Holy Trinity University College of Health Sciences

In Partial Fulfillment Of the Requirements

In: ______________________________
A CASE STUDY ON UNDEFFIRENTIATED SCHIZOPHRENIA

______________________________
Submitted by: Mr. Michael Joseph P. Masabio Mr. Isidro Carlo Bunac Ms. Bernard Mar Dumaran Mr. Lexter Dale Liao
SN 3, GROUP H

Presented to: Jhundy B. Tamayo, RN, MAN

Clinical instructor

APPROVAL SHEET

This case study entitled schizophrenia has been prepared and submitted by: Michael Joseph Masabio, Isidro Carlo Bunac, Bernand Mar Dumaran, Lexter Dale Liao., SN3. This serves as partial fulfillment of the requirements in Related Learning Experience, Clinical Exposure- Summer Affiliation. It was examined and approved with the grade of __________%.

___________________________________ Jhundy B. Tamayo, RN, MAN

Clinical instructor

NATIONAL CENTER FOR MENTAL HEALTH

TABLE OF CONTENTS

Approval Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Statement of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . Significance of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . Scope and Delimitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER I HISTORY TAKING Personal Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Present Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mini-Mental Status Examination . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER II Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER III Psychodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Growth and Developmental Task . . . . . . . . . . . . . . . . . . . . . . . . . CHAPTER IV

2 3-4 5-6 7 7 7 8

9 10 11 12 13 15 16 17

18 - 22

23 - 24 25 26 30

Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 31 Laboratory Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-33 Therapeutic Plan and Intervention . . . . . . . . . . . . . . . . . . . . . . . . 34 Pharmacological Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 48 39

Nursing Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-47

INTRODUCTION

Schizophrenia is an extremely complex mental disorder in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into fullblown illness in late adolescence or early adulthood. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. Medication treatment can control the positive symptoms but frequently the negative symptoms persist after positive symptoms have abated. The persistence of these negative symptoms over time presents a major barrier to recovery and improved the functioning of clients daily life. Types of schizophrenia: Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity or hostile and aggressive behavior, Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior, Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor, Schizophrenia; undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations. Residual schizophrenia this subtype is diagnosed when the patient no longer displays prominent symptoms. In such cases, the schizophrenic symptoms generally have lessened in severity. Hallucinations, delusions or idiosyncratic behaviors may still be present, but their manifestations are significantly diminished in comparison to the acute phase of the illness.

The patient is still ill, as indicated by undifferentiated symptoms that are represented by either:

1. 1. Negative symptoms such as flattened affect, loose speech or reduced speech output or lack
of volition (goal oriented behavior), or

2. 2. An attenuated form of at least 2 characteristic symptoms of schizophrenia

1. 2. 3. odd beliefs (related to delusions) distorted perceptions or illusions (hallucinations) odd speech (disorganized speech) Peculiarities of behavior (disorganized behavior).

4.

Some of the possible treatments listed in sources for treatment of undifferentiated schizophrenia may include: Antipsychotic medication, atypical antipsychotics, typical antipsychotics, Chlorpromazine Hydrochloride, Vitamin C, and Psychotherapy. Just as the symptoms of schizophrenia are diverse, so are its ramifications. Different kinds of impairment affect each patients life to varying degrees. Some people require custodial care in state institutions, while others are gainfully employed and can maintain an active family life. However, the majority of patients are at neither of these extremes. Most will have a waxing and waning course marked with some hospitalizations and some assistance from outside support sources. People having a higher level of functioning before the start of their illness typically have a better outcome. In general, better outcomes are associated with brief episodes of symptoms worsening followed by a return to normal functioning. Women have a better prognosis for higher functioning than men, as do patients with no apparent structural abnormalities of the brain. In contrast, a poorer prognosis is indicated by a gradual or insidious onset, beginning in childhood or adolescence; structural brain abnormalities, as seen on imaging studies; and failure to return to prior levels of functioning after acute episodes. This case study was chosen to be studied because the researchers aim to learn more about this case especially the needed intervention.

STATEMENT OF THE PROBLEM

This case study aims to answer the following questions:

1. What is undifferentiated schizophrenia? 2. What are the clinical manifestations of the patient with undifferentiated schizophrenia? 3. What is the nursing management for undifferentiated schizophrenia? 4. What is the medical management for undifferentiated schizophrenia? 5. What caused undifferentiated schizophrenia?

SIGNIFICANCE OF THE STUDY

This study is significant to all nursing students especially in Holy Trinity University Students wherein it will serve as a learning material for future research works. It helps us in becoming aware of the present trend of medicines to manage undifferentiated schizophrenia. Moreover, it helped us to become keen observers and at the same time be able to do research regarding patients condition. This study may aid the students as they progress in their major studies and professional training field in nursing.

