OBJECTIVESy GENERAL OBJECTIVE:After the end of the case presentation, the students will be able to acquire the knowledge, enhance their skills and develop attitude towards dealing of psychiatric patients with Schizophrenia:

Specifically, this aims to:y KNOWLEDGE: 1. To be able to obtain the psychiatric history of

the patient such as: General data Chief complaint History of present illness Past personal history Family history Current social situation and home environment Pre-morbid personality

2. To be able to obtain information

about the mental status of the patient and to determine the different psychiatric signs and symptoms the patient is exhibiting by observing his: 3General appearance and behaviour 3Characteristics of speech

3. Note the clients problems and

identify his coping skills.4. Understand how this illness/process

has affected the clients life.

SKILLS: 1. Demonstrate the appropriate approach used in dealing with psychiatric patients with schizophrenia. 2. Perform therapeutic verbal and non-verbal communication skills. 3. Perform nursing care and interventions with competence and confidence in rendering care to psychiatric patients with schizophrenia.

ATTITUDE: 1. Establish rapport to patient and folks. 2. Encourage folks to cooperate in the interventions that are being performed to the patient. 3. Collaborate with all the health team to promote efficient care to the patient.

PSYCHIATRIC HISTORYI. General Data Name: S. I. Age: 24 Sex: Male Educational Attainment: High School Graduate; Vocational Course TESDA (Food and Beverage Services) Civil Status: Single Nationality: Filipino Address: Nabitasan, Leganes Iloilo Religion: Roman Catholic

II. Chief Complaint Patient was admitted with a chief complaint of restlessness and talking irrelevantly. Two weeks prior to admission, he became restless and violent. For the reason that his mother did not give him money to attend the burial of his godchild in Kalibo. Because of that he started to wander around naked and talking irrelevantly. Then he was brought to Pototan Mental Health Unit by his mother to be admitted.

III. History of Present Illness y At the age of 9, patient S.I. was scolded and pinched by their principal in front of his classmates for being suspected in doing such things he never did. He was ashamed and humiliated. He never told his parents at first, because he was afraid of how they would react. y When he was 13 years old, he often witnessed how his father would abuse his mother physically during arguments. He also saw how his neighbour, a policeman, assaulted his elder brother and how the same person aimed a gun to his father. y After a week, he also witnessed the same neighbour brought a grenade to their house and how his mother and family panicked because of this incident.

y Also, in his high school years, his mother decided

to go to Manila to work and earn money. S.I. was depressed. They were left with their grandmother who is a gambler. Because their grandmother isnt always there, S.I. dropped out from high school but continues to sell any commodities in their community. He would not eat until he could sell all of his items.

y Last 2006, he was staying at Kalibo when he was

imprisoned for a day because of being violent while under the influence of alcohol. Also from that year, he manifested auditory hallucinations. He went home to Iloilo and was brought to the hospital by his mother for a check-up, as he also started to wander aimlessly, wanting to be left alone. He was diagnosed with disorganized Schizophrenia and was given medications by his doctor.

y Last October 2010, he and his mother opted to go downtown

(Iloilo City) to get remittance from his sister working abroad. While waiting for his mother, he decided to go ahead without any money. He ended up at SM City Iloilo and ordered HaloHalo from Dulcinea Restaurant. Because he has no money to pay his bill, the security officers brought him to Bolilao Police Outpost. He was then transferred to Mandurriao Police Station. His mother came looking for him and found him with bruises on some parts of his body. He appeared to be frail and seems to be in shock. wanted to attend the burial so he asked his mother for money. When his mother cannot give him any, he became restless, violent, talking irrelevantly. He began to take off his clothes and walked around their barangay naked, convincing his mother to give him money. He was brought to Pototan Mental Health Unit for treatment and was diagnosed of schizophrenia, disorganized type.

y Two weeks prior to admission, his godchild from Kalibo died. He

IV. PAST HISTORYy Patient S.I. has no severe illness except for having fever and

common colds. When he was 2 years old, he had an allergic reaction to Birch Tree Milk. He was never admitted but was only given Antihistamine drugs. When he reached 5 years of age, a lump was found in his testicles. They consulted a doctor but he told them that he was too young to be operated. His mother then brought him to a quack doctor; they were given a herbal medicine to drink. His lump, eventually, burst oozing with pus. One year later, another lump grew in his left axilla, approximately 3 cm in diameter. His mother did not attempt to consult the doctor because of financial constraints. y Patient S.I. is an active smoker. He started smoking when he was 15 years old. He can consumed 1 pack of cigarettes per day. He also drinks alcoholic beverages (tanduay, beers etc.) occasionally, 2-3 bottles every 2 weeks.

V. FAMILY HISTORY y (+) Hypertension paternal sidey They have a history of mental illness on his maternal

side; his uncle has been diagnosed with a mental illness and was also admitted at PMHU for two years. y His father has no stable job and his mother is a food vendor in their barangay and a nearby school. Aside from food, his mother also sells other commodities such as vegetables and fish. He has also a sister who works abroad as a domestic helper and a brother who is a carpenter. He has a harmonious relationship with his siblings and family, except in times when his father tends to physically abuse his mother when he is drunk.

