Undifferentiated Schizophrenia

COLLEGE OF NURSING

Our Lady of Fatima UniversityResearch and Development Center

NURSING MANAGEMENT 1

Nursing Management of Patient with

Undifferentiated Schizophrenia

Dela Cruz, Victor Jr S.

BSN3Y3-9B

Our Lady of Fatima University

Valenzuela City

Ma’am Rosario Fernando

Clinical Instructor

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Nursing Management of Patient with Undifferentiated Schizophrenia

Introduction

R.A, 34 years old, male from Concessionaires area, PNPA. Patient is the

5th siblings, 2nd year college level when he became mentally ill 12 years prior

to admission. He had regular check-up at this center on January 27, 2003.

Given drugs of monthly Levozepromazine. His last check-up was on March

17, 2008 and has subsequent check-up care of Trece Martines.

Schizophrenia (from the Greek roots skhizein ("to split") and phrēn

("mind") is a severe mental illness characterized by a variety of symptoms

including but not limited to loss of contact with reality. Schizophrenia is not

characterized by a changing in personality; it is characterized by a

deteriorating personality. Simply stated, schizophrenia is one of the most

profoundly disabling illnesses, mental of physical that the nurse will ever

encounter (Keltner,2007). There are 5 subtypes of schizophrenia naming;

paranoid, disorganized, catatonic, undifferentiated, and residual.

Schizophrenia undifferentiated is the type of schizophrenia wherein

characteristic symptoms (delusions, hallucinations, disorganized

speech, grossly disorganized or catatonic behavior, and negative

symptoms) are present, but criteria for paranoid, catatonic,

or disorganized subtypes are not met.

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Schizophrenia is not a terribly common disease but it can be a

serious and chronicone. Worldwide about 1 percent of the population

is diagnosed with schizophrenia. About 1.5 million people will be

diagnosed with schizophrenia this year around the world. Ninety-five percent

(95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americans

suffer from schizophrenia; fifty percent (50%) experience serious

side effects from medications; and ten percent (10%) kill themselves

(Keltner, 2007).

According the study of cureresearch.com done 697,543 out of

86,241,697 of Filipinos or approximately 0.8% are suffering from

schizophrenia. 5 schizophrenia ranks among the top 10 causes of

disability in developed countries worldwide. Schizophrenia is a

disease that typically begins in early adulthood; between the ages of

15 and 25. Men tend to get develop schizophrenia slightly earlier

than women; whereas most males become ill between 16 and 25

years old, most females develop symptoms several years later, and the

incidence in women is noticeably higher in women after age 30. The average

age of onset is 18 in men and 25 in women. Schizophrenia onset is quite rare

for people under 10 years of age, or over 40 years of age.

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Anatomy and Physiology

The nervous system is an intricate, highly organized network of

billions of neurons and neuroglia. The structures that make up the

nervous system include the brain, cranial nerves, spinal nerves, ganglia,

enteric plexuses and sensory receptors. The two main subdivisions of the

nervous system are the central nervous system and the peripheral nervous

system.

The central nervous system consists of the brain and spinal cord. The

brain is the center for registering sensations, correlating them with one

another and with stored information, making decisions and taking

actions. It also is the center for the intellect, emotions, behavior, and

memory. The major parts of the brain include: the brain stem, cerebellum,

diencephalon, and cerebrum. The spinal cord is connected to a section of

the brain called the brainstem and runs through the spinal canal.

Cranial nerves exit the brainstem. Nerve roots exit the spinal cord to both

sides of the body. The spinal cord carries signals (messages) back and

forth between the brain and the peripheral nerves.

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The brain stem is continuous with the spinal cord and consists

of the medulla oblongata, pons, and midbrain. The medulla oblongata

forms the inferior part of the brain stem. The medulla contains the cardiac,

respiratory, vomiting and vasomotor centers and deals with

breathing, heart rate and blood pressure. The pons is a bridge that

connects parts of the brain with one another. The midbrain extends from

the pons to the diencephalon. The midbrain is a short section of the

brainstem between the diencephalon and the pons.

