I.

Introduction

Schizophrenia, a disease of the brain, is one of the most disabling and emotionally devastating illnesses known to man. But because it has been misunderstood for so long, it has received relatively little attention and its victims have been undeservingly stigmatized. Schizophrenia is not a split personality, a rare and very different disorder. Like cancer and diabetes, schizophrenia has a biological basis; it is not caused by bad parenting or personal weakness. Schizophrenia is, in fact, a relatively common disease, with an estimated one percent to one and a half percent of the U.S. population being diagnosed with it over the course of their lives. While there is no known cure for schizophrenia, it is a very treatable disease. Most of those afflicted by schizophrenia respond to drug therapy, and many are able to lead productive and fulfilling lives. Schizophrenia is characterized by a constellation of distinctive and predictable symptoms. The symptoms that are most commonly associated with the disease are called positive symptoms, which denote the presence of grossly abnormal behavior. These include thought disorder, delusions and hallucinations. Thought disorder is the diminished ability to think clearly and logically. Often it is manifested by disconnected and nonsensical language that renders the person with schizophrenia incapable of participating in conversation, contributing to his alienation from his family, friends and society. Delusions are common among individuals with schizophrenia. An affected person may believe that he is being conspired against (called paranoid delusion). Broadcasting describes a type of delusion in which the individual with this illness believes that his thoughts can be heard by others. Hallucinations can be heard, seen or even felt; most often they take the form of voices heard only by the afflicted person. Such voices may describe the persons actions, warn him of danger or tell him what to do. At times the individual may hear several voices carrying on a conversation. Less obvious than the positive symptoms but equally serious are the deficit or negative symptoms that represent the absence of normal behavior. These include flat or blunted affect (i.e. lack of emotional expression, apathy and social withdrawal) Due to the insurmountable curiosity brought up by recent Psychiatric Nursing exposure, the nursing students have chosen this topic, not only because it is one of the most common psychological problems affecting people nowadays, but since it is also one of the most interesting cases. It gives the students a sense of understanding towards eccentric and unique behavior of patients as well as a sense of responsibility to give holistic caring care for the improvement of intellectual and motor functioning. The nursing students expect to learn the disease process of schizophrenia, how it affects man and to properly deal with schizophrenic clients. In seven days of exposure, the students also expect the patients to gain added knowledge, acceptable attitudes, and increase skills especially in terms of performing activities of daily living.

II. Objectives

SPECIFIC OBJECTIVES: After 7 days of giving holistic caring care, the student nurse will be able to: 1. establish rapport with the client 2. assess client as to: - personal profile - individual and family information - level of growth and development - mental status 3. explain schizophrenia as to its: - pathophysiology - psychopathology - psychodynamics - signs and symptoms 4. formulate Nursing Care Plan in relevance to patients condition 5. formulate Drug Therapeutic Record base on patients conditon 6. develop Health Teaching Plan

SPECIFIC OBJECTIVES: After 7 days of giving holistic caring care, the resident will be able to: 1. establish rapport with the student nurse 2. maintain trusting relationship with the student nurse as evidenced by answering personal and family background questions so as to assess level of growth and development and patients mental status 3. acquire a little insight about the present condition through student nurses explanation of the disease 4. increase social interaction as evidenced by establishing communication to other ward mates 5. reduce manifested signs and symptoms through the medications given 6. perform independent self-care skills 7. verbalize feelings regarding the interaction with the student nurse

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

In middle adulthood, the individual makes lasting contributions through involvement with others. Generally the middle adult years begin around the early to mid 30s and last through the late 60s, corresponding to Levinsons developmental phases of setting down and the pay-off years. Many middle adults find particular joy in assisting their children and other young people to become productive and responsible adults. They may also begin to help aging parents while being responsible for their own children, placing them in the sandwich generation. Using leisure time in satisfying and creative ways is a challenge that, if met satisfactorily, enables middle adults to prepare for retirement.

