I.

Introduction My patient name is GV a 45 yr-old male construction worker, married and with 5 children. His youngest son died as mentioned by the patient. Gabriel belongs to a lower class family that lives at the province. He was diagnosed to be suffering from mild mental retardation with auditory hallucination and paranoia. No family history of mental illness and with a chief complaint of killing his mother.

II. Psychopathology
Schizophrenia is a mental disorder characterized by disintegration of thought processes and of emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. ("Schizophrenia" Concise Medical Dictionary. ) The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.30.7%. Diagnosis is based on observed behavior and the patient's reported experiences. (Kapur S.) People who have it may hear voices, see things that aren't there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other symptoms include: unusual thoughts or perceptions, disorders of movement, difficulty speaking and expressing emotion, problems with attention, memory and organization No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives. Typhoid fever is a life-threatening bacterial infection caused by bacteria called Salmonella typhi. Typhoid is contracted through consumption of food and water that has been contaminated with Salmonella typhi. Untreated typhoid can cause permanent psychiatric problems such as delirium, hallucinations and paranoia over the long term. Hallucinations are false and distorted perceptions of events. Paranoia is a symptom of a psychotic disorder in which patients become suspicious of others and feel that the world is out to get them. The disorder appears to be more common in families with psychotic disorders such as schizophrenia and delusional disorder, which suggests genes, may be involved. However, environmental factors may play a role, as well. The condition appears to be more common in men. III. History Patient shows strangeness in his behavior and becoming uneasy due to his belief that someone will kill him. Patient was seen running purposelessly as if someone was after him. No consultation and medication was done to the patient due to lack of funds. Informant further advised that every time the patient is in this state they usually tie him up. Until one fateful night, the patient was in his restless behavior and thought that someone was trying to kill him and thought that the killer was entering the door and accidentally killed his mother with a bamboo

pole. Family and relatives then decided to have his wife bring him for consultation and medication.

IV. Nursing Physical Assessment

The patient upon observation has dry skin. He has a bad posture. Clench his hands while talking. No eye contact. He seems to be aware of his surroundings and know that he is being treated for his mental problems. Patient has dry parched lips and clear eyes. He keeps on tapping his head for no apparent reason.

V.

Related Treatments The patient is receiving 4 medications namely:

DRUG NUMBER 1 Generic Name Brand Name Classification ACTION Amlodipine besylate Norvasc Antianginals Inhibits calcium ion influx across cardiac and smooth-muscle cells, thus decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles. Drug-Food Grapefruit juice: may increase drug level and adverse reactions. Discourage use together. *Chronic stable angina, vasospastic angina (Prinzmetal's or variant angina) *Hypertension *Contraindicated in patients hypertensive to drug. *Use cautiously in patients receiving other peripheral vasodilators, especially those with severe aortic stenosis, and in those with heart failure. GI: nausea, abdominal pain. CNS: headache, somnolence, fatigue, dizziness, lightheadedness, paresthesia. MUSCULOSKELETAL: muscle pain. RESPIRATORY: dyspnea. SKIN: rash, pruritus. GU: sexual difficulties. *Monitor blood pressure frequently during initiation of therapy. Because drug induced vasodilation has a gradual onset, acute hypotension is rare. *Notify prescriber if signs of heart failure occur, such as swelling of hands and feet or shortness of breath. *Monitor patient carefully. Some patients, especially those with severe obstructive coronary artery disease, have developed increase frequency, duration, or severity of

