Schizophrenia Case Study

I. INTRODUCTION

Psychiatric disorders place a substantial burden and suffering on clients, their families, society, and the healthcare system. Caring for clients with psychiatric problems is complex and requires and understanding of neurobiological, cognitive, and psychosocial underpinnings associated with specific psychiatric conditions.

Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Increased dopamine activity in the mesolimbic pathway of the brain is commonly found in people with schizophrenia. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood.

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women.

The symptoms of schizophrenia are categorized into two major categories:

The positive or hard symptoms which include: Ambivalence: Holding seemingly contradictory beliefs or feelings about the same

person, event or situation Associative looseness: Fragmented or poorly related thoughts and ideas

Delusions: Fixed false beliefs that have no basis in reality

Echopraxia: Imitation of the movements and gestures of another person whom the client is observing

Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another

Hallucinations: False sensory perception or perceptual experiences that do not exist in reality

Ideas or reference: False impressions that external events have special meaning for the person

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Perseveration: Persistent adherence to a single idea or topic, verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

Negative or soft symptoms which included: Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of

content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feeling of indifference toward people, activities, and events Blurred affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of

agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood

Lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks

The DSM-IV-TR contains five sub-classifications of schizophrenia:

Paranoid type: Where delusions and hallucinations are present but thought disorder, disorganized behavior, and affective flattening are absent. (DSM code 295.3/ICD code F20.0)

Disorganized type: Named hebephrenic schizophrenia in the ICD. Where thought disorder and flat affect are present together. (DSM code 295.1/ICD code F20.1)

Catatonic type: The subject may be almost immobile or exhibit agitated, purposeless movement. Symptoms can include catatonic stupor and waxy flexibility. (DSM code 295.2/ICD code F20.2)

Undifferentiated type: Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met. (DSM code 295.9/ICD code F20.3)

Residual type: Where positive symptoms are present at a low intensity only. (DSM code 295.6/ICD code F20.5)

Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for them, so they rely on others for help. Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

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II. PSYCHIATRIC MENTAL HEALTH NURSING HISTORY

A. Demographic DataPatient name: Danillo Dimaala

Historian: JI Raymond AE De Joya

Hospital: CCMH

Consultant: Dr. Escaño

Date Interviewed: 8/15/10

B. General Data

This is a case of D.D., a 44 years old right handed male, single, the eldest among his six siblings. Born and currently residing in Nasugbu, Batangas. A High School Graduate and works as water pump tender in a sugar factory in Batangas. He is a Roman Catholic who speaks Tagalog and English, accompanied by his mother to seek consultation to a Psychiatrist for the first time in Cavite Center for Mental Health last August 13, 2010.

C. Chief Complaint

Patient complained of “nagugulat pag nakakita ng babae at lalaki”

D. Premorbid Personality and Level of Functioning

The patient is a calm and happy person. He loves his family and friends very much. He has lot of friends and works well with his colleagues for 16 years. He has no problems or conflict among his family, friends and other people.

E. History of Present Illness

5 years prior to consultation, when the patient fees or meets an individual, he gets nervous, vision gets blurred, dizzy(slight) and starts to have palpitations. He thinks that people around him, talk about him, and sometimes likes to hurt or threaten him. He hears voices inside his head, whether he is alone or not, that tells his unclear or vague commands. He ignores it and he claims that the voices get mad if he ignores them. Hearing the voices happens anytime of the day. He is unable to sleep and ends up restless. He claims that people call him “manyakis”. He consulted to a psychiatrist from nasugbu and prescribed him

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medications such as Prozac, Vitamin B Complex, and Rintril. His sleep pattern improved after taking these medications. After 3 months, he refused to follow-up on his check-up. He stated to have visual perception of moving shadows and red lights telling him unclear comments. He claims to have fewer friends at work and accuses his work colleagues of spreading rumors about him. He plans to resign at work. He usually stays at home after work and watches TV.

F. Past medical History

5 years prior to consultation, the patient had itchiness and soreness around the area of his penis. There are white-wormy-like rigid structures in his pubic area with erythema and rashes. Patient has black papules present around his body.

Patient doesn’t have any history of psychiatric or mental illness. He has a primary love doctor. Patient’s sister died at Diabetes mellitus complications (3rd Sibling).

