A Case Study Presented to the Faculty of The Ateneo de Davao University College of Nursing
A Case Study on Schizophrenia Undifferentiated Submitted to:
Mrs. Anabel Bauzon, RN, MN Clinical Instructor – Panelist of the Case Study
Submitted by: [Group 1]
Abarquez, Eva Rica V. Ampilanon, Rae Maikko M. Ausa, Ryan S. Balboa, Tessa Marie R. Batuhan, Katherene P. Beltran, Maribel S. Bulosan, Von Rainier S. Cabonita, Kristi Ann J. Campaner,Marie Allexis I. BSN-3H
09 February 2010
TABLE OF CONTENTS Acknowledgement…………………………………………………………………..…..3 Introduction…………...……………………………………………………………….…4 Objectives (General & Specific)……………………………..……………………….….6 Personal Data…………………………………………...……………………………….9 Genogram……………………………………………………………………….………11 Anamnesis………………………………………………………………………….…...12 Theories of Development………………………………………………………….....…24 Etiology and Symptomatology….……………………………………………….……44 Psychodynamics………………………………………………………………..………62 Mental Status Exam……………………………………………………………….…..68 Multi Axial Assessment………………………………………………………………..78 Nurse Patient Interaction ……………………………………………………………..81 Complete Diagnosis…………………………………………………………......…….101 Differential Diagnosis……………………………………………………………....…104 Anatomy and Physiology…………………………………………………….…..……115 Doctor’s Order…………………………………………………………...……………126 Drug Study……………………………………………………………………….……130 Nursing Care plan ……………………………………………………………..………149 Prognosis………………………………………………………………..…….......……176 Recommendations………………………………..………………………...…………180 Significance of the Study……………………………………………………...………182 Appendices……………………………………………………..………………...……183 References……………………………………………………...………………...……195 2
ACKNOWLEDGEMENT The group wishes to express their deepest gratitude and warmest appreciation to the following people, who, in any way gave us the possibility making this case study a success: First of all, to the Almighty God, who never cease in loving us and for the continued guidance and protection. To the group’s clinical instructor, Mrs. Apple V. Guiao, R.N,M.N for her guidance and support in the duration of the study and during the psychiatric nursing exposure , whose help, stimulating suggestions and encouragement helped us in all the time of making this case study. To Mrs. Zenaida Lagrosa RN, Mrs. Anabel Bauzon RN and Mr. Richard Cheng,RN for their unlimited patience, guidance and being with us during our psychiatric nursing exposure . Finally to Ms. Melba Irene Gabuya RN for imparting knowledge and learning experience during our lectures on Psychiatric nursing. Without their encouragement and constant guidance, our Psychiatric Nursing exposure would not have been a very meaningful learning experience. The group also wishes to acknowledge the invaluable assistance and cooperation of the staff nurses of the Davao Mental Hospital (DMH), for allowing us to conduct this study, for essential assistance in reviewing the patient files and giving us the opportunity to care for the mentally-ill patients. Special appreciation is extended to the client subjected for this study and other informants for their selfless cooperation, time and entrusting personal information needed for this study. To the group, we would like to show our endless gratitude to each other by specifying our names; Maikz, Eva, Allexis, Kat, Bel, Kitty, Ryan, Tessa and Von; for the understanding, believing in each other, and teamwork. May we continue working hard for future studies.
3
And lastly, to our parents who have always been very understanding and supportive both financially and emotionally. INTRODUCTION Schizophrenia (from the Greek roots skhizein ("to split") and phrēn, phren- ("mind")) is a severe mental illness characterized by a variety of symptoms including but not limited to loss of contact with reality. Schizophrenia is not characterized by a changing in personality; it is characterized by a deteriorating personality. Simply stated, schizophrenia is one of the most profoundly disabling illnesses, mental or physical, that the nurse will ever encounter (Keltner, 2007). There are 5 subtypes of schizophrenia naming; paranoid, disorganized, catatonic, undifferentiated, and residual. Schizophrenia undifferentiated is the type of schizophrenia wherein characteristic symptoms (delusions. Hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms) are present, but criteria for paranoid, catatonic, or disorganized subtypes are not met. Schizophrenia is not a terribly common disease but it can be a serious and chronic one. Worldwide about 1 percent of the population is diagnosed with schizophrenia. About 1.5 million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net). Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americans suffer from schizophrenia; fifty percent (50%) experience serious side effects from medications; and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of 86,241,697
of
Filipinos
or
approximately
0.8%
are
suffering
from
schizophrenia
(cureresearch.com). Here in Davao, Dr. Padilla said that the Davao Mental Hospital receives an average of eight to 10 patients a day suffering from schizophrenia, depression and bi-polar illnesses (Positivenewsmedia.net).
4
Schizophrenia Ranks among the top 10 causes of disability in developed countries worldwide (World Health Organization, www.who.int) Schizophrenia is a disease that typically begins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophrenia slightly earlier than women; whereas most males become ill between 16 and 25 years old, most females develop symptoms several years later, and the incidence in women is noticeably higher in women after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onset is quite rare for people under 10 years of age, or over 40 years of age (schizophrenia.com). The group 1 of BSN-3H was given opportunity to have a hospital exposure in Davao Mental Hospital last January 19 – 30, 2010 for their psychiatric exposure. It was on that said dates that the group found a creditable case sensible to be presented as case presentation as suggested their Clinical Instructor Apple V. Guiao, R.N. M.N. and was agreed by whole group. The patient, Bob, not his real name, was one of the patients admitted to the Crisis Intervention Unit of Davao Mental Hospital due to Schizophrenia Undifferentiated. The group chose Bob as their subject primarily because his case posed as a very intricate case requiring due understanding and knowledge. Making this case is a good avenue to broaden the proponents’ knowledge about the mental illness involved.
5
OBJECTIVES General Objective: The main goal of the group is to be able to present an extensive and comprehensive case study of our chosen client that would present a comprehensive discussion of Schizophrenia Undifferentiated to yield important information for the case study.
Specific Objectives: In order to meet the general objective, the group aims to: Cognitive: •
interpret the pertinent data gathered from the patient and his significant others;
•
present the anamnesis by thorough gathering of the client’s pertinent personal data, appropriate selection of informants, and familial history tracing;
•
evaluate the developmental stage of the patient according to the theories of Erikson, Freud and Piaget;
•
determine the etiology factors (precipitating and predisposing) of the mental disorder;
•
evaluate the presence or absence of signs and symptoms seen in the patient in relation to the mental disorder;
•
present the psychodynamics of the client’s diagnosis by recognizing its predisposing and precipitating factors with appropriate rationales; To track down the significant events during the client’s developmental stage as shown in the psychodynamics;
•
Interpret and analyze nurse-patient interaction taken through spontaneous and effective use of therapeutic communication; 6
•
thoroughly define the complete diagnosis of the patient;
•
come up with a differential diagnosis with accord to the client’s maladaptive behaviors;
•
discuss thoroughly the Anatomy and Physiology of the involved organs and organ systems in accord to the final diagnosis;
•
present the doctor’s order with its rationalization;
•
formulate effective, specific, measurable, attainable, realistic and time-bounded nursing care plans base on identified actual and potential nursing problems;
•
arrive to a general realistic prognosis drawn from the information gathered and factors affecting the patient’s condition;
•
provide the significance of the case study;
Psychomotor: •
gather pertinent data about the client through detailed chart taking, and effective therapeutic communication and interaction with the client and his significant others;
•
commence the patient with his personal data and present and past health history;
•
trace the health history of the client and family illnesses (past and present) through a genogram;
•
assess client’s mental status thoroughly during the orientation and termination phase as well as the Multi-Axial diagnosis;
• present the medications given to the client, including their respective modes of action, indications, contraindications, side effects, adverse reactions, nursing responsibilities, and importance to the client’s condition; •
render quality nursing care in line with the formulated nursing care plans; 7
•
impart appropriate recommendations to the client, his significant others and community, medical world, and the group as a part of the nurse’s holistic care.
Affective: •
establish rapport to the patient and the patient’s significant others; and
•
establish a trusting nurse-patient relationship with the client and his significant others through provision of holistic care toward the client and use of appropriate verbal and nonverbal therapeutic communication skills with the client and significant others during the data gathering;
8
PATIENT’S DATA PERSONAL DATA: CODE NAME: Bob AGE: 40 SEX: Male BIRTHDAY: April 9, 1969 BIRTHPLACE: Cagayan de Oro City ADDRESS: Prk. 1 Rizalian, Bayugan Agusan del Sur Tulip Drive, Matina, Davao city ORDINAL RANK: 1st CIVIL STATUS: Single NATIONALITY: Filipino RELIGION: Catholic EDUCATIONAL ATTAINMENT: 2nd Year College undergraduate OCCUPATION: None NUMBER OF CHILDREN: 0 NUMBER OF BROTHERS: 2
NUMBER OF SISTERS: 2
MOTHER: Aina AGE: 58 EDUCATIONAL ATTAINEMNT: college undergraduate OCCUPATION: Businesswoman FATHER: Danni EDUCAIONAL ATTAINMENT: college undergraduate 9
OCCUPATION: Businessman CLINICAL DATA: WARD/SERVICE: Crisis Intervention Unit/Psychiatry ADMITTING PHYSICIAN: GIOIA FE D. DINGLASAN, M.D ADMITTING DIAGNOSIS: Schizophrenia, undifferentiated PRINCIPAL DIAGNOSIS: Schizophrenia, undifferentiated DATE OF AMISSION: January 19, 2010 DATE OF DISCHARGE: January 21, 2010 INSTITUTION: Davao Mental Hospital
10
11
GENOGRAM Super Lola
Super Lolo Ω †
Angeli ta †
Angelit o†
†
Apolinari o†
as
Gran Ma †
Gran Pa †
Jeorgin o
Legend: L - Male - Female
∞ - schizophrenia Ω - hypertension Ѳ - Diabetes
Aina 58 years old
Fielit aѲ
Bob 40 years old
∞
†
Carmz 31 years old
Ronan aΩ
Dennz 26 years old
Watusi Ω†
Watus a†
Lola Al Ω
Lolo Al †
Ronan
Emman 39 years old
Apolin aria Ω
†
Danni 59 years old
Leo †
Lea
Yose 20 years old
†-deceased 12
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ANAMNESIS A. INTERVIEWS Informant #1 Name: Aina Age: 58 Address: Purok 1, Rizalian, Bayugan, Agusan del Sur Sex: Female Civil Status: Married Relationship to Client: Mother Length of Time Known by the Patient: Since Birth up to Present (40 years) Apparent Understanding of the Present Illness of the Client: According to Aina, her son, Bob, started having the condition when he stopped schooling in late August of 1987 and went back to Agusan because he thought lessons in school are becoming too difficult for him. Bob also verbalized that something is wrong with him and that he needed a psychological check-up. Yet, Aina did not pay attention to what he said; until two days after, Bob’s tongue shrunk, hindering his speech. This event forced Aina to bring Bob to San Pedro Hospital for a check-up. In San Pedro, no diagnoses indicating any mental illness resulted and they were asked to come back for a follow-up check up the following month. On November 1987, Aina brought Bob back to Davao City for a check-up but transferred to Davao Mental Hospital. There, Bob was diagnosed with Schizophrenia Catatonic Type and was admitted for two weeks; after which, he was discharged and was asked to go back to the hospital once a month for psychiatric evaluation and for monthly doses of a depot. Aina says that Bob at times would show extreme hostility and wild behavior. She believes that Bob’s wild behavior which is the reason for his second admission in December 2007 and 14
current admission this January 2010 is due to Bob’s incompliance with the advices of the doctor to stop drinking coke, alcoholic beverages and smoking. The current admission of Bob is already his third admission. Bob and Aina were only at the Davao Mental Hospital to have Bob’s monthly dose of his depot but Bob shouted at the doctor without any apparent reason, exhibiting extreme hostility and wild behavior. This action convinced the doctor that Bob may need a three-day admission at the CIU for observation. After which, he was then discharged Characteristics and Attitude of Informant: Sincerity and concern regarding the condition of the patient is highly evident in the verbal and non verbal cues of the informant during the interview. She looks straight to the eyes and is very cooperative all throughout the interview, trying her best to recall all events that took place in connection to the condition of her son.
Informant #2 Name: Emman Age: 39 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Male Civil Status: Married Relationship to Client: Brother Length of Time Known by the Patient: Since Birth up to Present (39 years) Apparent Understanding of the Present Illness of the Client: Emman said that the illness began when Bob went to Bukidnon in August 1987 to fetch him and go home with him to Agusan. On the night of Bob’s arrival, he started having a convulsion and 15
was given paracetamol. Hours later, Bob was caught eating his own feces and drinking urine from a potty. After the incident, they went home to Agusan. Since then, Bob started to think and talk illogically, displaying disorganized speech and delusions. Weeks later Bob was brought to Davao for a check-up, first as San Pedro then at DMH. Since then, Bob has always been visiting Davao Mental Hospital and was even admitted two times, one in November 1987 then in December 2007, prior to the recent admission. Emman sees Bob’s condition rooted from that convulsion which took place in Bukidnon. As to the reason of the convulsion and the events that took place prior to the convulsion, the brother does not claim any knowledge. Characteristics and Attitude of Informant: Emman was very open and receptive to the group during the interview. He had shown efforts to recollect all salient points regarding the condition of his brother.
Informant #3 Name: Carmz Age: 18 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Female Civil Status: Single Relationship to Client: Sister Length of Time Known by the Patient: Since Birth up to Present (18) Apparent Understanding of the Present Illness of the Client: Mae understands Bob’s condition because she is a student nurse. According to her, Bob’s manifestations are indeed characteristics of schizophrenia. She believes that Bob’s condition will be 16
best improved if Bob follows all medication orders of the doctor and strictly avoid everything that the doctor prohibits him to take. Characteristics and Attitude of Informant: The informant was very responsive in the conversation, showing strong desire to tell the group everything that she knows about the illness of the patient.
Informant #4 Name: Mimi Age: 39 Address: 162 Interior Tulip Drive, Matina, Davao City Sex: Female Civil Status: Married Relationship to Client: Sister-in-law Length of Time Known by the Patient: Since Marriage up to Present (20 years) Apparent Understanding of the Present Illness of the Client: According to Mimi , the patient has been isolated and withdrawn since she first met him when she married his brother, Emman wayback in May of 1990, the patient was 21years old by then. She noted that Bob is irritating to the family members at times because there are instances wherein he seems to act like a child. She cited incidents wherein he wakes them up in the midnight because he was hungry and asks them for something to eat or drink. Bob also occasionally asks his mother to sleep with him at night. Taking this information to consideration, the sister-in-law concluded that, somehow, Bob is a burden to their family. She can see that the siblings of Bob have been exhausted in trying to understand him. Yet, in spite this, the family still show their invaluable support and love to Bob. 17
Characteristics of the informant: The informant was open and hospitable to the group. She made ways for the group to contact the family and talk to other members of the family in order to gather data that she could not provide. The warm and welcoming attitude of the informant made it possible for the group to know more about the patient.
Informant #5 Name: Boy Age: 18 Address: 162 Tulip Drive, Matina, Davao City Sex: Male Civil Status: Single Relationship to Client: Nephew Length of Time Known by the Patient: Since Birth up to Present (18) Apparent Understanding of the Present Illness of the Client: Boy says that Bob’s condition was not improving. He said that what Bob’s actions now are the same as what he does in the past. He was always isolated, self-preserved and indifferent with others. He could even go for a whole day without talking to anybody and just watch TV. Boy also says that Bob’s strange actions like talking to the television, flight of ideas and hostile behaviors are not unusual of Bob anymore. Characteristics of the informant: Boy was at the first visit unresponsive to the questions asked by the group. However, on the next home visit, he volunteered to talk about what he knows about his uncle in a warm manner.
18
B. FAMILY HISTORY a. Maternal and Paternal Lineage Direct bilateral lineage of the patient show no conditions of mental illness. On the paternal side, prominent family illnesses only concern some members having hypertension. Aside from the condition, no other illnesses run the family. On the maternal line, no illness were reported to run in the family, except one family member having diabetes mellitus type 2, an illness condition occurring singularly to be considered familial. Generally, no mental illness can be traced on both sides of the family. b. Father The father is 59 years old; a known small time businessman in their place at Agusan; owning a small rice mill enough to support the needs of his family. He is a Civil Engineering Undergraduate and was able to finish only until 3rd year of the above course, due to his early fatherly obligation. He impregnated the patient’s mother, when he was only 19 years old, then eloped with her, thwarting him to finish his studies then at the University of Mindanao. As a father, he was lenient in his relationship with his children. Most of his time is spent in their rice mill and would only go home in the afternoon or at night. Moreover, he is a kind of father who would not spank or scold his children and he seldom verbalizes what he feels. He would only speak to his children wherever they do something incorrect.
19
c. Mother The mother helps in their small rice mill. Pregnant at the age of 18, she was unable to finish her college education at the University of Mindanao. She was in her second year in college when she dropped out of her Chemical Engineering course. The mother says that she brought her children up in discipline and love; she said she doesn’t spank her children because it does them no good. Like the father, she doesn’t also believe in punishing her children through spanking and the like when they do something wrong. However, as she states, she left her children to the care of nannies when they were young. And put her children in their house in Davao City to pursue their education from elementary school, leaving them, still with a nanny, and visiting them once a week. According to her, this is the best way for her to offer the best education and life to her children and help improve their business in Agusan. d. Siblings The family is composed of five siblings; Bob being the eldest, followed by the second informant, Emman, then by Carmz, Denns and then Yose . His relationship with his siblings is not so good. As a child, although they were the only ones that he would play with, he would still isolate himself when with them. He never shares his thoughts with them. Furthermore, when they grew up and the illness took place, the siblings gradually got irritated with him because of his hostility towards others. 20
III. Personality History a.) Prenatal Being the result of the early pregnancy of his mother, the patient was an unexpected child. Only 18 when she was impregnated, the mother was not ready and did not know what to do, so she eloped with the patient’s father without giving her parents the knowledge as to the reason why she ran away. The mother stayed with the father’s family in Cagayan for the whole duration of her pregnancy. On course of nine months, the mother has adequate prenatal check-ups at a nearby health center. Moreover, she was able to eat adequately because the parents of her husband supported them. They provided her with enough support for her pregnancy. b. Birth Bob was born in the Provincial Hospital in Cagayan de Oro City on the 9th of April 1969 through Normal Spontaneous Vaginal Delivery. No complications took place in the delivery. The mother, Aina, described that her labor was very long, she started having labor pains in the morning and delivered in the afternoon. She did not also breastfeed the patient because she is having pain breastfeeding him and as reported, no breast milk would come out; so instead, she bottle fed the patient with a 21
formula milk in a timed manner. Moreover, she hired a nanny named Nena to look after the baby because she did not have any experience in taking care of a baby, considering her age. c. Infancy and Childhood Characteristics After the birth, in June of 1969 Aina went back to Agusan to talk to her parents. She told them that she ran away because she was pregnant and apologized for everything that she has done. Her parents did accept her apology and welcomed her back. On the August of 1969, Aina and Danni married each other and decided to reside in Agusan. Trying their luck in a new business, the couple got busy with their rice mill that they decided to leave Bob in the care of Nena, Bob’s nanny since birth, while they attend to their business. The nanny was very caring to the child, cuddling him always and looking after him. However, when Bob was almost five months, Nena went home to her province and was replaced by another nanny named Ging-ging. Moreover, Aina instructed her nanny to continue the timed bottle feeding routine every three hours, a routine which continued until the patient was three years old. She instructed to feed the baby every three hours, believing that this would help the nanny attend to other tasks while taking care of the baby. In cases that the baby would cry Ging-ging would just give him a pacifier for him to stop crying. Bob was toilet trained when he was 2 years old. Toilet training was mostly implemented by the nanny Ging-ging, and she is not strict in it. As he had a nanny, Aina instructed the Ging-ging to teach him to urinate and defecate in a potty because 22
it irritates her to find urine and stool just anywhere. Aina is very strict in toilet training. But on instances that Bob would pee or defecate anywhere, Ging-ging would just clean the mess, not correcting Bob. Bob started talking when he was a year old and started walking on that certain age more or less as reported. As to the strategies and the relationship of the nanny to the child, the mother did not exactly describe because according to her, she changed nannies several times. According to her, the relationship of the nanny was not so important to her as long as the needs of her children are met and her children’s safety is not harmed. She carefully instructed the nannies to give to the children everything they want to keep them from having tantrums that could hinder the nanny from doing other household chores. The mother could not remember whether or not the patient’s immunization is complete; but what she does remember is that the patient had measles before he was one year old. d. Psychosexual History The patient’s sexual awareness started when he was 16 years old, on his 4th year in high school. It was on this time that he started having a crush and actually had a girlfriend who after sometime broke up with him. This break-up with his only girlfriend bagged down his self esteem. In addition, his mother also keeps on teasinf him that his girlfriend’s teeth resembles that of a rat which further decreased his self-confidence and esteem as he tried to compare himself with the boys of his age. In his adolescence, he also engages in sexual activities with GROs. 23
e. Play Life Bob does not engage so much in cooperative play and prefers solitary play. He would only sit by himself and play alone in a corner. His playmates were his siblings and would choose to play only in their yard. As a child, he is not talkative, he is uncooperative and becomes aggressive when forced to play with other kids. Furthermore, he likes being a follower in a game rather than a leader. f. School History The patient began preschool in June of 1974, when he was five years old where he was sent to Davao to study at Assumption up to second grade. He stayed in their residence in Davao which is in 162, Interior Tulip Drive, Matina, Davao City. He stayed in Davao together with his brother Emman and their nanny. The first days in school were terrible for Bob, he would cry inside their classroom and would not separate from his nanny. In his third grade, he was transferred to Our Lady of Fatima School, which he did not really approve that he cries in between classes just to be sent home. He is withdrawn from the rest of his classmates and would talk only to a few people. His grades were also affected by his isolation, he did not perform well in school and was not interested in studying. He spent his high school days still at Fatima. In June of 1982, when he is 13 years old, he entered first year highschool, where he formed new set of friends which he grew much attached to. These friends of him were not of good influence because when they started hanging out, he began cutting classes, extorting money from his parents and having low grades. He started drinking and smoking. Also, he started using marijuana.
