Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING

Acute Polymorphic Psychotic Disorder with symptoms of Schizophrenia, Unstable ruled out substance abuse
(Behavioral Analysis)

In Partial Fulfilment Of The Requirements in Nursing Care Management 104 Related Learning Experiences (National Center For Mental Health)

Presented to SOCORRO A. LARION,RN Clinical Instructor

Presented By: FREYA ROSE ANN C. VILORIA BSN III-GAZANIA

MAY 18,2012

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

COLLEGE OF NURSING

--------------------------------CASE STUDY GRADING SHEET-------------------------------PARAMETERS Introduction and Objectives Personal data and result of interview Nursing history of past and present illness Assessment Diagnostic Procedures Psychodynamics Drug study Nursing Care Plan Discharge planning Bibliography Updates TOTAL PERCENTAGE(%) 5 ACTUAL GRADE

5 15 5 15 10 20 10 5 10

CI REMARKS: ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ _____

SOCORRO LARION,RN Clinical Instructor

TABLE OF CONTENTS Title page....i Grading sheet.ii Table of contentsiii I. II. III. IV. V. VI. VII. VIII. Introduction and Objectives1-2 Personal data and result of interview.2 Nursing history of past and present illness.3 Assessment..3-4 Diagnostic Examination..4-.6 Psychodynamics..6-8 Drug study 9-10 Nursing care plan.1113 IX. Treatment/Management..1415 X. Discharge planning ..1516 XI. XII. Bibliography.16 Updates....1617

I.

INTRODUCTION
An acute psychotic disorder in which the polymorphic and unstable clinical

picture is present, despite this instability, however, some symptoms typical of schizophrenia are also in evidence for the majority of the time. If the schizophrenic symptoms persist the diagnosis should be changed to schizophrenia. This diagnosis is considered not only as the first with schizophrenia manifest, but also in favorable cases of the disease, such as long-term remission and spontaneous output of psychosis, it is advisable each subsequent psychosis attributed to this group, but not to schizophrenia or schizoaffective disorder. In the clinic of acute psychosis in this group there are productive the first rank symptoms characteristic of schizophrenia, but there are no negative emotional-volitional disorders. There is affect of anxiety, expansion and confusion. Motor activity is increased until the excitation. Symptoms of acute polymorphic psychotic disorder with symptoms of schizophrenia:1. Rapid changes in symptoms of delirium, including delusions of control, delusional interpretation and delusional perception, which is characteristic of schizophrenia.2. Hallucinations, including auditory commenting, contradictory and mutually exclusive, compelling and true pseudohallucinations, somatic hallucinations, a symptom of the openness of thought, the sound of the own thoughts related to the first-rank symptoms in schizophrenia.3. Symptoms of emotional distress, fear, anxiety, irritability, confusion.4. Motor stimulation. 5. The above-mentioned productive symptoms of schizophrenia occur no more than a month. In treatment is necessary to apply detoxication therapy, neuroleptics in the middle, and sometimes in the highest dose. It should always be given supportive treatment prolong or conduct occasional short courses of therapy because of the risk of developing schizophrenia, but also insist on an outpatient observation of patients, at least for one year. Pay attention to periods of sleep disorders, mood disorders (anxiety episodes), suspicion. It is these symptoms that may precede exacerbations, and therefore they are a signal for warning of therapy. This case study is focused on a patient named Peter Ang, a 42 year old male from 918 Tomas Mapua st. Sta Cruz, Manila.He is a son of Mr. Kim Shing Ang and Mrs. Rosa Chi Ang . He was diagnosed with Acute Polymorphic Psychotic Disorder with symptoms of Schizoprenia, Unstable rulled out substance abuse . She was confined at National Center for Mental Health last December 9,2003 at 11:10 pm. It was his first time of hospitalization in that institution.