Physical Changes In middle adult years, most visible changes are graying of the hair, wrinkling of the skin, and thickening of the waist. Decreases in hearing and visual acuity are often noted during this period. Often these physiological changes have an impact on selfconcept and body image. The most significant physiological changes during middle age are menopause in women and the climacteric in men. Climacteric in men is caused by decreased levels of androgens.

Cognitive Changes Changes in cognitive function of middle adults are rare except with illness or trauma. The middle adult can learn new skills and information. Some middle adults often educational or vocational programs to prepare themselves for entering the job market or changing jobs.

Psychosocial Changes The psychosocial changes in the middle adult may involve expected events. Such as children moving away from home, or unexpected events, such as marital

separation or the death of a close friend. Many middle adults may find themselves in the sandwich generation, having the responsibility of raising their own children while caring for aging parents. These changes may result in stress that can affect the middle adults overall level of health. In the middle adult years, as children depart from the household, the family enters the post parental family stage. Time and financial elements on the parents decrease, and the couple faces the task of redefining their own relationship. According to Erik Ericksons development theory, the primary development task of the middle years is to achieve generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. If middle fail to achieve generativity, stagnation occurs.

Sexuality changes After the departure of their last child from their home, many couples recultivate their relationships and find increased marital and sexual satisfaction during middle age. The onset of menopause and the climacteric can affect the sexual health of the middle adult. A woman may desire increased sexual activity because pregnancy is no longer possible. Menopausal women may also experience vaginal dryness and dyspareunia or pain during sexual intercourse. During middle age, a man may notice changes in strength of his erection and a decrease in his ability to experience repeated orgasm. Both partners may experience stresses related to sexuality changes or a conflict between their sexual needs and selfperceptions and social attitudes or expectations.

1.3.2 The Ill person at particular stage of patient Physical changes such as additional fat deposits, badness, gray hair, wrinkles and varicosities confront the middle adult. People realize that they look older and they may feel older as well. Work may be stressful in middle-age people feel that they have less stamina, endurance and vigor to cope with the task at hand. This reduced energy is often a result of lower basal metabolism and reduced muscle tone. Often middle adulthood is the time of self-reflection and evaluation. Individuals are likely to re-

examine their lives, considering whether they are satisfied with what they have accomplished and how they want to live the rest of their lives. This time of reflection may be difficult as an individual considers what is right and what is wrong in his life. Even though this self-reflection may be difficult at times, it can foster growth and a more integrated self-concept. Illness or death of loved ones can create concerns about personal health. The person may feel inferior to youth as the previous self image of a strong and healthy body with boundless energy is replaced with a self-image reflecting the changes of aging. Difficulties in accepting the loss of youth are also caused by fear of the effects of menopause, folklore about sexuality and social and advertising pressures describing the virtues of youth.

During middle age a man may notice changes in the strength of his creation and a decrease in his ability to experience repeated orgasm. Both partners may experience stresses related to sexuality changes or a conflict between their sexual needs and selfperceptions and social attitudes or expectations.

BIBLIOGRAPHY

Books: Beck, A., et al. Schizophrenia: Cognitive Theory, Research and Therapy. New York, NY: Guilford Press, 2009. Boyd, Mary Anne. Psychiatric Nursing Contemporary Practice, 4th Ed. Lippincott Williams & Wilkins, 2008. Doenges, Marilynn E. et al. Nurses Pocket Guide, 12th Ed. F.A. Davis Company, 2010. Karch, Amy. Nursing Drug Guide, 12th Ed. Lippincott Williams & Wilkins, 2011. Videbeck, Sheila L. Psychiatric-Mental Health Nursing, 5th Edition, Lippincott Williams & Wilkins, 2011.