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His bad school records started worsening when his girlfriend in his fourth year high school broke up with him, these events pulled his confidence down, that he started isolating himself and increased his use of marijuana, drinking and smoking. Yet he is able to graduate from high school in the March of 1986. Troubles in school were rampant, being evident even when he is already in college. He was occasionally caught brawling with classmates. Furthermore, his mother was once called by the Guidance Office because he threw an eraser to his teacher because the eraser hit him when the teacher threw the eraser at his classmate. He was also suspected of using marijuana during this time but is persistently denying the accusations, although it was really true. Peer pressure can be seen as a great contributing factor in his use of marijuana because his friends would tease him when he refuses to use marijuana.
In his college days, he spent his two years of college education at the University of Mindanao, in the Civil Engineering course. However, he did not have good grades and still continued cutting classes and indulging in his vices. On his second year, he finally decided to stop, claiming that he is already having difficulty catching up with the lessons. g. Religious and Social Adaptability The family is Roman Catholic. However, when he was in college, their family converted to Seventh-day Adventists. However, the patient still follows the Catholic Faith and does not go to Seventh-day Adventist religious celebrations. h. Occupational History 25
When the patient stopped studying during his second year in college, late in the August of 1987, he stayed in Agusan and helped in their rice mill business. There, he would help in the loading and unloading sacks of rice and also in operating the mill. Bob doesn’t get regular salary because what he gets is ten percent of the day’s income. i. Marital History The patient is single. However, he is looking forward to marrying someday. According to his verbalizations, he wants to be married so badly that he would even marry their maid at home. According to him, he already told the maid that he wanted to marry her, but unfortunately, after telling her, the maid ran away. j. Onset of the present illness The recent admission is already the third admission of Bob. Recurrence of hostile behavior is the primary reason why Bob was admitted for three days in the CIU of Davao Mental Hospital. He suddenly shouted at a doctor in the hospital upon having his monthly depot injection and check-up.
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THEORIES OF DEVELOPMENT These are just a few of the fascinating aspects of the field of “human development”: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each theory has its own perspective on the development of man. ERIK ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future.
LIFE STAGE
INDICATORS
INDICATORS
OF POSITIVE
OF NEGATIVE
RESOLUTION RESOLUTION Infancy (birth to Learning how Mistrust, 1 year)
to trust others
Central
task:
Trust
vs.
Mistrust
ASSESSMENT
Mistrust
JUSTIFICATION
Aina, his mother,
withdrawal,
did not breastfeed
estrangement
Bob because she is having
pain
breastfeeding
him
and as reported and no
breast
milk
The first stage,
would come out; so
centers
the
instead, she bottle
basic
fed the patient in a
infant's
on
27
needs being met
timed manner. She
by the parents.
would feed the baby
The
infant
every three hours,
depends on the
believing that this
parents,
would
train
the
baby
to
be
especially
the
mother, for food,
disciplined.
sustenance,
and
Moreover, she hired
comfort.
If the
a Yaya Nena to
parents
expose
look after the baby
the
child
warmth
to and
dependable affection,
because she did not have
any
experience in taking the
care
of
a baby,
infant's view of
considering her age.
the world will be
After 5 months on
one of trust.
the service, Yaya
if
the
Nena left and Yaya
caregivers
are
Ging-ging
neglectful,
the
over her place in
But
took
taking care of Bob.
infant
instead
learns
mistrust-
Because Bob was
that the world is
given not enough
in
attention and left
an
unpredictable
under a care of a
and
nanny he had built a
place.
an
unsafe
sense of mistrust to his parents. He has not been fed well since he’s being fed in a timed manner, he hasn’t feel the 28
sense of comfort since
his
parents
haven’t been there for him to cuddle him
when
he’s
crying or to play with Early Childhood Self(2 to 3 years) Central
without loss of self-discipline
task: self
Autonomy
self-
necessary. Shame and doubt The patient started talking
when
he
was 1 year old and
to willfulness and
started walking on
cooperate
and defiance
caregivers express oneself
encourage
when
–esteem; Or compliance;
vs. ability
Shame & Doubt If
control Compulsive
him
that age as well. The
patient
was
toilet trained when he was 2 years old.
sufficient behavior,
child
As he had a nanny
develops a sense
(Yaya
Ging-ging),
of autonomy- a
the
sense of being
instructed
able to handle
Ging-ging to teach
many things on
him to urinate and
their own. But if
defecate in a potty
caregivers
because it irritates
mother Yaya
too
his mother to find
much too soon,
urine and stool just
refuse
let
anywhere, she was
children perform
too demanding that
tasks of which
the child will learn
they are capable;
how to toilet train
children
may
right away. On the
develop
other hand, Yaya
demand
instead
to
Ging-ging
doesn’t 29
shame and doubt
train him well; she
about
their
has not disciplined
ability to handle
the child well if the
things.
child
pees
anywhere
because
of
unstrict
the
training Yaya Gingging
implemented
on Bob. The child was
unable
to
master this kind of task in this stage, since he developed the sense of shame and doubt in which he was unable to handle
things
because
of
the
different implementation
of
the nanny and his Late
Childhood Learning degree Lack
(4 to 6 years) Central Initiative
of
self Guilt
of assertiveness confidence;
task: and
purpose pessimistic and
vs. influence
Guilt
the over restriction
environment;
of own activity
mother. The client does not engage
much
cooperative
play
and prefers solitary play.
He
would
to this begins stage, the child evaluate one’s learns to take own behavior.
only sit and play
initiative and get
mother and brother,
ready
he’s a silent type of
During
for
alone in a corner. According to his
person,
he’s
not 30
leadership
talkative. He likes
and
goal achievement
playing
roles.
bike and would play
If
together with his
and
siblings.
support
As verbalized by
children’s efforts,
the mother, when
while
also
playing, he was a
helping
them
follower.
make
realistic proper
his
only in their yard
adults
encourage
with
and choices,
children develop initiativeindependence in planning
and
undertaking activities. But if, adults discourage the
search
of
independent activities, children develop guilt about their needs
and
desires. School Age (7 to Developing 12 years) Central Industry Inferiority
sense
Sense of being Inferiority of mediocre;
Task: competence and withdrawal vs. perseverance
He
attended
his
nursery until Grade 2 in Holy Cross of
from peers and
Davao
College.
school.
When he was grade 3, he transferred at 31
stage,
Our Lady of Fatima
are
School. There, he
learn
again developed a
accomplish
separation anxiety,
more
complex
as he needed to
skills:
reading,
leave
At
this
children eager and
to
writing,
telling
his
friends,
old
teachers
and classmates. He
time. If children are encouraged
to
make
do
and
things and are then praised for their accomplishments , they begin to demonstrate industry by being diligent, persevering tasks completed putting
at until and work
before pleasure. If children are instead ridiculed or punished for their efforts or if
was a silent type of person and not very cooperative
and
expressive.
He
withdraws himself with his classmates, he only have few friends due to lack of interaction with them.
He
displays
also poor
performance school
in and
uninterested
with
his studies. He has not
met
the
expectations of his parents from him, which is to do well in his studies.
they find they are incapable
of
meeting
their
teachers'
and 32
parents' expectations, they
develop
feelings
of
inferiority about their capabilities. Adolescence (13 Sense of to 19 years) Central
and
plans
self Feelings
of Role Confusion
to confusion,
Task: actualize one’s hesitancy,
At this stage the client had his first
and
year high school at
Identity vs. Role abilities
possible
Holy Cross College
Confusion
antisocial
of Davao and later
The adolescent is
behavior
on,
they’ve
newly concerned
transferred to Cebu,
with how they
he enrolled himself
appear to others.
to Cebu Avillana
The
of
High School, and
identity
there, due to being a
appears through
shy type, he had not
sexual,
gained new friends.
emotional,
A certain group of
educational,
people make friends
ethnic,
cultural,
with him but they
vocational
were bad influence.
sense
central
and
discovery.
The
adolescent person
He started drinking and
also
smoking
because
of
peer
develops
pressure. Also, he
coherent sense of
started
using
self and plans to
marijuana,
when
actualize
one’s
they
group
abilities.
The
sense of self can
have
sessions
he’s
cutting his class and 33
be confused if a
because of his vices
core
identity
he always got low
does not solidify.
grades. When he
Feelings
was 4th year high
of
confusion, hesitancy,
school and
(16
years
old), he met his first
possible
love and became his
antisocial
girlfriend, but when
behavior also emerge.
may
he brought her at home, her girlfriend was being criticized by his mother to have big front teeth which are similar to a rat, this incident bagged down his self-esteem.
He
spent his two years of college education at the University of Mindanao, in the Civil
Engineering
course.
However,
he did not have good
grades
still
and
continued
cutting classes and indulging vices
and
stopped
in
his
finally studying
when he was in 2nd year
high
school 34
due to difficulty in catching up with his Early Adulthood Intimate
Avoidance
(20 to 34 years)
relationship,
Central
relationship
Task: with
Intimacy
another career
of Isolation
a
sense
the
relationship he had, or
vs. person and has lifestyle
Isolation
lessons. After though
crushing
with other girls, he
of commitments
never
developed
people commitment to and have established work their identities, relationships
another
they are ready to
had
make long-term
intimate
commitments to
relationships
others.
They
friends, though he
become capable
considers people to
of
be his friends, he
Once
intimate
relationship
with
another woman. He
forming
not
form with
intimate,
didn’t trust them
reciprocal
enough. He felt that
relationships and
he’s being envied
willingly
make
by his friends. He
the sacrifices and
continues to isolate
compromises
himself from others.
that
such
relationships require. If people cannot these
form intimate
relationships--a sense of isolation may result. Middle
Working
Lack
of Stagnation
The patient is not so 35
Adulthood ( 35 towards to 65 years)
the productivity;
Central
betterment task: the
During
helping
his
illness.
He’s
society; society to move
being dependent to
forward
his family, though
Generativity vs. being Stagnation
of not
productive due to
productive
generating
small
middle
income for helping
age the primary
in the Rice Mill, but
developmental
still he’s not being
task is one of
productive because
contributing
the little money he
society
to and
earned
is
being
helping to guide
wasted for buying
future
what
generations.
prohibited for him
When a person
to be used, like
makes
marijuana
and
cigarettes
that
a
contribution
is
being
during
this
contributes
in
period,
perhaps
worsening
his
by
raising
family
a or
illness. He has no own
family
to
working toward
support that’s why
the betterment of
he
society, a sense
money for his own
of generativity- a
wants.
sense
of
wasted
When
his
he
productivity and
had free time, he
accomplishment-
went to the plazas
results.
In
or parks to eat or
contrast, a person
drink. He also loves
who
self-
to watch television
and
shows. The client
is
centered
36
unable
or
also adapt to his
unwilling to help
physical changes in
society
his
move
body
and
forward develops
accepted this as part
a
of him, about his
feeling
of
stagnation-
disease, he hasn’t
dissatisfaction
understand
with the relative
fully
lack
further explanation
of
and
this needs
productivity.
for
A person in this
understand. And as
stage
a Filipino citizen,
have
should time
for
him
to
he has done his part
companionship
in becoming a good
and
citizen,
recreation.
he
is
a
He also knows
registered voter and
his
planned to vote for
responsibilities
Noynoy Aquino in
and knows that
the coming election
he is accountable
period, in a way
of
he’s
whatever
actions he takes.
being
productive because he has done his duty
for
the
betterment of the country. But still, he’s not helping the country
to
forward
since he
had
violated
move the
Republic Act 6425 or the Dangerous 37
Drug Act of 1972, Article III, Sec. 8 which is regarding the usage of the prohibited drugs.
SIGMUND FREUD’S PSYCHOSEXUAL THEORY The concept posits that from birth human have intellectual sexual appetites (libido) which unfold in a series of stages. Each stage is characterized by erogenous zone that is the source of libidinal drive during that certain stage. LIFE STAGE CHARACTERISTICS IMPLICATIONS ASSESSMENT Oral (Birth to 1 The center of pleasure Feeding NOT
JUSTIFICATION Though the
1/2 year)
mother,
is the mouth; it is the produces major
source
of pleasure, a sense comfort
Aina,
doesn’t breastfed
pleasure
and of
or
her child because
satisfaction
and ease and safety.
she felt that it is
exploration.
The Feeding
should
painful, still he
child’s primary need be pleasurable, it
feds Bob through
is security or safety.
be
bottle-feeding but
when
in a timed manner
Major
should
conflict: provided
weaning ANAL (1 1/2 The to 3 years)
ACHIEVED
necessary. sources
which is every 3
of Controlling
pleasure are the anus expelling and
the
(sensual
feces ACHIEVED
bladder give pleasure and
satisfaction, sense of comfort.
self control).
Toilet
Major conflict: toilet should training.
and NOT
hours. Toilet
training
was
not
strict.
Bob
was
toilet
trained
by
his
training
nanny which was
be
instructed by his
a
pleasurable
mother to instruct
experience.
him to defecate in 38
a
potty.
nanny,
Her Yaya
Ging-ging not
able
implement
was to well
the instructions of her Ma’am Aina, the Bob,
mother Bob
of was
still urinating and defecating everywhere. Yaya Ging-ging not
able
discipline well
when
was to Bob it
comes to toilet PHALLIC (4-6 The genitals are the The years)
child ACHIEVED
training. At this stage, he
center of gratification. determines
was able to learn
Masturbation
that a boy is for a
offer together with the
pleasure to the child. parent
of
the
Other actions include opposite sex and fantasy,
girl, and a girl is for a boy.
later takes on a
experimentation with love relationship peers, and questioning outside
the
of adults about sexual family. issues
or
sexual
matter. Major conflicts: the Oedipus
Complex
(refers to the male child's attraction for 39
his
mother
unfriendly towards
and
attitudes his
father)
and Electra Complex (refers to the female's attraction
for
her
father and sees her mother as her rival), which resolves when the
child
when
identifies
the
child
identifies with parent of same sex. LATENCY (6 Energy is heading for Encourage child NOT
He started to go
years
to school by this
puberty)
to physical
and with physical and ACHIEVED
intellectual activities. intellectual
time;
Sexual impulses tend pursuits.
gained
to
friends and few
be
repressed. Encourage sports
he
few
Develop relationships and
other
playmates
between peers of the activities
with
because
same sex.
same-sex peers.
had
he
prefers himself to be
alone.
He
isolates himself to his peers. He had not
been
performing
well
to
school
and
uninterested
to
study his lessons. Genital (puberty after)
Energy and toward
is
directed Encourage
NOT
full
sexual separation
from ACHIEVED
independent, until
being
now , he
maturity and function parents,
He
is
not still 40
and development of independent and
lives
skills needed to cope able
parents and being
with the environment.
to
make
with
right and good
dependent
decisions
them,
his to
especially
when it comes to his basic needs and as well as to meet his personal needs to gratify his desires, like asking money to have
sexual
gratification together
with
some GROs and to buy marijuana or cigarettes. He’s not matured when it comes to his sexuality.
JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT This theory pertains to the nature and development of human intelligence. LIFE STAGE CHARACTERISTICS ASSESSMENT Sensorimotor Thought • In this stage, inACHIEVED
JUSTIFICATION The client as an infant
(birth-2years)
fants build an un-
was
derstanding of the
breastfed
world by coordi-
mother; he was fed
nating sensory ex-
with the use of the
not
being by
her
41
periences (such as
bottle, when giving
seeing and hear-
the bottle, the infant
ing) with physical,
Bob grasp it as a
motoric actions.
response
Infants gain
hungriness.
knowledge of the
mother, at times, gives
world from the
him a pacifier when
physical actions
the child is crying thus
they perform on
fulfilling the child’s
it. An infant pro-
wants.
of
his The
gresses from reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage. •
Thought derives from sensation and movement.
•
The child learns that he is separated from his environment and that aspects of his environment continues to exist even they may be outside the reach of
Preoperational Thought (2-7 years)
•
his senses. Thinking is still egocentric: has
ACHIEVED
At this age, was fond of
drawing
that 42
•
difficulty taking
represents his ideas.
the point of view
He also draws to show
of others.
what is inside of him,
The children begin
to express his feelings
to represent the
through images that
world with images
he creates.
and words. Symbolic thought goes further than connections of sensory information and physical action. •
Objects are classified in simple ways, especially by significant feature; the child isn’t able to conceptual-
Concrete Operational •
ize abstractly. The child starts to
Thought (7-12 years)
think abstractly
how to arrange his
and conceptualize,
things systematically
forming logical
or in order depending
structures that ex-
on its size, shape or
plains his or her
any
physical experi-
characteristics;
ences.
disorganized when it
Children can exe-
comes to his things.
•
NOT ACHIEVED
Bob does not know
other he’s
cute operations and logical reasoning replaces intuitive thought as 43
long as reasoning can be applied to specific or concrete examples. •
Children show thinking is decentered -they consider multiple aspects of the problem (e.g. understanding the significance of height and width). They focus on the dynamic change in the problem. And, most importantly, they show the reversibility of true
Formal
Operational •
mental operation. The person is ca-
ACHIEVED
During this stage, the
Thought (12 years and
pable of deductive
client was able to
above)
and hypothetical
understand what love
reasoning.
means
The logical quality
about his plans about
of the adolescent's
getting married in the
thought is when
future
children are more
chance;
likely to solve
wanted to marry their
problems in a tri-
helper, according to
al-and-error fash-
him. Though he never
ion.
courted the girl, he
•
.He
if
shared
given he
a
really
44
•
•
•
During this stage
just directly asked her
the young adult is
to marry him but the
able to understand
woman
such things as
answer him and went
love, "shades of
home
gray", logical
hometown.
proofs and values.
In addition to that,
During this stage
when asked, “Kung
the young adult
makakita ka ug pitaka
begins to entertain
na
possibilities for
unsaon man nimo ang
the future and is
pitaka, iuli o gastuhon
fascinated with
ang kwarta?”; he then
what they can be.
replied “Iuli nako, kay
At this stage, they
basig
can also reason
tag-iya ang kwarta.”
logically and draw
He was able to draw
conclusion from
conclusion from the
what information
given
is available.
available.
refused to
punog
to their
kwarta,
kailangan
sa
situation
45
ETIOLOGY AND SYMPTOMATOLOGY A. ETIOLOGY
Predisposing Present/ Absent Factors Family History
Absent
Rationale
Justification
Individuals
with Schizophrenia is not
schizophrenia
seem
to present in any of the
inherit a predisposition to family members of the
disorder
schizophrenia
because the patient in both runs
in paternal and maternal
families. The relatives of lineages. individuals
with
schizophrenia
have
a
greater incidence of the disorder than chance would allow.
Although
an
amazing
amount
of
resources
have
directed genetic
at
finding cause
been the of
schizophrenia, the results are far from specific. In fact,
almost
every 46
chromosome
has
been
linked with schizophrenia. Keltner, Neurostructural
Absent
Anomalies
N.
Psychiatric
Nursing. Chapter 4. The theorists proposed
have The patient’s chart that did not show any
schizophrenia, is a direct laboratory results to effect
of
three confirm the existence
nuerostructural
defects. of such anomalies if
Ventricular brain
enlargement, such are present in
atrophy
dysfunctional blood
and the patient. cerebral
flow.
These
anatomical anomalies in the brain play a major role in the illness. Keltner,
N.
Psychiatric
Nursing. Chapter 4. Precipitating Present/ Absent Factors Intake of drugs, Present
Dopamine is known to be The patient admittedly
substances
or
the neurotransmitter which takes marijuana since
chemicals
which
is prominently affecting he was thirteen. All
increase dopamine.
levels
of
Rationale
the
occurrence
Justification
of informants also concur
schizophrenia. In patients that
the
patient
is 47
with
schizophrenia, indeed
dopamine
levels
using
are marijuana.
invariably high. Therefore, intake or use of drugs, substances and chemicals which
promote
elevation
of
the
dopamine
levels in the brain would trigger
schizophrenia.
Example
of
levodopa,
these
are
ampethamines
and marijuana. Keltner, Perinatal Factors
Absent
N.
Psychiatric
Nursing. Chapter 4. Some researchers believe The mother did not that schizophrenia can be report
any
linked
perinatal abnormalities
and
influenza, complications
during
to
exposure birth
to during
winter, her
pregnancy
and
exposure to lead, minor birth. The mother also malformations during early verbalized no exposure gestation,
exposure
to to
any
infections
viruses from house cats during her pregnancy. and
complications
pregnancy,
of
particularly 48
during labor and delivery. Keltner, Developmental Factors
Present
N.
Psychiatric
Nursing. Chapter 4. Developmental factors There are some stages include
the
internal of
development
reaction of an individual to according to Erikson life stressors or conflicts. that the patient did not Three theorists could be successfully meet. considered here: Meyer, Freud and Erikson. For Meyer, events in early life can cause problems that are
as
severe
as
schizophrenia. For Freud, developmental include
factors
poor
boundaries,
ego
fragile
inadequate
ego, ego
development,
superego
dominance, regressed or id behavior,
ambivalent
relationships and arrested psychosexual development. Furthermore, Erikson
believed
that 49
eight-stage
model
of
human
development
starting from Trust Vs. Mistrust highly influences development condition.
of
the The
accomplishment or failure in the levels affect a person’s
developmental
aspect. Keltner,N. Convulsion
Present
Psychiatric
Nursing. Chapter pp. Convulsion, in medicine, The
patient
had
a
series of involuntary con- convulsion when he tractions of the voluntary was
18
years
muscles. The eyeballs fre- Informants
old. have
quently roll upward or to attested that after the one side during a convul- incident, sion; breathing appears la- started bored, and saliva oozes behavior
the having
patient odd and
from the mouth. The teeth disturbance in thought usually
are
tightly process.
clenched, sometimes causing serious bites to the
50
tongue and the cheeks. Convulsions are a common symptom of epilepsy. They also occur in young children as a part of the reaction of the body to infection.
Such
convulsions,
called febrile convulsions, usually last only a few minutes and are not dangerous. Other causes of convulsions are virus infections; brain tumors or hemorrhages;
toxemias,
such as uremia or lead or cocaine poisoning; chemical disorders, such as hypoglycemia; and acute or chronic alcoholism. A doctor
should
be
notified
whenever a convulsion occurs. Until the arrival of a physician,
emergency
treatment is directed to51
ward protection of the victim from biting or other forms of self-injury. Anticonvulsant drugs include diazepam,
phenobarbital,
and phenytoin. A convulsion may have a significant effect in an individual due to restriction of brain oxygenation in the occurrence of the convulsion. Damage to brain tissues range from mild to severe depending on the type of convulsion and how long. Furthermore, brain cell damage is irreversible. Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.