OBJECTIVES
After completing this case study, the student nurse will be able to obtain appropriate knowledge, skills and attitude in dealing with a patient suffering from Acute Polymorphic Psychotic Disorder with symptoms of Schizophrenia, Unstable. For the student nurse: To establish proper nurse-patient interaction To assess the patient correctly To obtain proper conduction of mental status exam To plan a psychotherapeutic treatment regimen to the patient For the patient: To establish trust to the patient during interactions To establish a therapeutic relationship between the patient and student nurse To assess the self of the patient about his present illness To be able to maintain his realistic life II. PATIENTS PROFILE BASED ON CHART PERSONAL DATA NAME AGE SEX BIRTHDAY BIRTHPLACE ADDRESS RELIGION NATIONALITY CIVIL STATUS EDUCATIONAL ATTAINMENT FATHERS NAME MOTHERS NAME CLINICAL DATA DATE OF ADMISSION TIME OF ADMISSION ADMITTING DIAGNOSIS Peter y Chi Ang 42 Male June 24,1969 Sta Cruz, Manila 918 Tomas Mapua st. Sta Cruz, Manila Protestante Filipino Single High school graduate Kim Shing Ang Rosa Chi Ang December 9,2003 11:10 pm Acute Polymorphic Psychotic Disorder with symptoms of Schizophrenia, Unstable ruled out substance abuse Dr, Agcaoili 11-27-88 RESULT OF INTERVIEW Peter Ang 42 Male June Sta Cruz, Manila Sta Cruz, Manila Protestante Chinese Single College graduate Kim Ang Rosa Ang December 9,2003 No response Not known

ADMITTING PHYSICIAN HOSPITAL NUMBER

Not known Not known

III. NURSING HISTORY OF PAST AND PRESENT ILLNESS

Patient was the only sibling born to a G1P0 mother via NSD assisted by Medical Doctor, no fetomaternal complaints noted. He started schooling at 7 years old, more of a follower than a leader. In high school, he had a lot of friends but allegedly for unknown reason he stopped schooling and stayed at home doing simple household chores. Allegedly he seldom show interest with opposite sex. He was occasional alcoholic beverage drinker consuming 5-6 bottles of beer per session. He was also a occasional cigarette smoker consuming 1 pack for 2-3 days. He started drinking and smoking of approximately 1-2 years prior to admission. He has no family history of mental illness. He has also no history of hypertension, Diabetis mellitus, pulmonary tuberculosis and asthma. He has no history of seizure. But he has history of head trauma(stabbed wound), self-inflicted last December 4 2003. Patient was apparently well until 4 days prior to admission, he allegedly became withdrawn and for no apparent reason he allegedly stabbed himself in his head with a knife. He was taken at Metro Hospital and was confined for 3 days. At home 1 day prior to admission, he allegedly hit his mother for no apparent reason nor provocation. He became increasingly irritable, restless and assaultive hence consult and subsequent admission. He was brought by his mother and cousin.

IV.

ASSESSMENT

MENTAL STATUS EXAMINATION CRITERIA GENERAL DESCRIPTION Appearance Overt behaviour and psychomotor activity RESULT Patient had a medium body built with proper clothing, grooming and hygiene Patient had a good behaviour with no symptoms of hyperactivity, agitation, restlessness. However upon interview, there is occasional depressive moods being shown by the patient. Patient is cooperative upon performing the PE. The patient had a euthymic type of mod. The patient had a normal range of affect. The patient had an appropriate affect in response to the examiner. The patient had a spontaneous, hypoproductive speech. Patient denied any form of hallucination. The patient had no suicidal, homicidal

A.