Internet: http://psychcentral.com/disorders/sx31t.htm http://www.beckinstitute.org/cbt-for-schizophrenia/?gclid=CMq61MBhrUCFSU44godCCwA8A

NURSING INTERVENTION 1. Care Guide Certain personal characteristics are considered necessary when working therapeutically with a schizophrenic patient. The mental health professional needs to be straightforward, simple, and accepting, and hold unconditional regard for the dignity of another human being. Influencing the Clients Disturbances of Thinking Deciphering Meaning-when confronted with the clients symbolic words, actions, or other examples of disordered thinking, the nurse remembers that, although some behavior may seem at times almost impossible to understand, it does have a meaning to the client. The nurse tries to listen for the themes and search for the hidden meanings in communication. Reinforcing reality- Much of the nurses work with the schizophrenic client will be centered on helping to clarify reality and validate perceptions. This is accomplished by describing a real event or circumstance to the client n conversations or activities that focus on the here and now. Promoting Clarification- the client with a confused sense of identity will require much clarification from the nurse. When ambiguous and confusing topics arise, the nurse must stop the conversation and request clarification from the client. Obtaining information directly from the client is the only sure way to understanding the message being conveyed. Intervening in Hallucinations- the client who is hallucinating is preoccupied and frightened; leaving such a client alone only deepens preoccupation and fear. The nurses very presence is a reassuring force that helps calm fears. T is crucial for the nurse to remember that the hallucination is real to the client. When working with a hallucinating client, the nurse communicates concern that he is upset or bothered by the things that he hears or sees.

A)

B)

Interrupting the Clients Disturbances of Feeling Role Modeling- the nurse models appropriateness of affect by displaying a somber facial expression when discussing a serious topic or joyful expression when engaging in a happy or pleasant topic of conversation. Using body language to convey a mood appropriate to the thought is one aspect of the nurses repertoire of communication skills. Developing Tolerance- bizarre or inappropriate client behavior or affect must not be reinforced by a nurses smile, nod, anger, or laughter. The therapeutic self is primarily a person of honesty and any insights about ones feelings must be acknowledged openly before they can be faced.

C)

Diminishing the Clients Social or Behavioral Disturbances Developing Trust- the development of a trusting relationship is basic to the care of patients with schizophrenia. Through body languages, facial expressions, eye contact, tone of voice, and verbalizations, the client receives messages about the nurses trustworthiness. The client in turn, responds to these messages. Encouraging Self-care- encouraging self-care skills and rewarding or reinforcing his participation in activities of daily living will promote independent behavior. Dealing with Hostility- the need to deal with clients hostility may arise because of the nature of the close therapeutic relationship may engender outburst from the client.

VI. EVALUATION AND IMPLICATION Nursing Practice This case study is geared towards widening the understanding on schizophrenic client care. This will enhance the ability of the student nurse to manage and improve the condition of the client. Furthermore, this also aims to encourage support systems of the client to take part in the therapy and help him have a normal living as much as possible. It will be made possible through proper nursing interventions and health teachings. With this study, one can infer that it is really not that easy to deal with these kinds of clients. A great amount of effort and a lot of useful knowledge are very vital in order to improve their condition. The nurses should be able to combine both their theoretical and practical skills so as to provide essential caring care. A comprehensive plan of care is needed most especially to be made by the nurses to guide them all throughout the process to reflect if patient has responded or is having progress during the duration of care.

Nursing Education This study enables not only the student nurses but also the nursing professionals in acquiring broadened information about a particular case of schizophrenia. Thus, it improves the skills and equips the nursing student with new interventions in giving holistic care to the mentally ill client. This also helps the student nurse experience his learned knowledge and appreciate the special skills which will contribute to the said case.

Nursing Research Further research investigation is necessary when it comes to mental disorders. Information at hand is not sufficient to enable student nurses to have a clear picture on what these diseases are. A research about schizophrenia will greatly help in the rapid treatment of patients with this mental illness. This study may be able to help in such a way that it provides researchers a starting point on the clients condition and possib le modes of treatment that may be viable.

Normal Anatomy and Physiology

The brain is the largest and the most complex mass of the nervous tissue in the body; it is commonly discussed in terms of its four major regions cerebral hemispheres, diencephalon, brain stem and cerebellum.