B. SYMPTOMATOLOGY Symptoms
Present/Abse
Rationale
Justification 52
nt
OBJECTIVE SIGNS A. Alterations in Personal Relationships Decreased
Present
attention to
Frequently, patients become less The patient has troubled concerned with their appearance and relationship with other
appearance and
might not bathe without persistent people.
social amenities
prodding. Table manners and other
related to
social skills might diminish to the
introspection and
point that the patient becomes
autism. Inadequate or inappropriate communication
disgusting to others. Present
Keltner, N. Psychiatric Nursing. Patients with schizophrenia have Communication troubled
personal
relationships. of the patient show
Often, these problems develop over a constant long
period,
schizophrenia
well
incoherent
before statements,
is diagnosed,
and circumstantiality,
become more pronounced as the tangentiality illness
skills
progresses.
It
is
and
the
not like which are highly
uncommon to hear that a person was indicative of inadequate asocial, loner or a social misfit and before being diagnosed.
inappropriate
communication.
Keltner, N. Psychiatric Nursing.
53
Hostility
Present
Hostility can also be a common
As the illness progresses
theme, which distances patient from
the hostility became ap-
others.
parent in the patient. The
Keltner, N. Psychiatric Nursing.
patient has tantrums, confronting people with no apparent reason, tumbling tables and chairs and wants to hit people.
Withdrawal
Present
Patients withdraw,
with
schizophrenia
which
further
compromises their ability to engage in meaningful activities. Keltner, N. Psychiatric Nursing
As the informant could remember the patient prefers solitary play in his childhood. Moreover in his adolescence he would hangout with a few friends. Patient has diminished or lost interest in communicating with people.
B.
Alterations in Activity
Psychomotor
Absent
retardation
Catatonic rigidity
Absent
Psychomotor retardation, the markedly slow
The patient did
speech and body movements which occurs
not exhibit this
as a symptom of schizophrenia
symptom.
Keltner, N. Psychiatric Nursing Patients with schizophrenia also display
The patient did
alterations of activity. They may be too
not exhibit this
active or they may be inactive or catatonic.
symptom 54
Keltner, N. Psychiatric Nursing
SUBJECTIVE SIGNS A.
Altered Perception
Hallucinations
Present
Hallucinations
which
Absent
false
Hallucinations, espe-
sensory perceptions, which can be
cially those which are
auditory, visual, tactile, gustatory or
auditory in form is
somatic
are
highly evident in the
by
verbalizations of the
.
Hallucinations
probably
Illusions
are
caused
hyperdopaminergic state in the
patient and also in his
limbic areas.
actions as described by
Keltner, N. Psychiatric Nursing
the informants.
Illusions are misinterpretations of
The patient does not ex-
stimuli.
hibit this symptom.
Like
hallucinations,
illusions also occur as a result of hyperdopaminergic state in limbic areas. books.google.com.ph/books? Paranoid thinking
Present
isbn=0471245313 Suspiciousness of others and their
In connection to perse-
actions also occur as a symptom of
cutory delusions of the
schizophrenia which happens due to
patient, he is becoming
the
suspicious and distrust-
alteration
of
the
normal
perceptual pattern of an individual
ful of people around 55
affected by the condition.
him. He is in deep be-
www.asialink.unimelb.edu.au
lief that people are out there trying to kill him, thus, he becomes paranoid.
B.
Alterations of Thought
Loose associations Present
This is the stringing together of unrelated
Loose associa-
topics with vague connection. This occurs as
tions can be
a result of the altered thought process in
traced in many
individuals with schizophrenia.
of the state-
Keltner, N. Psychiatric Nursing.
ments made by the patient in conversations. Details which do not have anything to do with the topic are being mentioned by the patient.
Retardation
Absent
Retardation is the slowing of mental
This symptom
activity, which is also a direct effect of
is not exhibited
thought process alterations in individuals
by the patient.
affected by schizophrenia. 56
Keltner, N. Psychiatric Nursing.
Blocking
Present
Blocking is the interruption of a thought and
Blocking is ap-
inability to recall it. Blocking may be caused
parent in con-
by the intrusion of hallucinations, delusions
versations with
or emotional factors.
the patient.
Keltner, N. Psychiatric Nursing.
There are several instances wherein he would suddenly stop right in the middle of a conversation.
Ambivalence
Absent
Ambivalence is a state in which two
This symptom
opposite
is not exhibited
strong
feelings
exist
simultaneously. Schizophrenic patients may be
immobilized
by
their
by the patient.
ambivalence
regarding a matter as simple as deciding whether to drink an apple juice or an orange juice. Delusions
Present
Keltner, N. Psychiatric Nursing. Delusions are fixed false beliefs and can
Persecutory
take many forms. Delusions are defined as
delusions are
false belief firmly held by a person even
highly evident 57
though other people recognize the belief as
in the patient’s
obviously untrue. For example, a person
verbalizations
who truly believes he is Napoleon Bonaparte
and actions de-
is delusional. Religious beliefs or popular
scribed by the
conceptions, such as the belief that people
informants.
have been abducted by aliens, are not delusions because they are widely held beliefs. Delusions are a type of psychotic symptom that indicate a person has lost contact with reality (see Psychosis). There are many different types of delusions. A person with a paranoid delusion believes that others—such as the FBI, CIA, or the Mafia—are trying to harm or plot against him or her. A person with a delusion of reference believes that events or people refer specifically to him or her when they do not. For example, a woman with schizophrenia may believe that a television news broadcaster is talking personally to her rather than to the entire viewing audience. A grandiose delusion is a belief that one is extremely famous or that one has special powers, such as
58
the ability to magically heal people Keltner, N. Psychiatric Nursing. en.wikipedia.org/wiki/Delusion Poverty of Speech Absent
Poverty of speech is manifested by the
This is not
inability to formulate and articulate thoughts
manifested by
that are relevant to the discussion at hand.
the patient.
This is also highly connected in the alterations of thought process taking place in individuals with schizophrenia. Ideas of
Absent
Reference
Keltner, N. Psychiatric Nursing. Ideas of reference and delusions of reference
This is not ex-
involve people having a belief or perception
hibited by the
that irrelevant, unrelated or innocuous
patient.
phenomena in the world refer to them directly
or
have
special
personal
significance. In psychiatry, delusions of reference form part of the diagnostic criteria for psychotic illnesses such as schizophrenia during the elevated stages of mania. Autism
Absent
Keltner, N. Psychiatric Nursing. Autism occurs when patients
are
so
This is not
introspective that they are distracted from
manifested by
external
the patient
events.
Patients
become
preoccupied with themselves and may be 59
oblivious to the reality around them.This results in a personalized view of reality. Keltner, N. Psychiatric Nursing. C.
Altered Consciousness Confusion
Present
Confusion is an anxiety-producing symptom
Disorientation
that is associated with psychosis. Keltner, N.
to time is evi-
Psychiatric Nursing.
dent in the patient. The patient is obviously confused as to the time and chronological arrangement of events in his life.
Incoherent Speech
Present
Like confusion, incoherent speech is also a
The patient
direct
displays inco-
effect
of
schizophrenia
in
the
functioning of an affected individual.
herent speech
Keltner, N. Psychiatric Nursing.
as evidenced by the disorganization of thoughts and flight of ideas which are illogical to fol60
low.
D.
Alterations in Affect
Inappropriate,
Absent
Affective
flattening,
inappropriateness,
This is not
blunted, flattened
lability are affective symptoms sometimes
manifested by
or labile
associated with schizophrenia. They often
the patient.
respond to antipsychotic drug. Flat affect is a
cardinal
symptom
of
negative
schizophrenia and may only respond to an atypical antipsychotic drug. Apathy
Absent
Keltner, N. Psychiatric Nursing. Apathy is another symptom associated with
This is not
the affective alterations brought about by
manifested by
schizophrenia. It can be defined as a lack of
the patient.
concern or interest. It is the inability to generate a normal response to people, situations or the environment. Overreaction
Present
Keltner, N. Psychiatric Nursing. Because of emotional limitations,
the
The patient
schizophrenic patients overreact to normal
overreacts to
events to overcome mental and social
normal situa-
inertia. Keltner, N. Psychiatric Nursing.
tions. The informants verbalized that the 61
patient overreacts even in simple television shows. Anhedonia
Absent
Anhedonia is the inability to experience
This is not
pleasure which is highly associated with the
manifested by
detrimental effects of schizophrenia in the
the patient.
affect
of
individuals
schizophrenia.
Keltner,
suffering N.
from
Psychiatric
Nursing.
62
PSYCHODYNAMICS
63
NARRATIVE PSYCHODYNAMICS Bob’s parents, Aina and Danni, eloped at the age of 18 and 19 respectively. They ran away to Cagayan because Aina got pregnant. They lived together with Danni’s parents there while Aina’s parents did not know about anything. Anxiety, guilt and shame caused emotional distress in both of them in this stage. Both undergraduates in their courses, Aina and Danni, stopped studying and were dependent to Danni’s parents to support them in Aina’s pregnancy. Danni’s parents, supportive of their child, provided a jeepney for Bob to use as a temporary means of income for them to use in the course of Aina’s pregnancy. In the course of her pregnancy, Aina had adequate prenatal check-ups at a nearby heath center. Young for pregnancy and emotionally anxious, Aina’s situation puts her child, Bob at high risk of fetal abnormalities. In the prenatal stage, the mother’s pregnancy is highly affecting the baby. According to researches, the mother’s emotional state during pregnancy may bring about long term effects in the fetus. This is so because stress-induced changes in the endocrine system of a woman during pregnancy is said to cross the placental barrier, thereby, affecting the fetal environment. Researches in low income African American populations in 2002 made by Mulder, et. Al., presented that depressed and anxious mothers during pregnancy were more likely to have negative consequences to the baby which extend far beyond the events of childbirth. During birth, the mother may experience complications, premature labor and delivery and even spontaneous abortion. Depression during pregnancy may also induce immunologic and neurological anomalies in growing fetus. Cognitive impairment, together with motor retardation may also be possible. 9th of April 1969. Aina felt labor pains early in the morning, unfortunately, Danni was out making a living, and it was some time before Danni was successfully called by a neighbor that his wife was already in labor. Aina was rushed to Cagayan de Oro Provincial Hospital. There, she 64
delivered Bob through NSVD without any complication. However, according to her labor was rather long and extremely painful. From birth, Bob was left in the care of a nanny named Nena. Aina entrusted Bob to Nena because she did not have enough skills in tending a child. Furthermore, she also has to go home to Agusan in order to talk to her parents. Bob was not breastfed because Aina felt pain when she attempted to breastfeed Bob. So she decided to feed him with formula milk in a timed manner every three hours. Bob being left to the care of a nanny and the limited presence of his parents, started building the sense of mistrust in the part of Bob as a baby. Furthermore, as Bob was not able to be breastfed, he was unable to absorb significant nutrients from his mother, together with oxytocin and colustrum, which directly contributes to poor mother-child bonding. In the August of 1969, Aina and Danni married each other in Agusan and moved there, starting a rice mill business. Trying their luck on their new business, the couple got busy in their rice mill and left Bob to the care of Nena. They would only go home at night and has poor bonding with the child. As a result feelings of Mistrust formed in the child’s psyche.
Moving on, in Bob’s toddlerhood, the core conflict in this stage, according to Erikson is Autonomy Vs. Shame and Doubt. And in the resolution of this conflict, the child must learn to imitate. Imitation being the core process involved in the resolution of the conflict in this stage, Bob is not at all fortunate. His parents’ availability was limited and the attitude of his mother and nanny were very variable. Thus, Bob developed a sense of confusion and inability to identify to any of his parents. Bob was unable to master skills such as eliminating and dressing up because everything was just handed to him readily by the nanny. Although this “spoiling” of the nanny to Bob may
65
contribute to his sense of autonomy, his lack of figures of attachment bringing about confusion and inability to master certain tasks further outweighs his derived autonomy. Thus, Bob gained doubt. During his play age, Bob was a loner. He would want to be in solitary play. He would only play with his siblings and would only play inside their yard. He was not open to other children. In this stage, the core conflict is Initiative Vs. Guilt. Initiative is the inquiry of the child to the world. The child begins to explore and uncover the wonders of the world around him and use his senses to perceive the order of things. In this stage the child learns to adapt and resolve the conflict thru education. However, Bob was a loner, withdrawing from other people in play. Furthermore, first signs of hostility were noted on Bob at this stage, because he would become hostile whenever asked or forced to join other kids in their play. Bob is also a good follower rather than a leader in games. During this stage, he did not accomplish the developmental task of forming initiative but instead formed sense of guilt. In school age, Bob was as withdrawn as he is in his past developmental stage. He has a difficulty in relating to others and as a result, his school performance is highly affected. He consistently has separation anxiety and cries inside the classroom every time his nanny would be out of his sight. Because of this, Bob was unable to form meaningful relationships with others and thus formed inferiority. In his adolescence, Bob entered high school at the age of 13 in the June of 1982. Bob became attached to a certain group of friends who doesn’t seem to be a good influence to him. As a shy person, Bob didn’t have many friends, so when this small group of people asked him to hang out with them, Bob was overwhelmed, believing that they could provide belongingness and acceptance. Bob treasured this small group of friends because this is all that he has. Bob was easily affected by peer pressure. Fearing rejection if he does not do what his friends would want him to do.
66
So when his friends asked him to join them in their vices, Bob also joined in. Bob started drinking alcoholic beverages and smoking. Worse, Bob also began using marijuana. During his fourth year in high school, Bob was 16 years of age, he met a girl named Rowena and courted her. Rowena became Bob’s only girlfriend. There was actually a time wherein Bob brought Rowena home, but his mother disapproved of her because she said her teeth looks like rat teeth. This created anger and insecurity in Bob. Later on, Rowena broke up with him for an unknown reason. This break up bagged down Bob’s self esteem. He started isolating himself again and increased his use of marijuana, drinking and smoking. In this stage, Bob is obviously not in control of his life. His decisions were affected by the people around him. Even his role in the society and the people that he chooses to be with are dictated by peer pressure and the ideas of his mother. Bob therefore has role confusion. Entering college at 17, Bob went to the University of Mindanao for Civil Engineering course. However, due to his constant to constant absences and tardiness, Bob’s academic performance trampled. Coupled with his consistent use of marijuana, cigarettes and alcohol, Bob’s life was greatly affected. Behavioral changes emerged, his hostility grown so large that he already fights with teachers and brawls with classmates. He was also called in by the Guidance Counselor regarding his behavior. With this in mind, Bob therefore failed to achieve this stage of development and formed isolation. It was also in this stage that the first onset of the illness happened. Bob was 18 back then when Bob stopped studying, he went back to Agusan with his brother. Prior to going to Agusan, he had a convulsion in a trip to Bukidnon in the August of 1987, there he ate his own stool and drank urine from a potty. First persecutory delusion also emerged there. After the incident, Bob was never the same again. He is already having flight of ideas, disorganized speech, hallucinations and extreme hostility. Because of this and his verbalization that there is something wrong with him, he 67
was brought to Davao City for a psychological chec-up. In San Pedro Hospital, no mental illness was diagnosed, but upon their return the next month and transferred to DMH, Bob was diagnosed with schizophrenia catatonic type. After then, Bob constantly visits DMH for his depot. At first, control of symptoms were at its best, but as the years progressed, he was again admitted in the December of 2007 because of the recurrence of symptoms of hostile behavior. The following admission, which is on the 19th of January 2010 was also due to his hostile behavior.
68
MENTAL STATUS EXAMINATION INITIAL Name: Bob
Diagnosis: Schizophrenia Undifferentiated
Age: 40 years old
Physician: Gioia Fe D, Dinglasan, MD
Ward: Crisis Intervention Unit
Date of Examination: January 21, 2009
I.
PRESENTATION A. General Apperance The patient appears to be younger than his real age which is 40. During the interview at Crisis Intervention Unit in Davao Mental Hospital, he wore a green polo shirt, denim shorts, and a pair of slippers and is seated on bed with his mother and sister-in-law. The patient appears to be untidy. He has dirty clothing, unkempt hair, long fingernails and toenails with traces of dirt evidently seen on both. At the time of the interview, the patient was alert and responsive. B. General Mobility a. Posture and Gait – The patient slouches when seated but holds himself erect when standing and walking. His mannerisms include manually hyper extending his fingers and scratching his head. b. Activity – The patient’s movement are organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity. c. Facial Expression – The patient’s facial expressions are very much appropriate to his verbal responses during the interview. He was composed and receptive to whatever the group asks him. 69
C. Behavior The patient was friendly and warm to us during the interview. He was sitting on bed calmly. He interacts well with the group and as what we had observed; he has a good relationship with his mother and his sister-in-law who were present at that time. D. Attitude towards the Examiner The patient accepted the group warmly. He entertained our questions and answered almost all of them. However, his eye contact was poor. He often looks down. II.
STREAM OF TALK A. Characteristic of Talk – During our conversation with the patient, we noticed that he is spontaneous most of the time. However, there are times in which blocking is evident in between his speech. His articulation words were clear but the content is slightly vague. B. Organization of Talk – The patient was eager to talk with the group. He tries to answer every question the group asks him however, in his answers, we apparently observe succession of circumstantiality and tangentiality. He provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesn’t arrive at the answer at all.
III.
EMOTIONAL STATES AND REACTION A. Mood – At the course of the interview, the patient’s mood was euthymic. His feelings were appropriate to the situations as he relays his answers to the group.
70
His mood was just appropriate and basing from his gestures and other nonverbal cues, his mood is fitting to the situation. B. Affect – The patient’s affect is appropriate as well. There is a marked harmony
between thought content, emotional response, and expressiveness. When asked, “Unsa may nabati nimu kadtong nagka-uyab mo?”, he replied, “Lipay kaayo ui. Alangan. Kaw gud daw magka uyab.” with a smile. IV.
THOUGHT CONTROL A. Perceptions – Throughout the interview, the group observed manifestations of illusions and hallucinations. When the patient was asked if he experiences any of the two, he told us that there are times that he hears someone whispering to him. “Naa may gahong-hong sa ako usahay na mag wild daw ko.”, as claimed by the patient. He denied that he had any visual hallucinations however, the mother and the sister-in-law attested that during tantrums, the patient verbalizes that he sees someone whom they cannot see. B. Delusion – There are several types of delusions that are present in the patient as claimed by the patient himself, and confirmed by the mother who witnessed them all. First, the patient claimed that there is some sort of outside force controlling his thought, compelling him into the belief that somebody has aa plan to kill him – which is a clear sign of persecutory delusion. He also has a feeling that others, especially his friends, hate him because they are jealous of him.
V.
NEUROVEGETATIVE STATE A. Sleep The patient usually sleeps at 12 in the midnight and usually wakes up at 5am getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and in71
stead, he just spends his time watching television until he falls asleep. Five in the morning for the patient is too early for him to wake up that is why he attempts to go back to sleep, but then, he is unable to do such. This is a manifestation of late or terminal insomnia. B. Appetite The patient has increased appetite. He eats a lot however, he is choosy in his food. “Ganahan man gud ko mukaon samot na kung lami ang sud-an.”, reported by the patient. “Kusog kaayo mukaon nang bataa na, pero pili-an lang jud ug sud-an.”, as verbalized by his mother. C. Diurnal Variation The patient’s mood varies during the day. He is usually fine in the morning and gets, uneasy, restless, and irritable as the day progresses. Other times, his day starts out worse in the morning and feels better later on. VI.
GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation The patient is well oriented of the time, place and person. When asked during the interview if what date and time was it, he answered correctly. However, as the conversation progressed, we noticed that he is confused and not well oriented with the time. When asked, when did he last used marijuana, he answered, “Two months ago. Mga 2008.” The group finds this statement confusing since two months ago, basing on the date of the interview, is around November of last year (2009). The patient is also oriented with the situation since he knows that he is the Davao Mental Hospital for his treatment. B. Memory 72
The patient has difficulty recalling remote memories. When asked what his age when he went to Bukidnon was, he replied; “Ambot lang. Wala ko kahinumdom.” On the other hand, the patient has a good memory when it comes to remembering recent and immediate memories. C. Calculation The patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and the like. He was able to answer all of them but there we long pauses before he can finally give the answer. D. General Information The patient knows basic general information like the current president of the Philippines and even of the United States. He know the capital of some Philippine provinces and he was able to name the national hero of the country. E. Abstract Thinking, Judgement and Reasoning The patient was given a maxim translated in Visaya to evaluate his reasoning and abstract thinking. He was asked to explain the quote Try and try until you succeed. He was able to explain it but not profoundly. He said, “Maningkamot gud.” And when asked to elaborate, he refused to. He was also given a situation wherein someone left her wallet, and he was asked what he should do. He replied, “Akong i-uli. Di man na akoa so dapat nako i-uli.” VII.
INSIGHTS The patient understands that he needs to go to the hospital for his treatment. Since he was 18, he knew that there is a problem in him and he even asked his mother to bring him to the doctor. However, he does not have concrete understanding of what his illness
73
is. He believes that there is a lube (grasa) in his brain that is why he is acting differently, thus, he has a fair insight.
74
FINAL
Name: Bob
Diagnosis: Schizophrenia Undifferentiated
Age: 40 years old
Physician: Gioia Fe D, Dinglasan, MD
Place of Interview: 162, Interior Tulip Drive, D.C. Date of Examination: January 23, 2009
I.
PRESENTATION A. General Apperance During the home visit the group did, the patient was wearing a blue shirt and denim pants. Again, Bob looked younger that his age which is 40. He was properly groomed and looked like he had just taken a bath. He was actually getting himself ready to go back to Agusan. His fingernails and toenails are still long and dirty. During the interview, the patient was again warm and yet a little aloof to us. He looked happy to see us again for the second time. B. General Mobility a. Posture and Gait – The patient still slouches when seated but holds himself erect when standing and walking. His mannerisms are still present and evident throughout the interview. b. Activity – During the interview, the patient was able to sit straight and fo-
cus on answering the questions asked to him. There is no overactivity or underactivity nor impulsiveness noted. He was very calm and composed along the interview.
75
c. Facial Expression – The patient was able to exhibit appropriate facial expression towards a certain topic. C. Behavior/Attitude towards the examiner The patient was still accommodating to the group but we noticed that he is a little shy this time. He seated on one corner and has minimal eye contact. II.
STREAM OF TALK A. Characteristic of Talk – He speaks in a loud tone and his words were very clear to us. Blocking was still evident especially when we bring in the discussion on his use of marijuana. He maintains limited eye contact this time and prefers to look down and do his mannerisms. His attention was still in the conversation though. B. Organization of Talk –Most of his statements were not comprehensible this time. Circumstantiality and Tangentiality still surfaced during the interview. He still cooperates with the discussion and still, he tries to answer the questions we gave him.
III.