Posterior to the brain stem is the cerebellum. Traditionally, the

cerebellum has been known to control equilibrium and coordination and

contributes to the generation of muscle tone. It has more recently

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become evident, however, that the cerebellum plays more diverse

roles such as participating in some types of memory and exert in a

comples influence on musical and mathematical skills. Superior to the

brainstem is the diencephalon, which consists of the thalamus,

hypothalamus, and epithalamus. The thalamus acts a relay center for

all sensory impulses, except smell to the cerebral cortex. The

hypothalamus is involved in the acceleration or deceleration of the heart.

Impulses from the posterior hypothalamus produce a rise in arterial

blood pressure and increase of the heart rate. Impulses from the

anterior portion have the opposite effect. The hypothalamus is also

involved in body temperature regulation. If the arterial blood flowing

through the anterior portion of the hypothalamus is above normal level, the

hypothalamus initiates impulses that cause heat loss through sweating

and vasodilation of cutaneous vessels of the skin. A below-normal

blood temperature causes the hypothalamus to relay impulses that result in

heat production and retention through the initiation of shivering, the

contraction of cutaneous blood vessels. The hypothalamus is also

involved in the regulation of hunger and control of gastrointestinal

activity. Low levels of blood glucose, fatty acids and amino acids are

partially responsible for the sensation of hunger elicited from the

hypothalamus. When sufficient amounts of food have been ingested, the

hypothalamus inhibits the feeding center. It also regulates sleeping and

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wakefulness. A specialized sexual center in the hypothalamus responds to

sexual stimulation of the tactile receptors within the genital organs. Also,

the hypothalamus is associated with specific emotional responses,

such asanger, fear, pain and pleasure. The hypothalamus produces

neurosecretory chemicals that stimulate the anterior pituitary gland to

release various hormones. The epithalamus is the posterior portion of the

diencephalon.

Supported on the diencephalon and brain stem is the

cerebrum, which is the largest part of the brain. The cerebrum is the

largest part of the brain and controls voluntary actions, speech,

senses, thought, and memory. The surface of the cerebral cortex

has grooves or infoldings (called sulci), the largest of which are termed

fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance.

Each convolution is delimited by two sulci and is also called a gyrus

(gyri in plural). The cerebrum is divided into two halves, known as

the right and left hemispheres. A mass of fibers called the corpus

callosum links the hemispheres. The right hemisphere controls voluntary

limb movements on the left side of the body, and the left hemisphere

controls voluntary limb movements on the right side of the body.

Almost every person has one dominant hemisphere. Each hemisphere

is divided into four lobes, or areas, which are interconnected.

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The frontal lobes are located in the front of the brain and are

responsible for voluntary movement and vie their connections with other

lobes, participate in the execution of sequential tasks; speech output;

organizational skills; and certain aspects of behavior, mood, and memory.

The parietal lobes are located behind the frontal lobes and in front of the

occipital lobes. They process sensory information such as temperature, pain,

taste, and touch. In addition, the processing includes information about

numbers, attentiveness to the position of one’s body parts, the space around

one’s body, and one's relationship to this space. The temporal lobes are

located on each side of the brain. They process memory and auditory

(hearing) information and speech and language functions.

The occipital lobes are located at the back of the brain. They receive

and process visual information.

Neurotransmitters are chemicals which relay, amplify, and modulate

signals between a neuron and another cell. Some neurotransmitters are

commonly described as "excitatory" or "inhibitory". The only direct effect of

a neurotransmitter is to activate one or more types of receptors. Examples of

neurotransmitters are acetylcholine, dopamine, gamma-aminobutyric acid,

dopamine, glutamate, aspartate, and serotonin. The chemical compound

acetylcholine is a neurotransmitter in both the peripheral nervous system

(PNS) and central nervous system (CNS) in many organisms including

humans. In the peripheral nervous system, acetylcholine activates muscles,

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and is a major neurotransmitter in the autonomic nervous system. In the

central nervous system, acetylcholine and the associated neurons form

a neurotransmitter system, the cholinergic system, which tends to

cause excitatory actions. Gamma-Aminobutyric acid (GABA) is the

chief inhibitory neurotransmitter in the mammalian central nervous system.