Attitude towards the examiner B. MOOD AND AFFECT Mood Affect Appropriateness of affect

C. D. E.

SPEECH CHARACTERISTICS PERCEPTUAL DISTURBANCE THOUGHT DISORDRES Thought and content

Thought process F. SENSORIUM AND COGNITION Consciousness Orientation

and compulsive thoughts. The patient had an idea coherent and goal oriented.

that

is

Concentration/attention/ calculation Abstract thinking Information and intelligence Disturbance in intellectual capacity Impulse control Judgement and insight

Patient had an alert type of consciousness. Patient is oriented to time, place and person with intact immediate, recent and remote memory. Patient had an intact calculation and concentration Patient had an intact abstract thinking Patient had an intact intelligence and information Patient had an intact intellectual capacity according to his age Patient had a controlled impulse control Patient had good judgement and insight when given different scenario

G. H.

V.

DIAGNOSTIC PROCEDURE

Physical Exam- all the results/findings are normal Neurologic exam - all the results/findings are normal Hematology (January 16,2012)
A calculation of the cellular makeup of blood. A CBC measures the concentration of white blood cells, red blood cells, and platelets in the blood and aids in diagnosing conditions and disease such as malignancy, anemia, or blood clotting problems. Also called blood profile.
PARAMETERS RESUL T NORMAL VALUES IMPLICATION NURSING RESPONSIBILITIES

Hgb

131

140-180g/L

Hct RBC WBC Diff count Neutrophils Lymphocytes

0.38 3.95 5.4 0.38 0.59

0.40-0.54 4.06.0x10^12/L 5-10x10^9/L 0.45-0.65 0.20-0.35

decreased (indicate anemia; decrease O2 carrying capacity on the blood) slightly decreased( may indicate anemia) slightly decreased normal decreased increased(indicate acute/ chronic lymphoytic leukemias normal

Monocytes

0.03

0.02-0.06

explain that the hematology is tested to detect abnormal blood conditions tell the patient that the test requires a blood sample tell him that he does not need to restrict food or fluids tell that he will feel slightly discomfort from the tourniquet and needle puncture

Urinalysis (January 7,2008)

A physical, chemical and microscopic analysis of the urine. It is useful for diagnosing renal disease or urinary tract infection and for detecting metabolic disease not elated to the kidneys. The color, appearance and odor of the urine are examined and the pH, protein, glucose ketones are tested. Specific gravity is measured with a urinometer and a microscopic examination of the urinaty sediment is performed to detect red and white blood cells. PARAMETER Color Transparency Specific Gravity Ph Protein Sugar WBC RBC Epithelial Cells Mucus Threads Amorphous Urates RESULT Yellow Clear 1.010 Acidic Negative Negative 0-2 0-1 Few Few Few NORMAL VALUES Amber/straw Clear 1.005-1.035 4.6-6.5 Negative Negative None None None None None IMPLICATION Normal Normal Normal Normal Negative Negative Increased may indicate infection Increased may indicate infection Increased may indicate infection Increased may indicate infection Increased may indicate infection NURSING RESPONSIBILITIES Explain the procedure to the patient Assist the patient in doing the procedure Instruct the patient to collect clean catch midstream urine Transport the specimen to the laboratory as soon as possible Refer result to the physician

Blood chemistry (September 2,2008)

CRITERIA FBS RESULT 3.4mmol/L NORMAL VALUE 4.2-6.4mmol/L IMPLICATION Decreased(may indicate malnutrition, alcoholism and hypoglycemic reaction) NURSING RESPONSIBILITIES Instruct the patient to maintain NPO except water for 12 hours before the test tell the patient that the test requires a blood sample Refer result to the physician

Radiology (February 8,2008)

TEST Chest X-ray RESULT Pleural reaction, Right NURSING RESPONSIBILITIES Explain the procedure to the patient to gain cooperation Prepare the patient before going to xray room Assist the patient Refer the result to the physician

VI.