EMOTIONAL STATES AND REACTION A. Mood – The patient was able to maintain a normal mood all through the home visit. He was responding well to the conversation and his mood was appropriate for the discussion. B. Affect – The patient’s affect was still appropriate as well. His statements jive very well with his facial expressions and gestures.
IV.
THOUGHT CONTROL A. Perceptions – Throughout the interview, the group did not observe any manifestations of illusions or hallucinations. He was very calm and composed. 76
B. Delusion –Delusion of paranoia was present. He believes that his friends were very much jealous of him since his family owns a rice mill. When he was asked why did he say so, he answered, “Dugay ra ko gaduda ana nila. Maka ingon jud ko na na sina ni sila nako kay din a muduol nako.” This is a manifestation of delusion of paranoia. He was also asked about his illness. “Naa man koy grasa sa utok. Murag gud ug makina. Madaot.” This is a manifestation of a somatic delusion. V.
NEUROVEGETATIVE STATE A. Sleep The patient said that he had a good sleep the night before the interview. According to his sister-in-law, he slept at around 11pm and woke up at around 5am. He said that he did not have any difficulty sleeping at night. “Na injectionan man gud ko gahapon mao nang maayo akong tulog.” B. Appetite The patient had a good appetite. He was eating his breakfast well and was able to consume a moderate amount of rice and viand. C. Diurnal Variation It was around 7:30am when we conducted the home visit and so far, he was relaxed and comfortable. He did not have any feeling of discomfort or uneasiness during the interview.
VI.
GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation
77
The patient is well oriented of the time, place and person. He was still able to recognize our group after two days of not seeing each other. He is aware of the time and the place as well.
B. Memory Most of our questions to him were about his adolescent life and we can say that he has difficulty remembering details. Long pauses before answering indicate that he was trying to retain information for him to come up with the answer. The nurse asked, “Pila man imong edad gasugod kag gamit ug marijuana?”. He replied “Ambot lang” and “Dili ko sigurado.” C. Calculation The patient was given again given mathematical equations. Still, he was able to answer all of them correctly and quickly. D. General Information The patient was asked to enumerate the presidentiables he knows for this upcoming election in May 2010. He was able to name Villar, Aquino, Estrada, and Gordon. He said that he would vote for Aquino since his mother was a good example to everyone. “Si Noynoy jud akong iboto kay maayo nang tao, liwat sa iyang mama.”, said with calm emotion by the client. E. Abstract Thinking, Judgement and Reasoning The patient was given another set of situations and questions to evaluate him. He was asked to tell the group the meaning of certain idiomatic expressions like parang basing sisiw. He was them each correctly but with limited words. When asked if he would cheat on a quiz if the teacher is not around, he insistently an78
swered NO. “Dili mana maayo nang manikas ka. Maski wala pa gatan-aw ang teacher, gatan-aw man ang Ginoo.” He explained.
VII.
INSIGHTS The patient still had the same understanding of his illness. Manifestation This time, he insists his false belief that marijuana is not harmful to him and even claimed that it is therapeutic for him. Delusions were more evident this time. He also insists that his vices especially smoking and drinking Coke, which the doctor prohibited, are helpful to him. With these statements, we can say that he has a poor insight.
79
MULTIAXIAL ASSESSMENT Axis I- Schizophrenia Undifferentiated This type of schizophrenia is manifested by pronounced delusions, hallucinations, and disorganized thought processes and behavior, but criteria for other types of schizophrenia are not met (Antai-Otong, 2003). Axis II Schizotypal Personality Disorder Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, odd behavior and thinking, and often unconventional beliefs. These people tend to turn inward rather than interact with others, and experience extreme anxiety in social situations. People with schizotypal personality disorder often have trouble engaging with others and appear emotionally distant. They find their social isolation painful, and eventually develop distorted perceptions about how interpersonal relationships form. (Psychiatric Nursing: contemporary practice. Mary Ann Boyd. 2007) Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 80
2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity
and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder
Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid) 6÷10 ×100 =60% Axis III- Axis 3 is not applicable to the client. Axis IV- inability to go back to school, unemployment Napoleon was unable to finish his schooling. He was a 2nd-year undergraduate at the University of Mindanao with a course of Civil Engineering. The reason for stopping school 81
was due o the onset of his illness. As a result of the patient’s mental illness, he has not landed a permanent job and is currently unemployed. The patient’s educational attainment also made him unable to land a job. The patient is currently living with his parents and depends on them for his basic needs. Axis V- Global Assessment of Functioning a) Initial Assessment (51-60) Moderate symptoms or moderate difficulty in social, occupational, or school functioning. According to the patient, he finds it hard to sleep at night. He usually sleeps at around 12am and wakes around 5am. Circumstantial and tangential speech is also noted since he provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesn’t arrive at the answer at all. According to Bob, he has very few friends. Also, he is quite withdrawn to people around him like the workers of his parents’ business. b) Final Assessment (51-60) Moderate symptoms or moderate difficulty in social, occupational, or school functioning. During the final assessment, circumstantiality and tangentiality is still noted in his speech. He was also quite aloof to the group, when the interview and assessment was being conducted.
82
NURSE-PATIENT INTERACTION Name: Bob
Diagnosis: Schizophrenia Undifferentiated
Age: 40 years old
Physician: Gioia Fe D. Dinglasan, MD
Ward: Crisis Intervention Unit
Date: January 21, 2009 – 1:40 pm FIRST NURSE-PATIENT INTERACTION
NURSE Verbal Maayong buntag!
PATIENT
ANALYSIS
Nonverbal Verbal Nonverbal Greets the Maayong buntag Looks at the Nurse: Gives the patient and his Greetings
Kami patient
diay
INTERPRETATION
client’s
pud. Unsa diay student nurses family a warm greeting to create presence as well as creating a good
mga with
estudyanteng
acknowledge
a inyong
and smiles
smile and pangutana?
a
positive
atmosphere
and start
Looks curious establish a good rapport upon
de
the purpose of acknowledges the nurses with a Fundamentals
University. Naa introduce
the interview
lang miy pipila the group
Greets
knowing
client’s
disposition.
nars sa Ateneo uses hand Davao gestures to
asking Patient:
and
back of
Nursing
by
smile and shows interest and Kozier, B. p. 430 curiosity
ka pangutana sa members imo. Ok ra ba nimu? Kumusta
man Looks
at Ok ra man. Laay Scratches head N:
ka? Unsa man the patient lang kaayo akong and imong
pamati and smiles
karong adlawa?
Starts
paminaw
to Gusto
establish a muuli.
dire. down na
ko
Tries
to
open
up
a Broad openings make explicit that
looks conversation by using questions the client has the lead in the that encourages patient to talk interaction. For the client who is and share
hesitant
about
talking,
broad
P: Exhibits boredom over his openings may stimulate him or her 83
good
hospital stay and expresses wish to take the initiative.
rapport
to go home
Psychiatric Mental Health Nursing by Frisch p 185
Kanus-a pa man Looks diay ka diri?
at Tulo na kaadlaw. Changes into a N: Asks a question to seek viable Seeking information is used to
the patient
Pero pirmi man comfortable
information
mi dire sige balik sitting position
P:
balik.
communicates his interest to to make clear that which is not
His
change
know more about client’s feelings, of
position thoughts and ideas. It is also used
participate in the conversation
meaningful or vague. Psychiatric Mental Health Nursing
Ah. Kabalo pd Continues
by Frisch p 185 Kabalo ui. Naa Makes an eye N: Attempt to evaluate patient’s Exploring is delving further into a
ka nganong naa to
may
ka diri karon ug maintain
hong
gahong- contact sa
ako the nurse
kung
ngano eye contact usahay na mag gabalik balik mo wild daw ko. dire? Magpatambal man
ko.
injection
with understanding and perception of subject or idea. This can help his own illness
patient
examine
the
issue
N: Reports understanding that he morefully. Any problem or concern needs to be treated and evaluated can once in a while by a doctor
be
explored.
better If
understood
patient
if
expresses
Pa
unwillingness to share, the nurse
ba.
must respect his or her wishes.
Tapos naa na pud
Mental Health and Psychiatric
nang
Nursing by Ann Isaacs p.197
mga sa
Auditory hallucinations are false
doctor nga balik
sensory impression heard by the
balik.
patient, usually, commanding in
pangutana
nature.
84
Mental Health and Psychiatric Magpatambal ka?
Nursing by Ann Isaacs p.197 O. Magpatambal Scratches head N: Repeats the statement made Clarification is putting into words
Moves
Ngano? closer
to ko. Kani man gud and
looks by the client to seek clarification. vague ideas or unclear thoughts of
Unsa diay sakit the patient
akong utok, naa down again
Asks further questions to delve in the client. Purpose is to help nurse
nimu?
niy grasa. Murag
to what the patient has said.
gud ug makina.
P: Explains his understanding of explain.
Kunga
his illness. Patient has a false idea Mental Health and Psychiatric
maguba,
understand, or invite the client to
kaylangan
that his brain had some sort of a Nursing by Ann Isaacs p.197
ayuhon.
lubricant.
His belief that there is a lube (grasa)
in
his
brain
is
a
manifestation of Somatic delusion. This type of delusion is a false notion or belief concerning body image or body function. Psychiatric Nursing by Keltner, N Ngano
naka Looks
at Mailhan
man Manually
Chap 9 pp.112-113 N: Attempts to focus and bring in Focusing is concentrating on a
ingon man ka na the patient
nako.
naay
mulain na akong his fingers in a P: Verbalizes his thought about topics or cues given by the client.
grasa
imong utok?
paminaw.
Basta hyperextending the discussion into a single topic
single point; Picking up on central
repetitive
what he believes towards his The nurse encourages the client to
manner
illness.
Starts
mannerisms.
to
show
his concentrate his energies on a sing le point, which may prevent a multitude of factors or problems from overwhelming the client.
85
Mental Health and Psychiatric Unsa diay imung Looks mga gipangbati?
at Naay mag hung Manually
the patient
Nursing by Ann Isaacs p.197 N: Asks question to open and Encouraging description
hung sa ako nga hyperextending explore a certain topic.
of
perceptions is asking the client to
mag wild daw ko his fingers in a P: Retells what he experiences verbalize what he or she perceives. ug Usahay
maglagot. repetitive
whenever his illness recurs. The To understand the client, the nurse
(pause) manner
pause in between his lines is a must see things from client’s
pud kay mu ana
manifestation of blocking speech.
perspective. Encouraging the client
nga patyon daw
to describe fully may relieve the
ko sa usa ka tao.
tension the client is feeling, and he might be less likely to take action on ideas that are harmful or frightening. Psychiatric Nursing by Keltner, N
Unya, unsa pud Looks imung
at Usahay
kay Looks
buhaton the patient tuohan man nako and
anang ga hung and hung nimo?
uses kay
hand
mura
pud head
bitaw ug tinuod.
Chap 9 p 233 down N: Evaluates how the patient Exploring is delving further into a scratches reacts to such stimulus
subject or idea. This can help
P: Patient has the tendency to patient examine the issue more heed to whatever this stimulus is fully. Any problem or concern can
gestures to
saying. Scratching his head is be better understood if explored. If
convey
another mannerism evident in the patient expresses unwillingness to
message
patient.
share, the nurse must respect his or her wishes. Mental Health and Psychiatric Nursing by Ann Isaacs p.197
86
Panan-aw nimu, Continues
Wala man. Nikalit Looks at the N: Tries to stimulate the patient Seeking information is used to
nganong nasakit eye cotact
ra man ni. Pero nurse
to recall past events of his life know more about client’s feelings,
man ka? Naay ba
kabalo ko na naay
that could have contributed to his thoughts and ideas. It is also used
kay
jud lain mao to
present illness.
mahinumduman
gusto
P: Patient cannot remember any meaningful or vague.
ngano
padoktor.
nagka
ingon ana ka? Ah… Kumusta Maintains man
Okay
pd
ra
ko
significant event which he thinks Psychiatric Mental Health Nursing is a contributing factor. by Frisch p 185 man. Looks at his N: Assesses patients relationship Focusing is concentrating on a
relasyon eye contact Palangga man ko mother
nimo sa imong and
and towards his family
nila. Samot na ni smiles
mama ug papa? presents a mama. Imung
mga conveying
igsuon?
to make clear that which is not
looks
single point; Picking up on central
then P: Expresses seriousness in his topics or cues given by the client. at
the tone of voice
The nurse encourages the client to
Suod pud mi sa nurse again
Tells the nurse how close he is to concentrate his energies on a sing
hand
akong
his family
gesture
manghud.
The
Kamaguwangan
statement
(pause) man ko.
manifestation of blocking speech.
Suod
mga
ming
pause
le point, which may prevent a in
between
is
again,
his multitude of factors or problems a from overwhelming the client. Mental Health and Psychiatric Nursing by Ann Isaacs p.197
Emman. Kadtong
Blocking is usually caused by
nagsunod sa ako.
affectively delusional
charged thoughts
topics, or
preoccupations. Psychiatric Nursing by Keltner, N Ah! Kung mag Looks away
mo
Chap 9 p 233 at Wala uy! Okay Looks at the N: Asks question to look at the General leads indicate that the
sa the patient
kaayo
among nurse with a current topic being discussed for nurse is listening and following
87
imung isgsuon
mga ug
imong
pamilya. I-agi ra face that tries further assessment
sa mga
what the client is saying without
gud sa storya. Di to convince
P: Strongly denies any presence taking away the initiative for the
man
of
kinhanglan
domestic
violence.
Seeks interaction.
They also encourage
ginikanan, naka
magsinakitay
affirmation from the nurse by the client to continue if he is
sinakitay mo?
diba?
asking “Diba”.
hesitant or uncomfortable about the topic. Mental Health and Psychiatric
Tama
pud
Maayo ingon
no. Maintains
Naa
gud.
Dula Scratches head
nang eye contact dula. Pero di man
Nursing by Ann Isaacs p.191 N: Commends the patient for the Giving recognition good insight given.
acknowledging
and
is
indicating
ana.
ko malingaw sa
Assess the patient’s childhood to appraisal to the client’s actions.
Kadtong bata pa
ilang mga (pause)
get viable information
ba ka, daghan ba
dulay usahay mao
P: Expresses gloom through fall esteem.
kag kadula?
nang ako na lang
of voice tone. Blocking of speech Mental Health and Psychiatric
isa madula sulod
is evident.
Nursing by Ann Isaacs p.197
sa balay. Nganong di man Sits on bed Dagan
dagan. Manually
pud
kaayo hyperextending allow patient to explain
malingaw?
ka and maintains
Lami
This helps elevate client’s self
N: Uses open-ended questions to Questioning
is
communication
a
therapeutic
technique
using
magdagan dagan. his fingers in a P: Restricted facial expression open-ended questions to achieve
eye contact Dili ko ganahan repetitive
and inconsistency of eye contact relevance and depth discussion.
sa ilang mga dula. manner
show that the patient is not Psychiatric Nursing by Keltner, N
Daghan
interested
kaayo
sila. Samukan ko.
on
the
topic. Chap 9 p 93
Circumstantiality is evident on If in response to a direct question, his
speech
as
he
provides the patient provides and excessive
irrelevant data before answering amount of irrelevant details before
88
the question.
finally answering the question, the condition
is
called
circumstantiality. Psychiatric Nursing by Keltner, N Kadtong
Looks the Ok
elementary
ug patient
ra
gud. Uses
Chap 9 p 113 hand N: Changes the topic since the Questioning is
Barkada barkada. gestures as he patient
started
to
exhibit communication
a
therapeutic
technique
using
high school ka,
Bugoy
bugoy talks
disinterest in the conversation
kumusta
man
kadali.
Bisyo
P: Is interested again in the relevance and depth discussion.
imong
pag
bisyo.
skwela?
Mura
gud
ra
conversation as his vocal tone Psychiatric Nursing by Keltner, N
ug
rises and as he gestured while Chap 9 p 93
ordinaryong Bisyo? Unsa pud Maintains na nga bisyo?
talking
studyante. Sigarilyo ug Coke Does his finger N:
eye contact jud ako (pause) mannerisms ganahan,
open-ended questions to achieve
inom- again
Tries
to
explore
and Exploring is delving further into a
encourage the patient to recall his subject or idea. This can help vices
patient examine the issue more
inom, chiks chiks.
P: Blocking is evident in his fully. Any problem or concern can
Ana lang gud.
speech as he enumerates his vices
be better understood if explored. If patient expresses unwillingness to share, the nurse must respect his or her wishes. Mental Health and Psychiatric
Ah.
Ganahan Looks
diay kag Coke?
patient
Nursing by Ann Isaacs p.197 at Ganahan mo lang. Looks up at the N: Focuses the topic on a Focusing is concentrating on a Kadtong
New ceiling
particular subject
single point; Picking up on central
89
Year, halos isa ka
P: Retells a particular event topics or cues given by the client.
case ako nahurot.
where his craving for Coke was The nurse encourages the client to
Boring man gud
evident.
concentrate his energies on a sing
maghulat ug alas
le point, which may prevent a
dose.
multitude of factors or problems from overwhelming the client. Mental Health and Psychiatric
Wala
pud
nitisting
ka Maintains
Droga??? Shabu? Looks
anang eye contact Wala
droga droga?
ui. and
down N:
Explores
for
Nursing by Ann Isaacs p.197 further Seeking information is used to
scratches significant details
know more about client’s feelings,
Marijuana
nuon. head
P: has a delusion marijuana is not thoughts and ideas. It is also used
Pero
mana
an prohibited and dangerous drug
di
droga.
to make clear that which is not meaningful or vague. Psychiatric Mental Health Nursing
Nagagamit marijuana? Sukad pa?
Oo ui. Kadtong Smirks
by Frisch p 185 N: Uses restatement to verify The nurse repeats what the client
high school pa ko.
acquired information
Uso mana didto sa
P: Smiked when the topic on his the same words the client has used.
expression
agro. Kami tanan
peers and their marijuana use was This restatement lets the client
while
sa among barkada
brought in
kag Conveys curious
kanus-a facial
keeping an gagamit
Unsa
ana.
has said in approximately or nearly
know that he or she communicated the idea effectively.
eye contact Ganahan man gud
Mental Health and Psychiatric
with
Nursing by Ann Isaacs p.197
patient diay Looks
ko sa feeling ba. at Lami
kaayo
sa Smiles
and N: Seeks significant information Exploring is delving further into a
90
mabati-an nimu the patient
paminaw ui. Mura looks
kung mugamit ka
kag galutaw sa nurse
patient
ana?
hangin
P: Shows elated response as he fully. Any problem or concern can
patient examine the issue more
Walay problema.
smiles and verbalized how he be better understood if explored.
Mag sige lang kag
enjoys marijuana
Mental Health and Psychiatric
Tistingi
ra
Nursing by Ann Isaacs p.197
gud,
maganahan ka. at Dili mana Shakes
makadaot
ng the patient
makadaot.
marijuana
sa
Makatambal
imo?
the on the effect of marijuana to the subject or idea. This can help
pero.
katawa.
Kabalo ba kang Looks
at
head N:
and frowns pa
Gives
information
and When it is obvious that the client is
presents reality to patient that misinterpreting reality, the nurse marijuana use is not good neither can indicate what is real. The nurse
man gani na. Si
beneficial
mama,
P: Shows disagreement as he expressing the nurse’s perceptions
sige
kasab-an
ko
bahin
does this by calmly and quietly
shook his head and frowned
or the facts not by way of arguing
ana kay di lage
with the client or belittling h is
daw maayo.
experience. Mental Health and Psychiatric
Unsa pud imu Looks ginabuhat
at Muhilom
kung the patient
lang. Scratches head N:
Pero di man ko and
Explores
on
the
Nursing by Ann Isaacs p.199 topic Exploring is delving further into a
looks discussed to get more information subject or idea. This can help
kasab-an ka sa
mutuo niya. Wa down
P: Insists his belief that marijuana patient examine the issue more
imong mama.
man ko nadaot.
is not harmful
fully. Any problem or concern can be better understood if explored. Mental Health and Psychiatric Nursing by Ann Isaacs p.197
91
Panan-aw nimu? Stands up Ang
babae Shakes
Dili kaha mao from
ganina,
wala and
nang
nikaon.
Sayang down
rason sitting
nganong nasakit position ka?
head N: Assesses patient’s perception To understand the client, the nurse looks on how marijuana affected his must see things from client’s
ang pagkaon ba.
illness
perspective. Encouraging the client
P: Provided irrelevant answers to describe fully may relieve the
Continues
and never arrived to the real tension the client is feeling, and he
to
answer – a manifestation of might be less likely to take action
maintain
tangentiality.
on ideas that are harmful or
eye contact
frightening. Mental Health and Psychiatric Nursing by Ann Isaacs p.192 Tangentiality is when patient gets lost in unnecessary and irrelevant details and never answers the question. Psychiatric Nursing by Keltner, N
Bob, naa koy ipa Smiles
Dapat
explain
muundang
Unsa
nimu. imo
dili Looks down
skwela.
ug Sige
ka
ug
N: Evaluates the abstract thinking of the patient of the client P: Uses self as example. Looking
pagsabot sa try
dapat
and try until you
skwela
para
disappointment.
succeed?
maabot
ang
Has concrete understanding of
pangarap
ba.
the the quotation given.
Dapat
dili
musundog nako.
down
could
indicate
Chap 9 p 93 1. Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods
92
2.
3.
4.
5.
in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others. Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself. Reward positive behav93
ior to help the patient improve his level of functioning. 6. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior. 7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or oth94
ers at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject. 8. Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor. 9. Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact 95
with facility personnel until the patient is less suspicious or agitated. 10. Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully. 11. Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills. 12. Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic 96
syndrome. Make sure you document and report such effects promptly. Psychiatric Nursing by Keltner, N Chap 9 p 93 Testing the abstract thinking ability is a test to note the congruence between the patient’s economic status and his abstracting abilities. Mental Health and Psychiatric Aw.
lang sa mi kutob patient’s
Okay ra kaayo ui. waves hand
and
sa
Adto mog balay
scheduled meeting
pagpangutana.
ha? Kita kita ta
Recognizes effort of the patient thanking
Bisitahun ra ka
didto
who was accommodating to the participation
namu
Sabado.
among back
unya
sa
inyong
balay
karong
Sabado
para
magstorya
Sige
sa panahon.
sige. Smiles
Nursing by Ann Isaacs p.194 and N: Terminates the conversation The nurse gives recognition in a
Diay ba? Dire Taps
karong Salamat inyong
orients
group
patient
on
the nonjudgmental way. The nurse then terminates
throughout
the the
interaction client and
for
by his
cooperation
the during the whole interview.
conversation
Fundamentals
of
Nursing
by
Shows gratitude to patient for the Kozier, B. p 470 time he and his family spared for
na pd ta. Ayos ba
us.
na? Salamat sa
P:
imung panahon.
cooperation
Shows
understanding by
and
responding
positively to nurse’s statement
97
SECOND NURSE-PATIENT INTERACTION Place of Interview: 162, Interior Tulip Drive, Davao City (Patient’s City Address)
NURSE
PATIENT
Date: January 23, 2009 – 7:30 pm
INTERPRETATION
ANALYSIS
Verbal Nonverbal Verbal Nonverbal Maayong buntag Smiles and Nindot kaayo ang Stares blankly Nurse: Greets the patient to The nurse greets the patient Bob! Kumusta man looks at the adlaw.