SCOPE AND DELIMITATION

This case study is focused on the factors that developed the condition, which includes the signs and symptoms manifested; the nursing management and improvement from the treatment in the area of our duty the National Center for Mental Health, Pavilion 6 Ward 1 E.

DEFINITION OF TERMS

Antipsychotic drug these drugs are used to treat schizophrenia, bipolar disorder, and other psychoses. Additionally, various other manifestations of mental illness are amenable to treatment with these agents. Auditory hallucination imaginary perceptions of sounds, usually voices Avolition lack of initiative or goals, one of the negative symptoms of schizophrenia. The person may wish to do something, but the desire is without power or energy. Delusion a false belief inconsistent to ones knowledge and experience, and with evidence to contrary Idiosyncratic behavior it is a peculiar or individual reaction to an idea, action, drug, food or some other substance. Special characteristic by which one person differs from another or reacts differently from another. Hallucination a sense of false perception Psychotherapy- is a general term for a process of treating mental and emotional disorders by taking about your condition and related issues with a mental health provider. Psychodyanamics- is the systematized study and theory of the psychological forces that underlie human behavior, emphasizing the interplay between unconscious and conscious motivation. Schizophrenia a form of psychosis with disorder of thinking, affect, and behavior. Patients have delusions and hallucinations with loss of self-identity. Undifferentiated Schizophrenia- are condition meeting the general diagnostic criteria for schizophrenia but not conforming to any of the above subtypes, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.

CHAPTER 1 PERSONAL DATA

Name Alias Age Address Birthday Place of Birth Gender Nationality Civil Status Educational Attainment Religion Date / Time of Admission Admitting Diagnosis Attending Physician Source of Data :

: : :

Mr. Marshmallows Marsh 46 years old

289 Hulo St. San Antonio Nueva Ecija : : : : : : : : : : : January 26, 1962 Caloocan City Male Filipino Married High school graduate Christian (Roman Catholic) JULY 08, 2008 @ 10:00 pm Undifferentiated Schizophrenia Dr. Corpus Patients Chart and Patient

MEDICAL HISTORY

PRESENTING COMPLAIN 1. Mainit 2. Na mimiss ko na pamilya ko 3. Gusto ko na lumabas

PAST MEDICAL HISTORY The patient has diagnosis of mental illness (undifferentiated Schizophrenia) since 1998 with previous confinement at the center last January to June 2008. PRESENT MEDICAL HISTORY The patient has diagnosis of mental illness (undifferentiated Schizophrenia) since 1998 with previous confinement at the center last January to June 2008, brought home by conduction and was prescribed with unrecalled medication ( only levomepremazine 100 mg was recalled ) after discharge his symptoms persisted and relapse were first tolerated. 3 weeks prior to admission, he referred to take medication and would just throw his in toilet bowl. Here he stated to have relapse of restlessness and disorganized behavior. He also resumed his vices of cigarette smoking persisted of seen symptoms prompted

PRESENT MEDICAL HISTORY

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PRESENT CONDITION Perception and Expectation of illness or hospitalization Pumasok ako dito para mag apply ng trabaho tinangggap naman ako ng nurse,ayon po nagtrabaho ako dito para maglinis pero tinanggal nila ako nung nakaraang 1 buwan ngayon po ako yong naglilinis ng C.R. tuwing hapon. The patient do not perceived that he is having a mental illness. Elimination Needs According to the patient he defecates every other day. His usual stool is semi-formed in consistency, brown in color and aromatic in odor approximately 200cc per stool output. He urinates 7-8 times a day, yellowish in color approximately 120cc per urination. Rest and Comfort According to the patient sometimes he has difficulty in falling asleep due to hot environment but sometimes if the environment is not so hot he does not have any difficulty when sleeping at night. He usually sleeps from 9pm-5am in the morning without interruptions. Safety Needs He is currently staying at the Pavilion 6 Ward 1E in National Center for Mental Health. He has his own single bed made from wood that is colored green with 1 pillow and cushioned foam covered with linen. No side rails seen on bed. Approximately one meter is the distance of his bed from the other patients. They are supervised and taken care of by the Staff Nurse on Duty and also being taken care of by the Student nurses. Sexuality He is masculine in the way he acts, speaks and dress. At the course of illness his father role to his son was altered due to his present condition. He has a moderate tone of voice.