It plays a role in regulating neuronal excitability throughout the nervous

system. In humans, GABA is also directly responsible for the regulation of

muscle tone. Dopamine has many functions in the brain, including important

role in behavior and cognition, voluntary movement, motivation, punishment

and reward, inhibition of prolactin production (involved in lactation and

sexual gratification), sleep, mood, attention, working memory, and learning.

In the frontal lobes, dopamine controls the flow of information from other

areas of the brain. Dopamine disorders in this region of the brain can cause a

decline in neurocognitive functions, especially memory, attention, and

problem-solving. Reduced dopamine concentrations in the prefrontal cortex

are thought to contribute to attention deficit disorder. Dopamine is

commonly associated with the pleasure system of the brain, providing

feelings of enjoyment and reinforcement to motivate a person proactively to

perform certain activities. Dopamine is released (particularly in areas such as

the nucleus accumbens and prefrontal cortex) by naturally rewarding

experiences such as food, sex, drugs, and neutral stimuli that

become associated with them. Recent studies indicate that

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aggression may also stimulate the release of dopamine in this way.

This theory is often discussed in terms of drugs such as cocaine,

nicotine, and amphetamines, which directly or indirectly lead to an

increase of dopamine in the mesolimbic reward pathway of the brain,

and in relation to neurobiological theories of chemical addiction (not

to be confused with psychological dependence), arguing that this

dopamine pathway is pathologically altered in addicted persons.

Projection neurons that produce dopamine are found in the diencephalon

and the brainstem. In the diencephalon, dopamine cell bodies give rise

to tuberopophysial dopamine projections, which inhibit the release of

prolactin and melanocyte-stimulating hormone from the anterior and

intermediate lobes of the pituitary, respectively, and the

incertohypothalamic projections, which connect the zona incerta in

the posterodorsal diencephalon with the anterior hypothalamus and

septal area. A third dopamine projection system arises from neurons

scattered along the ventricular system in the periaqueductal gray, the

dorsal motor of the nucleus of the vagus, and the nucleussoli tarius.

The preventricular system provides terminals in the gray matter

along the course of theventricles.Longer dopamine projection systems

arise from the substantia nigra and the ventral tegmentalarea (VTA) of the

midbrain. The former, the nigrostriatal dopamine system, is a particularly

important in the control of motor function. The function of the

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VTA’s dopamine projections to the forebrain, called the mesolimbic and

mesocortical systems, has been linked to the complex group of disease we

refer to as schizophrenia. Sociability is also closely tied to dopamine

neurotransmission. Low D2 receptor-binding is found in people with social

anxiety. Traits common to negative schizophrenia (social withdrawal, apathy,

anhedonia) are thought to be related to a hypodopaminergic state in certain

areas of the brain. In instances of bipolar disorder, manic subjects can

become hypersocial, as well as hypersexual. This is credited to an increase in

dopamine, because mania can be reduced by dopamine-blocking anti-

psychotics. The locus ceruleus at the rostal end of the floor of the

fourth ventricle on each side marks the position of a nucleus with a

rich vascular supply and consisting of neurons containing

melanin pigment. The nucleus (also known as nucleus pigmentosus) is

partly in the pons and partly in the midbrain, lying dorsolateral to the

oral pontine reticular nucleus. The locus ceruleus is the largest of about a

dozen nuclei I the brainstem that produce catecholamines. Most

produce norepinephrine, but some of those in the medulla produce

epinephrine. A third catecholamine is dopamine, a transmitter used

by the large neurons of the substantia nigra and ventral tegmental

area, and by certain nuclei of the hypothalamus. Serotonin or 5-

Hydroxytryptamine (5-HT) is a monoamine neurotransmitter that is primarily

found in the gastrointestinal (GI) tract and central nervous system (CNS) of

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humans and animals. Approximately 80 percent of the human body’s total

serotonin is located in the enterochromaffin cells in the gut, where it is used

to regulate intestinal movements. The remainder is synthesized in

serotonergic neurons in the CNS where it has various functions, including the

regulation of mood, appetite, sleep, muscle contraction, and some cognitive

functions including memory and learning. Modulation of serotonin at

synapses is a thought to be a major action of several classes of

pharmacological antidepressants. Serotonin secreted from the

enterochromaffin cells eventually finds its way out of tissues into the blood.