Lami and
looks create a positive environment and upon seeing each other and
ang imong tulog patient
manglaba karon kay down
establish
kagabii?
init.
conversation
Ok
lang
man.
opening.
rapport. using
Starts uses broad openings to start a
broad their
conversation.
Broad
openings lead or invite the
Nakatulog man kog
Patient: Able to answer the client to explore thoughts or
tarong. Sayo sayo
question but circumstantiality is feelings.
gani ko kamata.
evident and poor eye contact was questions specify only the noted.
Open-ended
topic to be discussed and invite answers that are longer than one or two words. Circumstantiality is when in a response to a direct question, the
patient
excessive
provides amount
an of
irrelevant detail before finally answering the question.
98
Kozier, B. Fundamentals of Nursing. Chapter 26, p. 469.
Ah. Maayo. Mao Smiles
Aw. Kani? Mubalik Touches
pud diay sayo ka
na man gud ming and smiles
to
nakaligo no? Asa
mama sa Agusan.
presentable during the interview.
diay
Excited na gani ko.
P:
ron? Nindot man
Gikapoy
enthusiasm
lage kag suot?
gud ko didto sa
with the nurse and expresses his communication.
hospital ba.
feelings regarding his stay in the Acknowledgment
ka
muadto
na
man
shirt N: Acknowledges patient’s effort Giving groom Shows
self
and
excitement while
hospital.
recognition,
in
a
look nonjudgmental way, of a change in behavior, an effort
and the client has made, or a
conversing contribution
with
to
or
a
may
be
without
understanding,
verbal
or
nonverbal. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. Diay ba? Abi nako Smiles and Ang among bugasan Looks at the N: Asks a question to explore a Questioning uses open-ended naay kay pormahan establishes
sa
karong
kaayo ug kita.
adlawa? eye contact
Nagkauyab ba ka?
Oo.
Agusan Ka-usa
Kadtong
kusog nurse smiles ra.
and certain topic.
questions
to
P: Shares his experiences and relevance
and
opinions
about
his
achieve depth
in
previous discussion (not closed/yes-no
high
relationship in a comical manner. questions). The nurse ask
school pa ko. Pero
Irrelevant details are provided questions to explore and gain
dili naman mi uyab
before arriving to answer – a information from a new topic.
99
karon. man
Pangit gud
na
manifestation
siya.
of Circumstantiality is when in a
circumstantiality.
response to a direct question,
Ngipon niya murag
the
patient
ngipon sa ilaga.
excessive
provides
an
amount
of
irrelevant detail before finally answering the question. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter Unsa may pangalan Maintains
7, p. 93. Ah. Kadto siya? Si Points finger at N: Focuses on the topic to gather Focusing is helping the client
ato? Nagdugay pud eye contact
Rowena. Taga dinha the
mo ato?
ra man to sa una oh! direction
his past experiences.
Namalhin na man
P: Shares information about his important for the nurse to
siguro
experience
to
specified more information and look into expand on and develop a
sila.
with
topic of importance. It is a
former wait until the client finishes
Dugay dugay pud.
girlfriend. Patient is trying to stating the main concerns
Mga pipila ka bulan.
remember
Pero wa ni abot ug
relationship lasted.
how
long
their before attempting to focus. The focus may be an idea or
tuig.
feeling. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. and N: Inquires about the history on Questioning uses open-ended
Ah! Gi unsa nimu Smiles
Wala na uy! Ning Giggles
pagka uyab sa iya?
ngisi ra man to siya scratches head
how the relationship with her questions
Gi ligawan pa ba
nako. Naka crush
former girlfriend started.
nimu siya?
siguro ba. Ni ngisi
P: Narrates their story in an discussion (not closed/yes-no
ra pud kog balik.
amusing
manner
relevance as
he questions).
to and
achieve depth
The
in
nurse
100
Mao to. Uyab na
remembered
what
dayon mi.
between them.
happened questions or inquires about the client’s past history. Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter
Kuyawa ba.Gwapo Laughs and Wala na. Wala na Laughs diay kaayo ka no continues to man
koy continues
ka yang babae man look at the nagustuhan. ni-una. Pagkahuman
patient sa
iya? Wala na kay
7, p. 93. and N: Actively listens to client and Active listening pays close
Mga scratch head
to compliments on his physical attention attributes by giving recognition. nonverbal
to
verbal
and
communications,
pangit na man ang
The nurse then resumes focusing patterns of thinking, feelings
uban uy. Bati ug
on the previous topic by asking and behaviors and the nurse
nawong.
questions.
na uyab?
gives a positive recognition as
P: Shares to the nurse his lack of a response to the patient’s interest in having a relationship statement. and
his
perceptions
about Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter
women. Pero sa edad nimu Conveys
a Gusto
uy! gani
Gusto Manually
N:
Explores
on
7, p. 93. patient’s The nurse assists the client to
ron, gusto pa ka more
man
nako hyperextending perceptions and thoughts about explore thoughts and feelings
magminyo?
serious
minyoon
facial
katabang
expression
pangit. Pero kataw- manner
married and his intention of tries to assess the client’s
an ra man ko nila
marrying their helper. Patient perceptions to the questions
man pag ako silang
tells the nurse the reaction of his asked.
ingnon.
family about his decision of Kozier, B. Fundamentals of
among his fingers in a getting married at his age. bahalag repetitive
and acquires understanding
P: States his interest in getting from the client. The nurse
marrying their helper.
Nursing. Chapter 26, p. 473.
101
Ngano gusto man Maintains
Wala namay lain. Smiles
pud nimu minyoon eye contact
Kadto na lang. Wala looks down
statement on his objective of making the client’s broad
inyo katabang nga
na may lain. Pero di
marrying their helper, even if, overall
pangitan man diay
man
according to him is unattractive.
ka?
mama. Di na jud
P: Replies to question with understandable. To clarify the
siguro ko maminyo
noticeable desperation. Shows message, the nurse can restate
ani.
that he is no longer interested the basic message or confess
musugot
and N:
si
Clarifies
the
patient’s Clarification is a method o
with the topic.
meaning
of
message
the more
confusion and ask the client to
repeat
or
restate
the
message. Kozier, B. Fundamentals of Nursing. Chapter 26, p. 470. Unya Bob, karong Looks at the Ambot ato nila ui. Looks at the N: Shifts topic to explore on The nurse assists the client to pag-uli
Nasina man to sila nurse
another subject that may have explore thoughts and feelings
magkita na pud mo
nako kay ako tig
significance
sa
operate sa rice mill
illness.
unya sila kay driver
P: Shares insights about his tries
lang. Di na lang ko
friends back in his hometown and patient’s perceptions on the
muduol nila kay lain
his views about them.
imong
nimu, patient mga
barkada?
with
his
mental and acquires understanding from the client. The nurse still
pagkabalo
nimu Maintains nga eye contact
nasina sila nimu?
Mabati-an nako.
on
the
Kozier, B. Fundamentals of Nursing. Chapter 26, p. 473. gyud Looks at the N: Focuses on the topic and seeks Focusing is helping the client
nako. Sige silag tan- nurse aw
explore
question asked.
naman sila. Giunsa
to
and an
Sigeg scratches head
panabis. Di na ko
understanding
from
the expand on and develop a
patient’s feelings towards his topic friends.
of
importance.
The
focus may be an idea or
102
ganahan
mustorya
nila.
P: Relates his thoughts and feeling. The nurse then seeks feelings about his friends and understanding after focusing how
they
respond
to
him, on the topic.
according to his observations. Wala
pud
ka Maintains
Wala na uy! Klaro Looks
Kozier, B. Fundamentals of
Nursing. Chapter 26, p. 470. away N: Seeks more information, by The nurse seeks informing by
nitisting ug duol eye contact
na kaayo sa TB TB from the nurse asking questions regarding the asking questions about the
nila
na lain jud ilang and
unya
mangutana?
shakes topic, from the patient to further topic. Questioning uses open-
buot sa ako. Bahala head
understand his situation with his ended questions to achieve
gud sila.
friends.
relevance
and
depth
in
P: Responded according to what discussion (not closed/yes-no he felt and from his viewpoint questions). about his friends. Lack of interest Keltner, et. al, Psychiatric was observed when asked to Nursing, 5th Edition. Chapter Bob, kung kita ka Looks at the Daghan ug
pitaka,
baligya sa gawas ba. nurse
from the given situation.
nabilin sa tag-iya.
Akong
P: Answers accordingly from the meaning or importance of
Unsa
Alangan. Dili man
given
na ako.
appropriate behavior.
man
buhaton?
unya patient
approach his friends. 7, p. 93. pitaka Looks at the N: Evaluates patient’s judgment Encouraging evaluation asks
imu
I-uli.
situation
that
for patient’s views of the showed something. Circumstantiality is when in a response to a direct question, the patient provides an excessive amount of irrelevant detail before finally
answering
the
question.
103
Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter 7, p. 93. head N: Further evaluates patient’s The nurse is trying to evaluate
Dili pud kaha nimu Maintains
Dili uy. Dili man na Shakes
kuhaon? Kwarta na eye contact
ako. Kung wala koy and looks at judgment
gud
na.
kwarta, magayo ra the nurse
situation and how he would further.
Makatabang
na
gud ko. Dili jud
respond from it.
nako na hilabtan.
P: Explained his intention of views of the meaning or
nimu.
from
the
given on
the
client’s
judgment
Encouraging
evaluation asks for patient’s
returning the money that showed importance
of
something.
a correct behavior from the given Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter
situation. Wow! Maayo no Smiles and Daghan kaayo ug Looks at the N: kay i-uli jud nimu maintains
kawatan
ang
silingan. Samot na
positive behavior in the given an effort the client has made,
kung
situation.
pitaka eye contact
magkina-unsa man.
dira
sa nurse
7, p. 93. affirmative The nurse gives recognition
Provides
gabii.
reinforcement to the patient’s on the client’s behavior and
Masakpan pa gani
P:
nako usahay
irrelevant
or
Responded from
to
the their
Tangentiality was noted.
a
contribution
to
a
nurse communication. topic. Acknowledgment with
may
or
understanding, nonverbal.
be
without verbal
or
Tangentiality
differs from circumstantiality in that the patient gets lost in unnecessary and irrelevant detail
and
never
directly
104
answers the question. Kozier, B. Fundamentals of Bob,
unsa
Nursing. Chapter 26, p. 470. ba Looks at the Math. Mao ganing Looks at the N: Asks a question to explore on The nurse asks a new
paborito nimu nga patient
nag
Civil nurse
subject?
Engineering ko.
and a new topic.
smiles
question to the client to delve
P: Answered appropriately to the in a new topic. Questioning question asked. Relates it to his uses open-ended questions to reason of taking up his course.
achieve relevance and depth in discussion (not closed/yesno questions). Keltner, et. al, Psychiatric Nursing, 5th Edition. Chapter
Sige daw bi.
Moves
Laughs
1+1?
closer to the 2 uy.
looks
7+2?
patient
ceiling
9.
7, p. 93. and N: Evaluates the client’s skill in The nurse is evaluating as at
the calculation. P:
Answered
well as exploring on the most
of
the client’s
ability
to
solve
40-7?
33. Grabe pud.
calculations asked to him to solve mathematical solutions.
6x8?
Ahmm.. 48!
on his own. Took time answering Videbeck. Psychiatric-Mental
25/5?
5
questions that were quite hard to Health Nursing. Chapter 6.
100-7? Tama!
(pause) 97? Paborito Smiles and Sige. Kay excited na Smiles
solve. p.107. N: Provides a positive feedback The nurse gives recognition
nimu siguro ang maintains
pud ko muuli. Si
to the client’s skill in calculation in a nonjudgmental way. The
math.
papa lang man gud
and shows acknowledgment by nurse then terminates the
Murag mulakaw na
isa
balay.
giving recognition. Establishes interaction by thanking the
jud
Gikapoy na pud ko
information that the nurse is client for his participation and
Sige mo
Bob. eye contact kay
sa
105
naghulat Mama
na
si
dire. Salamat pud sa
leaving and wishes him well cooperation during the whole
nimu.
pag storya storya
upon
nako.
Terminates
Mulakaw na lang
their
next
encounter. interview. nurse-client Kozier, B. Fundamentals of
pud mi ug una.
relationship.
Salamat! Hangtod
P: Responds appropriately and
sa atong sunod na
shows an eagerness to go back
pagkita. Pamansin
home and see his father.
Nursing. Chapter 26, p. 470.
ha?
106
107
DEFINITION OF COMPLETE DIAGNOSIS SCHIZOPHRENIA UNDIFFERENTIATED SCHIZOPHRENIA Schizophrenia is one of the most common causes of psychosis. It is not characterized by a changing personality; it is characterized by a deteriorating personality. Simply, schizophrenia is one of the most profoundly disabling illnesses, mental or physical. It is a diagnostic term used by mental health professional to describe a major psychotic disorder. It is characterized by disturbances in thought and sensory perception (hallucinations, delusions), thought disorders, and by deterioration in psychosocial functioning. Keltner, et. al, Psychiatric Nursing (p. 351).3rd Edition (1999) Philippines: C&E Publishing Inc. Schizophrenia is a disorder associated with a variety of a complex combination of symptoms, including hallucinations, delusions, disorganized speech, disorganization, flat affect, alogia, and avolition (APA, 2000; Bleuler, 1950). Persons experiencing an earlier onset of schizophrenia usually have more problems with movement from adolescence into adulthood and development of inappropriate social relationships and interactions.The course of the disease may be different for each person, depending on when the disorder manifests itself and if symptoms of the schizophrenia are compounded by a person’s use of alcohol or other substance (Brunette and Drake, 1998). Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 347). Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).
Refers to a group of psychotic disorders in which there are certain characteristic disorders like disturbances in reality testing, hallucinations, delusions, withdrawal from society, etc. 108
Schizophrenia is a major mental disorder having a characteristic set of symptoms. It is most closely approximate what most of us think as “craziness.” Schizophrenia ranges from mild to intense. It is the label given to a group of psychoses in which deterioration of functioning is marked by severe distortion of thought, perception and mood, by bizarre behaviour and by social withdrawal. Jafar Mahmud. Abnormal Psychology (p. 186). APH Publishing Corp. (2002)
Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the world. People with schizophrenia have an altered perception of reality, often a significantloss of contact with reality. They may see or hear things that don’t exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched. With such a blurred line between the real and the imaginary, schizophrenia makes it difficult—even frightening—to negotiate the activities of daily life. In response, people with schizophrenia may withdraw from the outside world or act out in confusion and fear. Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing, Quezon City, Phils. (2004)
UNDIFFERENTIATED TYPE Undifferentiated schizophrenia is manifested by pronounced delusions, hallucinations, and disorganized thought processes and behavior. Deborah Antai-Otong. Psychiatric Nursing: Biological and behavioural concepts (p. 348). Australia; Clifton Park, NY: Thomson/ Delmar Learning (2003).
109
Subtype in which the clients clearly meet the general criteria of schizophrenia, yet do not fit into any of the other three subtypes. James Hansen & Lisa Damour. Abnormal Psychology (p. 406). Hobeken, N.J.: Wiley (2005). Clients with diagnosis of undifferentiated schizophrenia display forbid psychotic symptoms (delusions, hallucinations, incoherence, disorganized behavior) that do not clearly fit under any other category. Forti Nash & Holoday Worret. Psychiatric Nursing Care Plans (p. 113). 4th Edition. Mosby Inc., St. Louis, Missouri. The essential feature of undifferentiated schizophrenia is that it cannot be classified in any category listed or that meet the criteria for more than one of the other mentioned schizophrenic disorders. Jafar Mahmud. Abnormal Psychology (p. 188). APH Publishing Corp. (2002) This type is characterized by some symptoms seen in all of the other types but not enough of any one of them to define it a particular type of schizophrenia. Maria Loreto Evangelist-Sia. Psychiatric Nursing: A Textbook and A Reviewer (p. 231). RMSIA Publishing, Quezon City, Phils. (2004)
110
DIFFERENTIAL DIAGNOSIS SCHIZOPHRENIA Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the clinical picture that occasioned the most recent evaluation or admission to clinical care and may therefore change over time. They are defined by their symptomatology. The disorder lasts for at least 6 months and includes at least one month of the active phase symptoms namely two or more of the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The subtypes are: 295.30 Paranoid Type 295.10 Disorganized Type 295.20 Catatonic Type 295.90 Undifferentiated Type 295.60 Residual Type
Diagnostic Criteria for Schizophrenia A. Characteristic symptoms. Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
(1) delusions (2) hallucinations (3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior (5) negative symptoms (i.e. affective flattening, alogia or avolition) 111
Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction. For a significant portion of the time since the onset of the disturbance, one or
more major areas of functioning such as work, interpersonal relations, or selfcare are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) C. Duration
Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.) D. Schizoaffective and Mood Disorder exclusion:
Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, Or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance
(e.g. a drug of abuse, a medication) or a general medical condition F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated. Total
7÷10×100= 70% 112
295.30 Schizophrenia Paranoid Type The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent. Delusions are typically persecutory or grandiose or both but delusions with other themes may also occur. Hallucinations are also typically related to the content of the delusional theme. Diagnostic criteria for 295.30 Paranoid Type A. Preoccupation with one or more delusions or frequent auditory hallucinations B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. TOTAL
1÷2×100 = 50%
295.10 Schizophrenia Disorganized Type The essential features of the Disorganized Type of Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not organized into a coherent theme. Diagnostic criteria for 295.10 Disorganized Type A. All of the following are prominent 1. disorganized speech 2. disorganized behavior 3. flat or inappropriate affect B. The criteria are not met for catatonic type TOTAL
1÷4×100 = 50%
113
295.20 Schizophrenia Catatonic Type The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include stereotypes, mannerisms, and automatic obedience or mimicry. Diagnostic criteria for 295.20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor 2. excessive motor activity (that is apparently purposeless and not influence by external stimuli) 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism 4. peculiarities of voluntary movement as evidenced by posturing √ (voluntary assumption of inappropriate bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing 5. echolalia or echopraxia TOTAL
1÷5×100 =20%
295. 90 Schizophrenia Undifferentiated Type Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly fit under any category. 114
Diagnostic criteria for 295.90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type TOTAL
1÷1×100 = 100%
295.60 Schizophrenia Residual Type The Residual Type of Schizophrenia should be used when there has been at least one episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing evidence of the disturbance as indicated by the presence of negative symptoms or two or more attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and are not accompanied by strong affect. Diagnostic criteria for 295.60 Residual Type A. Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of
negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experience) TOTAL
1÷2×100 = 50%
301.22 Schizotypal Personality Disorder Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute 115
discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity
and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid) 6÷10 ×100 =60% Schizoid Personality Disorder Individuals with schizoid personality disorder are emotionally detached and prefer to be left alone. Diagnostic criteria for 301.20 Schizoid Personality Disorder 116
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. neither desires nor enjoys close relationship, including being a part of a family 2. almost always chooses solitary activities 3. has little, if any, interest in having sexual experiences with
another person 4. takes pleasure in few, if any , activities 5. lacks close friends or confidants other than first degree
relatives 6. appears indifferent to the praise or criticism of others 7. shows emotional coldness, detachment, or flattened activity B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizoid Personality Disorder (Premorbid)” TOTAL
4÷8 ×100 =50%
297.1 Delusional Disorder The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not prominent. Tactile or olfactory hallucinations may be present if they are related to delusional themes. Diagnostic Criteria for 297.1 Delusional Disorder A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or 117
lover, or having a disease) of at least 1 month’s duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not
markedly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. TOTAL
2÷5×100 =40%
Substance-Induced Psychotic Disorder The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations or delusions that are judged to be due to the direct physiological effects of a substance. Hallucinations that the individual realizes are substance induced are not included here and instead would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic symptoms occur only during the course of delirium. Diagnostic criteria for Substance-Induced Psychotic Disorder A. Prominent hallucinations or delusions.
Note: Do not include hallucinations if the person has insight that they are substance induced B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms of Criterion A developed during or within a month of, Substance intoxication or Withdrawal 2. Medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a Psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a 118
Psychotic Disorder that is not a substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance –induced Psychotic Disorder (e.g., a history of recurrent non-substance related episodes. D. The disturbance does not occur exclusively during the course of delirium. Note: This diagnosis should be made instead of a diagnosis of Substance intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. 1÷5×100 TOTAL
= 20%
295.70b Schizoaffective Disorder Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some time in the absence of any mood syndrome.
Diagnostic criteria for 295.70b Schizoaffective Disorder A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet criterion A for Schizophrenia. Note: The Major Depressive Episode must include criterion A1: depressed mood. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. 119
D. The disturbance is not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medication. 1÷4×100 = 25% Substance Intoxication Delirium Diagnostic criteria for Substance Intoxication Delirium A. Disturbance in consciousness(i.e., reduced clarity of awareness of the
environment) with reduced ability to focus, sustain or shift attention B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia C. The disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) Criteria Present 1. the symptoms in Criteria A and B developed during Substance Intoxication 2. medication use is etiologically related to the disturbance* 2÷5×100 =40% INITIAL SUMMARY Schizophrenia
70%
Paranoid Type
50%
Disorganized Type
50%
Catatonic Type
20%
Undifferentiated Type
100%
Residual Type
0%
Schizotypal Personality Disorder
60% 120
Schizoid Personality Disorder
50%
Delusional Disorder
40%
Schizophreniform Disorder
50%
Substance-Induced Psychotic Disorder
20%
Schizoaffective Disorder
25%
Substance Intoxication Delirium
40% ANATOMY AND PHYSIOLOGY
The nervous system is an intricate, highly organized network of billions of neurons and neuroglia. The structures that make up the nervous system include the brain, cranial nerves, spinal nerves, ganglia, enteric plexuses and sensory receptors. The two main subdivisions of the nervous system are the central nervous system and the peripheral nervous system. The central nervous system consists of the brain and spinal cord. The brain is the center for registering sensations, correlating them with one another and with stored information, making decisions and taking actions. It also is the center for the intellect, emotions, behavior, and memory. The major parts of the brain include: the brain stem, cerebellum, diencephalon, and cerebrum. The spinal cord is connected to a section of the brain called the brainstem and runs through the spinal canal. Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both sides of the body. The spinal cord carries signals (messages) back and forth between the brain and the peripheral nerves.
