social Withdrawal Manifested -sometimes doesnt alone. want to -it is noticed and can be expressed patient in degrees- when conversion is get returned back. Manfreeda pp. 390 )

along and wants to be ( Psychiatric Nursing 10th ed.by:

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20 Care Guide in Patients with Schizophrenia 1. Remove clients from, or avoid, situations known to cause agitation. 2. Maintain eye contact during interactions with client. 3. Explain all procedures and interventions, including medication management. 4. Avoid criticism and do not argue with clients. 5. do not whisper or laugh in the presence of the client. 6. Decrease stimulants such as caffeine, bright lights and loud noise or music. 7. Provide for personal space and do not touch without warning the client. 8. Avoid display of anger, discouragement or frustration when interaction with the client. 9. Assess client for physical discomfort such as pain or any physical illness. 10. Assist client to watch any programs on the television to minimize external stimuli that may precipitate hallucination. 11. Set limits and follow thought with consequences if a violation occurs. 12. Administer prescribed medication as ordered. 13. Do not argue with the client or attempt to disapprove delusional or suspicious thoughts. 14. Assess client. For command hallucinations that may precipitate aggressive or violent behavior.

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Name: Yap, Jahnson S. Name of Patient: Mr. Barrero, Robert NURSING CARE PLAN Needs / Nursing Scientific Basis Social the effects to when prevent person accepted sociocultural >Poor eye to eye contact > Disoriented to time and date Subjective cues: Di, di, di ko apil, di ko, ko norms or when motivation deteriorates resulting in social withdrawal isolation lifes directly Behaviors causing these problems in the development of relationships and from activities.

Diagnosis: Schizophrenia Sex: Male

Objective

Nursing Intervention 1 Measures to

Rationale

Problem cues Diagnosis Psychological Impaired Deficit Impaired social interaction Objective Cues: Social Interaction: Low Esteem Related Self Concept

of Care problems After illness student Direct nurse

may result from hour Self directly.

of enhance social interactions: Avoid 1.touch by a be misinterpreted as a sexual or threatened gesture. This is particularly true client. Source: Psychiatric Nursing plan 229 Care by for a paranoid

occur interaction symptoms the patient 1. the will from able social interaction. to client. be touching the stranger can

Disturbance socializing within enhance

Varcarolis pp.

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22 kamao. the patient. As include disinterest recreational activities, inappropriate sexual and related withdrawal friends, and peers 3. Source: Principles practice psychiatric Nursing 8th Gail W. Stuart and of day include planned times brief interactions with by families behavior stigma social in 2. If the 2. is interested to presence can provide sense of being worth while. Source: Care by An

verbalized by

inappropriateness,

client unable respond verbally, spend frequently, with patient.

short period Psychiatric the Nursing plan 229 Structure 3. Helps the each patient develop to a sense of a safety nonfor threatening environment. Source: Care by in a

Varcarolis pp.

times

and activities Psychiatric the Nursing patient on a plan basis. 229 4. Even simple 4. If patient activities help is in trouble drew patient concentrating away from the

one on one Varcarolis pp.

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23 at this time, delusional provide very thinking simple concrete activities with onto reality in the environment. Source: Care by

client Psychiatric plan 229

like drawing Nursing and painting.

Varcarolis pp.

5.

Structure 5. Patient can

activities that lose interest in work at the an activity that clients pace is and ability. ambitious, which increase sense failure. Source: Psychiatric Nursing plan 229 6. patient remove herself Teach 6. dealing anxiety Teach with and Care by can a of too

Varcarolis pp.

to patient skills in

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24 briefly when increasing feeling work some exercise deepbreathing. 7. Arguing will 7. the to Do not only ioncrease with clients patient defensive correct thereby false beliefs. argue sense on Source: Psychiatric Care by plan 229 agitated and control. a of

anxiety-relief Nursing

examole like Varcarolis pp.

belief or try position, false beliefs reinforcing using facts. This will result in the client feeling more and misunderstood. Source: Psychiatric Nursing plan 229 Care by even isolated

Varcarolis pp.