Spirituality He is a Roman Catholic. During NPI he verbalized kapag may simba dito nagsisimba ako. Oxygenation

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He doesnt complain any difficulty in breahing. According to the patient Nung dun pa ako sa labas malakas ako manigarilyo katunayan nga nakaka 3 hanggang 4 na kaha ako ng sigarilyo. Nung dito na ako sa loob nakakasigarilyo pa din ako pero paminsan-minsan na lang kasi bawal nga manigarilyo dito.Pero kapag meron naman hati-hati kami sa sigarilyo Nutrition and Fluids Needs He usually eat one cup of rice with different kinds of viands depend on the viands has being serve according to the patient approx. 2 cups per meals. When at morning they eat bread with langgonisa or egg, when at lunch they eat fish like bangus and at night they eat vegetable. He usually drinks 8-10 glasses of water approximately 350cc of glass per day. The patient has a Diet As Tolerated. Others Communication According to him he can speak Tagalog, English. But during NPI he uses tagalog language and answer questions unclearly due to minimized tone of voice. Allergy- have none reported allergies

PHYSICAL ASSESSMENT
HEENT Head

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Hair is short approximately 2 to 3 mm long, distributed evenly with black and white strands; Head is normocephalic (normally shaped and sized within its limits); scalp is smooth, without nits, and lice; without dandruff; (-) lesions; capable of extension and flexion; can frown; can turn head; (-) lice; (-) redness;

Eyes

Symmetrical in size and shape; in normal positions; eyebrows and eyelids are intact, arched along bony prominences above orbits, with the eyelids open; lashes are present on upper and lower lids, evenly distributed and turned outward; with pale palpebral conjunctivae noted; without swelling of lacrimal gland or duct; PERRLA with pupillary sizes of 2.5 mm in diameter; with icteric sclerae; no lumps or lesions noted; with medial movement of eyes noted, symmetric movement of eyelids noted; with inferior movement of the eyes as observed; with lateral movement of the eyes; able to distinguish things around, able to distinguish color; (-) lesion; (-) scar noted; (-) rashes

Ears

color same as facial skin; upper point of attachment to the head is in line with the outer cantus of the eye; auricles are symmetrically leveled to the position of the eyes; no lesions; no wounds noted or any abnormalities noted; pinna recoils when folded; with slight amount of wax; with moderate amount of cerumen on both ears; Both ears perpendicularly in lined with the neck; with sensitivity of both ears to sounds in response to stimulation and balance noted; no tenderness noted; no lumps or masses; (-) obstruction noted; with slightly difficulty of hearing when asked.

Nose

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located on the midline of the face; same color as in face; moderately-bridged; nasal septum firm and centered, no deformities; patent nostrils; with vibrissae at approximately 1-2 mm in length; mucosa is dry and pale yellowish in color; negative nasal congestion and discharges, no polyps or abnormalities noted; no nasal flaring; sinuses are non-tender; no palpable masses; (-) deformity; (-) obstruction; (-) redness noted; (-) scars noted.

Throat, Mouth and Neck

lips are intact and symmetrical, pale pink and exhibits slight dryness; (-) dentures; (-) lesions; (-) rashes; (-) obstruction; (-) inflammation; pinkish tongue; pinkish and slightly dry oral mucous membranes; uvula in midline; tonsils not inflamed; with

chewing/mastication and movement of jaw noted, with gag and swallowing reflex noted, no abnormalities; no lumps, or mass on neck; thyroid gland not enlarged. CHEST and LUNGS

Inspection: color conforms the rest of the chest; symmetrical lung expansion observed; no evidence of abnormalities in breathing; clear breath sounds on both lung fields; clavicles are symmetrical; areola is darker in color than the rest of the body;

Palpation: no bumps, lumps, or mass on chest and breast confirmed by palpation; uniform temperature on the anterior and posterior thorax; with diaphragmatic excursion of 4 cm; tactile fremitus present.

Percussion: Not able to assess Auscultation: Not able to assess

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ABDOMEN

Inspection: color is the same for the rest of the body; flat abdomen noted; umbilicus located at midline; (-) lashes; (-) lesion; (-) scar noted.

Auscultation: Normoactive bowel sound of 2 to 3 seconds. Palpation: warm to touch; (-) lesions; (-) tenderness noted Percussion: Not able to assess

GENITOURINARY Unable to assess

SKIN AND EXTREMITIES

Inspection: flushed and warm to touch; (+) scars on the dorsal part of right foot; (-) scars on both

dorsal part of patient's arms; finger nails are clean and set of digits on both finger and toes are complete; (+)lesions on left upper thumb. GENERAL CONDITION

The patient is conscious. He responds accurately when asked if he comprehends orientation to 4 spheres such as asking the date, time, place or his identity. Patient is cooperative to the nursing students. The problem to him during the entire NPI was he has a problem in his affect.

