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IntroductionMr. Apo a 49yr old male single patient in dorm two was born on March 12, 1960. He
weight 74 pounds and height of 5’10. He lived at barrio matalaba lingayen. He has a
Filipino nationality and his religion is Roman catholic. His educational attainment was a
2nd year college only. He was admitted at NCMH on August 13,1960, involuntarily and
accompanied by his relatives especially his sister Arlene. His sister decided to admit Mr.
Apo due to unwanted behavioral changes like restlessness and Sleeping disturbance. He
was diagnosed as undifferentiated schizophrenia and now his current diagnosis was
undifferentiated schizophrenia.
Undifferentiated schizophrenia is a mental disorder which is part of the family of disorders broadly known as
“schizophrenia.” There are a number of subcategories of schizophrenia including
paranoid schizophrenia, catatonic schizophrenia, disorganized schizophrenia, residual
schizophrenia, and schizoaffective disorder; undifferentiated schizophrenia is often
defined as a form in which enough symptoms for a diagnosis are present, but the patient
does not fall into the catatonic, disorganized, or paranoid subcategories.
Schizophrenia is characterized by a lack of grounding in reality, known as psychosis.
People in a state of psychosis can experience hallucinations, delusions, and other events
in which they break from reality. Individuals with schizophrenia experience psychosis
and can also develop symptoms such as disorganized speech, lack of interest in social
interactions, a flat affect, inappropriate emotional responses to situations, confusion, and
disorganized thinking.
Patients with undifferentiated schizophrenia do not experience the paranoia associated
with paranoid schizophrenia, the catatonic state seen in patients with
catatonic schizophrenia, or the disorganized thought and expression observed in patients
with disorganized schizophrenia. However, they do experience psychosis and a variety of
other symptoms associated with schizophrenia, including behavioral changes which may
be noticeable to family and friend.
Psychopathology
Causes One of the reasons for the ongoing difficulty in classifying schizophrenic disorders is
incomplete understanding of their causes. It is thought that these disorders are the end
result of a combination of genetic, neurobiological, and environmental causes. A leading
neurobiological hypothesis looks at the connection between the disease and excessive
levels of dopamine, a chemical that transmits signals in the brain (neurotransmitter). The
genetic factor in schizophrenia has been underscored by recent findings that first-degree
biological relatives of schizophrenics are ten times as likely to develop the disorder as are
members of the general population.
Prior to recent findings of abnormalities in the brain structure of schizophrenic patients,
several generations of psychotherapists advanced a number of psychoanalytic and
sociological theories about the origins of schizophrenia. These theories ranged from
hypotheses about the patient's problems with anxiety or aggression to theories about
stress reactions or interactions with disturbed parents.
Psychosocial factors are now thought to influence the expression or severity of
schizophrenia rather than cause it directly. As of 2004, migration is a social factor that is
known to influence people's susceptibility to psychosis.
Psychiatrists in Europe have noted the increasing rate of schizophrenia and other
psychotic disorders among immigrants to almost all Western European countries. Black
immigrants from Africa or the Caribbean appear to be especially vulnerable. The stresses
involved in migration include family breakup, the need to adjust to living in large urban
areas, and social inequalities in the new country.
Another hypothesis suggests that schizophrenia may be caused by a virus that attacks the
hippocampus, a part of the brain that processes sense perceptions. Damage to the
hippocampus would account for schizophrenic patients' vulnerability to sensory overload.
As of 2004, researchers are focusing on the possible role of the herpes simplex virus
(HSV) in schizophrenia, as well as human endogenous retroviruses (HERVs). The
possibility that HERVs may be associated with schizophrenia has to do with the fact that
antibodies to these retroviruses are found more frequently in the blood serum of patients
with schizophrenia than in serum from control subjects.
Symptoms
Patients with a possible diagnosis of schizophrenia are evaluated on the basis of a set or
constellation of symptoms; there is no single symptom that is unique to schizophrenia. In
1959, the German psychiatrist Kurt Schneider proposed a list of so-called first-rank
symptoms, which he regarded as diagnostic of the disorder.
These symptoms include:
delusions
somatic
hallucinations
hearing voices commenting on the patient's behavior
thought insertion or thought withdrawal
Somatic hallucinations refer to sensations or perceptions concerning body organs that
have no known medical cause or reason, such as the notion that one's brain is radioactive.
Thought insertion and/or withdrawal refer to delusions that an outside force (for example,
the FBI, the CIA, Martians, etc.) has the power to put thoughts into one's mind or remove
them.