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Name: Yap, Jahnson S. Name of Patient: Mr. Barrero, Robert NURSING CARE PLAN Needs / Problem Cues PSYCHOL OGIC DEFICIT 1. DI SORIE NTAT ION Objective Cues: disor iented with the time, date and person around has short term Nursing Diagnosi s Scientific Basis / Significa After hours is holistic nursing the client will be able to time, 8 Measures of orienting client: Objectives of Care

Diagnosis: Schizophrenia Sex: Male

Nursing Actions

Rationale

nce Disturbed Schizoph Thought : Disorient ation mental disorder (Schizop hrenia) renia referred r/t thought disorder is Processes often

in the Determines participate Source: in / executing care. Nurses 9th ed. Pocket Doenges, ability planning to /

1. Assess attention span distractibility make decisions or problemof solve. 2. Perform neurologic assessments

to as a care,

because it be oriented the to place, events primary the disease; thought processes become disorder, and y continuit thoughts

and ability to Guide.

Marilynn, et. al. p. 531

feature of persons, the day as evidenced by clients own verbalizatio after being the student-

Early recognition of changes promotes Nurses 9th ed. proactive Pocket Doenges, modifications to plan of care.

as indicated Source: and compare Guide. with baseline. Note

the n

Marilynn, et. al. p. 531

of oriented by

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26 memory decr eased attention span decr eased ability to grasp ideas has difficult y in making decision s has disorder ed thought sequenci ng inacc urate interpret ation of environ ment Subjective Cues: Source: Videbeck , L. Psychiatr ic Mental Health Nursing. 2nd edition. Pgs. 308 and 310 4. Provide safety measures like close Provides stimulation without supervision. To prevent injury to occur. Source: Guide. Nurses 9th ed. Pocket Doenges, Sheila 3. Reorient to time place person. Inability / orientation Source: Guide. to is a maintain sign of and informati on processin g Clients are commonl y disoriente d to time and sometime s place. is disrupted. nurse. changes level s such increased lethargy, confusion, drowsiness, irritability; changes ability e. in to in of and as

consciousnes cognition,

communicat

/ disorientation. Nurses 9th ed. Pocket Doenges,

Marilynn, et. al. p. 531

Marilynn, et. al. p. 531

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27 Karun kay miyerkules alas sa (but nueve buntag it is Client 6. Maintain a quiet environment and a slow, calm manner. Defensive 7. Present reality briefly do challenge illogical thinking. To avoid triggering fight / 8. Reduce provocative stimuli, negative criticism, arguments and flight responses. Source: Guide. Nurses 9th ed. Pocket Doenges, occur. Source: Nurses 9th ed. Pocket Doenges, reactions may the anxious may or if respond startled with or aggressive 5. Schedule structured activity rest periods. undue fatigue. Source: and Guide. Nurses 9th ed. Pocket Doenges,

Marilynn, et. al. p. 531

Monday, 8:10 in the morning), as verbalized by client.

pleasant, behaviors Source: Guide.

overstimulated. Nurses 9th ed. Pocket Doenges,

approach in Marilynn, et. al. p. 532

concisely and Guide. not

and Marilynn, et. al. p. 532

Marilynn, et. al. p. 532

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28 confrontation . Client may feel threatened 9. Refrain and may withdraw or rebel. Nurses 9th ed. Pocket Doenges, from forcing Source: activities and Guide. communicati ons. Client is extremely sensitive 10. Be sincere about others and can or and recognize insincerity. comments

Marilynn, et. al. p. 532

honest when Evasive communicati

hesitation reinforces mistrust.

ng with the Source: Psychiatric Mental client. Avoid Health Nursing. 2nd edition. evasive remarks. Videbeck, Sheila L. pgs. 316

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29 Name: Yap, Jahnson S. Name of Patient: Mr. Barrero, Robert NURSING CARE PLAN Needs / Problem Cues PSYCHOL OGIC DEFICIT Nursing Diagnosi s Scientifi c Basis / Signific After hours holistic nursing care, client the will 8 Measures 1. Determine level and dependence to May range from complete of dependence (dysfunctional) to partial or relative independence Source: Nurses Pocket Guide. al. p. 276 Objectives of Care Nursing Actions Rationale Diagnosis: Schizophrenia Sex: Male

ance Ineffectiv Clients e Health with Maintena nce: disorder ed

of aware the client:

INEFFECT unable to thought IVE HEALTH MAINTEN ANCE Objective Cues: altered ability to make deliber ate and thought ful judgme nts meet self- processe care activities r/t impaired cognitive functioni ng. s environ mental misinter s have great difficult y t. is severe that clients judgmen

and be able to be aware of his own health and needs as

independence 9th ed. Doenges, Marilynn, et.

pretation evidenced will by doing his 2. own care activities minimal selfDetermine level adaptive behavior, knowledge, and about health maintenance, environment, and safety.