There, it is actively taken up by blood platelets, which store it. When the

platelets bind toa clot, they disgorge serotonin, where it serves as

a vasoconstrictor and helps to regulate hemostasis and blood clotting.

Serotonin also is a growth factor for some types of cells, which may give it a

role in wound healing.

Psychopathology

The pathophysiology of schizophrenia has long remained a mystery

and still today, even with various hypotheses, remains somewhat uncertain:

there are too many variants; not enough consistency in findings; and,

despite research, a lack of documented proof.

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The most well-known and respected hypothesis with regards to the

pathophysiology of schizophrenia began in the 1990s and consisted primarily

of the notion there is a problem with the dopamine levels in the brain of

schizophrenics.

Dopamine is both a hormone and a neurotransmitter, which means

that it activates five different receptors in the brain, aptly named D1, D2, D3,

D4, and D5. That said, it may not be the only neurotransmitter involved in

the pathophysiology of schizophrenia. Glutamate and Serotonin have also

been implicated.

Contributing to this hypothesis is the fact that drugs administered to

aid dopaminergic activity bring on schizophrenic characteristics such as

psychosis, in a patient, whereas drugs administered to block them help

reduce, or eliminate symptoms of schizophrenia altogether.

Additional studies affecting the pathophysiology of schizophrenia

include suggestions that maternal factors such as infection, malnutrician,

location of birth, season of birth, and delivery, may play a significant part in

the formation and subsequent appearance of schizophrenia. Studies have

shown that the worldwide rate of births affected with schizophrenia is up to

8% higher when occurring in spring or winter, though no explanation for this

can be offered.

Another aspect of the pathophysiology of schizophrenia that has been

explored in relative detail is that of genetics, and their relation to the

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likelihood of immediate relatives being born with the disease. Shockingly, it

has been found that 10% of all immediate family members of an infected

person will be struck down with the disease. This is specifically in relation to

parents, siblings, and children. With regards to twins or other multiple births,

the chances they will share the disease is 50%. Genetic reports suggest that

it is the X chromosome which determines whether or not a person is infected

with schizophrenia, specifically, chromosomes 1, 3, 5, and 11, however

further studies are needed in order to prove this theory.

Though there are many theories and hypotheses regarding the

pathophysiology of schizophrenia, there is, unfortunately, still no cure for the

disease. The best a sufferer can hope for nowadays is to benefit from

available medication which keeps the disease under control or in remission

for the duration of time for which it is taken.

History

R.A, 34 years old, male from Concessionaires area, PNPA admitted on

February 7,2012. Patient is the 5th siblings, 2nd year college level when he

became mentally ill 12 years prior to admission. He had regular check-up at

this center on January 27, 2003. Given drugs of monthly Levozepromazine.

His last check-up was on March 17, 2008 and has subsequent check-up care

of Trece Martines. Medication just conditioned to be manifested.

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1 week prior to admission, patient became assaultive and distractive

infront of family.

2 days prior to admission, patient strambulated father and was

helpless to calls, restless and sleep hence brought to the center.

According to mother “nananakit”, “nanununtok”, “sina-sabal ang

tatay”, “naghuhubad” and “di-nakatulog”.

According to patient “check-up lang” and “hindi po totoo yun”.

Mental Status Exams

Name: R.A Diagnosis: Undifferentiated

Schizophrenia

Age: 34 Ward: Pavillion 6, Pay Ward 1-E

Appearance

34 year-old Filipino, male, 5’7 in height. At the time of examination, patient

was well groomed and dressed. He was not confined to bed. R.A was

cooperative throughout the interview. He maintained eye contact, except

during the times when recounting the history before he was admitted. Then,

he appeared depressed. His level of personal hygiene was fairly good. The

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patient’s movements are organized and purposeful during the interview. He

moves in a normal pace and does not show any signs of over and under

activity. The patient’s facial expressions are very much appropriate to his

verbal responses during the interview. He was composed and receptive to

whatever the I ask him.