Review of systems: (+) itchiness on penile area

G. Family Profile

The Dimaala family is a very kind and supportive family among its household members. They are very supportive among each other. The family members are very supportive on the patient’s illness and the death of his third sister with the arrangements. Dennis, the youngest among the patient’s sibling is the closest sibling to the patient. Dante, 43 years old male, is the second sibling in the family. He is a kind and gentle person. He has no work and helps the family. Divira, 41 years old female, is a seamstress but died of Dm complications yet she is a very humble person. Dennis, 39 years old male, is a pig caretaker and a very happy person. Dolor, 37 years old female, is a housewife and a very supportive mother. Darwin, 35 years old male, sells in a sari-sari store near their house and a very funny and disobedient person at times.

H. Genogram

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III. ANAMNESIS

A. Pre-natal and perinatal historyPatient is a planned pregnancy, no pregnant complications noted. No mental or emotional

problems noted. No alcohol or drug taken.

B. Early ChildhoodHe was properly breastfed and bottle-fed. Feeding habits, early development, and toilet

training are unremarkable. No tantrums, night tremors, or thumb sucking noted.

C. Middle ChildhoodThe patient is cooperative and participative in pre-school activities. He has a lot of

friends and has average academic performance. There is no history of hair pulling, cheating, or lying.

D. Late childhoodHe hates sports and joining extra-curricular activities. He has average academic

performance. He has strong self-esteem and loves helping people. There is no history of smoking, intake of alcohol, illicit drug use, etc.

E. AdulthoodPatient doesn’t attend Sunday mass for 5 years and goes to church activities before his

illness. Patient has no problems with his work, colleagues, and started drinking alcohol when he was 20 years old. He never invited or dated a girl in his life.

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IV. MENTAL HEALTH EXAMINATION

A. General Description: Patient has upright posture, well-posed, well-groomed and appropriately dressed. He has

no mannerism or ticks. Patient is cooperative and friendly towards the examiner. He maintains eye contact with the examiner.

B. Speech: He is quiet, moderate in late of production and in moderate volume. He does not interrupt

the examiner in the interview. He has no monotonous speech.

C. Mood & Affect: He has a ramous mood with full affect.

D. Perception: He has no auditory and visual hallucinations, illusions, derealization or

depersonalization.

E. Thought & Process: He has paucity of ideas, no looseness of association, clang association, word salad

or neologism. He has flight of ideas, tangential sometimes. He has no echolalia or perseveration.

F. Thought & Content: He has delusion of reference and persecutory delusions, but no obsessions.

G. Sensorium and Cognition: Patient is alert and conscious. He is oriented to the time place and person. He has

intact remote, recent past, resent and immediate recall memory. He has intact concentration. He was having hard time subtracting 7 from 100, 7 from 93 and so on. He was able to spell LIKHA forward and backward. He can write a complete sentence. He can draw a clock hanging on a wall from an actual wall clock. He knows the current President and Vice-president of the Philippines.

H. Judgment:

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He has intact judgment by helping a victim of pick pocketing.

I. Insight:The patient is fully aware of the illness and accepts it.

J. Reliability: He has established good rapport to the examiner.

V. FINAL DIAGNOSIS

Undifferentiated Schizophrenia

It is characterized by mixed schizophrenic symptoms (of other types) along with disturbances

of thought, affect and behavior.

VI. ANATOMY & PHYSIOLOGY IN SCHIZOPHRENIA

THE BRAIN

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Structures of the brain that are implicated in schizophrenia focus on three systems in the brain: the Basal Ganglia, Limbic System and Tegmentum.

BASAL GANGLIA

The basal ganglia is a collection of subcortical (beneath the cortex) nuclei in the forebrain (front area of the brain). The cortex is the brain matter that makes up the outside of the brain; cortex literally means "bark," so you can think of it as the bark of the brain.

The major parts of the basal ganglia consist of the

caudate nucleus, the putamen and the globus pallidus.

The basal ganglia is involved in the control of movement. The nucleus accumbens contains neurons that are part of the basal ganglia. Thus, this structure may play a role in the regulation of movement, including the control of complex motor activity and the cognitive aspects of motor control. In addition, this structure has been found to possibly be the area that becomes activated in situations that involve reward and punishment.