PSYCHODYNAMICS
Psychodynamic psychotherapy is a form of depth psychology, the primary

focus of which is to reveal the unconscious content of a clients psyche in an effort to alleviate psychic tension. It relies on the interpersonal relationship between patient and therapist more than other forms of depth psychology. In terms of approach, this form of therapy also tends to be more electric than others, taking techniques from a variety of sources, rather than relying system of intervention. It is a focus that has been used in individual psychotherapy, group psychotherapy, family therapy. Exercise It is an activity where the therapist engages the patient in an exercise. This is an opportunity to channel strong emotions and feelings in a productive way. The effects are not only on the physical health but also on the mental health. Before each activity, the patients should have their routine exercise so that they will not be sleepy during the activities. As I observe to Peter, he is active and willing to participate in all the activities. Music and Art Therapy (May 10,2012) Music therapy is done in many forms. It elicits mood or emotional responses ranging from pleasure and excitement to sadness and fear depending on past experiences and symbolic significance. Art therapy is a form of expressive therapy that uses art materials such as paints, chalk and markers. It combines traditional psychotherapeutic theories and techniques with an understanding of the psychological aspects of the creative process especially the affective properties of the different art materials. The patients were given a bond paper and a box of crayon with 8 different colours. They were asked to draw what they feels after listening to a slow instrumental music and a fast music. On the activity, Peter wrote his name and gave meaning which is Proud-Energetic-Talented-Expert-Romantic. He use different colours.

RED(the image of vitality) It is a symbol of life force. It demonstrate vitality, etrength, energy, interest in life and involvement with people. It is the color of love and anger. BROWN(the image of warmth and stability) It suggest that you are friendly, competent and practical. YELLOW(the image of change and creativity) Color of sunshine and good cheer. It is a color of optimist. It signifies hope, variability, change, creativity and originality if thought.it is also the color of caution and cowardice. GREEN(the image of healing and envy) It is an ancient symbol of life, fertility and healing. It is also the color for jealousy. BLUE(the image of trust and loyalty) It stands for integrity and honesty. It says that whatever you do, you do it well and are reliable. Emotionally, it creates a feeling of peace and serenity. It suggest sincerity, helpfulness, honesty and openness. With this of therapy, the patient was able to express his feelings and thought through the use of different colours. The student nurse was able to detect and recognize the patients deeper problems. Play therapy (May 11,2012) It is a technique used as a therapeutic method to assist patients in coping with emotional stress or trauma.it is also the systematic use of a therapeutic model to establish an interpersonal process wherein the play therapist use the therapeutic powers of play to help patients prevent or resolve psychosocial challenges and achieve optimal growth and development. The student nurses did three different games such as pinoy henyo, stop dance and hephep huray. My patient actively participated in those games. I observed that he enjoyed the activity. Remotivation therapy (May 15,2012) It is a simple socialized group therapy usually 10-12 participants with an effort to reach the unwounded area of patients personality and moving against toward reality. It comes from the word motivation with a prefix re which means that the technique is done repeatedly. The purposes of this therapy are to bring back patient to reality, to develop the ability to communicate and share ideas and experiences with others, to develop feelings of acceptance and

recognition and to promote good harmony and identification. It values the patient to think about something and talk about himself and make him part of the group. The student nurses asked to conduct the therapy prepared a picture and a poem about the environment. First, the student nurses read the poem and also asked the patient to read the poem. My patient actively participates in the activity showing his interest. The student nurses asked the patient on what are the different things that they can see on the picture. My patient answered correctly with the different questions asked. Bibliotherapy (May 14,2012) It 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. It has been shown to be effective in the treatment of depression. It consist solely of reading, or it can be complemented with discussion or play therapy. It is also a form of therapy with the use of printed materials as a means of modifying, stimulating patients emotion and at the same time providing information to the patient. The student nurses who lead the activity presented stories entitled bimbo, ang batang hindi naliligo at si eko kuneho at si pampagong which took place outside the pavilion. The student nurses first read the story and afterwards, they let the patient read the story. The student nurses asked questions about the stories.My patient volunteered to summarize the story. My patient showed some interest in the activity. Occupational therapy (May 16,2012) It promotes health by enabling people to perform meaningful and purposeful occupations. Therapist helps their client works toward a more independent life with the feeling of accomplishment. They want their patient to live well and accept whatever problems they have to overcome by finding new ways to manage them. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Our activity for the day was making a picture frame. Our patient was given the instructions to follow in making a picture frame. The things needed were a Styrofoam, cartolina, paste and other decorations. The patient did the activity successfully by himself