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THE MINI-MENTAL STATUS EXAMINATION

Orientation Score 1. What is the Year? Season? Date? Day? Month? 1 1 1 1 1 1 1 1 1 1 Point 1 1 1 1 1 1 1 1 1 1

2. Where are we

State? Country? Town or City? Hospital? Floor?

Registration 3. Nametag Bond paper Yarn Attention and Calculation 4. 100-7 93-7 86-7 79-7 72-7 Recall 5. Nametag Bond paper Yarn Language 6. Pencil 1 1 1 1 1 1 1 1 = = = = = 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

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Watch

1 1 2

1 1 3

7. No ifs, ands, or buts 8. Take the paper in your right hand.

Fold the paper in half. Put the paper on the floor.

9. CLOSE YOUR EYES. 10. Your generosity will be rewarded

With a very long life

1 1 1 _______________ 29

1 1 1 _________________ 30

11. DRAWING

TOTAL SCORE - 28 INTERPRETATION: The Mini-Mental Status Exam shows that the patient does not have cognitive impairment.

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CHAPTER II Anatomy and Physiology of the Human Brain

Cerebrospinal Fluid Cerebrospinal fluid

18

Cerebrospinal fluid (CSF) is a watery liquid similar in composition to blood plasma. It is formed in the choroid plexuses and circulates through the ventricles into the subarachnoid space, where it is returned to the dural venous sinuses by the arachnoid villi. The prime purpose of the CSF is to support and cushion the brain and help nourish it. Major regions of the brain and their functions

Major Regions of the Brain. Cerebral hemispheres The cerebral hemispheres, located on the most superior part of the brain, are separated by the longitudinal fissure. They make up approximately 83% of total brain mass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm thick grey matter surface layer and, because of its many convolutions, accounts for about 40% of total brain mass. It is responsible for conscious behaviour and contains three different functional areas: the motor areas, sensory areas and association areas. Located internally are the white matter, responsible for communication between cerebral areas and between the cerebral cortex and lower regions of the CNS, as well as the basal nuclei (or basal ganglia), involved in controlling muscular movement. Diencephalon

19

The diencephalon is located centrally within the forebrain. It consists of the thalamus, hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus acts as a grouping and relay station for sensory inputs ascending to the sensory cortex and association areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible for maintaining the bodys homeostatic balance. Moreover it forms a part of the limbic system, the emotional brain. The epithalamus consists of the pineal gland and the CSFproducing choroid plexus.

Major Regions of the cerebral hemispheres Brain stem The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts. Its major regions are the midbrain, pons and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways between higher and lower brain centres, contains visual and auditory reflex and subcortical motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial nerves. The medulla oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in the medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord and higher brain centers.

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Cerebellum The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes impulses received from the cerebral motor cortex, various brain stem nuclei and sensory receptors in order to appropriately control skeletal muscle contraction, thus giving smooth, coordinated movements. The cerebral circulatory system Blood is transported through the body via a continuous system of blood vessels. Arteries carry oxygenated blood away from the heart into capillaries supplying tissue cells. Veins collect the blood from the capillary bed and carry it back to the heart. The main purpose of blood flow through body tissues is to deliver oxygen and nutrients to and waste from the cells, exchange gas in the lungs, absorb nutrients from the digestive tract, and help forming urine in the kidneys. All the circulation besides the heart and the pulmonary circulation is called the systemic circulation.

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Major cerebral arteries and the circle of Willis Blood supply to the brain The major arteries are the vertebral and internal carotid arteries. The two posterior and single anterior communicating arteries form the circle of Willis, which equalizes blood pressures in the brains anterior and posterior regions, and protects the brain from damage should one of the arteries become occluded. However, there is little communication between smaller arteries on the brains surface. Hence occlusion of these arteries usually results in localized tissue damage.

CHAPTER III
22

PSYCHODYNAMICS
Predisposing factor: Age: 48 years old Gender: Male Precipitating factor: Separation from his wife & Children Erick Erickson Develop overly trusly to parents Independence to parents Out of school youth Establishing relationship with the opposite sex Married & have 2 children Separated to his wife & children Cigarette smoking & alcoholism Confusion Low self esteem Weak ego Pre psychotic phase Stages of DABDA Unable to cope/move on with the acceptance stage

Contributing factor: Cigarette

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Anorexia Anhedonia Social isolation Deterioration in hygiene

Psychotic phase

Flat affect Somatic hallucination UNDIFFERENTIATED SCHOZOPHRENIA

PSYCHOPATHOLOGY

Male Age Genetic pathway

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A traumatic/severely depressing event in the life that weakens the ego integrity of the person such as the separation from his wife