The nucleus accumbens is a nucleus of the basal forebrain. It receives dopamine-secreting terminal buttons from neurons of the ventral tegmental area (VTA) and is thought to be involved in reinforcement and attention.

LIMBIC SYSTEM

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This system consists of a couple of brain structures. First it includes several regions of one form of cortex called the limbic cortex; this cortex is also known as the cingulate cortex as shown in the picture.

Besides the limbic cortex, the most important parts of the limbic system are the hippocampus and the amygdala.

The limbic system has been implicated in learning and memory and emotions. The implication in emotions involves feelings and

expressions of emotions, emotional memories and recognition of emotions in other people.

TEGMENTUM

The tegmentum consists of an area of the midbrain. It includes the bottom end of the reticular formation, the periaqueductal gray matter, the red nucleus, the substantia nigra and the ventral tegmental area.

The reticular formation is a large structure consisting of many nuclei. It is also characterized by a diffuse, interconnected network of neurons with complex dendritic and axonal processes. The reticular formation receives sensory information and projects axons to the cerebral cortex, thalamus and spinal cord.

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NEURONS

Cells in the nervous system are called neurons. The neuron is an information processing and transmitting cell that undermines all bodily functions. It is estimated that the human brain contains over 100 billion neurons, with each neuron potentially communicating with hundreds of other neurons. This vast interconnectedness allows simple neuronal activity to translate into complex neuronal messages creating human behavior.

NEUROTRANSMISSION

The basic structure of a neuron includes a cell body (soma), dendrites, axon and axon terminal.

Neurotransmission is an electrochemical message that allows neurons to communicate information with one another neuron.

Electrochemical messages pass from the dendrites (projections from the cell body)

Through the soma or cell body

Down the axon (long extended structures)

And across the synapses (gaps between cells)

To the dendrites of the next neuron

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NEUROTRANSMITTERS

Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitory).

These neurotransmitters fit into specific receptor cells embedded in the membrane of the dendrite.

After neurotransmitters are released into the synapse and relay the message to the receptor cells, they are either transported back for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase

These neurotransmitters are necessary in just the right proportions to relay messages across synapses

GABA

GABA is the most common inhibitory neurotransmitter in the nervous system and is found throughout the body. Produce calming effects and are target sites for benzodiazepines.

Glutamate

Glutamate is an excitatory neurotransmitter that is involved in learning and memory. Alterations in production may play a role in the underpinnings of neurodegenerative disorders, such as Alzheimer’s disease and schizophrenia.

Acetylcholine

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Acetylcholine is responsible for muscular movement and has been shown to have a role in memory formation. It was the first neurotransmitter to be discovered, and thus is the best known.

Epinephrine and Norepinephrine

Epinephrine and norepinepherine act very similarly. They are associated with vigilance and the fight-or-flight response. Their activity revs up the sympathetic nervous system, preparing a body to face danger or run away from it.

Serotonin

Serotonin plays a role in mood, apptetite, sleep rhythms and arousal. Decreases in serotonin have been shown to correlate with clinical depression and risk for suicide.

Dopamine

Dopamine has been implicated in numerous functions within the body, including movement, attention, learning, and the reward and reinforcement. Schizophrenia and other psychotic disorders are associated with increased or dysregulation of dopamine

VII. PSYCHOPATHOPHYSIOLOGY

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VIII. DRUGSTUDY

Drug Name Action Indication Contraindication Adverse Reaction Nsg Consideration

Generic Name:Haloperidol

Brand Name:Haldol

Classification:Antipsychotic

A butyrophenone that probably exerts antipsychotic effects by blocking postsynaptic dopamine receptors in the brain.

psychotic disorders

chronic psychosis requiring prolonged therapy

nonpsychotic behavior disorders

Tourette syndrome

Delirium

Hypersensitivity to drug, tartrazine, sesame oil or benzyl alcohol

CNS: confusion, drowsiness, restlessness, sedation, lethargy, insomnia, vertigo, dyskinesia, seizures, neuroleptic, malignant syndrome

CV: hypotension, hypertension

EENT: blurred vision, dry eyes

GI: constipation, drymouth, anorexia

GU: urinary retention, menstrual irregularities, gynecomastia

HEMATOLOGIC: anemia

RESPIRATORY: dyspnea

Monitor CNS status closely, cardiovascular status and respiratory status

Advice patient to minimize GI upset by eating frequent small serving of meal

Instruct patient to report signs and symptoms of serious adverse reaction

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Generic Name:Clozapine

Brand Name:Leponex

Classification:Antipsychotic

Unclear. Thought to interfere with dopamine binding in limbic system of CNS, with high affinity for dopamine receptors