IX. TREATMENT/MANAGEMENT
IDEAL MEDICATIONS clozapine(Clozaril , FazaClo) -used to treat schizophrenia. This medicine is only used when others have not worked. It has a risk of serious side effects olanzapine(Zyprexa , Zyprexa Zydis) used to treat schizophrenia, psychotic disorders, and bipolar disorder. Bipolar disorder is also known as manic-depression. aripiprazole(Abilify , Abilify Discmelt) -is an atypical antipsychotic. It is used to treat schizophrenia and bipolar disorder, also known as manic-depression risperidone(Risperdal , others...) -is an antipsychotic. It is used to treat schizophrenia, bipolar disorder, and some symptoms of autism. haloperidol(Haldol , Haldol Decanoate) -is used to treat schizophrenia. This medicine is also used to control tics and vocal outbursts in patients with Tourette's syndrome thioridazine(Mellaril ) -is used to treat schizophrenia. This medicine should only be used when other medications have not worked. quetiapine(Seroquel , Seroquel XR) -is an antipsychotic. It is used to treat schizophrenia and bipolar disorder, also known as manic-depression. ziprasidone(Geodon ) -is used to treat schizophrenia and bipolar disorder, also known as manicdepression. loxapine(Loxitane , Loxitane C) -is used to treat schizophrenia. This medicine can help you to keep in touch with reality and reduce your mental problems. chlorproMAZINE(Thorazine , Ormazine) -has many different uses. It is used to treat certain mental and behavioral disorders. It is also used to control nausea and vomiting fluphenazine(Prolixin , others...) -helps to treat disordered thoughts and some other emotional, nervous, and mental problems. perphenazine(Trilafon ) -is used to treat schizophrenia. It also is used to treat severe nausea and vomiting in adults. paliperidone(Invega ) -is used to treat schizophrenia and schizoaffective disorder. trifluoperazine(Stelazine ) -is used to treat schizophrenia. This medicine may also be used for the short-term treatment of anxiety. thiothixene(Navane ) -This medicine may be used for other purposes; ask your health care provider or pharmacist if you have questions. prochlorperazine(Compazine , others...)

-helps to control severe nausea and vomiting. This medicine is also used to treat schizophrenia. ECT It can be a viable treatment for people whose schizophrenia has of medications trials and psychological

inadequately responded to a number interventions.

FAMILY THERAPY It can significantly decrease relapse rates of schizophrenic family member. Supportive family therapy can reduce this relapse rate to below 10%. It encourages the family to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem. ACTUAL Fluphenazine decanoate 25mg 1cc IM once a month - Long-acting parenteral preparations for the management of manifestations of schizophrenia Chlorpromazine 100mg HS -Used in the treatment of both acute and chronic psychoses, including schizophrenia and the manic phase of bipolar disorder as well as amphetamine-induced psychose

X. DISCHARGE PLAN

M E

edications

xercise

reatment

ealth teaching

Take home medications are not yet available since the patient is still in. Emphasize the importance of taking medications prescribe and also the consequences of not taking those medications. Provide a clear instruction about taking the medications. The medications of the patient in the ward are Fluphenazine Decanoate, 25mg 1cc IM once a month and Encourage the patient to exercise regularly unless it is contraindicated to its condition. Encourage the patient to do his activities of daily living as long as he is capable. Encourage to do exercise every day to prevent weakness of the bones. Provide relaxation and diversion activities for the patient. Tell that continuation of medications is very important. Instruct to avoid triggering factors that may cause relapse of the disease. Always maintain reality presentation. Dont forget to give medications to control the extrapyramidal effects of the medications as prescribed. Adhere to complete medication regimen. Take medications on time. Encourage the patient to have adequate rest and sleep. Avoid stressors and stimuli because it can trigger the patient.