Living with his son and daughter Conflict with the family member

Impaired Ego homeostasis

Maladaptive ego defense mechanism

Dopamine Serotonin Glutamate

Practice antisocial acts

Depressed neurolimbic pathway

Engaged in smoking

Anhedonia Associative looseness

Isolation and confusion

Altered self motivation and arousal

Emotional detachment Physical detachment Intellectual detachment

Extreme introvert Undifferentiated Schizophrenia

Growth and Developmental Task

Psychosocial theory of Erik Erikson

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"It is human to have a long childhood; it is civilized to have an even longer childhood. Long childhood makes a technical and mental virtuoso out of man, but it also leaves a life-long residue of emotional immaturity in him." Erik Homburger Erikson (1902-1994) Age 1. Infancy: Birth to 18 Months Ego Development Outcome: Trust vs. Mistrust Basic strength: Drive and Hope Book Prolife Infancy as the Oral Sensory Stage (as anyone might who watches a baby put everything in her mouth) where the major emphasis is on the mother's positive and loving care for the child, with a big emphasis on visual contact and touch. If we pass successfully through this period of life, we will learn to trust that life is basically okay and have basic confidence in the future. If we fail to experience trust and are constantly frustrated because our needs are not met, we may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general. Not surprisingly, the most significant relationship is with the maternal parent, or whoever is our most significant and constant caregiver. 2. Early Childhood: 18 Months to 3 Years Ego Development Outcome: Autonomy vs. Shame Basic Strengths: Self-control, Courage, and Will During this stage we learn to master skills for ourselves. Not only do we learn to walk, talk and feed ourselves, we are learning finer motor development as well as the much appreciated toilet training. Here we have the opportunity to build self-esteem and autonomy as we gain more control over our bodies and acquire new skills, learning right from wrong. And one of our skills during the "Terrible Two's" is our ability to use the powerful word "NO!" It may be pain for parents, but it develops important skills of the will. It is also during this stage, however, that we can be very vulnerable. If we're shamed in the process of toilet training or in learning other important skills, we may feel great shame and doubt of our capabilities and suffer low self-esteem as a result. The most significant relationships are with parents. 3. Play Age: 3 to 5 During this period we experience a desire to The patient was not According to the patient sabi ng nanay ko tinuruan nya din nya ako kung saan yong tamang lugar pag tumatae nung nasa dalawat kalahating taon ako Life Profile According to the patient mahal naman ako ng magulang ko Remarks The patient was not able to give some details regarding his infancy stage, if his needs are being met.

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Years Ego Development Outcome: Initiative vs. Guilt Basic Strength: Purpose

copy the adults around us and take initiative in creating play situations. We make up stories with Barbie's and Ken's, toy phones and miniature cars, playing out roles in a trial universe, experimenting with the blueprint for what we believe it mean to be an adult. We also begin to use that wonderful word for exploring the world"WHY?" While Erikson was influenced by Freud, he downplays biological sexuality in favor of the psychosocial features of conflict between child and parents. Nevertheless, he said that at this stage we usually become involved in the classic "Oedipal struggle" and resolve this struggle through "social role identification." If we're frustrated over natural desires and goals, we may easily experience guilt. The most significant relationship is with the basic family.

able to recall this stage due to his age.

4. School Age: 6 to 12 Years Ego Development Outcome: Industry vs. Inferiority Basic Strengths: Method and Competence

During this stage, often called the Latency, we are capable of learning, creating and accomplishing numerous new skills and knowledge, thus developing a sense of industry. This is also a very social stage of development and if we experience unresolved feelings of inadequacy and inferiority among our peers, we can have serious problems in terms of competence and self-esteem. As the world expands a bit, our most significant relationship is with the school and neighborhood. Parents are no longer the complete authorities they once were, although they are still important. Development mostly depends upon what is done to us. From here on out, development depends primarily upon what we do. And while adolescence is a stage at which we are neither a child nor an adult, life is definitely getting more complex as we attempt to find our own identity, struggle with social interactions, and grapple with moral issues. Our task is to discover who we are as individuals separate from our family of origin and as

The patient was not able to recall this stage due to his age.

5. Adolescence: 12 to 18 Years Ego Development Outcome: Identity vs. Role Confusion Basic Strengths: Devotion and Fidelity

According to the patient nung sa kabataan ko natoto sa pagiging responsible maging anak at kuya when he was 13 years old

27

members of a wider society. Unfortunately for those around us, in this process many of us go into a period of withdrawing from responsibilities, which Erikson called a "moratorium." And if we are unsuccessful in navigating this stage, we will experience role confusion and upheaval. A significant task for us is to establish a philosophy of life and in this process we tend to think in terms of ideals, which are conflict free, rather than reality, which is not. The problem is that we don't have much experience and find it easy to substitute ideals for experience. However, we can also develop strong devotion to friends and causes. It is no surprise that our most significant relationships are with peer groups.