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angina or acute MI after initiation of calcium channel blocker therapy or time of dosage increase. DRUG NUMBER 2 Generic Name Brand name Classification ACTION Toprol-XL Metoprolol succinate Antihypertensive Unknown. A selective beta blocker that selectively blocks beta1 receptors; decreases cardiac output, peripheral resistance, and cardiac oxygen consumption; and depresses renin secretion. Cimetidine: May increase beta-blocker effects. Consider another H2 agonist, or decrease dose of beta blocker. I.V Lidocaine: May reduce hepatic metabolism of lidocaine, increasing risk of toxicity. Give bolus doses of lidocaine at a slower rate, and monitor lidocaine level closely. Drug-herb. Ma huang: may increase antihypertensive effects. Discourage use together. Drug-food. Food: May increase absorption. Encourage patient to take drug with food *Hypertension *Early intervention in acute MI *Angina pectoris *Stable symptomatic heart failure resulting from ischemia, hypertension, or cardiomyopathy *Contraindicated in patients hypertensive to drug or other beta blockers. *Contraindicated in patients with sinus bradycardia, greater than first-degree heart block, cardiogenic shock, and overt cardiac failure when used to treat hypertension or angina. CNS: fatigue, dizziness, depression. CV: bradycardia, hypotension, heart failure, AV block, edema. GI: nausea, diarrhea. RESPIRATORY: dyspnea. SKIN: rash. *Always check patients apical pulse rate before giving drug. If its slower than 60 beat/minute, withhold drug and call prescriber immediately. *in diabetic patients, monitor glucose level closely because drug masks common signs and symptoms of hypoglycemia. *Monitor blood pressure frequently; drug masks common signs and symptoms of shock.

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DRUG NUMBER 3 Generic Name Brand name Classification Apo-Carbamazepine, Carbatrol, Epitol, Equetro, Novocarbamaz, Tegretol, Tegretol CR, Tegretol-XR, Teril Carbamazepine Anticonvulsants Unknown. Thought to stabilize neuronal membranes and limit seizure activity by either increasing efflux or decreasing influx of sodium ions across cell membranes in the motor cortex during generation of nerve impulses. Mycin: May inhibit metabolism of carbamazepine, increasing carbamazepine level and risk of toxicity. Avoid using together. Drug-herb. Plantains (psyllium seed): May inhibit GI absorption of drug. Discourage use together. *Generalized tonic-clonic and complex partial seizures, mixed seizure patterns. *Restless legs syndrome. *Acute manic and mixed episodes in bipolar I disorder. *Trigeminal neuralgia. *Non-neuritic pain syndromes (painful neuromas phantom limb pain) *Contraindicated in patients hypertensive to this drug or tricyclic antidepressants and in those with a history of bone marrow suppression. *Contraindicated in those who have taken an MAO inhibitor within 14 days. CNS: dizziness, vertigo, drowsiness, fatigue, ataxia, headache, worsening seizure, confusion, fever, syncope. CV: heart failure, hypertension, hypotension, aggravation of coronary artery disease, arrythmias, AV block. EENT: conjunctivitis, dry pharynx, blurred vission, diplopia, nystagmus. GI: dry mouth, nausea, vomiting, abdominal pain, diarrhea, anorexia, stomatitis, glossitis. GU: urinary frequency, urine retention, impotence, albuminuria, glycosuria. HEMATOLOGIC: aplastic anemia, agranulocytosis, eosinophilia, leukocytosis, thrombocytopenia. HEPATIC: hepatitis RESPIRATORY: pulmonary hypersensitivity. SKIN: rash, urticaria, erythema multiforme, stevens-johnson syndrome, excessive diaphoresis. OTHER: chill.

ACTION

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NURSING CONSIDERATION

*Watch for worsening of seizures, especially in patients with mixed seizure disorders, including atypical absence seizures. *Obtain baseline determinations of urinalysis, BUN and iron levels, liver function, CBC, and platelet and reticulocyte counts. Monitor these values periodically thereafter. *Shake oral suspension well before measuring dose. *Never stop drug suddenly when treating seizures. Notify prescriber immediately if adverse reaction occurs. *Adverse reactions may be minimized by gradually increasing dosage. *When managing seizures, take appropriate precautions. *ALERT: Watch for signs of anorexia or subtle appetite changes, which may indicate excessive drug level.

DRUG NUMBER 4 Generic Name Brand name Classification ACTION Chlorpromanyl-20, Chlorpromanyl-40, Largactil, Novochlorpromazepine, Thorazine Chlorpromazine hydrochloride Antipsychotics A piperidine phenothiazine that may block postsynaptic dopamine receptors in the brain. Antacids: May inhibit absorption of oral phenothiazines. Separate antacid and phenothiazine doses by at least 2 hours. Drug-herb. St. john's wort: May cause photosensitivity reactions. Advised patient to avoid excessive exposure to sunlight. *Psychosis, mania *Nausea and Vomiting *Acute intermittent poryphyria, intractable hiccups *Tetanus *Surgery *Contraindicated in patients hypersensitivity to drug; in those with CNS depression, bone marrow suppression, or subcortical damaged; and in those in coma. CNS: extrapyramidal reactions, drowsiness, sedation, seizure, tardive dyskinesia, pseudoparkinsonism, dizziness, neuroleptic malignant syndrome. CV: orthostatic hypotension, tachycardia, quinidine-like ECG effects. EENT: ocular changes, blurred vision, nasal congestion. GI: dry mouth, constipation, nausea. GU: urine retention, menstrual irregularities, inhibited ejaculation, priapism. HEMATOLOGIC: leukopenia, agranulocytosis, eosinophilia, hemolytic anemia, aplastic anemia, thrombocytopenia.