VII. MARITAL HISTORYy Patient is single, never married although he had

experience having girlfriends in the past. He could not recount on how many relationships he had. Lately he has been courting a girl he knew at Pototan Mental Health Unit when he was having his check-up. He would visit the girl and bring orchids, which he would pick from his uncles garden.

VIII. CURRENT SOCIAL SITUATION AND HOME ENVIRONMENTy Patient is residing at Nabitasan, Leganes together with his parents and siblings. The family lives in a clustered kind of neighbourhood wherein the houses are within close proximity with each other. Their neighbourhood is somewhat peaceful, with the occasional altercations and conflicts brought about by arguments amongst neighbours and sometimes from drunkards. People from their place are wellacquainted with each other since they live closely and most of them are relatives. Patient has a good relationship with his parents and siblings. Both his parents consult one another in deciding for their major and minor decisions in the household, but oftentimes the wife is the decision maker.

y The family is not that financially stable since their

expenses are sometimes greater than their income. The mother tends to mismanage their money since she occasionally lends money to some of their neighbours even though they have barely enough. Sometimes they ask for money from their relatives especially with regards to the medications. Their source of income ranges from the selling of food at the nearby school to casual jobs like selling assorted goods and products.

IX. PRE-MORBID PERSONALITY y Patient is a quiet type of person, even as a child he was silent and well-behaved. His elementary and high school teachers are fond of him. He is sociable and enjoys the company of a small group of friends but he tends to keep his problems to himself, he doesnt like to open up and talk about his feelings even to his family.

MENTAL STATUS EXAMINATION

General Appearance and Behavior: y S.I. is a 24 years old male of average height of 5 2 and average weight of 62 kgs. At the time of examination, he was kempt, well groomed with short hair neatly combed. He is clad in clean clothes and dressed appropriately. He attends to his hygiene by taking a bath everyday. No signs of abnormal body movements or any mannerism. He is behaved, manageable, helpful and mingled with co-patients inside the ward. He is also able to manage activities of daily living with minimum assistance. During interaction, Steve was cooperative and maintained eye contact, except during the times when recounting the incident between Rommel and his family. Then, he appeared angry.

Characteristics of Speech: y S.I. articulated himself clearly. He answered questions relevantly and spontaneously, on a normal rate and speed. He talks in a normal audible voice with coherence.

Mood or Affect: y S.I.s mood is appropriate to his thought content. His affect was sad with normal range of mood. He was sad for he already wanted to go home. He also appeared to be angry at the sight of patient R.J.

Content of Thought: y S.I. did not exhibit any formal thought disorders. He was able to answers question spontaneously and directly. He did not use any new or created words. S.I. has no other positive symptoms, such as delusions, phobias or compulsions. Suicidal ideation was not detected. He exhibits normal perception. Symptoms, such as illusions, hallucinations and misinterpretations, were not elicited. However, he was sad, wanting to go home and angry, seeing patient R.J., blaming him for the circumstance that happened to him and his family.

Sensorium Functions: y S.I. was alert and oriented to time, place and person. He was able to answer questions with good immediate, remote and recent memory. He recalls his past without difficulties. His attention is easily aroused and sustained.

Insight and Judgment: y S.I. has the ability to size up a situation, when asked about what he would do if he was able to go home, he would answer that he will put up a business or any means of income. When questioned about her condition, S.I. accepted the fact that he is ill and requires treatment. He is cooperative with the doctors and nurses and is compliant with management.

HOSPITAL COURSE AND OBSERVATION

y On the tenth day of December 2010, S.I. was admitted to open ward with restraints on both arms and extremities. y By 6:25 PM, Haloperidol 5mg/amp + diphenhydramine 50mg/amp was given IM. y Two days after admission, patient was responsive to queries but with limited verbal response. y Around 6:00 PM, he kicked his mother without any apparent reason y He usually roams around with his backpack with incongruent affect verbalizing that he wants to go home. y Then he started attending activities and by the 16th day of December, he was already participative and manageable.

y Disorganized schizophrenia, also known

as foldermenia is a subtype of schizophrenia as defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV code 295.10.

y Disorganized schizophrenia is marked by

thoughts, speech and behavior that are inappropriate and don't make sense.

y A person with disorganized schizophrenia may

also experience behavioral disorganization which may impair his/her ability to carry out activities of daily living such as showering or eating.

Diagnostic criteria for disorganized schizophrenia include: y Disorganized speech y Disorganized behavior y Lack of emotion y Emotion inappropriate for the situation It can sometimes be difficult to diagnose disorganized schizophrenia, especially because different conditions can have similar symptoms.

PSYCHOPATHOLOGY

24 years old uncle who has a mental illness low socio economic status.

Incident when he was: 9 y.o. His brother was assaulted. His father was aimed with a gun. Grenade His mother went to Manila

PRE MORBID PHASE PRODROMAL PHASE ONSET OF SCHIZOPHRENIA s/sx: Disorganized speech Lack of attention to personal hygiene

He was imprisoned in Kalibo (2006)

s/sx: Auditory hallucinations Disorganized behavior Social isolation occur

DISORGANIZED SCHIZ s/sx: Disorganized speech s/sx: Disorganized behavior Incongruent affect

PROGRESSIVE PHASEClient recovered from the first episode and can experience relapse

Dulcinea event His Godchild died, mother cant give money RELAPSE of Schiz

MEDICATIONS

NURSING CARE PLAN