6. Young adulthood: 18 to 35 Ego Development Outcome: Intimacy and Solidarity vs. Isolation Basic Strengths: Affiliation and Love

In the initial stage of being an adult we seek one or more companions and love. As we try to find mutually satisfying relationships, primarily through marriage and friends, we generally also begin to start a family, though this age has been pushed back for many couples who today don't start their families until their late thirties. If negotiating this stage is successful, we can experience intimacy on a deep level. If we're not successful, isolation and distance from others may occur. And when we don't find it easy to create satisfying relationships, our world can begin to shrink as, in defense, we can feel superior to others. Our significant relationships are with marital partners and friends.

The patient was married according to him when he was 22 years old. They had their 2nd child when he was 26 years old. And after 10 years, his family left him. When he was 31 years old due to having a mental illness.

The Young adulthood stage of the patient was met.

7. Middle Adulthood: 35 to 55 or 65 Ego Development Outcome: Generativity vs.

Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. The significant task is to perpetuate culture

Hes been a father to his two daughters and was able to raise them child in a bountiful life. This stage is where he experience divorce with

The Middle adulthood stage of the patient was met.

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Self absorption or Stagnation Basic Strengths: Production and Care

and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. As our children leave home, or our relationships or goals change, we may be faced with major life changesthe mid-life crisisand struggle with finding new meanings and purposes. If we don't get through this stage successfully, we can become self-absorbed and stagnate. Significant relationships are within the workplace, the community and the family.

his wife. Naghiwalay kami ng asawa ko kasi nag-away kami, dahil pinasok nya ko sa mental as he verbalized. This happened when he was 32 years old.

8. Late Adulthood: 55 or 65 to Death Ego Development Outcome: Integrity vs. Despair Basic Strengths: Wisdom

Erikson felt that much of life is preparing for the middle adulthood stage and the last stage is recovering from it. Perhaps that is because as older adults we can often look back on our lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and we've made a contribution to life, a feeling Erikson calls integrity. Our strength comes from a wisdom that the world is very large and we now have a detached concern for the whole of life, accepting death as the completion of life. On the other hand, some adults may reach this stage and despair at their experiences and perceived failures. They may fear death as they struggle to find a purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel they have all the answers (not unlike going back to adolescence) and end with a strong dogmatism that only their view has been correct. The significant relationship is with all of mankind "my-kind."

Not yet at this age.

The Ego development outcome of the patient experiences despair and perceived failures.

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CHAPTER IV

PSYCHOTHERAPIES
THERAPY RATIONALE

RECREATIONAL THERAPY Date Performed: May 11, 2010 -also referred to as recreational therapy and therapeutic recreation, contributes to the broad spectrum of health care through treatment, education , and the provision of adapted recreational opportunities all of which aid in improving and maintaining physical , cognitive, emotional, and social functioning, preventing secondary health conditions, enhancing independent living skills and overall quality of life. BIBLIOTHERAPY Date Performed: May 20, 2010 -is an expressive therapy that uses an individuals relationship to the content of books and poetry and other written words as therapy. It is often combined with writing therapy. ART THERAPY Date Performed: May 19, 2010 -is a form of expressive therapy that uses art materials, such as paints, chalk and markers. Art therapy combines traditional psychotherapeutic theories and techniques with an understanding of psychological aspects of the creative process, especially the affective properties of the different art materials. MUSIC THERAPY Date Performed: May 19, 2010 -is an interpersonal process which the therapist To improve learning, build self-esteem, reduce stress, support physical exercise, and facilitate a To use artistic materials to express conflicts and discuss those artistic representations within a therapeutic group format led by an art therapies. To provide an environment to use traditional childrens toys and materials to exhibit, express and resolve issues or conflicts that are creating.

The purpose of bibliotheraphy is to broaden and deepen the client understands of the particular problem that requires treatment.

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uses music and all of its facets- physical, emotional, mental, social, aesthetic, and spiritual To help clients to improve or maintain their health. OCCUPATIONAL THERAPY Date performed: May 17, 2010 -meaningful and purposeful occupation to enable people with limitations or impairments to participate in everyday life REMOTIVATION THERAPY Date Performed: May 14, 2010 -any of various group therapy techniques used with long term , withdrawn patients in mental hospitals to stimulate their communication, vocational, and social skills and interest in their environment.

host of other health-related activities.