Cerebral Hemisphere The paired cerebral hemispheres, collectively called the cerebrum, are the most superior part of the brain and together are a good deal larger than the other three brain regions combined. The entire surface of the cerebral hemispheres exhibits elevated ridges of tissue called gyri (gyrus), separated by shallow grooves called sulci (sulcus). Speech, memory, logical and emotional response as well as consciousness, interpretation, and voluntary movement, are all functions of neurons of the cerebral cortex, and many of the functional areas of the cerebral hemispheres. The somatic sensory area is located in the parietal lobe posterior to the central sulcus. Impulses travelling from the bodys sensory receptors are localized and interpreted in this area of the brain. The somatic sensory area allows you to recognize pain, coldness, or a light touch.

The primary motor area that allows us to consciously move our skeletal muscles is anterior to the central sulcus in the frontal lobe. The axons of these motor neurons from the major voluntary motor tract descend to the cord. A specialized area that is very involved in our ability to speak, Brocas area, is found at the base speech area is located at the junction of the temporal, parietal and occipital lobes. The corpus callosum connects the cerebral hemispheres. The corpus callosum arches above the structures of the brain stem and allows the cerebral hemispheres to communicate with one another.

Diencephalon Diencephalon or interbrain, sits atop the brain stem and is enclosed by the cerebral hemispheres. The major structures of the diencephalon are the thalamus, hypothalamus and epithalamus. The thalamus which encloses the shallow third ventricle of the brain is a relay station for sensory impulses passing upward to the sensory cortex. The hypothalamus makes up the floor of the diencephalon. It is an important autonomic nervous system center, because it plays a role in the regulation of body temperature, water balance and metabolism. It also the center for many drivers and emotions, and such it is an important part of the so-called limbic system or emotional visceral brain. The epithalamus forms the roof of the third ventricle. Important parts of the epithalamus are the pineal body and the choroid plexus of the third ventricle. The choroid plexus, knots of capillaries within each ventricle, from cerebrospinal fluids.

Brain Stem Brain stem is about the size of a thumb in diameter and approximately 3 inches long. Its structures are the midbrain, pons and medulla oblongata. Midbrain is a relatively small part of the brain stem. Anteriorly, the midbrain is composed primarily of two bulging fiber tracts, the cerebral peduncles, which convey ascending and descending impulses. Dorsally located are four rounded protrusions called the corpora quadrigemina because they reminded some anatomists of two pair of twins. These bulging nuclei are reflex centers involved in the control of breathing. Medulla oblongata

is the most inferior part of the brain stem. It merges into the spinal cord below without any obvious changes in structure. Medulla is an important fiber tract area. It also contains many nuclei that regulate vital visceral activities. It contains centers that control the heart rate, blood pressure, breathing, swallowing and vomiting among others. The pons is the rounded structure that protrudes just below the midbrain. Pons means bridge, and this area of the brain stem is mostly fiber tracts. However, it does have important nuclei involved in the control of breathing. The neurons of the reticular formation are involved in motor control of the visceral organs. A special group of reticular formation neurons, the reticular activating system (RAS), plays a role in consciousness and the sleep/wake cycles.

Cerebellum The cerebellum projects dorsally from under the occipital lobe of the cerebrum. The cerebellum has an outer cortex made up of gray matter and an inner region of white matter. The cerebellum provides the precise timing for skeletal muscle activity and controls our balance and equilibrium making body movements smooth and coordinated.

Protection of the Central Nervous System Nervous tissue is very soft and delicate, and the irreplaceable neurons are injured by even the slightest pressure. Nature has tried to protect the brain and spinal cord by enclosing them within bone (the skull and vertebral column), membranes (meninges) and a watery cushion (cerebrospinal fluid). Protection from harmful substances in the blood is provided by the so-called blood-brain barrier.

Meninges These are the connective tissue membranes covering and protecting the CNS structures. The outermost layer, the dura mater, meaning tough or hard mother, is a double-layered membrane surrounding the brain. One of its layers is attached to the inner surface of the skull, forming the periosteum. The other layer forms the outermost covering of the brain and continues as the dura mater of the spinal cord.