Schizophrenia in patient unresponsive to other therapies

hypersensitivity to drugs

uncontrolled seizure

severe CNS depression or coma

CNS: sedation, drowsiness, dizziness, vertigo, insomnia, disturbed sleep, nightmares, restlessness

CV: tachycardia, hypotension, hypertension, chest pain

EENT: visual disturbances

GI: dry mouth, constipation, nausea, vomiting, excessive salivation

GU: urinary frequency or urgency, urine retention

Respi: repiratory arrest

Patient monitoring 1. Monitor wbc count weekly for 6 months 2. Monitorecg and liver function test 3. If drug must be withdrawn abruptly, monitor patient for psychosis and cholinergic rebound (head ache, nausea, vomiting and diarrhea)

Patient teachings 1. Tell patient to allow orally disintegrating tablet to dissolve in mouth 2. Advise patient to immediately report of new onset of lethargy, weakness, fever, sore throat. Malaise, mucous membrane ulcers, or other signs and symptoms of infections

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Generic Name:Diphenhydramide

Brand Name:Celestamine

Classification:Antihistamine

Interferes with histamine effects at h1 receptors site; prevents but doesn’t reverse histamine-mediate response.

Allergy sypmtoms caused by histamine release

nausea and vertigo, cough

dyskinesia; parkinsons disease

mild nighttime sedation

hypersensitivity to drug

Alcohol intolerance

Acute asthma attacks

MAO inhibitor use within past 14 days

Breastfeeding

Neonates, premature infants

CNS: Drowsiness, dizziness, headache, paradoxical stimulation (especially in children)

CV: Hypotension, palpitations, tachycardia

EENT: Blurred vision, tinnitus

GI: Diarrhea, constipation, dry mouth

GU: Dysuria, urinary frequency or retention

Skin: Photosensitivity

Other: decreased appetite, pain at I.M. injection site

Patient monitoring: monitor cardiovascular status

Patient teaching: 1. Advise patient to avoid alcohol 2.Caution patient to avoid driving and other hazardous activities until he knows the drug effects 3.Review all significant adverse reaction


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Generic Name:Clonazepam

Brand Name:Rivotril

Classification:Anticonvulsant

May enhance activity of gamma-amino butyric acid, and inhibitory neurotransmitter in CNS

Lennox-Gastaut syndrome, atypical absence seizures, akinetic and myoclonic seizures

Panic disorder

Acute manic episodes of bipolar disorder

Adjunct treatment for schizophrenia

Periodic leg movements during sleep

Parkinsonian dysarthria

Neuralgias

hypersensitivity to drug or benzodiazepines

severe hepatic disease

acute angle-closure glaucoma

CNS: fatigue, drowsiness, behavioral changes, depression and reduced intellectual ability

CV: palpitations

EENT:, blurred vision, diplopia, nystagmus, sinusitis, rhinitis, pharyngitis,

GI: constipation, diarrhea, hypersalivation

GU: dysuria, nocturia, urinary retention, dysmenorrhea, delayed ejaculation, erectile dysfunction

Respi: respiratory depression, shortness of breath

Paient monitoring 1. Monitor patient for respiratory depression 2. Monitor hematologic and liver function test results

Caution: tell patient not to stop taking drug abruptly, advise patient not to drink alcohol which may increase drowsiness, dizziness, and risk for seizures


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Generic Name:Akineton

Brand Name:Biperiden

Classification:Anti-parkinsonian

Synthetic anticholinergic drug, blocks cholinergic responses in the CNS

Parkinsonian syndrome especially to counteract muscular rigidity and tremor, extrapyramidal symptoms

narrow angle glaucoma

mechanical stenoses in gastrointestinal and mega colon, prostatic adenoma and diseases leading to perilous tachycardia

hypersensitivity to bipereden.

skin rashes dyskinesia ataxia twitching impaired speech micturation difficulties fatigue dizziness at higher

doses restlessness agitation anxiety confusion

Document indication for therapy, onset of signs and symptoms and other agents tried in outcome of therapy

Assess for parkinsonism or EPS, shuffling gait, muscle rigidity, involuntary movement, pill rolling, muscle spasm, drooling before and during treatment

Assess for mental status: affect mood CNS depression worsening of mental symptoms during early therapy

Monitor for constipation cramping pain in the abdomen, and abdominal distension. Increase fluids, add fiber to diet and exercise


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Generic Name:Vitamin B complex

Brand Name:Crystamine

Classification:Vitamins

A coenzyme that stimulates metabolic function and is needed for cell replication, hematopoiesis and nucleoprotein and myelin synthesis.