To prepare an individual to return to his/ her prior work role or to prepare to enter a new occupation.

To rekindle a persons interest in work, family participation or type of group or activity to which a person has belonged and lost interest in serving an active living.

LABORATORY EXAMINATIONS

Procedure: Complete Blood Count Date: October 10, 2008 Definition: A determination of the number of red and white blood cells per cubic mm of blood. A CBC is one of the most routinely performed tests in a clinical laboratory and one of the most valuable screening and diagnostic techniques.

HEMATOLOGY Diagnostic procedure Result Normal Values Interpretation Rationale

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To determine the amt. of 132g/l Hemoglobin 125-160g/L The result is within normal range. Hgb. and is a good indicator of the bloods ability to carry O2 throughout the body. Hematocrit .40 0.40 0.54 The result is within normal range To determine the presence of anemia

To serve as useful guide to the severity of the WBC Count 7.2 g/L 5 10 g/L The result is within normal range disease process since WBCs defend the body against invasion by infections through antibody production. 0.70 Neutrophils 0.45 0.65 The result is above normal range, which indicates presence of bacterial infection. To determine the phagocytic function of the body

The result is below normal Lymphocytes 0.26 0.20 0.35 range, which indicates that there is presence of viral or bacterial infection.

To detect selected autoimmune diseases such as lymphoma & lymphatic leukemia

Eosinophils

0.04

0.01 0.04

Within normal range, indicates no presence of allergic or parasitic infections.

To determine the presence of existing allergy and parasitic infections. To measure the amount

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Monocytes

0.02

0.02 0.08

The result is within normal range.

of monocytes in blood, used to evaluate and manage blood disorders, certain problems with immune system, and cancers including monocytic leukemia.

Nursing consideration: Be sure that the patient has not taken any medication that could alter or yield erroneous results; if so, report to the medical technologist.

Instruct the patient or the SO the need for the laboratory tests; Orient with the location of the
laboratory for further instruction.

THERAPEUTIC PLAN AND INTERVENTION

DIET

THERAPY

Type of Diet Date Ordered Rationale

: : :

DAT To meet the patients normal and desired needs.

PHARMACOLOGIC TREATMENT
GENERIC NAME BRAND NAME : : Vitamin C Ascorbic acid Vitamin Water soluble vitamin

THERAPEUTIC CLASSIFICATION : CHEMICAL CLASSIFICATION :

INDICATIONS Therapeutic effect RDA

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 Prevention of vitamin C deficiency in patient with poor nutritional habits or increased requirements.

ACTION

Chemical effect: Stimulates collagen formation and tissue repair; involved in oxidation-reduction
reactions throughout body. : Raises vitamin c level in body. CONTRAINDICATIONS In pregnant women, give only if clearly needed. In breast- feeding women, use cautiously. ADVERSE REACTION AND SIDE EFFECTS CNS GI GU : : : Dizziness with rapid IV delivery, Faintness Diarrhea Acid urine, oxaluria, renal calculi

ACTUAL DOSAGE AND ROUTE 1 tab OD PO USUAL DOSAGE AND ROUTE PO (Adults): 90mg daily NURSING IMPLICATIONS Assess patient condition before starting therapy and regularly thereafter to monitors drugs effectiveness. When giving for urine acidification, check urine pH to ensure effectiveness. Be alert for adverse reactions and drug interactions. If adverse GI reactions occur, monitor patients hydration. Assess patients and familys knowledge of drug therapy. Instruct patient to take medication exactly as directed, even if feeling better.

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Generic name: Chlorpromazine Hydrochloride Brand name: Chlorpromanyl, Largactic, Novo- Chlopromazine Chemical Class: Phenothiazine Functional Class: Antipsychotic, anxiolytic, antiemetic Dosage: Usual: Adults: 25m I.M if necessary, give an additional 25 to 50 mg in 1 hour. Children ages 6 mos. To 12 years old: 0.55mg/kg P.O q4 to 6 hours as needed, or o.55mg/kg I.M. q6 to 8 hours not to exceed 40mg/day in children ages 6 mos. To 5 years old, or 75 mg/day in children ages 6 to 12, or 1mg/kg P.R. q 6 to 8 hours p.r.n Actual: 100mg 1 tab Dosage form: Availability: Capsules. 30mg, 75mg, 150mg, 200mg, 300mg Injection. 25mg/ml Oral Concentrate. 30mg/ml, 40mg/ml, 100mg/ml Suppositories. 25mg, 100mg Syrup: 10mg/5ml, 25mg/5ml, 100mg/5ml Tablets: 10mg, 25mg, 50mg, 100mg, 500mg