Other factors are considered to determine clients response and of attitude regarding health maintenance. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et.

with with This assistance or so prompting.

skills al. p. 276

Allows

for

incorporating

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30 unable to meet basic health practic es lack of adaptiv e behavi ors to environ mental change s needs to ed do task has difficul ty in making decisio ns disorie nted with time, Source: Videbec k, Sheila L. Psychiat ric Mental Health Nursing. 6. of information one material through selfpaced time. be to a instruct cannot meet their needs for safety and protectio n this difficult y lead failure to care even when desperat ely ill. 5. Encourage socialization involvement. Allows client time to process Limit amount and store new information. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. seek medical To prevent regression. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. may to and 4. Provide anticipatory guidance. To maintain and manage practices effective health 3. Develop plan existing disabilities, adapting, with client self-care the and organizing care as for necessary. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. al. p. 277

during periods of wellness and identify ways client can adapt. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. al. p. 277

and personal al. p. 277

presented at al. p. 277 Present new

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31 date and person around has disorde red thought sequen cing Enhances Subjective Cue: No verbal cues. 8. to stress management skills. clients coping Assist client ability to any stressful situation develop that may occur. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. al. p. 276 7. to exercise program. 2nd edition. pg 311 instruction when possible. To meet clients Identify ways needs / changing and abilities

adapt environmental concerns. Source: Nurses Pocket Guide. 9th ed. Doenges, Marilynn, et. al. p. 277

To serve as basis for other 9. Provide information about individual health needs. health care providers on what care will be given to the patient. Source: Nurses Pocket Guide. al. p. 277 To provide continuation of 10. Provide for care. communicat ion coordination Source: Nurses Pocket Guide. al. p. 277 and 9th ed. Doenges, Marilynn, et. care 9th ed. Doenges, Marilynn, et.

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32 between the healthcare facility team.

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33 SOAPIE # 1 S No verbal cues. O Seen patient wearing t-shirt, shorts, and a pair of slippers; alternately sits and walks around; smiles when being asked; interacts to student-nurses but has a short attention span; disoriented to the time and person around; participates in activities but does not really follow the lagda; keeps on holding the arms of the student-nurse he wants to hold; keeps on singing his favorite song. A Disturbed Thought Processes: Disorientation r/t mental disorder (Schizophrenia) P To orient the patient to time, place, person, circumstances of the day. I - Reoriented to time, place, persons; reminded the patient of the activities for the day; approached patient in a calm manner; given simple directions/instructions to be followed; encouraged participation in resocialization activities; allowed client time to respond to questions. E Patient was able to state the student-nurse's name and the place where he is currently staying at the end of interaction.

SOAPIE # 2

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S No verbal cues. O Seen patient wearing t-shirt, shorts, and a pair of slippers; does not stay in one place; always smiles broadly when being asked; always seems happy and interacts to almost all nursing students; has a short attention span; disoriented to time and person around him; participates in different activities when encouraged but does not follow instructions; keeps on holding the arms of the student-nurse he wants to hold; always being reminded to do the things like personal hygiene. A Ineffective Health Maintenance r/t impaired cognitive functioning. P To be aware of his own health and needs. I Encouraged patient to participate in different activities; instructed the patient on the right way to do things; assisted the patient during his activities with safety precaution; reoriented the patient of the usual activities for the day like morning stretch, bathing; continued encouragement to socialize with others; needs attended. E Patient was able to met and perform health activities like taking medications and joining the morning stretch with the assistance of student-nurse.