HistoryThe patient diagnosed as undifferentiated schizophrenia and current undifferentiated
schizophrenia. He has lesions in legs, arms, back of the body and knee. He does not
undergo in any surgery. His medications are only for his mental illness. His previous
medications are Nozinan and haloperidol. His current medications are nozinan,
haloperidol and chlorpromazine.
Nursing physical assessmentApo was alert and oriented to person, place and time. The patient’s temperature 36.0
Celsius, pulse rate was 80, respiratory rate 20, blood pressure was 120/90. The patient has
no skeletal deformities. The skin of the patient was dry with scar. The musculoskeletal
status of the patient are weakness and tremors. The patient scars was located at leg, arms,
and at the back of the body. The patient stated her pain level. The bowel sounds of the
patient is good. The color of urinalysis is light yellow, transparency was slightly turbid.
The patient was on regular diet. The fasting blood sugar of the patient is 5.31 and specific
1.010. The weight of Apo is 74 pounds. Apo was regular exercise everday.
Related TreatmentMr. Apo is now receiving a Haloperidol 1mg tablet, which an typical antipsychotic
medication. It works by changing the effects of chemicals in the brain. It is used to treat
undifferentiated schizophrenia. Haloperidol 10mg/capsule it is used in the treatment of
schizophrenia and is also used in the management of pain, distress, nausea and vomiting
associated with terminal illness. Nozinan 10mg/ capsule it is used in the treatment of
schizophrenia and is also used in the management of pain, distress, nausea and vomiting
associated with terminal illness. Chlorpromazine is used to treat the symptoms of
schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest
in life, and strong or inappropriate emotions) and other psychotic disorders (conditions
that cause difficulty telling the difference between things or ideas that are real and things
or ideas that are not real) and to treat the symptoms of mania (frenzied, abnormally
excited mood) in people who have bipolar disorder (manic depressive disorder; a
condition that causes episodes of mania, episodes of depression, and other abnormal
moods).
Nursing care planNursing Diagnosing & Patient GoalA doctor must make a diagnosis of schizophrenia on the basis of a standardized list of
outwardly observable symptoms, not on the basis of internal psychological processes.
There are no specific laboratory tests that can be used to diagnose schizophrenia.
Researchers have, however, discovered that patients with schizophrenia have certain
abnormalities in the structure and functioning of the brain compared to normal test
subjects. These discoveries have been made with the help of imaging techniques such
as computed tomography scans (CT scans).
When a psychiatrist assesses a patient for schizophrenia, he or she will begin by
excluding physical conditions that can cause abnormal thinking and some other behaviors
associated with schizophrenia. These conditions include organic brain disorders
(including traumatic injuries of the brain), temporal lobe epilepsy, Wilson's disease, prion
diseases, Huntington's chorea, and encephalitis. The doctor will also need to rule
out heavy metal poisoning and substance abuse disorders, especially amphetamine use.
After ruling out organic disorders, the clinician will consider other psychiatric conditions
that may include psychotic symptoms or symptoms resembling psychosis. These
disorders include mood disorders with psychotic features; delusional disorder;
dissociative disorder not otherwise specified (DDNOS) or multiple personality disorder;
schizotypal, schizoid, or paranoid personality disorders; and atypical reactive disorders.
In the past, many individuals were incorrectly diagnosed as schizophrenic. Some patients
who were diagnosed prior to the changes in categorization should have their diagnoses,
and treatment, reevaluated. In children, the doctor must distinguish between psychotic
symptoms and a vivid fantasy life, and also identify learning problems or disorders. After
other conditions have been ruled out, the patient must meet a set of criteria specified:
the patient must have two (or more) of the following symptoms during a one-
month period: delusions; hallucinations; disorganized speech; disorganized or
catatonic behavior; negative symptoms
decline in social, interpersonal, or occupational functioning, including self-care
the disturbed behavior must last for at least six months
mood disorders, substance abuse disorders, medical conditions, and
developmental disorders have been ruled out.
Nursing intervention1. 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
in closed containers that he can open. If you give liquid medication in a unit-dose
container, allow the patient to open the container.
2. 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.
3. 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.
4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient
what he can't do for himself.
5. Reward positive behavior 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 others 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
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
syndrome. Make sure you document and report such effects promptly.
EvaluationThe client was able to maintain reality orientation. He is oriented to time when asked
what day it is. The patient was demonstrate behaviors that show positive self esteem as
evidenced by inability to have an eye contact.
RecommendationHe 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. Even if nursing students find it difficult to establish
therapeutic relationships with mentally-ill 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.