121
The brain stem is continuous with the spinal cord and consists of the medulla oblongata, pons, and midbrain. The medulla oblongata forms the inferior part of the brain stem. The medulla contains the cardiac, respiratory, vomiting and vasomotor centers and deals with breathing, heart rate and blood pressure. The pons is a bridge that connects parts of the brain with one another. The midbrain extends from the pons to the diencephalon. The midbrain is a short section of the brain stem between the diencephalon and the pons. Posterior to the brain stem is the cerebellum. Traditionally, the cerebellum has been known to control equilibrium and coordination and contributes to the generation of muscle tone. It has more recently become evident, however, that the cerebellum plays more diverse roles such as participating in some types of memory and exerting a complex influence on musical and mathematical skills. Superior to the brain stem is the diencephalon, which consists of the thalamus, hypothalamus, and epithalamus. The thalamus acts a relay center for all sensory impulses, except smell, to the cerebral cortex. The hypothalamus is involved in the acceleration or deceleration of the 122
heart. Impulses from the posterior hypothalamus produce a rise in arterial blood pressure and an increase of the heart rate. Impulses from the anterior portion have the opposite effect. The hypothalamus is also involved in body-temperature regulation. If the arterial blood flowing through the anterior portion of the hypothalamus is above normal level, the hypothalamus initiates impulses that cause heat loss through sweating and vasodilation of cutaneous vessels of the skin. A belownormal blood temperature causes the hypothalamus to relay impulses that result in heat production and retention through the initiation of shivering, the contraction of cutaneous blood vessels. The hypothalamus is also involved in the regulation of hunger and control of gastrointestinal activity. Low levels of blood glucose, fatty acids and amino acids are partially responsible for the sensation of hunger elicited from the hypothalamus. When sufficient amounts of food have been ingested, the hypothalamus inhibits the feeding center. It also regulates sleeping and wakefulness. A specialized sexual center in the hypothalamus responds to sexual stimulation of the tactile receptors within the genital organs. Also, the hypothalamus is associated with specific emotional responses, such as anger, fear, pain and pleasure. The hypothalamus produces neurosecretory chemicals that stimulate the anterior pituitary gland to release various hormones. The epithalamus is the posterior portion of the diencephalon. Supported on the diencephalon and brain stem is the cerebrum, which is the largest part of the brain. The cerebrum is the largest part of the brain and controls voluntary actions, speech, senses, thought, and memory. The surface of the cerebral cortex has grooves or infoldings (called sulci), the largest of which are termed fissures. Some fissures separate lobes. The convolutions of the cortex give it a wormy appearance. Each convolution is delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is divided into two halves, known as the right and left hemispheres. A mass of fibers called the corpus callosum links the hemispheres. The right hemisphere controls voluntary limb movements on the left side of the body, 123
and the left hemisphere controls voluntary limb movements on the right side of the body. Almost every person has one dominant hemisphere. Each hemisphere is divided into four lobes, or areas, which are interconnected.
The frontal lobes are located in the front of the brain and are responsible for voluntary movement and, via their connections with other lobes, participate in the execution of sequential tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory. The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They process sensory information such as temperature, pain, taste, and touch. In addition, the processing includes information about numbers, attentiveness to the position of one’s body parts, the space around one’s body, and one's relationship to this space. The temporal lobes are located on each side of the brain. They process memory and auditory (hearing) information and speech and language functions. The occipital lobes are located at the back of the brain. They receive and process visual information.
124
Neurotransmitters are chemicals which relay, amplify, and modulate signals between a neuron and another cell. Some neurotransmitters are commonly described as "excitatory" or "inhibitory". The only direct effect of a neurotransmitter is to activate one or more types of receptors. Examples of neurotransmitters are acetylcholine, dopamine, gamma-aminobutyric acid, dopamine, glutamate, aspartate, and serotonin. The chemical compound acetylcholine (often abbreviated ACh) is a neurotransmitter in both the peripheral nervous system (PNS) and central nervous system (CNS) in many organisms including humans. In the peripheral nervous system, acetylcholine activates muscles, and is a major neurotransmitter in the autonomic nervous system. In the central nervous system, acetylcholine and the associated neurons form a neurotransmitter system, the cholinergic system, which tends to cause excitatory actions. Gamma-Aminobutyric acid (GABA) is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating neuronal excitability throughout the nervous system. In humans, GABA is also directly responsible for the regulation of muscle tone. Dopamine has many functions in the brain, including important roles in behavior and cognition, voluntary movement, motivation, punishment and reward, inhibition of prolactin production (involved in lactation and sexual gratification), sleep, mood, attention, working memory, and learning. In the frontal lobes, dopamine controls the flow of information from other areas of the brain. Dopamine disorders in this region of the brain can cause a decline in neurocognitive functions, especially memory, attention, and problem-solving. Reduced dopamine concentrations in the prefrontal cortex are thought to contribute to attention deficit disorder. Dopamine is commonly associated with the pleasure system of the brain, providing feelings of enjoyment and reinforcement to motivate a person proactively to perform certain activities. Dopamine is released (particularly in areas such as the nucleus accumbens and prefrontal cortex) by naturally rewarding experiences such as food, sex, drugs, and neutral stimuli that become associated with them. Recent studies indicate 125
that aggression may also stimulate the release of dopamine in this way. This theory is often discussed in terms of drugs such as cocaine, nicotine, and amphetamines, which directly or indirectly lead to an increase of dopamine in the mesolimbic reward pathway of the brain, and in relation to neurobiological theories of chemical addiction (not to be confused with psychological dependence), arguing that this dopamine pathway is pathologically altered in addicted persons. Projection neurons that produce dopamine are found in the diencephalon and the brainstem. In the diencephalon, dopamine cell bodies give rise to tuberopophysial dopamine projections, e which inhibit the release of prolactin and melanocyte-stimulating hormone from the anterior and intermediate lobes of the pituitary, respectively, and the incertohypothalamic projections, which connect the zona incerta in the posterodorsal diencephalon with the anterior hypothalamus and septal area. A third dopamine projection system arises from neurons scattered along the ventricular system in the periaqueductal gray, the dorsal motor of the nucleus of the vagus, and the nucleus solitarius. The preventricular system provides terminals in the gray matter along the course of the ventricles. Longer dopamine projection systems arise from the substantia nigra and the ventral tegmental area (VTA) of the midbrain. The former, the nigrostriatal dopamine system, is particularly important in the control of motor function. The function of the VTA’s dopamine projections to the forebrain, called the mesolimbic and mesocortical systems, has been linked to the complex group of disease we refer to as schizophrenia. Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor-binding is found in people with social anxiety. Traits common to negative schizophrenia (social withdrawal, apathy, anhedonia) are thought to be related to a hypodopaminergic state in certain areas of the brain. In instances of bipolar disorder, manic subjects can become hypersocial, as well as hypersexual. This is credited to an increase in dopamine, because mania can be reduced by dopamine-blocking anti-psychotics.
126
The locus ceruleus at the rostal end of the floor of the fourth ventricle on each side marks the position of a nucleus with a rich vascular supply and consisting of neurons containing melanin pigment. The nucleus (also known as nucleus pigmentosus) is partly in the pons and partly in the midbrain, lying dorsolateral to the oral pontine reticular nucleus. The locus ceruleus is the largest of about a dozen nuclei I the brainstem that produce cathecolamines. Most produce norepinephrine, but some of those in the medulla produce epinephrine. A third catecholamine is dopamine, a transmitter used by the large neurons of the substantia nigra and ventral tegmental area, and by certain nuclei of the hypothalamus. Serotonin or 5-Hydroxytryptamine (5-HT) is a monoamine neurotransmitter that is primarily found in the gastrointestinal (GI) tract and central nervous system (CNS) of humans and animals. Approximately 80 percent of the human body's total serotonin is located in the enterochromaffin cells in the gut, where it is used to regulate intestinal movements.[1][2] The remainder is synthesized in serotonergic neurons in the CNS where it has various functions, including the regulation of mood, appetite, sleep, muscle contraction, and some cognitive functions including memory and learning. Modulation of serotonin at synapses is a thought to be a major action of several classes of pharmacological antidepressants. Serotonin secreted from the enterochromaffin cells eventually finds its way out of tissues into the blood. There, it is actively taken up by blood platelets, which store it. When the platelets bind to a clot, they disgorge serotonin, where it serves as a vasoconstrictor and helps to regulate hemostasis and blood clotting. Serotonin also is a growth factor for some types of cells, which may give it a role in wound healing. Serotonin is eventually metabolized to 5-HIAA by the liver, and excreted by the kidneys. One type of tumor, called carcinoid, sometimes secretes large amounts of serotonin into the blood, which 127
causes various forms of the carcinoid syndrome of flushing, diarrhea, and heart problems. Due to serotonin's growth promoting effect on cardiac myocytes, persons with serotinin-secreting carcinoid may suffer a right heart (tricuspid) valve disease syndrome, caused by proliferation of myocytes onto the valve. Glutamate is the most abundant excitatory neurotransmitter in the vertebrate nervous system. At chemical synapses, glutamate is stored in vesicles. Nerve impulses trigger release of glutamate from the pre-synaptic cell. In the opposing post-synaptic cell, glutamate receptors, such as the NMDA receptor, bind glutamate and are activated. Because of its role in synaptic plasticity, glutamate is involved in cognitive functions like learning and memory in the brain. CRANIAL NERVES
Cranial nerves are nerves that emerge directly from the brain stem, in contrast to spinal nerves which emerge from segments of the spinal cord. There are 12 pairs cranial nerves emerging from the brain, and these are:
Cranial nerve number
Sensory, Name
Motor
Function
or Both 128
I
Olfactory nerve
Purely Sensory
II
Optic nerve
Purely Sensory
Transmits the sense of smell; Located in olfactory foramina of ethmoid Transmits visual information to the brain; Located in optic canal Innervates levator palpebrae superioris, superior
III
Oculomotor nerve
Mainly Motor
rectus, medial rectus,inferior rectus, and inferior oblique, which collectively perform most eye movements; Located in superior orbital fissure Innervates the superior oblique muscle, which
IV
Trochlear nerve
Mainly Motor
depresses, rotates laterally (around the optic axis), and intorts the eyeball; Located insuperior orbital fissure
V
Trigeminal nerve
VI
Abducens nerve
Both Sensory
Receives sensation from the face and innervates
and Motor
the muscles of mastication
Mainly Motor
Innervates the lateral rectus, which abducts the eye; Located insuperior orbital fissure Provides motor innervation to the muscles of facial expression, posterior belly of the digastric muscle, and stapedius muscle, receives the special sense of
VII
Facial nerve
Both Sensory and Motor
taste from the anterior 2/3 of the tongue, and provides secretomotor innervation to the salivary glands (except parotid) and the lacrimal gland; Located and runs through internal acoustic canal to facial canal and exits at stylomastoid foramen
VIII
IX
Vestibulocochlear
Senses sound, rotation and gravity (essential for
nerve (or auditory-
balance & movement). More specifically. the
vestibular
Mostly sensory vestibular branch carries impulses for equilibrium
nerveor statoacoustic
and the cochlear branch carries impulses for
nerve)
hearing.; Located in internal acoustic canal
Glossopharyngeal
Both Sensory
Receives taste from the posterior 1/3 of the tongue,
nerve
and Motor
provides secretomotor innervation to the parotid gland, and provides motor innervation to 129
the stylopharyngeus (essential for tactile, pain, and thermal sensation. Some sensation is also relayed to the brain from the palatine tonsils. Sensation is relayed to opposite thalamus and some hypothalamic nuclei. Located in jugular foramen Supplies branchiomotor innervations to most laryngeal and all pharyngeal muscles (except the stylopharyngeus, which is innervated by the glossopharyngeal); provides parasympathetic fibers to nearly all thoracic and abdominal viscera down X
Vagus nerve
Both Sensory
to the splenic flexure; and receives the special sense
and Motor
of taste from the epiglottis. A major function: controls muscles for voice and resonance and the soft palate. Symptoms of damage: dysphagia (swallowing problems),velopharyngeal insufficiency. Located in jugular foramen Controls sternocleidomastoid and trapezius
Accessory nerve XI
(or cranial accessory nerve or spinal
muscles, overlaps with functions of the vagus. Mainly Motor
Examples of symptoms of damage: inability to shrug, weak head movement; Located in jugular
accessory nerve)
foramen Provides motor innervation to the muscles of the
XII
Hypoglossal nerve
Mainly Motor
tongue and other glossal muscles. Important for swallowing (bolus formation) and speech articulation. Located in hypoglossal canal
130
DOCTOR’S ORDER Date 01/19/10
Order
Rationale
Please admit to CIU.
2:40pm
Remarks
For close monitoring of the patient Admitted and proper management of his condition. The crisis intervention unit is a special unit operating on a 24-hour basis, which serves as a receiving and action center for walk-in referred, and rescued individuals
Secure
consent
care.
and families in crisis situation. to This is done to ensure that the Secured. client or significant others has been
adequately
informed
of
significant information concerning treatment
processes
and
procedures. When persons, due to age or mental status, are legally incapable
of
giving
informed
consent, doctors obtain informed permission
from
authorized
person,
substitute
consent
a
legally if
is
such legally
permissible. To secure the consent of the client is important for legal purposes. DAT with aspiration This is done to give appropriate Done precaution.
and adequate nourishment with the prevention or minimization of risk factors in the patient at risk for 131
aspiration. Monitor
vsq6
and Vital signs are important for Taken
record please
baseline
assessment
and
and
to recorded.
monitor patients condition which evaluates the whole treatment course, especially the medications he receives that could be a contributing factor in the variation results of the vital signs. Meds:
Given
Haloperidol
5mg Haloperidol is an older 1amp IM now then antipsychotic used in the treatment q12
of schizophrenia.
Flupentixol dec 20mg 1ampule now then q monthly
Flupentixol injection weekly
is
given to
a
long
two
or
people
acting three with
schizophrenia who have a poor compliance with medication and suffer frequent relapses of illness.
Hcl Biperiden is commonly used to 2mg/tab 1 tab BID improve parkinsonian signs and symptoms related to antipsychotic PRN for EPS Biperiden
drug therapy. Homicidal
and This is ordered so that the patient Done
suicidal
tendencies will be monitored closely and to
escape
precaution avoid the harming of patient's life
please
or others.
Restrain patient when Psychiatric facilities often use Done necessary.
medical interventions in the form of restraints to reduce safety risks posed by violent patients and to 132
prevent patients from harming themselves and others. Refer accordingly
This may create a collaborative Referred treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client.
01/20/10 11:40am Hold Haloperidol IM To change to chlorpromazine. Start Chlorpromazine This is given as a substitute for
Done Given
decanoate 200 mg/tab Haloperidol. This is an atypical ½ tab in am, 1 tab at drug and is considered to have less HS. 01/21/10 07:40 AM CONTINUE MEDS
EPS side effects. To promote the patient's well Done
For possible discharge being. MGH:
The patient’s psychotic episodes
Done
have diminished. The patient is advised to go home so the patient may go back to his normal life.. Home meds:
This is ordered as patient's mainte-
1. Chlorpromazine
nance medications for his condi-
200mg 1tab, ½ in AM
tion.
2. Biperiden HCL 2g/tab 1tab BID 3. Flupentixol dec 20mg/1amp IM qmonthly (last dose 1/1910) >Follow up at OPD This is ordered for patient's reafter 1 month.
assessment and constant monitoring. 133
134
DRUG STUDY
Generic Name:
Haloperidol
Brand Name: Aloperidin, Bioperidolo, Brotopon, Dozic, Duraperidol (Germany), Einalon
S, Eukystol,
Haldol, Halosten, Keselan, Linton, Peluces, Serenace, Serenase, and Sigaperidol Classification(s):
Typical Antipsychotic
Suggested Dose: Individualized dose depends on indication and response. AVAILABLE FORMS: Haloperidol: Tablets – 0.5 mg, 1 mg, 2 mg, 5mg, 10 mg, 20 mg. Haloperidol decanoate: Injection – 50mg/ml, 100 mg/ml Haloperidol lactate: Injection – 5mg/ml. Oral concentration: 2 mg/ml. Ordered dose: Mode of Action:
Haloperidol 5 mg 1 amp IM now then q 12 (January 19, 2010) Unknown. A butyrophenone that probably exerts antipsychotic effects by blocking postsynaptic dopamine receptors in the brain.
ROUTE
ONSET
PEAK
DURATION
P.O.
Unknown
3-6 hr
Unknown
I.V.
Unknown
Unknown
Unknown 135
I.M.
Unknown
3-9 days
Unknown
(decanoate) I.M. (lactate) Unknown
10-20 min
Unknown
Indications: ♂
Psychotic disorders (Adults and children older than age 12: Dosage varies for each patient. Initially, 0.5 to 5 mg P.O. b.i.d. or t.i.d. Or, 2 to 5 mg I.M. haldol lactate q 4 to 8 hours, although hourly administration may be needed until control is obtained.)
♂
Chronic psychosis requiring prolong therapy (Adults: 50 to 100 mg I.M. haloperidol decanoate q 4 weeks.)
♂
Tourette Syndrome (Adults: 0.5 to 5 mg P.O. b.i.d., t.i.d., or p.r.n.)
Contraindications: ♂ In patients hypersensitive to drug and in those with parkinsonism, coma, CNS depression. ♂ Use cautiously in elderly and deliberated patients; in patients with history of seizures or EEG abnormalities, severe CV disorders, allergies, glaucoma, or urine retention; and in those and those taking anticonvulsants anticoagulants, antiparkinsonians, or lithium. Drug Interaction: Drug – Drug ♂
Anticholinergics: May increase anticholinergic effect and glaucoma. Azole antifungals, buspirone, macrolides: May increase haloperidol level. Carbamazepine: May increase haloperidol level. CNS depressants: May increase CNS depression. Lithium: May cause 136
lethargy and confusion after high doses. Methyldopa: May cause dementia. Rifampin: May decrease haloperidol level. Drug – Lifestyle ♂
Alcohol use: May increase CNS depression.
Side Effects: ♂ CNS: severe extrapyramidal reactions, tardive dyskinesia, sedation, drowsiness, lethargy, headache, insomnia, confusion, vertigo. ♂ CV: tachycardia, hypotension, hypertension, ECG changes ♂ EENT: blurred vision. ♂ GI: dry mouth, anorexia, constipation, diarrhea, nausea, vomiting, dyspepsia. ♂ GU: urine retention, menstrual irregularities, priapism. ♂ Hematologic: leukocytosis. ♂ Hepatic: Jaundice. ♂ Skin: rash, other skin reactions, diaphoresis. ♂ Other: gynecomastia. Adverse Effects: ♂ CNS: seizures and neuroleptic malignant syndrome. ♂ CV: torsades de pointes, with I.V. use. ♂ Hematologic: Leukopenia Nursing Responsibilities: ♂ Although drug is least sedating of the antipsychotics, warn patient to avoid activities that require alertness and good coordination until effects of the drugs are known. ♂ Educate patient that drowsiness and dizziness usually subside after a few weeks. 137
♂ Inform patient to avoid alcohol while taking this drug. ♂ Tell patient to relieve dry mouth with sugarless gum or hard candy. ♂ Always remember, don’t give deconate form IV. ♂ Monitor the client for signs of tardive dyskinesia which may occur after prolonged use. It may not appear until months or years later and may disappear spontaneously or persist for life, despite ending drug. ♂ Watch out for signs and symptoms of neuroleptic malignant syndrome, which is rare but fatal. ♂ Inform patient to do not withdraw the drug abruptly unless required by severe adverse reactions. ♂ Remind patient to always protect the drug from light. Slight yellowing injection or concentrate is common and doesn’t affect potency. Discard the drug if there is a markedly discolorations in the solutions. ♂
Stop taking haloperidol and check the patient with their doctor right away if they have any of the following symptoms while using haloperidol: convulsions (seizures); difficulty with breathing; a fast heartbeat; a high fever; high or low blood pressure; increased sweating; loss of bladder control; severe muscle stiffness; unusually pale skin; or tiredness. These could be symptoms of a serious condition called neuroleptic malignant syndrome (NMS).
BIBLIOGRAPHY:
26th Edition Nursing 2006 Drug Handbook by Lippincott Williams
and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition. 138
Generic Name:
Flupentixol
Brand Name:
Fluanxol; Depixol; Depixol Low Volume; Depixol-Conc
Classification(s): Ordered dose:
Typical Antipsychotics Flupentixol decanoate 20 mg 1 amp now then q monthly (January 19,
2010) Mode of Action:
Flupenthixol is a type of thioxanthene drug and acts by antagonism of D1 and D2 dopamine receptors (as well as serotonin). Side effects are similar to 139
many other typical antipsychotics, namely extrapyramidal symptoms of akathisia, parkinsonian tremor and rigidity. However, anticholinergic adverse effects are low. The typical antipsychotics are less commonly used now that the atypical antipsychotics are available (with less side effects). Indications: ♂ Schizophrenia and other psychoses Dose: oral (rarely used) - initially 3-9mg twice daily, max. dose 18mg/day Depot antipsychotic (Depixol) (brand name: Fluanxol Depot in Australia) o test dose of 20mg IM, o if tolerated, further dose of 20-40mg after 7 days, o usual interval 2-4 weeks between doses, o usual maintenance dose between 50mg every 4 weeks and 300mg every 2 weeks, o max. 400mg IM weekly. ♂ Depression Dose: o initially 1mg/day, increased after 1 week to 2mg/day, o use half above doses in the elderly, o max 3mg/day (2mg in the elderly), o doses above 2mg (1mg in the elderly) should be gived as divided doses.
140
Contraindications: ♂ If patient is allergic to flupentixol or any other medicine of this class. ♂ If patient is allergic to any other medicine including preservative and dyes. ♂ Elderly people should be prescribed flupentixol with caution. ♂ If patient has history of kidney problem, liver problem or epilepsy. ♂ If patient has a problem of heart disease, high blood pressure or diabetes. ♂ If patient has a problem of enlarged prostate, thyroid problem or Parkinson’s disease. ♂
If two drugs are taken together, they may interact with each other. If patient is taking any prescribed or non-prescribed, food supplements or herbal medicine.