SOAPIE # 3

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S Wa pa ko naligo, as verbalized by the patient. O Seen patient in the male grounds walking; wearing a shirt, pajama, and a pair of slippers the same as yesterday; keeps on scratching his head and his arms; wants to be with the student-nurse when doing something; keeps himself busy interacting with other nursing students; keeps on constant reminder to be able to remember things. A Self-Care Deficit: Inability to recognize the need for bathing r/t cognitive/mental impairment. P To perform self-care activities within level of own ability and capacity. I Reminded patient to do self-care activities; encouraged and informed on the importance of doing self-care activities; assisted patient on his bathing, changing clothes, and eating his meals; allowed the patient to do on his own ability like eating and changing clothes; gave compliment after accomplishing an activity; other needs attended. E Patient was able to do self-care activities like bathing, eating, and changing clothes in his level of ability and with minimal prompting and supervision of his student-nurse.

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36 Name of patient: Barrero, Robert Diagnosis: Schizophrenia

HEALTH TEACHING PLAN Objective Content Methodolog y Time Allotted Resources Evaluation

General Objectives: At the end of 8 hours of student nurse-patient interaction, to Specific Objectives: After 45 minutes of student nursepatient interaction the patient will be able to: After minutes patient interaction, the patient able to: was 45 of the patient will be able

student nurse-

1. Define proper Definition personal base on his level hygiene: of understanding

of Studentinteraction

10

Fundamentals of Nursing by: Barbara Kozier pp.698

1. proper

Defined

hygiene proper personal nurse patient minutes -is the self care by which people attend to such functions bathing, as

personal hygiene based on his level of understanding

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37 toileting, general body hygiene, and grooming. Hygiene science promotion preservation health. is a that and of It

deals with the

involves care of the skin, hair, nails, teeth, oral, eyes, ears, nasal cavities areas. and perineal genital

2. importance proper hygiene.

State Importance personal hygiene: -to

of Studentinteraction to

Fundamentals Kozier, Barbara pp.706

2. Stated the proper personal hygiene.

of proper personal nurse patient minutes stimulate

of nursing by: importance of

circulation the skin

-to produce a sense of wellbeing -to promote relaxation

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38 -to prevent or eliminate unpleasant odors 3. Enumerate the Causes of self- Studentcauses of self-care care deficits: deficit. -weakness tiredness -severe anxiety -neuromuscular or musculoskeleta l impairment - decreased or lack motivation pain or discomfort of or interaction 10 Fundamentals Kozier, Barbara pp.702 3. Enumerated self deficit care

nurse patient minutes

of nursing by: the cause of

4. basic

Demonstrate Basic skills in Demonstrati skills personal hygiene: face and hand - taking a bath or shower everyday - brushing the teeth twice a demonstratio

20

Fundamentals Kozier, Barbara pp.698

4. beginning skills in proper personal hygiene

of proper personal on and return minutes - washing the n

of Nursing by: demonstrated

proper hygiene

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39 day - always wear slippers - perineal care cloth changing after

taking a bath - wash hands before and after eating - fixing bed or bed making upon rising - wash hands every elimination combing of hair 5. Show awareness about the health teaching by nurse the conduct student after

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40 Drug / Dose / Frequenc y / Route Biperiden Classification: / 2 mg 1 tab / OD / n P.O. 8 AM c Antiparkinso agent Anticholinergi Indications: 1. Advise patient 1. Assess Classification / Mechanism Side effects / Indications / Contraindications Principle of Care Treatment

Adjunctive treatment of all to including extrapyramidal drug-induced exactly effects and directed.

take parkinsonian and extrapyramidal as symptoms before and throughout therapy.

/ forms of Parkinson's disease, medication

acute dystonic reactions. 2. Advise patient Mechanism of Contraindications: action: cholinergic Blocks Narrow-angle Bowel-obstruction; activity in the Megacolon; CNS, which is dyskinesia. partially responsible for Side effects: the symptoms of Parkinson's depression, disease. Restores of neurotransmitt ers in the CNS. hallucinations; the sedation; weakness. vision, dry mydriasis. hypotension, 3. to

avoid 2. Assess bowel that function daily. Monitor for pain,

Hypersensitivity to drug; activities

glaucoma; require alertness until response to 3. Tardive drug is known. constipation, abdominal