Indications:

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Acute schizophrenia or mania Nausea and vomiting Nausea and vomiting during surgery Preoperative sedation In tractable Hiccups Acute intermittent porphyria Tetanus

Contraindications:

Hypersensitivity to drug, other phenothiazines, sulfites (injection), benzyl alcohol Angle- closure glaucoma Bone marrow- depression Severe hepatic or cardiovascular disease

Therapeutic Effect: Unknown. May block postsynaptic dopamine receptors in brain and depress areas involved in wakefulness and emesis. Also possess anticholinergic, antihistaminic, and andrenergic- blocking properties. Side Effect: CNS: dizziness, drowsiness, excitation in children, sedation, poor coordination, fatigue, confusion, restlessness, nervousness, tremor, headache, hysteria, tingling sensation, sensation of heaviness and weakness in hands. CV: palpitations, hypotension, bradycardia, tachycardia, extrasystoles EENT: blurred vision, vertigo, nasal congestion, dry nose, dry mouth, sore throat GI: nausea, vomiting, diarrhea, constipation, epigastric distress, anorexia GU: urinary retention, dysuria, early menses, decreased libido, erectile dysfunction. Respiratory: thickened bronchial secretions, chest tightness, wheezing Skin: urticaria, rash, photosensitivity, diaphoresis Others: chills, increased appetite weight gain.

Adverse Effect: CV: arrhythmias GI: GI obstruction Hematologic: hemolytic anemia, hypoplastic anemia, thrombocytopenia, luekopenia, pancytopenia, agranulocytosis Others: anaphylactic shock

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Drug- Interaction: Drug-drug. Anticholinergic, anticholinergic like drugs such as some antidepressants, atropine, haloperidol, phenothiazines, quinidine, disopyramide: additive anticholinergic effects. Drug-diagnostic tests. Allergy skin test: false-negative reactions. Drug-behaviors. Alcohol use: additive CNS depression Sun exposure: photosensitivity

Nursing Consideration:

Assess for urinary retention and frequency. Monitor respiratory status throughout therapy. Advice patient to take with full glass of water. Tell patient not to crush timed- release tablets or sustained-release capsules. Instruct him to swallow them whole. Advise parents to give dose to children in evening, because morning doses or may cause inattention in school.

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PROBLEM LIST AND NURSING CARE

Nursing Diagnosis Disturbed thought process r/t disintegration of thinking processes Self care deficit r/t Perceptual and cognitive impairment Ineffective coping r/t unrealistic perception

Date Identified

Date Evaluated

Rank

May 16,2010

May 17,2010

May 18,2010

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Risk for loneliness r/t affectional depriviation

May 20,2010

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ASSESSMENT

NSG. DIAGNOSIS

PLANNING

NURSING INTERVENTION

EVALUATION

Disturbed thought process Discharge Plan 1. Reoriented to Defining STG: r/t Characteristics: time/place/person disintegration At the end of of thinking Inappropriate the shift of to made the patient oriented processes response to the SN, will be 2. Conducted therapies the able to: Definition: such as remotivatonal questions Participate in and music and arts Disruption in Inappropriate the therapy therapy cognitive facial operations and To stimulate their communication, expression activities vocational, and social skills and to the mood LTG: interest in their environment. Background Decreased Theory: At the end of 3. Used therapeutic ability to techniques 1week nursing grasp idea According to intervention Imogene kings to assess the feelings will be able goal attainment or reactions of the to: theory. Nursing patient is helping Maintain profession that 4. Encouraged participation in Participation assists resocialization in any therapy individuals to activities/groups when attain, maintain, that we will available and restore, conduct. health. The to made an social nursing care is interaction to other focused on patients
helping the client to wellness state and prevents other risk of the condition.

Patient

displaye d interests in the activitie s and therapie s that were conduct ed by the SN.

5. Promoted socialization within individual limitation to make the patient not tired

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M Instruct patient on medication the proper medicine, route, dosage, and duration. Educate the patient about the purpose of drug therapy, proper dosage and how long the regimen will last.

E Instruct about proper financial and social assistance for economic needs.

T Treatment includes dietary management, pharmacotherapy, proper hygiene, exercises and adequate rest periods.

H Explain also the importance of compliance to drugs, balance diet, and adequate rest periods. Teach the patient proper hygiene.

O Out-patient or home care should be continued for check-ups and diagnostic procedures. Client should be instructed not to self-medicate as well as not to exceed prescribed time of medication and therapy also instruct to consult psychiatrist/physician regularly, for follow ups

D instruct about diet. Teach and explain the importance and compliance to treatment regimen, especially nutrition.

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