Behavior

Behavior was passively cooperative during examination. The patient was

friendly and warm during the interview. He was sitting on chair calmly.

Speech

R.A articulated himself clearly. During the interview, he was pleasant and

cooperative and displayed a positive attitude. He went into details, the

circumstances surrounding his admission. He was able to maintain adequate

eye contact. His speech was coherent, spontaneous and appropriate with

normal rate, volume and rhythm. He described his mood as depressed.

Affect and mood

Patients affect was depressed and her range of mood reduced. He also

appeared anxious and irritable.

Thought

Patients thought stream was decreased. It was also disturbed and his speech

slowed down and content reduced significantly when mentioning past

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unhappiness. He did not exhibit any formal thought disorders. She was able

to answer questions spontaneously and directly. She did not use any new or

created words. He did experience thought block when exploring sensitivities

in his past. No negative thought disorder was detected. Other than feeling of

guilt, R.A has no other positive symptoms, such as delusions, phobias or

compulsions. Suicidal ideation was not detected.

Perception

R.A exhibits normal perception. Symptoms such as illusions,

misinterpretations, depersonalization and passivity phenomena were not

elicited.

Cognition

His memory was intact for recent and remote events. He was able to answer

questions and recall his past without difficulties. I was able to establish

adequate rapport with him throughout the interview and he was able to

follow directions. He denied any ideation of worthlessness or hopelessness.

Insight and judgement

When questioned about his condition, R.A accepted the fact that he is ill and

requires treatment. He has cooperated with doctors and nurses and is

compliant with management.

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Nursing Physical Assessment

R.A, 34 years old, was conscious, not in cardiorespiratory distress. With

a blood pressure of 120/80, respiratory rate of 22, temperature of 36.9 and

has respiratory rate of 110. Abdomen is flat, soft, NABS (Normal Active Bowel

Sounds), no masses and tenderness. Anicteric sclera pink palpebrable

conjunctiva, no symmetric chest expansion, no retractions, clear breath

sounds adynamic precordium. Has tachycardia, regular rhythm, no murmur.

Flat, soft, normoactive bowel sounds. Grossly normal extremities, no

cyanosis, no edema and has psychosocial problem.

Related Treatments

The patient was given Haloperidol 5mg. OD, it is classified as

Antipsychotics to alters the effects of dopamine in the CNS and also has

anticholinergic and alpha-adrenergic blocking activity and diminished signs

and symptoms of psychoses. It is indicated for organic psychoses, acute

psychotic symptoms; relieve hallucinations, delusions, disorganized thinking,

severe anxiety and seizures. Common side effects are: extrapyramidal

symptom such as muscle rigidity or spasm, shuffling gait, posture leaning

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forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive

dyskinesia, headache, seizures, tachycardia, arrhythmias, hypertension,

orthostatic hypertension. blurred vision, glaucoma, dry mouth, anorexia,

nausea, vomiting, constipation, diarrhea, weight gain, urinary frequency,

urine retention, impotence, enuresis, amenorrhea, gynecomastia, anemia,

leucopenia, agranulocytosis, rash, dermatitis, and photosensitivity. It is

contraindicated to seizure disorder glaucoma and elderly clients. Nursing

considerations are;Assess mental status prior to and periodically during

therapy. Monitor BP and pulse prior to and frequently during the period of

dosage adjustment. May cause QT interval changes on ECG. Observe patient

carefully when administering medication, to ensure that medication is

actually taken and not hoarded. Monitor I&O ratios and daily eight. Assess

patient for signs and symptoms of dehydration. Monitor for development of

neuroleptic malignant syndrome (fever, respiratory distress, tachycardia,

seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe

muscle stiffness, loss of bladder control. Report symptoms immediately. May

also cause leukocytosis, elevated liver function tests, elevated CPK. Advise

patient to take medication as directed. Take missed doses as soon as

remembered, witih remaining doses evenly spaced throughout the day. May

require several weeks to obtain desired effects. Do not increase dose or

discontinue medication without consulting health care professional. Abrupt

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withdrawal may cause dizziness, nausea, vomiting, GI upset, trembling, or

uncontrolled movements of mouth, tongue or jaw.