A case study
Presented to the faculty of
Our lady of Fatima University
College of Nursing
A Case Study on Undifferentiated Schizophrenia
Submitted to:
Ms. Leyden Dela cruz RN
Clinical instructor
Submitted by
Belardo, Gillian abegail F.
Group A
Nursing care planAssessment
Subjective
“Sobrang lamig ng tubig nakakatamad maligo, ay ang haba pala ng kuko ko” as
verbalized by the patient
Objective
Untrimmed fingernails and toenails with visible dirt noted
DiagnosisSelf care deficit bathing/ hygiene related to lack of motivation. The patient has an
impaired ability to provide self care requisites due to environmental and psychological
factors.
PlanningAfter 2 hours of nusing care, the client will be able to
a) Verbalize self care need
b) Demonstrate techniques to meet self care needs
Interventions1. Establish rapport.
R: to gain client’s trust and facilitate a good working relationship.
2. Identify reason for difficulty in self-care.
R: underlying cause affects choice of interventions/ strategies.
3. Determine hygienic needs and provide assistance as needed with activities like
care of nails and brushing teeth.
R: basic hygienic needs may be forgotten.
4. 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 self-care like various toiletries.
R: increases the client’s awareness of different materials for self-care.
6. Let the patient 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
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.
Evaluation
GOAL PARTIALLY MET
After 2 hours of nursing care, the client was able to:
a) verbalize self care need
b) but was unable to demonstrate techniques to meet self-care needs.
Nursing care planAssessmentSubjective
“Hindi ako masyado makatulog sa gabi” as verbalized by the patient
Objective
restlessness
dark circles under eyes
irritability
frequent change of mood
V/S taken as follows
T: 36.5˚C
P: 54
R: 12
BP: 110/ 80
DiagnosisDisturbed Sleep Pattern related to hyperactivity
Planning After 8 Hours, Patient will be able to report feeling rested and show improvement in sleep/rest
pattern.
Intervention
INDEPENDENT
1. Assess past patterns of sleep in normal environment: amount, bedtime rituals, depth,
length, positions, aids, and interfering agents.
2. Document nursing or caregiver observations of sleeping and wakeful behaviors.
Record number of sleep hours. Note physical (e.g., noise, pain or discomfort, urinary
frequency) and/or psychological (e.g., fear, anxiety) circumstances that interrupt
sleep.
3. Instruct patient to follow as consistent a daily schedule for retiring and arising as
possible.
4. Avoid including in the meal alcohol or caffeine as well as heavy meal
5. Increase daytime physical activities as indicated.
6. Recommend an environment conducive to sleep or rest (e.g., quiet, comfortable
temperature, ventilation, darkness, closed door).
COLLABORATIVE
Administer sedatives as ordered.
Evaluation
After 8 hours of Nursing Interventions, the patient was able to show improvement in
his sleeping pattern.
Nursing care planAssessment Subjective
“Ang aking mga sugat ay nangangati” as verbalized by the patient
Objective
(pain)
Localized erythema
Disruption of the skin
DiagnosisImpaired skin integrity related to inflammatory response secondary to infection.
Planning Following a 3-day nursing intervention, the client will be able to display improvement in
wound healing as evidenced by:
Intact skin or minimized presence of wound.
Absence of redness or erythema.
Absence of purulent discharge.
Absence of itchiness.
Intervention Assessed skin. Noted color, turgor, and sensation. Described and measured wounds
and observed changes.
Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.
Instructed family to maintain clean, dry clothes, preferably cotton fabric (any T-
shirt).
Emphasized importance of adequate nutrition and fluid intake.
Demonstrated to the family members on how to make a guava decoction to apply to
the wound as alternative disinfectant.
Instructed family to clip and file nails regularly.
Provided and applied wound dressings carefully.
Evaluation
At the end of the 3-day nursing intervention, the client was able to display improvement
in wound healing as evidenced by:
Minimized presence of wounds.
Several wounds have dried up.
Minimized erythema.
Minimized purulent discharge.
(Continue cleaning the wound with disinfectant)
Presence of itchiness (Continue instructing client to avoid scratching the wound)
Nursing process RecordingMr. Apo drawn a heart and uses a red crayon to make it. He described the drawing as a symbol love and passion. He also said that symbolizes people who love each other. My patient thinks of love and the way people express it, and show it, in the way that people can appreciate the true meaning of LOVE. Why do people fall in love and what is it for. Is it important to people to love in able to attain peace or to unite people and be happy with their special someone. The answer is clear and the only thing that makes people happy is because of LOVE.