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HEPATIC: jaundice. SKIN: mild photosensitivity reactions, pain at IM injection site, sterile abscess, skin pigmentation changes. OTHERS: gynecomastia, lactation, galactorrhea. *Obtain baseline blood pressure measurements before starting therapy, and monitor regularly. *Watch for orthostatic hypotension, especially with parenteral administration. *Monitor blood pressure before and after I.M. administration; keep patient supine for one hour afterward and have him get up slowly. *wear gloves when preparing solutions and avoid contact with skin and clothing. Oral liquid and parenteral forms can cause contact dermatitis. *Monitor patient for tardive dyskinesia, which may occur after prolonged use.

VI. Nursing Care Plan

A. Nursing Diagnosis &Patient Goal

Risk for self-directed violence R/T depressed mood, hopelessness, AEB history of patient banging his head on the wall. Social isolation R/T maladaptive social behavior, inadequate resources AEB feelings of rejection, sad and dull affect. Goal for the patient at the end of the nursing care: the patient will should be able to maintain orientation to time, place, person, and circumstances. Patient should know how to direct his negative thoughts to positive thoughts.

B. Nursing Interventions 1. Assess mood, behavior, and thoughts.

Rationale: This will help in assessing what mode of treatment and therapy should be done with the patient.

2. Assess interactions with others.

Rationale: To develop patient social relation with others.

3. Assist the patient in determining socially adaptive behaviors.

Rationale: To explain to the patient and discuss with him what is socially accepted behaviors.

4. Encourage positive interactions with the patient by spending time with him or her and
providing supportive contact. Rationale: To make the patient feel that he is accepted and supported.

5. Acknowledge the patient's involvement in activities of daily living.

Rationale: This will encourage the patient to be more outgoing and to be more involve on other social activities.

6. Encourage participation in group activities as tolerated. Assist the patient in

identifying life interests and people who have meaning to him/her. Rationale: This will help the patient and prepare the patient for reintroduction to the society.

7. Assess the patient's potential for self-directed violence and evidence of risk factors
that may increase the potential for a suicide attempt. Rationale: This will check the patients attitude if he will relapse and possibly hurt others or himself.

8. Provide for a safe environment.

Rationale: To make sure that the patient will not be able to hurt himself.

9. Assess for presence of ruminations, negative thoughts, and feelings of inadequacy

and assist the patient in identifying and reviewing negative self-perceptions Rationale: To maintain continuous positive thoughts for the patient.

10. Identify the patient's positive beliefs and characteristics.

Rationale: To encourage the patient to always think of positive things to help him create a good perception of his life.

11. Encourage the patient to be actively involved in all treatment planning.

Rationale: This will help the patient to make him feel that he is part in his treatment.

C. Evaluation
The patients mood was uplifted and he is slowly beginning to trust others. There is a noticeable change in his attitude when it comes to speaking to other people. He started to open up himself in terms of telling a story of what activities he had done for the day. He knows what is happening in his surroundings.

D. Recommendations 1. I do recommend that the patient continue with his medication and further
socialized with other people.

2. He should always be reminded to think of only positive thoughts and that

everything will be all right.

3. Group therapy or group discussion should be encouraged to further enhance his

social skills.

4. Check the patient moods from time to time to check on how he is coping.

Case Study: Schizoprenia

NATIONAL CENTER FOR MENTAL HEALTH

Nueva de Febrero St. Mandaluyong City Philippines

In Partial Fulfillment of the Requirements in NCM105A Group 1D Submitted to Mr. Jayson Bactat, RN, MAN Submitted by: Divine Grace D. Yap

July 15, 2011