Risperidone is an atypical antipsychotic drug that is used for treating

schizophrenia, bipolar mania and autism. Atypical antipsychotics differ from

typical antipsychotics due to the lesser degree of extrapyramidal

(movement) side effects and constipation. Risperdal Consta is an injectable,

long-acting form of risperidone. The exact mechanism of action of

risperidone is not known, but, like other anti-psychotics, it is believed that

risperidone affects the way the brain works by interfering with

communication among the brain's nerves. Nerves communicate with each

other by making and releasing chemicals called neurotransmitters. The

neurotransmitters travel to other nearby nerves where they attach to

receptors on the nerves. The attachment of the neurotransmitters either

stimulates or inhibits the function of the nearby nerves. Risperidone blocks

several of the receptors on nerves including dopamine type 2, serotonin type

2, and alpha 2 adrenergic receptors. It is believed that many psychotic

illnesses are caused by abnormal communication among nerves in the brain

and that by altering communication through neurotransmitters, risperidone

can alter the psychotic state. Risperidone was approved by the FDA in

December, 1993. Risperidone is used to treat schizophrenia, bipolar mania

[as a sole therapy or combination therapy with lithium (Eskalith, Lithobid)

or valproate (Depakene, Depacon) and for the treatment of irritability

http://www.medicinenet.com/script/main/art.asp?articlekey=6773



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associated with autistic disorder in children and adolescents. Clinical studies

involving small numbers of patients have shown some benefit in using

risperidone for stuttering and Tourette syndrome (non FDA-approved uses).

Another non-FDA approved use of risperidone is forobsessive-compulsive

disorders. Risperidone can be administered once or twice daily. Initial dosing

is generally 2 mg/day. Dose increases can occur in increments of 1-2

mg/day, as tolerated, to a recommended dose of 4-8 mg/day. In children,

risperidone should be initiated at 0.5 mg once daily, and can be increased in

increments of 0.5 or 1 mg/day, as tolerated, to a recommended dose of 2.5

mg/day. Risperidone can be given with or without meals. The recommended

dose of Risperdal Consta is 25 mg injected into the deltoid or gluteal muscle

every two weeks. Patients who have never received risperidone are started

on oral risperidone in order to evaluate tolerability. Patients then may be

transitioned to Risperdal Consta if oral risperidone is tolerated. Risperidone

may interfere with elimination by the kidneys of clozapine (Clozaril), a

different type of antipsychotic medication, causing increased levels of

clozapine in the blood. This could increase the risk of side effects with

clozapine.

Biperiden hydrochloride is a prescription medication that belongs to a

class of drugs called anticholinergics. Biperiden HCl is a weak peripheral

anticholinergic agent. It has, therefore, some antisecretory, antispasmodic

and mydriatic effects. In addition, Biperiden possesses nicotinolytic activity.






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Parkinsonism is thought to result from an imbalance between the excitatory

(cholinergic) and inhibitory (dopaminergic) systems in the corpus striatum.

The mechanism of action of centrally active anticholinergic drugs such as

Biperiden is considered to relate to competitive antagonism of acetylcholine

at cholinergic receptors in the corpus striatum, which then restores the

balance. The parenteral form of Biperiden is an effective and reliable agent

for the treatment of acute episodes of extrapyramidal disturbances

sometimes seen during treatment with neuroleptic agents. Akathisia,

akinesia, dyskinetic tremors, rigor, oculogyric crisis, spasmodic torticollis,

and profuse sweating are markedly reduced or eliminated. With parenteral

Biperiden, these drug-induced disturbances are rapidly brought under

control. Subsequently, this can usually be maintained with oral doses which

may be given with tranquilizer therapy in psychotic and other conditions

requiring an uninterrupted therapeutic program. Only limited

pharmacokinetic studies of biperiden in humans are available. The serum

concentration at 1 to 1.5 hours following a single, 4 mg oral dose was 4-5

ng/mL. Plasma levels (0.1-0.2 ng/mL) could be determined up to 48 hours

after dosing. Six hours after an oral dose of 250 mg/kg in rats, 87% of the

drug had been absorbed. The metabolism of Biperiden is also incompletely

understood, but does involve hydroxylation. In normal volunteers a single 10

mg intravenous dose of biperiden seemed to cause a transient rise in plasma

cortisol and prolactin. No change in GH, LH, FSH, or TSH levels were seen.