♂ If patient is pregnant, or plan to become pregnant.
Drug Interaction: ♂
Prescription and nonprescription medications, especially those that may cause drowsiness such as: sedatives, narcotic pain relievers (e.g., codeine), anti-anxiety agents (e.g., diazepam), antidepressants or other psychiatric medicine, dopamine-type drugs (e.g., cabergoline, pergolide, bromocriptine, pramipexole), muscle relaxants (e.g., cyclobenzaprine), drowsiness-causing antihistamines (e.g., diphenhydramine), atropinelike drugs, anti- seizure drugs.
♂
Many cough-and-cold products contain ingredients that may add a drowsiness effect.
Side Effects:
141
•
Nausea, drowsiness, dizziness, diarrhea, constipation, blurred vision, insomnia, urine problem, tremor, weakness, vomiting, and difficulty in breathing, slow heart rate, irregular blood pressure and convulsions.
•
Less common side effects of flupentixol include skin rashes, muscle problem, dizziness while rising from bed, sore throat, dark urine, increased sweating, yellowness of skin and eyes, decreased sex drive and painful erection, chest pain and muscle spasms.
Nursing Responsibilities: ♂ Educate patient that Flupentixol can cause drowsiness, dizziness and blurred vision. ♂ Remind client that alcohol will increase feelings of drowsiness. ♂ Remind patient that before having any surgery, including dental or emergency treatment, tell the surgeon, doctor or dentist that you are taking flupentixol. ♂ Inform client that Flupentixol can occasionally cause a dry mouth. If patient experiences this, try chewing sugar-free gum, sucking sugar-free sweets or pieces of ice. ♂ Flupentixol can cause some people's skin to become more sensitive to sunlight than it usually is. Avoid strong sunlight and sunbeds until you know how your skin reacts and use a suncream higher than factor 15. ♂ If client experience 'flu like' symptoms such as stiffness, high temperature, abnormal paleness, leaking bladder and a racing heartbeat contact their doctor or go to the accident and emergency department of your local hospital immediately. ♂ Educate the patient that the symptoms of overdose may include seizers, muscle spasms, weakness, fast heartbeat, fever, difficult breathing, severe dizziness, drowsiness, convulsions, irregular heartbeat, disturbed concentration, constipation and coma. 142
♂ Inform patient to take the medicine with a full glass of water. ♂ Remind the patient that the medicine can be taken with or without food. ♂ Instruct to the patient that he can swallow the medicine as whole. Don’t cut or chew the medicine. BIBLIOGRAPHY:
26th Edition Nursing 2006 Drug Handbook by Lippincott Williams
and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.
Generic Name:
Biperiden
Brand Name:
Akineton, Benzum 2, Berofin, Biperen, Bipiden, Desiperiden
Classification(s):
Anti-Parkinson's Agent, Anticholinergic
Suggested Dose: Adults: 143
Parkinsonism: 2 mg 3-4 times/day Extrapyramidal: 2 mg 1-3 times/day Elderly: Initial: 2 mg 1-2 times/day Ordered dose: Mode of Action:
Biperiden Hcl 2 mg / tab 1 tab B.I.D. prn for EPS (January 19, 2010) Biperiden is a weak peripheral anticholinergic agent with nicotinolytic activity. The beneficial effects in Parkinson's disease and neuroleptic-induced extrapyramidal symptoms are believed to be due to the inhibition of striatal cholinergic receptors.
Indications: ♂ Adjunctive treatment of all forms of Parkinson's disease (postencephalitic, idiopathic, and arteriosclerotic). ♂ Improve parkinsonian signs and symptoms related to antipsychotic drug therapy. ♂ Relieves muscle rigidity, reduces abnormal sweating and salivation, improves abnormal gait, and to lesser extent, tremor. Contraindications: ♂ Hypersensitivity to biperiden or any component of the formulation ♂ Narrow-angle glaucoma ♂ Bowel obstruction, megacolon ♂ Myasthenia gravis
144
♂
Caution in patients with obstructive diseases of the urogenital tract, patients with a known history of seizures and those with potentially dangerous tachycardia.
Drug Interaction: Drug – Drug ♂ Amantadine, rimantadine: Central and/or peripheral anticholinergic syndrome can occur when administered with amantadine or rimantadine. ♂ Anticholinergic agents: Central and/or peripheral anticholinergic syndrome can occur when administered with opioid analgesics, phenothiazines and other antipsychotics (especially with high anticholinergic activity), tricyclic antidepressants, quinidine and some other antiarrhythmics, and antihistamines. ♂ Atenolol: Anticholinergics may increase the bioavailability of atenolol (and possibly other beta-blockers); monitor for increased effect. ♂ Cholinergic agents: Anticholinergics may antagonize the therapeutic effect of cholinergic agents; includes tacrine and donepezil. ♂ Digoxin: Anticholinergics may decrease gastric degradation and increase the amount of digoxin absorbed by delaying gastric emptying. ♂ Levodopa: Anticholinergics may increase gastric degradation and decrease the amount of levodopa absorbed by delaying gastric emptying. ♂ Neuroleptics: Anticholinergics may antagonize the therapeutic effects of neuroleptics. Side Effects: 145
♂
CNS : Drowsiness, vertigo, headache,
and dizziness are
frequent.
With
high
doses
nervousness, agitation, anxiety, delirium, and confusion. Biperiden may lower the seizurethreshold. ♂ Peripheral side effects : Blurred vision, dry mouth, impaired sweating, abdominal discomfort, and obstipation are frequent. Tachycardia may be noted. Allergic skin reactions may occur. ♂ Eyes : Biperiden causes mydriasis with or without photophobia. It may precipitate narrow angle glaucoma. Adverse Effects: ♂ Cardiovascular: Orthostatic hypotension, bradycardia ♂ Central nervous system: Drowsiness, euphoria, disorientation, agitation, sleep disorder (decreased REM sleep and increased REM latency) ♂ Gastrointestinal: Constipation, xerostomia, dry throat, nasal dryness ♂ Genitourinary: Urinary retention ♂ Neuromuscular & skeletal: Choreic movements ♂ Ocular: Blurred vision Nursing Responsibilities: ♂
Instruct patient to use caution when driving, operating machinery, or performing other hazardous activities. Biperiden may cause dizziness or blurred vision. If patient experience dizziness or blurred vision, avoid these activities. 146
♂
Remind patient to use alcohol cautiously. Alcohol may increase drowsiness and dizziness while client is taking biperiden.
♂
Remind client to avoid becoming overheated. Biperiden may cause decreased sweating. This could lead to heat stroke in hot weather or with vigorous exercise.
♂
Educate client to take each dose with a full glass of water.
♂
Educate patient to take biperiden after a meal if it upsets his stomach.
♂
Remind the patient to store biperiden at room temperature away from moisture and heat.
♂
This medication decreases saliva production, an effect that can increase gum and tooth problems (e.g., cavities, gum disease). Instruct client to take special care with their dental hygiene (e.g., brushing, flossing) and have regular dental check-ups.
♂
If client experiences signs of hyperthermia such as mental/mood changes, headache, or dizziness, promptly seek cool or air-conditioned shelter and/or stop exercising, and seek immediate medical attention.
♂
Remind patient to not share the medication to others.
♂
If patient misses a dose, remind them to take it as soon as they remember. If it is near the time of the next dose, skip the missed dose and resume their usual dosing schedule. Do not double the dose to catch up.
BIBLIOGRAPHY:
26th Edition Nursing 2006 Drug Handbook by Lippincott Williams
and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition
147
Generic Name:
Chlorpromazine Hydrochloride
Brand Name:
Chlorpromanyl, Largactil, Novo-Chlorpromazin, Thorazine
Classification(s):
Typical Antipsychotic
Suggested Dose: Individualized dose depends on indication and response. AVAILABLE FORMS: Capsules (extended release): 200 mg, 300 mg. Injections: 25 mg/ml Oral concentrate: 30 mg/ml, 100 mg/ml Suppositories: 25 mg, 100 mg Syrup: 10 mg/5ml Tablets: 10 mg, 25 mg, 50 mg, 100 mg, 200 mg Ordered dose: Mode of Action:
Chlorpromazine 200g/tab (January 20, 2010) Unknown. A piperidine phenothiazine that probably blocks postsynaptic dopamine receptors in the brain.
ROUTE
ONSET
P.O.
30-60min
I.M., I.V.
Unknown
PEAK Unknown
Unknown
DURATION 4-6hr
Unknown 148
P.R.
>1hr
Unknown
3-4 hr
Indications: ♂
Psychosis, mania (Adults: for hospitalized patients with acute disease, 25 mg I.M.)
♂
Nausea and vomiting (Adults: 10 to 25 mg PO q 4 to 6 hours, p.r.n. Or, 25 mg IM initially.)
♂
Acute intermittent porphyria, intractable hiccups (Adults: 25 to 50 mg PO t.i.d. or q.i.d.)
♂
Tetanus (Adults: 25 to 50 mg IV or IM t.i.d. or q.i.d.)
Contraindications: ♂ In patients hypersensitive to drug; in those with CNS depression, bone marrow suppression, or subcortical damage, and in those in coma. ♂ Use cautiously in elderly and deliberated patients and in patients with hepatic or renal disease, severe CV disease, respiratory disorders, hypocalcemia, glaucoma, pr prostatic hyperplasia. ♂ Use cautiously in acutely ill or dehydrated children. Drug Interaction: Drug – Drug ♂
Antacids: May inhibit absorption of oral phenothiazines. Anticholinergics such as
tricyclic antidepressants, antiparkinsonians: May increase anticholinergic activity, aggravated parkinsonian symptoms. Anticonvulsants: May lower seizure threshold. Barbiturates, lithium: May decrease phenothiazine effect. Centrally acting anthypertensives: May decrease 149
antihypertensive effect. CSN depressants: May increase CNS depression. Electroconvulsive therapy, insulin: may cause severe reactions. Lithium: May increase neurologic effects. Meperidine: May cause excessive sedation and hypotension. Propanolol: May increase levels of both propanolol and chlorpromazine. Warfarin: May decrease effect of oral anticoagulants. Drug – Lifestyle ♂
Alcohol use: May increase CNS depression, particularly psychomotor skills.
Side Effects: ♂ CNS: extra pyramidal reactions, sedation, tardive dyskinesia, pseudoparkinsonism. ♂ CV: orthostatic hypotension ♂ GI: dry mouth, constipation ♂ GU: urine retention ♂ Skin: mild photosensitivity reactions, pain at IM injection site Adverse Effects: ♂ CNS: Seizures and neuroleptic malignant syndrome. ♂ Hematologic: Leukopenia, agranulocytosis, aplastic anemia, thrombocytopenia Nursing Responsibilities: ♂ Obtain baseline blood pressure measurements before starting therapy, and monitor regularly. Watch client for orthostatic hypotension. ♂ Monitor client for tardive dyskinesia, which may occur after prolonged use. ♂ Warn patient to avoid activities that require alertness or good coordination until effects of drug are known. ♂ Remind client that drowsiness and dizziness usually subside after a few weeks.
150
♂ Advise patient not to crush, chew, or break extended release capsule form before swallowing. ♂ Educate patient to avoid alcohol while taking the drug. ♂ Have the patient to report signs of urine retention or constipation. ♂ Remind patient to use sunblock and to wear protective clothing to avoid oversensitivity to the sun. ♂ Advise client to relieve dry mouth with sugarless gum or hard candy. ♂ Withhold dose and notify prescriber if jaundice, symptoms of blood dyscrasia, or persistent extrapyramidal reactions develop.
BIBLIOGRAPHY:
26th Edition Nursing 2006 Drug Handbook by Lippincott Williams
and Wilkins; Phil. Pharmaceutical Directory Review, 7th edition.
SCIENTIFIC NAME:
Cannabis sativa L.
BRAND/STREET NAME:
Marijuana, Marihuana, Hemp, Hashish
CLASSIFICATION:
Psychoactive drug; stimulant; depressant; hallucinogen
ROUTE OF ADMINISTRATION: Inhaled smoke, screened bowls, bubblers (small pipes with water chambers), bongs, one-hitters, chillums, paper-wrapped joints and tobacco-leaf-wrapped blunts, tea, and orally. 151
CHEMICAL CONSTITUENTS: Cannabis chemical constituents including about 100 compounds responsible for its characteristic aroma. These are mainly volatile terpenes and sesquiterpenes. INDICATIONS: •
Amelioration of nausea and vomiting
•
Stimulation of hunger in chemotherapy and AIDS patients
•
Lowers intraocular eye pressure (shown to be effective for treating glaucoma)
•
General analgesic effects (pain reliever)
CONTRAINDICATIONS: •
Hypersensitivity to cannabis
•
Pregnant women, or planning to get pregnant
DRUG INTERACTIONS: •
Alcohol: Make both drugs stronger.
•
Amphetamines
•
Cocaine: (Uppers and downers)
•
Ecstasy: Extends and expands the experience of ecstasy.
•
Heroin: Complimentary effects.
•
Ketamine: Increases cannabis effects.
SIDE EFFECTS: •
General sense of well being and relaxation, giggliness and euphoria
•
Eyes: Reddening, decreased intraocular pressure.
•
Dreaminess, increased appreciation of music, sleepiness and time distortion
•
Dryness of the mouth 152
•
Increase heart rate
•
Muscle relaxation
•
Low blood pressure
•
Impairment of short-term episodic memory, working memory, psychomotor coordination, and concentration
•
Anxiety, panic, paranoia and feelings of impending doom
ADVERSE EFFECTS: •
Lung cancer
•
Chronic fungal infections
•
Paranoia
•
Confusion
•
Long-lasting toxic psychosis
NURSING RESPONSIBILITIES: •
Reassure client that anxiety attacks are common side effects of the drug and will disappear within hours.
•
Provide a supportive environment for the client when experiencing feelings of paranoia and anxiety.
•
Remind client to avoid strenuous activities like driving or operating machinery until the effects of the drug diminishes.
•
Educate client that effects at first can be subtle, first time users usually detect little or no effect at all.
•
Inform the client that if he is possibly experiencing marijuana OD symptoms, it is recommended that he calls the local emergency line. 153
•
Educate client that if he is a regular cannabis smoker (every day) and stopped smoking, he will experience some of the following withdrawal symptoms: restlessness, irritability, mild agitation, insomnia, nausea, sleep disturbance, sweats, and intense dreams.
154
155
NURSING CARE PLAN TIME
CUES
NEED
AND
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE Januar SUBJECTIVE: y
NURSING
21, “Naay
C
nagahung- O
Disturbed sensory At the end of 2 perception related hours
of nursing
build trust with the @ 2:30 PM
the
client
2009
hung sa akoa usahay G
to alteration in care,
@
nga mag-wild daw ko N
function of brain will be able to
12:30
ug
tissue
P.M.
verbalized
maglagot” by
as I
•
•
® The client must trust
orientation to ®It is the change
time,
V
in the amount or
person,
E
patterning
circumstances
Disoriented
-
incoming stimuli
for
to time
P
accompanied by a
period
Auditory and E
diminished,
time;
visual hallu- R
exaggerated,
• demonstrate
of
and
specified of
about hallucinations and other sensory-perceptual alterations
•
The pa-
tient was able to maintain orientation to time,
2. Continuously
orient
the client to actual environmental events or activities in a nonchal-
place, person and situation. “Huwebes karon. Mga
C
distorted,
Misinterprets
E
impaired
ception of the
response to such
environment
®Brief, frequent ori-
sa Mental hos-
stimuli.
by responding
entation
pital para mag-
appropriately
present reality to the
Schultz,
to stimuli in
client with sensory-
M.J.;Videback,
the surround-
perception disturbance
S.L.; Lippincott’s
ings; and
others
of P T
to U make simple A L decisions
or
place,
the nurse before talking
cinations actions •
GOAL UNMET
I
OBJECTIVE •
patient
• maintain
the T
patient
1. Establish rapport and January 21, 2009
Inability
accurate per-
udto na man
lenging way.
siguro. Naa ko helps
to
pacheck-up” •
However,
the client was not able to
156
•
Inappropriate responses
P A T T E R N
Manual
of
Psychiatric Nursing
• lessen visual and audi-
Care
Plans 7th edition
tory
halluci-
nations
demonstrate ac3. Reinforce and focus on reality. Talk about real events and real people. Use real situations and events to divert client from long, tedious, repetitive verbalizations
of
false
ideas
tion of the environment as evidenced by the presence of delusion and hallucination •
Presence
of auditory hal-
® Working with reality
curate percep-
lessens
patient’s
lucination is still evident.
initiation of his hallucinations. 4. Correct
client's
de-
scription of inaccurate perception, and describe the situation as it exists in reality ® Explanation of, and participation in, real situations and real activities
interferes
157
with the ability to respond to hallucinations. 5. Observe
for
verbal
and nonverbal behaviors associated with hallucinations ® Early recognition of sensory-perceptual disturbance promotes timely
interventions
and alleviation of the client’s symptoms. 6. Describe the hallucinatory behaviors to the client. ® The client may be unable to disclose perceptions and the nurse can openly facilitate disclosure by reflect-
158
ing on observations of the client’s behaviors, which helps the client engage in more open discussion with the nurse, which in itself brings relief. 7. Explore the content of hallucinations to determine the possibility to harm self, others or the environment ® Exploring the content of the hallucination helps the nurse identify if the sensoryperceptual disturbance is threatening or dangerous to the client, such as a command type of hallucination that may be telling the
159
client to harm or kill the client or others. The nurse can then reinforce treatment and safety precautions. 8. Use clear, direct, verbal
communication
rather than unclear or nonverbal gestures ®Unclear or
directions
instructions
can
confuse the client and promote distorted perceptions or misinterpretations of reality. 9. Modify the client’s environment to decrease situations that provoke anxiety ®Decreased
anxiety
can reduce the occur-
160
rence
of
hallucina-
tions 10. Reassure
the
client
(frequently if necessary) that the client is safe and will not be harmed ®Alleviation of fear is necessary
for
the
client to begin to trust the environment and to feel safe.
161
TIME
CUES
NEED
AND DATE Januar y
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS SUBJECTIVE
C
21, “Magpatambal ko. Kani O
Disturbed
At the end of 2
thought process hours of nursing
est when communi- @ 12:30 PM cating
2009
man gud akong utok, naa G
related
@
niy grasa.” as verbalized N
disintegration
7:00
by the patient
thinking.
I
A.M OBJECTIVE • •
Thought insertion
R
•
Incoherent speech
C
•
Demonstrates
tory hallucinations
GOAL PARTIALLY
Maintain
Demon-
•
Presence of audi-
client.
tremely
E
•
•
the
entation;
noia
sleep pattern
will be able to
with
I
-
in
patient
®Clients are ex- MET
Delusion of para- P
disturbance
the
reality ori-
Delusion of perse- E
a
to care,
T V
cution
1. Be sincere and hon- January 21, 2009
E P T U A L
®It
is
disruption
the in
•
cognitive operations
and
activities. Cognitive
by
which knowledge
is
acquired. These mental
about others and
client
was
strate reali-
can recognize insin-
able
ty
cerity. Evasive re-
maintain re-
thinking in
marks
ality orien-
verbal and
mistrust.
based
reinforce
•
to
tation. He is oriented
2. Assess client’s non-
behavior;
those
mental processes
The
nonverbal
processes include
•
sensitive
when
and
verbal
Demon-
such as gestures, fa-
day
it
is.
cial expression and
But
he
is
posture.
still
preoc-
strate
the
ability
to
behavior,
time
to
cupied with
abstract, conceptual-
asked what
®This
assessment
his
delu-
may help to meet
162
P
processes
ize, reason
the client’s needs
sions about
A
include
and calcu-
that cannot be con-
his
T
orientation,
late consis-
veyed
jealous
T
comprehension,
tent
speech.
E
awareness, and
ability to
R
judgment.
A
3. Encourage
N
disruption
in
client
reality
these
with
through
being to
him the
to
express
•
The
client
was
mental
feelings and do not
not able to
may
pry cross examine
demonstrate
for information
reality-
processes lead
to
inaccurate
based think-
interpretations
®Probing increases
ing in ver-
of
client’s
bal and non-
the
suspicion
environment
and interferes with
verbal
and may result
the therapeutic rela-
sponses. His
in an inability to
tionship
mannerism
evaluate reality accurately. Alterations
is 4. Show empathy to
in
thought
the
client’s
feel-
re-
largely
observed and
he
ings, reassure the
wasn’t able
client of your pres-
to establish
not limited to
ence
eye contact
any
tance
processes one
are age
group,
gender,
or
clinical
and
accep-
with any of the
inter-
®The client’s ex-
163
problem. (http://www1.us .elsevierhealth.c om/MERLIN/G ulanick/Constru
periences can be
viewer.
distressing. Empa-
•
thy conveys accep-
wever,
tance of the client
was able to
your caring and in-
exhibit
terest.
positive ab-
ctor/index.cfm? plan=53.01)
Ho he a
stract, 5. Avoid
laughing,
son,
reajudg-
whispering, or talk-
ment
ing quietly where
calculation
client can see but
abilities.
and
not hear what is being said. ®Suspicious clients often believe others are
discussing
them, and secretive behaviors reinforce the paranoid feelings. 6. Give simple directions using short words and simple
164
sentences. ® Giving simple directions lessen or prevent
confusion
of the patient 7. Never convey to the client that his delusions and hallucinations are real ®The delusion or hallucination would be reinforce if it’s accepted. 8. Maintain oriented
reality relation-
ship and environment ® Maintaining reality based relationship and environ-
165
ment lets the patient know that the relationship is temporary and prevents separation anxiety 9. Give positive feedbacks and acknowledge the client ®Positive feedback enhances sense of well-being
and
makes a more positive situation for the client. 10. Do not judge or belittle
client’s
be-
liefs. ®What the client feels or thinks is not funny for him. The client may feel
166
rejected
if
ap-
proached
by
at-
tempts of humor.