O D

ut patient

Always present the reality. The patient is not yet scheduled for an OPD check-up but patient can go to infirmary or other facilities of NCMH for check-ups. Encourage to increase oral fluid intake. Emphasize the importance of taking high CHON and CHO diet. Also with foods rich in vitamin C.

department

iet

XI. BIBLIOGRAPHY
a. books 2010 Edition Delmar Nurses Drug Handbook(George R. Spratto; Adrienne L. Woods) NursingCare Plan 8th Edition(Marilyn E. Doenges, Mary Frances Moorhouse, Alice C. Murr) Textbook of Medical-Surgical Nursing Vol1 and 2 12th edition(Brunner and Suddarths) internet http://www.psychopharmacologyupdate.com/samplearticles/treatinguunstable-schizophrenia.aspx http://en.wikipedia.org/wiki/Chlorpromazine http://www.healthyplace.com/other-info/psychiatricmedications/fluphenazine-decanoate http://www.patient.co.uk/health/Schizophrenia.htm

b.

XII. UPDATES
May,2011 Antipsychotic medication The main drugs used to treat schizophrenia are called antipsychotics. They work by altering the balance of some neurotransmitters (brain chemicals). Antipsychotic medication is used to relieve the symptoms. Antipsychotic drugs tend to work best to ease positive symptoms, and tend not to work so well to ease negative symptoms. Antipsychotic drugs are also used to prevent recurring episodes of symptoms (relapses). Therefore, antipsychotic medication is usually taken on a long-term basis.There are various different antipsychotic drugs, and different ones may be used in different circumstances. They are broadly divided into two categories: Newer or atypical antipsychotics. These are sometimes called second generation antipsychotics and include: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine, risperidone and sertindole. One of these drugs is commonly used first-line for new cases. This is because they seem to have a good balance between chance of success and the risk of side-effects. However, if you are already taking a typical drug and feel well on it, there is no need to change to a newer one. Older typical well established antipsychotics. These are sometimes called first-generation antipsychotics and include: chlorpromazine, trifluoperazine, haloperidol, flupentixol, zuclopenthixol, and sulpiride.

There are some differences between the various antipsychotic drugs. Therefore, one may be better for an individual than another. For example, some are more sedating than others. A specialist in psychiatry usually advises on which to use in each case. Sometimes, if one does not work so well, a different one is tried and may work well. A good response to antipsychotic medication occurs in about 7 in 10 cases. However, symptoms may take 2-4 weeks to ease after starting medication, and it can take several weeks for full improvement. Even when symptoms ease, antipsychotic medication is normally continued long-term. This aims to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms that clears completely with treatment, one option is to try coming off medication after 1-2 years. Your doctor will advise. Depot injections of an antipsychotic drug. In some cases, an injection of a long-acting antipsychotic drug is used once symptoms have eased. The drug from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses. The main advantage of depot injections is that you do not have to remember to take tablets every day. Research continues to find newer and better drug treatments. Psychological treatments Cognitive behavioural therapy (CBT) Psychological treatments include a variety of talking treatments, in particular a treatment called cognitive behavioural therapy (CBT). CBT is used as a treatment for various mental health and physical problems and is being increasingly used as a treatment for schizophrenia. CBT aims to help you to change the way that you think, feel and behave. CBT is actually a wide term which includes various types of therapy. Family intervention This may be offered and consists of about 10 therapy sessions for relatives of patients with schizophrenia. It has been found to reduce hospital admissions and the severity of symptoms for up to two years after treatment. Art therapy This has been found to be helpful, particularly if you have negative symptoms. Social and community support This is very important. Often the key worker plays a vital role. However, families, friends and local support groups can also be major sources of help. Contact details of the head offices of the main support organisations are listed at the end of this leaflet.