Cerebrospinal Fluid Cerebrospinal fluid (CSF) is a watery broth similar in its makeup to blood plasma, from which it forms. CSF is continually formed from blood by the choroid plexuses, Choroid plexuses are clusters of capillaries hanging from the roof in each of the brains ventricles. The CSF in and around the brain and cord forms a watery cushion that protects the fragile nervous tissue from blows and other trauma.

Blood-brain Barrier Neurons are kept separated from bloodborne substances by a so called bloodbrain barrier, composed of the least permeable capillaries in the whole body. Of water soluble substances, only water, glucose and essential amino acids pass easily through the walls of these capillaries. Metabolic wastes, such as urea, toxins, proteins and most drugs are prevented from entering the brain tissue. Nonessential amino-acids and potassium ions are not only prevented from entering the brain. But also are actively pumped from the brain into the blood across capillary walls. The blood-brain barrier is virtually useless against fats, respiratory gases and other fat soluble molecules that diffuse easily through all plasma membranes.

GORDONS FUNCTIONAL HEALTH PATTERNS 1. Health Perception Pattern The client believes that his health condition is good. It is usual for him to acquire some scratches or wounds on his body especially on his extremities. He does not mind any physiological discrepancies he experiences in the Banaglaum Home due to his belief that he is the son of God and that he cannot die. He is prescribed with Laractyl, Valparin XR, Abilify, Fluphenazine decanoate and Mupirocin. He is able to follow the medication regimen since it has been a habit of the resident to take his medications every after eating and before going to bed at night. 2. Nutritional-Metabolic Pattern The resident eats what is served by the kitchen. He has good appetite most of the time. He drinks adequate amount of water. However, there are instances when he does not consume any food during breakfast and lunch because he believes that he needs to fast. He secretly eats in the middle of the night when he experiences too much hunger. 3. Elimination Pattern The resident has no problem with elimination. He urinates and defecates regularly and does not need any assistive device to do so. His skin also has good turgor. 4. Activity-Exercise Pattern The resident usually does not participate in activities such as the morning stretch and other therapies. He spends most of his time praying in front of the gate. His body inclines to the right when he walks or stands. He is capable of performing self-hygiene but refuses to do so.

5. Cognitive-Perceptual Pattern He has no deficits in his senses hearing, sight, touch, smell, and taste. He is able to read and write and was able to finish civil engineering. He is an intelligent person. However, the resident manifests religious and persecutory delusions. He thinks that he is holy and that people around him want to persecute him.

6. Rest-Sleep Pattern The residents sleep pattern was adopted in the routines set by the Banaglaum Home. He sleeps at 10pm and wakes up at 6am. They also have siesta time starting at 1pm. He is usually stays at the Banaglaum grounds and goes inside his room to rest on his bed when he feels tired. 7. Self-Perception Pattern The resident believes that he is not mentally ill and that he is in Banaglaum because he has a mission to accomplish. He verbalized that the staff are the ones who need him and not the other way around. He assumes that he is a holy person and that he cannot die. 8. Role-Relationship Pattern He knows how to speak English, Cebuano and Filipino. But most of the times, he uses the English language in conversing with the student nurses. His speech is clear but is often incoherent. He lives with the other residents in Banaglaum and has roommates in the Male Ward I. His relationship with others is not good since he always condemns them, accusing they are all satans beasts. 9. Sexuality-Reproductive Pattern The resident is single and has no children. He knows his reproductive role as a male but he despises this since he believes that he is a holy person. He never thought of getting married or having children. The resident is very sensitive when it comes to this subject. 10. Coping-Stress Tolerance Pattern Praying is his primary way of coping. He does this every day and more often when he is confronted by a stressful situation. Fasting skipping meals and not taking a bath is also his way of managing stress. 11. Value-Belief System The resident is a Roman Catholic. He believes in God and religion is very important to him. He experiences a religious delusion believing that he is a prophet and that Christ is his brother. He wants to be called through his new name which is Very Very Little Jesus.