Caution distention, or the

patient to change absence of bowel CNS: confusion, positions slowly sounds. dizziness; to minimize 4. Monitor intake and output ratios and assess patient urinary headache; orthostatic EENT: hypotension. eyes,

natural balance blurred

CV: arrhythmias, 4. Advise patient for palpitations, to avoid antacids retention.

tachycardia. GI: constipation, or antidiarrheals dry mouth, ileus, nausea. GU: within 1-2 hours hesitancy, urinary retention. of Misc: decreased sweating. medication. this

Evaluation and Recommendation: 40

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Prognosis: The outlook for people with Schizophrenia has improved over the past few years. Although no totally effective therapy has yet been devised, it is important to remember that many people with the illness improve enough to lead independent satisfying lives. As we learn more about the treatment of Schizophrenia, we should be able to help more patients to achieve successful outcomes. Studies show that people with Schizophrenia for long periods, from the first episode to old age, reveal that wide range of outcomes is possible. 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 in five individuals recovers completely. In the case of our patient, the patient was able to enhance self-awareness and selfesteem from those activities, therapies, and interaction done by student-nurses, and the patient. The patient was able to achieve the goal and objectives set by the student nurse for two weeks interaction and intervention such as, patient was able to establish rapport with the student nurses, was able to share information about self and family, verbalize feelings and ideas, was able to cooperate with the nursing students in the implementation of psychotherapies and demonstrated positive coping through interacting appropriately with the student nurses.

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42 Recommendation: Schizophrenia is now officially categorized as a brain disease, not a psychological disorder and drug treatment is the primary therapy. Studies indicate, however, that an integrated approach is superior in preventing relapses compared to routine care (drugs plus monitoring and access to rehabilitation program). This involves motivational interviewing to encourage the patients commitment to change, use anti psychotic medications (generally typical or novel antipsychotic) with monitoring, community-based rehabilitation, cognitive- behavioral therapy which aims to reduce delusions and hallucinations and family interventions. In the study, relapse rates are 33 % in the integrating group and 67% in the group who receives routine care. In the past treatment has been focused in alleviating positive and negative symptoms, but thus days physicians are emphasizing on the patients ability to function. Rehabilitation programs may help patients during the long recovery and maintenance phase of the illness. Rehabilitation maybe especially important in patients who need to improve their job skills, want to work, have worked in the past and have few remaining symptoms.Psychosocial rehabilitation program: a club house program to help people improve works skills with the goal of getting and keeping a job. Psychiatric rehabilitation: a program teaching skills that will allow people to define and achieve personal goals regarding work, education, socialization and living arrangements.

Evaluation and Implication of this Case Study:

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Nursing Practice: This case study done on disease known as Schizophrenia is proposed as a guide and reference for students who are practicing in a psychiatric setting and for professional registered nurses providing psychiatric care to clients with cognitive impairments. This will also serve to direct those who intend to study and work in the psychiatric setting and aid them in their work. In this case study, the patients history nursing care plan, health teaching plan, are clearly present which aims for the attainment of more data about the disease of the brain known as Schizophrenia. Nursing Education: Psychiatric nursing education aims for the development of knowledge, attitude and skills in dealing with cognitive problems in psychiatric setting. This case study would help by proving information about the disease condition. Nursing Research: This case study will serve as a reference to others in knowing this case study or its other related disease condition. Nursing students and even registered nurses may serve this case study also as a foundation for other nursing researches and for more improvements and progress of this case study.

Bibliography:

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44 Keltner, Norman and Scwecke: Psychiatric Nursing 3rd edition. A Harcourt Health Sciences Publishing International Co.,1999 pp. 350-369 Manfreeda, Marguerette Luay and Krampitz, Sydney: Psychiatric Nursing 10th edition. F.A. Devis Co.,1997 pp.148-390 Videbeck, Shiela: Psychiatric Mental Heath Nursing Philadelphia J.B. Lippincott, 1993 Kozier, Barbara and Erb, Glenora; Fundamentals of Nursing 5th edition, California, Addison Wesley Longman, Inc.,1998 pp.560, 578, 614, 618 Townsend, Mary: Psychiatric Mental Health Nursing 1st edition. F.A. Davis, Co.,1999 pp. 655, 656

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