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Biperiden lactate (10 mg/mL) was not irritating to the tissue of rabbits when

injected intramuscularly (1.0 mL) into the sacrospinalis muscles and

intradermally (0.25 mL) and subcutaneously (0.5 mL) into the shaved

abdominal skin. Should be taken with food. Overdosage may result in dilated

and sluggish pupils; warm, dry skin; facial flushing; decreased secretions of

the mouth, pharynx, nose, and bronchi; foul-smelling breath; elevated

temperature, tachycardia, cardiac arrhythmias, decreased bowel sounds,

and urinary retention. Neuropsychiatric signs include delirium, disorientation,

anxiety, hallucinations, illusions, confusion, incoherence, agitation, loss of

memory, paranoia, combativeness, and seizures. May progress to stupor,

coma, paralysis, and cardiac and respiratory arrest and death. Treatment is

sympotomatic and supportive. Contraindicated to Closed-angle glaucoma or

narrow angle between iris and cornea; prostatic hyperplasia; myasthenia

gravis except to reduce adverse muscarinic effects of an anticholinergic;

hypersensitivity; bowel obstruction; megacolon.

Another drug given is Diphenhydramine 50 mg HS, an antihistamine

used for treating allergic reactions. Histamine is released by the body during

several types of allergic reactions and--to a lesser extent--during some viral

infections, such as the common cold. When histamine binds to its receptors

on cells, it stimulates changes within the cells that lead to sneezing, itching,

and increased mucus production. Antihistamines compete with histamine for

cell receptors; however, when they bind to the receptors they do not



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stimulate the cells. In addition, they prevent histamine from binding and

stimulating the cells. Diphenhydramine also blocks the action of

acetylcholine (anticholinergic effect) and is used as a sedative because it

causes drowsiness. The FDA originally approved diphenhydramine in 1946.

Diphenhydramine is used for the relief of nasal and non-nasal symptoms of

various allergic conditions such as seasonal allergic rhinitis. It is also used to

alleviate cold symptoms and chronic urticaria(hives). Although

antihistamines are the preferred class of drugs in allergic rhinitis, they only

reduce symptoms by 40%-60%. Diphenhydramine also is used for allergic

reactions involving the eyes (allergic conjunctivitis), to prevent or treat

active motion sickness, and for mild cases of Parkinsonism, including drug-

induced Parkinsonism. The last two uses (motion sickness and Parkinsonism)

are based on the anticholinergic effects of diphenhydramine, and not its

antihistamine effects. Diphenhydramine is also used for treating insomnia.

Diphenhydramine has its maximal effect about one hour after it is taken.

When used to combat insomnia, it is prescribed at bedtime. Patients over the

age of 60 years are especially sensitive to the sedating and anticholinergic

effects of diphenhydramine, and the dose should be reduced. Doses vary

depending on formulation. A common regimen for treating adult allergic

reaction is 25-50 mg every 4-6 hours not to exceed 300 mg daily.

Diphenhydramine adds to (exaggerates) the sedating effects of alcohol and






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other drugs than can cause sedation such as the benzodiazepine class of

anti-anxiety drugs.

Recommendation

To the patient:

He 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.

To the patient’s family:

The patient’s family plays an important role in the patient’s mental

illness and recovery. The family should make themselves physically present

so that the patient would feel their support and concern. They are

encouraged to continue interacting with the patient so that ideas of violence

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towards self and others will be diverted. In addition, it is of prime importance

that they are orientedand educated regarding the patient’s mental illness so

that they will understand him even better and assist him in his daily

activities.

References

mentalhelp.net

cureresearch.com

World Health Organization, www.who.int

schizophrenia.com

http://nursingcrib.com/pathophysiology/pathophysiology-of-schizophrenia/

medicinenet.com

http://wiki.medpedia.com

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Undifferentiated Schizophrenia