167
TIME
CUES
NEED
AND SUBJECTIVE:
Januar
“Maulaw man gyud ko E
21, basta ing-ana”
S
Situational low At the end of 2 self-esteem
L
related
2010
F
cognitive
@ 12 OBJECTIVE:
-
impairment
:30
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE . y
NURSING
•
PM
•
E
Lack social inter- R C
the
patient
will: •
@ 2:30 PM
ings in relation to GOAL UNMET •
Verbalize
knowledge pain of
It is the state in
understand-
loss. Support client
was unable to
which
ing
through process of
verbalize under-
grieving.
standing
an
of
Has little interest E P in activities
previously
had
precipitate
self-
current sit-
Talks only when T I asked
esteem
N
January 21, 2010
of functioning. Ac-
things that
O
express honest feelloss of prior level
individual who
action •
to care,
Lacking eye con- P tact
•
hours of nursing
1. Encourage client to
positive
uation; and
experience
a
negative feeling towards self due to
a
certain
situation
•
strate
haviors that show positive self-esteem
Handbook
of
Nursing Diagnosis
be-
by
of
things that lead ® Client may be fixed in anger stage of grieving process,
Demon-
The patient
which
is
turned
inward on the self, resulting diminished
in self-
esteem. 2. Devise methods for assisting client to
to current situation •
The patient
was unable to demonstrate behaviors show
that positive
self-esteem
as
evidenced
by
inability to have
168
Lynda CarpenitoMuyet
Juall
an express
feelings
properly..
eye-contact
as well as looking
® To explore the feelings
of the
client
thereby
down
at
during the interview.
allowing him to acknowledge his own strength and weakness. 3. Encourage
client's
attempts to communicate. If verbalizations are not understandable,
express
to client what you think he or she intended to say. It may be necessary to reorient client frequently. ® The ability to communicate
169
effectively
with
others may enhance self-esteem.
4. Encourage reminiscence and discussion of life review. Also
discuss
present-day events. Sharing picture albums, if possible, is especially good. ® Reminiscence
and
life review help the client resume progression
through
the grief process associated with disappointing life events and increase selfesteem as successes are reviewed. 5. Encourage participation in group ac-
170
tivities.
Caregiver
may need to accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication. ®
Positive
feedback
from
group members will increase
self-
esteem. 6. Offer support and empathy client
when expresses
embarrassment
at
inability to remember people, events, and places. ® Focus on accomplish-
171
ments to lift self-esteem. 7. Encourage client to be as independent as possible in selfcare activities. ® The ability to perform independently preserves
self-
esteem. 8. Listen to patient’s concerns and verbalizations without comment or judgment. ®It
enables
the
client to develop trust and thereby establish communication
172
9. Provide feedback to client’s
negative
feelings. ®To
allow
the
client experience a different view.
173
TIME
CUES
NEED
AND
NURSING
GOAL OF CARE
INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE January
SUBJECTIVE:
21,
The
2010
exactly
@12:30 PM
clarified
C
At the end of 3 day
1. Provide opportuni- January 21, 2010
memory related nursing care, the
ties
to neurological patient will be able
cence or recall past
months he was referring N
disturbances
events
about his last used of I
®Impaired
marijuana, he verbalized T
memory
“Kadtong 2007 man to, I aw 2008 diay”
was
when O
Impaired
the
OBHECTIVE: •
•
®Long-term mem-
awareness
ory may persist af-
was able to
directly related
of memory
ter loss of recent
verbalize
V
to
problems;
memory. Reminis-
awareness
E
general medical
and
cence is usually an
of memory
-
condition
Accept lim-
enjoyable
problems
ongoing effects
itations
for the client.
of
current
E
effects
is of or
substance.
•
of
activity
The patient
as he verbalized
Depending o n
rience of forget- C
the areas of the
client to use written
gyud
E
brain, the client
cues such as calen-
makalimot
are
dars or notebooks
na ko”
his P head when he is T unable to recall U Scratches
information •
•
GOAL MET
Observed expe- R ting
•
to:
reminis- @ 2:30 PM
Verbalize
Disorientation to P time
•
2 G
for
A
Inability to de- L
unable
to
condition
2. Encourage
the
“Usahay
recall
®Written cues de-
information,
crease the client’s
was able to
either remote or
need to recall activ-
verbalize
recent.
The
ities, plans and so
acceptance
client
may
on from memory.
•
The patient
174
termine if a be-
confabulate
to
3. Encourage ventila-
of his limi-
havior
fill in those lost
tion of feelings of
tations due
memories.
frustration,
to his con-
forme
is
per-
lessness,
helpand
so
ditions
forth. Refocus attention to areas of focus and progress. ®To lessen feelings of powerlessness/hope lessness 4. Provide for proper pacing of activities and having appropriate rest ®To avoid fatigue 5. Allow the client to do tasks on his own, but do not rush him to do it. Make the client feel that he can still do things independently. ®It is important to
175
maximize independent function, assist the
client
when
memory has deteriorated further. 6. Assist
the
client
deal with functional limitations
and
identify resources. ®To meet individual needs, maximizing independence. 7. Provide single step instructions
when
instructions
are
needed. ®Client with memory
impairment
cannot multistep
remember instruc-
tions 8. Do not contradict the client who experiences an illusion. Instead, sim-
176
ply explain reality, and find some practical solutions to the problem ®Therapeutic
re-
sponses promote reality while offering solutions that help enhances
the
client’s sense and may reduce fear, anxiety, and confusion. 9. Monitor client’s behavior and assist in use of stress-management techniques ®To reduce frustration 10. Determine client’s response to medication
medications
prescribe prove
to
im-
attention,
concentration,
177
memory
process
and to lift spirits and modify emotional responses. ®Helpful in deciding whether quality of life is improved when
using
medications TIME
CUES
NEED
AND
NURSING
GOAL OF CARE
the pre-
scribed. INTERVENTIONS
EVALUATION
DIAGNOSIS
DATE January
SUBJECTIVE: “Makatamad usahay 21, maligo. Wala pa gani ko 2010 @ ligo ron. Kapoy pud manlimpyo ug kuko”, as 12:30 verbalized by the P.M. patient. OBJECTIVE: Unkempt hair noted food stains visible on clothing untrimmed fingernails and toenails with visible dirt noted
A C T I V I T Y E X E
Self care deficit: After 2 hours of nursing care, the bathing / client will be able hygiene related to: a) verto lack of balize self motivation care need ® The patient b) De has an impaired monstrate ability to techniques provide self care to meet requisites due to self-care environmental needs and
1.
Establish
rapport. R: to gain client’s trust and facilitate a good working relationship. 2.
January 21, 2009 @ 2:30 PM GOAL PARTIALLY MET
Identify
After 2 hours of reason for nursing care, the client was able to: difficulty in selfa) ver balize self care. care need R: underlying cause afb) but fects choice of inwas unable to demonterventions/ strate-
178
R
psychological
gies.
C
factors.
3.
Determine
I
hygienic needs and
S
provide assistance
E
as
needed
strate techniques to meet selfcare needs.
with
activities like care P
of
A
brushing teeth.
T
R: basic hygienic needs may be forgotten.
T E R N
4.
nails
and
Discuss on
importance
of
hygiene. R: makes client aware of how hygiene is vital in caring for oneself. 5.
Orient
client to different equipment for selfcare like various toiletries. R: increases the client’s awareness of different materials for
179
self-care. 6.
Let the pa-
tient enumerate his ideas on the importance of hygiene. R: Encourages the patient to understand the need for hygiene. 7.
Discuss the
possible
negative
implications of not taking a bath such as infections and odor. R: Broadens the patient’s idea about the problem and encourages
him
to
meet the need. 8.
Encourage
client to perform self-care
to
the
maximum of ability as defined by the
180
client. Do not rush client. R: promotes independence and sense of control, may decrease feelings of helplessness. 9.
Allot plenty
of time to perform tasks. R: cognitive impairment may interfere with ability to manage even simple activities. 10.
Assist with
dressing neatly or provide
colorful
clothes. R: Enhances esteem and convey aliveness.
181
182
PROGNOSIS GOOD FAIR POOR Onset of the
☻
illness
JUSTIFICATION Bob first experiences the signs and symptoms of schizophrenia when he was 18 years old and now he is 40 years old. The first signs that Bob showed was when he ate feces and since then people who are close to him noticed that he has illogical speech and flight of ideas. It was until after two months, November 1987 that they decided to bring Bob to the hospital for check-up when Bob’s tongue shrunk. The onset of illness was poor since the family waited that the situation of Bob worsened and did not immediately seek medical advice immediately when there was changes in his behavior like when he ate stool and showed illogical speech
Duration of illness
☻
and flight of ideas. The client has been diagnosed with schizophrenia catatonic 22 years ago. The patient went to the Davao Medical Hospital for his third admission last January 19, 2010 and was diagnosed with schizophrenia undifferentiated. As we can see, the duration of illness has been very long since it was years ago since he was mentally sick thus rating him with poor prognosis.
183
Precipitating
☻
factors
Intake of drugs, substances or chemicals which increase levels of dopamine and developmental factors are the present precipitating factors seen in Bob. The proponents rated this area as poor since Bob is abusing substances like marijuana, alcohol, cigarette and soft drinks. In his development, Bob developed mistrust,
shame and doubt, guilt,
inferiority, role confusion, and isolation which rated him poor. Mood and Affect
☻
During the interview, Bob has appropriate mood and affect therefore rating him with good prognosis.
Family Support
☻
During the interview the mother and the sister-inlaw was with the patient. As the interview progresses the student nurses observed that the family is supporting the patient. The patient is receiving appropriate family support since his family is doing all they can to help him recover. They are helping him financially as well as emotionally. The family understood what he is undergoing and giving him the support he need for
Willingness to
☻
his recovery. Bob was brought to the hospital for check-up
take medications
because he demanded to his parents saying that
and treatment
something is wrong with him. Bob submits himself properly to the medication without missing any single dose. He may be taking the proper regimen, however, he is not listening to the advice of the doctor to stop alcohol, smoking, taking marijuana and even drinking soft drinks. For a person to be treated he must not only take the drugs prescribed but also to stop things that are contraindicated for him for his treatment. Because of this, Bob was 184
rated with prognosis with the willingness to take the Depressive
medication and treatment. During the interview, the patient does not show any
☻
features
depressive features. Bob knew that something is wrong with him and he need medical attention. Even though he is aware that something is wrong with him, he is still not depressed with this fact. He didn’t finish college but he is not depressed with this fact. Not getting the things he wants won’t make him depress but instead, Bob goes wild and becomes hostile. Computation:
Total
3
1
3
Poor: (3*1)/7
= 3/7
Fair:
(1*2)/7
= 2/7
Good: (3*3)/7
= 9/7
Total:
2.00
General Prognosis: 1-1.6
= POOR
1.7-2.3 = FAIR 2.4-3.0 = GOOD Rationale for Fair Prognosis: Bob has a fair prognosis therefore he has small chance, according to the calculation, of recovering from his illness. The onset of illness was 22 years ago. He was not immediately brought to the hospital but they waited 2 months and decided to bring him to the hospital because of shrinking of his tongue and he demanded so. The duration of illness is long since it was last November 1987 that he was first diagnosed of Catatonic Schizophrenia and just this last January 19, 2010 that he was diagnosed of Schizophrenia undifferentiated. He also abused many substances like marijuana, alcohol, cigarette and soft drinks. And during his development, he developed mistrust, shame and doubt, guilt, inferiority, role confusion, and isolation which rated him poor. 185
In addition to that, he didn’t listen to the advice of the doctor to stop alcohol, smoking, taking marijuana and drinking soft drinks. However, he submits himself to the regimen, taking the medications promptly even going to the hospital every month for his medication. Furthermore, during the interview, Bob has appropriate mood and affect therefore rating him with good prognosis. He has good family support as evidenced by the support of his mother and sister-in-law while he is in the hospital. His father is supporting him financially but is not able to go with him because of his work back in Agusan. The family understood what he is undergoing and giving him the support he need for his recovery. Lastly, the patient does not show any depressive features. Bob knew that something is wrong with him and he need medical attention. Even though he is aware that something is wrong with him, he is still not depressed with this fact. He didn’t finish college but he is not depressed with this fact. Not getting the things he wants won’t make him depress but instead, Bob goes wild and becomes hostile.
186
RECOMMENDATION The group 1 of section 3H would like to recommend the following:
To the patient: He is advised to take part in complying with the treatment; the medication and therapeutic regimen designed for his rehabilitation. He should realize the importance of complying with his medication and the benefits this practice would bring to the improvement of his well-being. To the patient’s family: The patient’s family plays an important role in the patient’s mental illness and recovery. The family should make themselves physically present so that the patient would feel their support and concern. They are encouraged to continue interacting with the patient so that ideas of violence towards self and others will be diverted. In addition, it is of prime importance that they are oriented and educated regarding the patient’s mental illness so that they will understand him even better and assist him in his daily activities.
To the Ateneo de Davao University- College of Nursing: The faculty and staff are encouraged to continue improving the standards of the Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be equipped with the knowledge and skill that they may impart to student nurses. They are challenged to not just teach but impart to us as well nursing experiences that we may apply in the course of caring for our future patients.
To the Davao Mental Hospital: 187
The group recommends that they should improve their facilities in treating the mentally-ill patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the patients and staff. Address the needs of each patient by first assessing the level of severity of the patient’s condition; let every patient be submitted for history and physical examination and be evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend that the psychiatric team would work together in order to provide mental health care service that promotes rehabilitation of the patient. Also they are recommended to know the latest trends in improving therapeutic communication between them and the patients.
To the student nurses: Even if nursing students find it difficult to establish therapeutic relationships with mentallyill patients because of the relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to our patients; and improve our therapeutic technique in caring for our patients; that we may play a part in the rehabilitation of our mentally-ill patients.
188
SIGNIFICANCE OF THE STUDY
This study will be a significant undertaking in depth understanding the reason behind our subject’s mental illness. This study will also be beneficial to the students and clinical instructors in College of Nursing in making use of different concepts taught inside the classroom related to psychiatric nursing.
This case study will give us better understanding regarding mentally-ill patients; provide recommendations on how to deal with them in the future. It will give us better grasp why certain people experience being mentally unstable by looking deeper into the history, physiology, brain chemistry; development of physical, emotional and cognitive; and social relations of the patient.
Some of the mentally ill patients remain undiagnosed and untreated because they never sought medical attention due to old stigmas and societal attitudes towards mental illness. Stigmas results in the social exclusion of people with a mental illness and is detrimental to the part of the family. Moreover, this study will be helpful to aid the family in caring their mentally-ill member; giving them more understanding, acceptance, and how to deal with the illness and issues concerning it.
189
APPENDICES DIAGNOSTIC STATISTICAL MANUAL CRITERIA FOR DIFFRENTIAL DIAGNOSIS Schizophrenia is one of a cluster of related psychotic brain disorders. It is a combination of disordered thinking, perceptual disturbances, behavioral abnormalities, affective disruptions and impaired social competency. The diagnosis of a particular subtype of schizophrenia is based on the clinical picture that occasioned the most recent evaluation or admission to clinical care and may therefore change over time. They are defined by their symptomatology. The disorder lasts for at least 6 months and includes at least one month of the active phase symptoms namely two or more of the following: hallucinations, disorganized speech, catatonic behavior, negative symptoms). The subtypes are: 295.30 Paranoid Type 295.10 Disorganized Type 295.20 Catatonic Type 295.90 Undifferentiated Type 295.60 Residual Type Diagnostic Criteria for Schizophrenia G. Characteristic symptoms. Two or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (6) delusions (7) hallucinations (8) disorganized speech (e.g. frequent derailment or incoherence) (9) grossly disorganized or catatonic behavior (10)
negative symptoms (i.e. affective flattening, alogia or avolition)
Only one Criterion A symptom is required if delusions are bizarre or 190
hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. H. Social/occupational dysfunction. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or selfcare are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) I. Duration Continuous signs of the disturbance persist for at least 6 months. This 6month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in attenuated form (e.g. odd beliefs, unusual perceptual experiences.) J. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, Or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. K. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition L. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated. Total
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295.30 Schizophrenia Paranoid Type The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations in the context of a relative preservation of cognitive functioning and affect. Symptoms characteristic of the Disorganized and Catatonic Types (e.g., disorganized speech, flat or inappropriate affect, catatonic or disorganized behavior) are not prominent. Delusions are typically persecutory or grandiose or both but delusions with other themes may also occur. Hallucinations are also typically related to the content of the delusional theme. Diagnostic criteria for 295.30 Paranoid Type A. Preoccupation with one or more delusions or frequent auditory hallucinations B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. TOTAL 295.10 Schizophrenia Disorganized Type The essential features of the Disorganized Type of Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect. Criteria for the Catatonic Type of Schizophrenia are not met, and delusions or hallucinations, if present, are fragmentary and not organized into a coherent theme. Diagnostic criteria for 295.10 Disorganized Type A. All of the following are prominent 1. disorganized speech 2. disorganized behavior 3. flat or inappropriate affect B. The criteria are not met for catatonic type TOTAL
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295.20 Schizophrenia Catatonic Type The essential feature of the Catatonic Type of Schizophrenia is a marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Additional feature include stereotypes, mannerisms, and automatic obedience or mimicry. Diagnostic criteria for 295.20 Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following 1. motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor 2. excessive motor activity (that is apparently purposeless and not influence by external stimuli) 3. extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism 4. peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing 5. echolalia or echopraxia TOTAL 295. 90 Schizophrenia Undifferentiated Type Clients with a diagnosis of Undifferentiated Schizophrenia display florid psychotic symptoms like delusions, hallucinations, incoherence and disorganized behavior that do not clearly fit under any category. Diagnostic criteria for 295.90 Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type TOTAL 295.60 Schizophrenia Residual Type
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The Residual Type of Schizophrenia should be used when there has been at least one episode of Schizophrenia, but the current clinical picture is without prominent positive psychotic symptoms (e.g., delusions, hallucinations, disorganized speech, or behavior). There is a continuing evidence of the disturbance as indicated by the presence of negative symptoms or two or more attenuated positive symptoms. If delusions or hallucinations are present, they are not prominent and are not accompanied by strong affect. Diagnostic criteria for 295.60 Residual Type A. Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior. B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experience) TOTAL 301.22 Schizotypal Personality Disorder Individuals with schizotypal personality disorder have odd thoughts, affects, perceptions, and beliefs. Diagnostic criteria fort 301.22 Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, by beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference (excluding delusions of reference) 2. odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense in children and adolescents, bizarre fantasies or preoccupations) 3. unusual perceptual experiences, including bodily illusions 4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped) 5. suspiciousness or paranoid ideation 6. inappropriate or constricted affect 194
7. behavior or appearance that is odd, eccentric or peculiar 8. lack of close friends or confidants other than first-degree relatives 9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizotypal Personality Disorder (Premorbid)
Schizoid Personality Disorder Individuals with schizoid personality disorder are emotionally detached and prefer to be left alone. Diagnostic criteria for 301.20 Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. neither desires nor enjoys close relationship, including being a part of a family 2. almost always chooses solitary activities 3. has little, if any, interest in having sexual experiences with another person 4. takes pleasure in few, if any , activities 5. lacks close friends or confidants other than first degree relatives 6. appears indifferent to the praise or criticism of others 7. shows emotional coldness, detachment, or flattened activity B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a 195
general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Schizoid Personality Disorder (Premorbid)” TOTAL
301.0 Paranoid Personality Disorder People with paranoid personality disorder are distrustful and suspicious and anticipate harm and betrayal. Diagnostic Criteria for 301.0 Paranoid Personality Disorder A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in variety of contexts, as indicated by four (or more) of the following: Criteria Present 1. suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her 2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her 4. reads hidden demeaning or threatening meanings into benign remarks or events 5. persistently bear grudges , i.e., is unforgiving of insults, injuries, or slights 6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition. Note: If criteria are met prior to the onset of Schizophrenia, add “Premorbid,” e.g., “Paranoid Personality Disorder (Premorbid)” 196
TOTAL 298.8 Brief Psychotic Disorder The essential feature of Brief Psychotic Disorder is a disturbance that involves the sudden onset at least one of the following positive psychotic symptoms: delusions, hallucinations, disorganized speech or grossly disorganized or catatonic behavior Diagnostic Criteria for 298.8 Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms 1. delusion 2. hallucination 3. disorganized speech 4. grossly disorganized catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning C. The disturbance is not better accounted for by a Mood Disorder With Psychotic Features , Schizoaffective Disorder, or Schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition TOTAL 297.1 Delusional Disorder The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month. Auditory or visual hallucinations, if present are not prominent. Tactile or olfactory hallucinations may be present if they are related to delusional themes. Diagnostic Criteria for 297.1 Delusional Disorder A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month’s duration. B. Criterion A for Schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in Delusional Disorder if they are related to the delusional theme. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. 197
D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. TOTAL 295.40 Schizophreniform Disorder The essential features of Schizophreniform Disorder are identical to those of Schizophrenia (Criteria A) except for two differences: the total duration of the illness (including prodromal, active, and residual phases) is at least 1 month but less than 6 months and impaired social or occupational functioning during some part of the illnesses not require although it may occur. Diagnostic Criteria for 295.40 Schizophreniform Disorder A. Criteria A, D, and E of Schizophrenia are met B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as “Provisional.”) TOTAL Substance-Induced Psychotic Disorder The essential features of Substance-Induced Psychotic Disorder are prominent hallucinations or delusions that are judged to be due to the direct physiological effects of a substance. Hallucinations that the individual realizes are substance induced are not included here and instead would be diagnosed as Substance Intoxication or Substance Withdrawal with accompanying specifier With Perceptual Disturbances. The disturbance must not be better accounted for by a Psychotic Disorder that is not substance induced. The diagnosis is not made if the psychotic symptoms occur only during the course of delirium. Diagnostic criteria for Substance-Induced Psychotic Disorder A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms of Criterion A developed during or within a month of, Substance intoxication or Withdrawal 2. Medication use is etiologically related to the disturbance 198
C. The disturbance is not better accounted for by a Psychotic disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not a substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance –induced Psychotic Disorder (e.g., a history of recurrent non-substance related episodes. D. The disturbance does not occur exclusively during the course of delirium. Note: This diagnosis should be made instead of a diagnosis of Substance intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. TOTAL 293.xx Psychotic Disorder Due to General Medical Condition Diagnostic criteria for 293.xx Psychotic Disorder Due to General Medical Condition A. Prominent hallucination or delusions B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. TOTAL 295.70b Schizoaffective Disorder Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia but with prominent mood disturbances. Their psychotic symptoms, however, must persist for some time in the absence of any mood syndrome.
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Diagnostic criteria for 295.70b Schizoaffective Disorder A. An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet criterion A for Schizophrenia. Note: The Major Depressive Episode must include criterion A1: depressed mood. B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medication.
Substance Intoxication Delirium Diagnostic criteria for Substance Intoxication Delirium A. Disturbance in consciousness(i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2) Criteria Present 1. the symptoms in Criteria A and B developed during Substance Intoxication 2. medication use is etiologically related to the disturbance*
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