RDA for cyanocobalamin

Vit B12 deficiency from inadequate diet, subtotal gastrectomy

Pernicious anemia or vit B12 malabsorption

Methylmalonic acid uria

hypersensitivity to Vit B12 or cobalt and in those with early Leber’s disease

use cautiously in anemic patient with coexisting cardiac, pulmonary or hypertensive disease

CV: peripheral vascular thrombosis, heart failure

GI: transient diarrhea

Respi: pulmonary edema

Skin: itching, urticaria

Determine hematocrit, iron, and Vit B levels before beginning therapy

Obtain a sensitivity test history before administration

Don’t give large oral doses routinely

Monitor patient for hypokalemia for first 48 hours

Teach patient using intranasal form how to administer drug

Instruct patient not to take folic acid as a replacement for vitamin B12

Drug Name Action Indication Contraindication Adverse Reaction Nsg Consideration19

Generic Name:Vitamin C (Ascorbic Acid)

Brand Name:Vita-C

Classification:Vitamins

Stimulates collagen formation and tissue repair; involved in oxidation-reduction reactions.

Increases protection mechanism of the immune system

Treatment and prevention of vitamin C deficiency, including a condition called scurvy

Extensive burns, delayed fracture or wound healing, severe febrile or chronic diseases states

To prevent vit C deficiency in patients with poor nutritional habits or increase requirements

To acidify urine

Allergy to tartrazine sulfites

Large doses in pregnant patients

CNS: faintness, dizziness

GI: diarrhea, heartburn, nausea, vomiting

GU: gastric urine, renal calculi

When giving for urine acidification, check urine pH to ensure efficacy

If using IM, explain that this route may promote better use of the vit by the body

Inform patient or relatives that vitamin is readily absorbed from citrus fruits, tomatoes, potatoes and leafy vegetables

Advise smokers to increase intake of vitamin

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IX. NURSING CARE PLAN

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective cues:“Nagugulat ako pag nakakakita ng babae at lalaki”

Objective cues: Auditory

hallucinations Visual

hallucinations Insomnia Restlessness Ramus mood

with full affect Paucity of ideas Tangential at

times Ideas of

reference Persecutory

delusions Flight of ideas Has a hard time

subtracting 7 from 100, 7 from 93 and so on

Disturbed thought processes related to presence of psychological conflicts as evidenced by delusions and hallucinations

After 2 weeks of nursing interventions the client will be able to: Interact and

respond to reality-based interactions initiated by others

Demonstrate reality based thinking in verbal and nonverbal behavior

Be sincere and honest when communicating with the client

Do not make promises that you cannot keep

Explain procedures and be sure the client understands the procedures before carrying them out

Interventions for Delusions: Give positive

feedback for client’s success

Interact with the client on the basis of real things, do

To establish a trusting relationship

Broken promises reinforce the client’s mistrust of others

The client feel less likely that he or she is being tricked

Enhances the client’s sense of well-being and helps to make nondelusional reality a more positive situation

Interacting about reality is healthy for the client

Goal met:After 2 weeks of nursing interventions the client was able to:

Socialize with others in reality-based conversations through verbal and nonverbal behavior

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not dwell on the delusional material

Directly interject doubt regarding delusions if client seems ready to accept reality

Interventions for Hallucinations: Elicit description of

hallucination

Engage client in reality-based activities such as card playing, occupational therapy, or listening to music

Help present or maintain reality by frequent contact and communication with the client

As the client trust you, he or she may be willing to doubt the delusion if you express your doubt

To protect the client and others. Understanding the hallucination will provide ways to calm or reassure the client

To limit or decrease the recurrences of hallucinations

To maintain reality orientation

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Documents

Schizophrenia Case Study