TABLE OF CONTENTS

I. INTRODUCTION II. OBJECTIVES III. NURSING ASSESSMENT 1. Personal History 1.1 Clients Profile 1.2 Family and Individual Information, Social and Health History 1.3 Level of Growth and Development 1.3.1 Normal Development 1.3.2 The Ill Person 1.4 Mental Status Examination 2. Diagnostic Results 3. Present Profile of Functional Health Patterns 4. Pathophysiology and Rationale 4.1 Normal Anatomy and Physiology 4.2 Psychopathology 4.3 Psychodynamics 4.4 Comparative chart of Classical and Clinical Signs and Symptoms IV. NURSING INTERVENTION 1. Care Guide of Client 2. Actual Client Care 2.1 BLM 2.2 NCP 2.3 Process Recording 2.4 Health Teaching Plan V. EVALUATION AND RECOMMENDATION VI. EVALUATION AND IMPLICATION 1. Nursing Practice 2. Nursing Education 3. Nursing Research VII. BIBLIOGRAPHY

II. NURSING ASSESSMENT 1. PERSONAL HISTORY Clients Profile Name: Age: Sex: Civil Status: Religion: Date of Admission: Room No.: Complaints: Euclid Igot 43 years old Male Single Roman Catholic August 21, 2010 Male Ward I Behavioral changes

Impression/Diagnosis: Schizophrenia Physician: Dr. Ma. Leore Igot

Family and Individual Information, Social and Health History The client was a graduate of civil engineering and was the owner of a shop selling motor parts. He had two siblings and his parents would usually visit him and bring him food. He was brought to Banaglaum by his mother due to behavioral changes. Upon admission, he was ambulatory, restless, untidy, and verbally aggressive and talked incoherently. He was wearing a purontong denim shorts with books ins erted in his waist. His right thigh was tied with straw strips which caused redness. He also had some scratches on his posterior chest. He was not able to establish a good relationship with the other residents in Banaglaum. He would sometimes talk to them aggressively condemning them to have evil souls. There were also some instances when he quarreled with them. He usually had wounds on his arms or legs because He also experienced an adverse reaction with haloperidol.

V. Evaluation and Recommendation This case study focused on Euclid, a patient who had been diagnosed with schizophrenia. Due to the evident positive and negative signs he continues to exhibit, the students have found him to be very recommendable for a case study on the condition. Doing a case study on the said patient was fascinating though exhausting undertaking, due to Euclids complex behavior, insubstantial conversational skills, and his occasional tendency to exhibit a verbally aggressive behavior. However, it proved to be the right choice because the students were able to gain further insight into the distortions of perception and bizarre movements exhibited, as well as witnessing firsthand an occasional delusion and flight of ideas. All in all, the study proved to be highly recommendable for it led the students to understand better and apply therapeutic communication and behavior most effective in dealing with such a client. However, the students evaluate the improvement of the patient as fair since he continues to exhibit the positive and negative symptoms. Most people with schizophrenia continue to suffer chronically or episodically throughout their lives. Studies that have followed people with schizophrenia for long periods, from the first episode to old age, reveal that a wide range of outcomes is possible. When large groups of patients are studied, certain factors tend to be associated with a better outcome for example, a pre-illness history of normal social, school, and work adjustment. However, the current state of knowledge, does not allow for a sufficiently accurate prediction of long-term outcome. Available treatments can relieve many symptoms, but most people with schizophrenia continue to suffer some symptoms throughout their lives; it has been estimated that no more than one in five individuals recovers completely. Medications and other treatments for schizophrenia, when used regularly and as prescribed, can help reduce and control the distressing symptoms of the illness. However, some people are not greatly helped by available treatments or may prematurely discontinue treatment because of unpleasant side effects or other reasons. Even when treatment is effective, persisting consequences of the illness lost opportunities, stigma, residual symptoms, and medication side effects may be very troubling.