Case Study Psych

7/30/2019 Case Study Psych

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INTRODUCTION

Psychosis is characterized by a loss of connectedness with reality. A person may

develop false ideas or beliefs about reality (delusions) which in themselves may be

based on false perceptions (hallucinations). People experiencing psychosis also have

characteristic flaws in the ways they think. These are termed thought disorders.

Examples are tangential thinking, loose associations between ideas, and incoherence.

Psychosis significantly impairs work, family and social functioning. People with

psychoses often experience poorer physical health. The worse the psychotic symptoms

are, the higher the associated level of impairment.

. Psychotic symptoms can occur in response to physical conditions, e.g. acute

delirium with septicemia. Alternatively, psychoses can be functional. There are two

broad classes of functional psychotic disorders: schizophrenia and bipolar disorder.

Generally, schizophrenia is a chronic condition with exacerbations, but always with

some background symptoms. Bipolar disorder is generally an intermittent condition with

the expectation of full recovery between episodes. There is considerable overlap

between the two conditions and fluidity of diagnosis.

Symptoms of schizophrenia are sometimes grouped into two categories:

Positive symptoms such as hallucinations and delusions.

Negative symptoms such as social withdrawal and lack of energy and motivation

that are similar to those found in depression.

While the clinician may realize that the psychosis could be drug-induced and is cautious

in the prescription of narcoleptics or sedatives to control the symptoms, they may be

under pressure to respond to the manifestation of bizarre or potentially destructive


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thinking or behavior. On the other hand, alterations to the way the person behaves and

thinks may be subtle in the early stages when early intervention may be most

appropriate. Shortening the period of untreated psychosis (whether this be substance

induced or the early stages of psychotic disorders) has the potential to have a positive

impact on treatment outcomes. (http://www.nationaldrugstrategy.gov.au)

Schizophrenia is a disorder in which patients have psychotic symptoms and

social and/or occupational dysfunction that persists for at least 6 months.

Schizophrenia affects I % of the population. The typical age of onset is the early 20s for

men and the late 20s for women. Women are more likely to have a first break later in

life; in fact, about one third of women have an onset of illness after age 30.

Schizophrenia is diagnosed disproportionately among the lower socioeconomic classes;

although theories exist for this finding, none have been substantiated.

The etiology of schizophrenia is unknown. There is a clear inheritable

component, but familial incidence is sporadic and schizophrenia does occur in families

with no history of the disease. Schizophrenia is widely believed to have a

neurobiological basis. The most notable theory is the dopamine hypothesis, which

posits that schizophrenia is due to hyperactivity in brain dopaminergic pathways. This

theory is consistent with the efficacy of antipsychotics (which block dopamine receptors)

and the ability of drugs (such as cocaine or amphetamines) that stimulate dopaminergic

activity to induce psychosis. Postmortem studies also have shown higher numbers of

dopamine receptors in specific subcortical nuclei of schizophrenics than in normal

brains. More recent studies have focused on structural and functional abnormalities

through brain imaging of schizophrenics and control populations. (http://www.health.am)


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Schizophrenia is a disorder characterized by what have been termed positive

and negative symptoms, a pattern of social and occupational deterioration, and

persistence of the illness for at least 6 months. Positive symptoms are characterized by

the presence of unusual thoughts, perceptions, and behaviors (e.g., hallucinations,

delusions, agitation); negative symptoms are characterized by the absence of normal

social and mental functions (e.g., lack of motivation, isolation, anergia, and poor self-

care). The positive versus negative distinction was made in a nosologic attempt to

identify subtypes of schizophrenia and because some medications seem to be more

effective in treating negative symptoms. Clinically, patients often exhibit both positive

and negative symptoms at the same time. Table 1-2 lists common positive and negative

symptoms.

To make the diagnosis, two (or more) of the following criteria must be met:

hallucinations, delusions, disorganized speech, grossly disorganized or catatonic (mute

and/or posturing) behavior, or negative symptoms. There must also be social and/or

occupational dysfunction. The patient must be ill for at least 6 months.

Patients with schizophrenia generally have a history of abnormal premorbid

functioning. The prodrome of schizophrenia includes poor social skills, social

withdrawal, and unusual (although not frankly delusional) thinking. Inquiring about the

premorbid history may help to distinguish schizophrenia from a psychotic illness

secondary to mania or drug ingestion.

(http://www.health.am/psy/more/schizophrenia/#ixzz2SCam9t8v)


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Objectives

To know the underlying cause of the disorder of my client.

To understand the causative factors leading to this condition by gathering

information from the clients history.

To know its desired medication by making a drug study for it.

To provide proper nursing intervention.

To provide the appropriate care to my patient.

Scope and limitation

The study focuses on the admitting diagnosis of patient C having a Chronic

Psychosis. She was admitted at St. Dymphna Foundation Drop- in Center, Agay-ayan

Gingoog City. The study covers the patients health history, present illness, laboratory

exams and result, psychiatric diagnosis, medical diagnosis, and medical & nursing

management. The study is also limited from the information being collected from the

patient and his personal chart. The data gathering was also limited during the

confinement of the patient. The study is limited to Chronic Psychosis.


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Patient profile

Name: Patient C

Age: 57 y.o

Sex: female

Date of birth: June 4, 1955

Add: Brgy 16 Gingoog city

Religion: Roman Catholic

Educational Attainment: Elementary Graduate

Primary Care Provider: Saint Dymphna Drop in center foundation

Date admitted: February 15, 2006

Medical Diagnosis: Chronic Psychosis

Attending Physician: Dr. Lagat

Accompanied by:

Chief complain: Talks but doesnt make sense


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Developmental Data

Erik Eriksons Theory: Generativity vs Stagnation (25 to 65 yrs. Old)

At this stage the person is Creative, Productive and concern for others, they only

think the situation of other people than for their own good.

Observation:

I observed that my patient always thinks about her children and her brother and

sister even if she is in St. Dymphna. She misses her family a lot she states that Gusto

nko mu uli sa amo maam para makita nako akong mga anak og igsoon. She is

productive and creative and she always participates in all the activities that we gave

them or ask them to do.

Harry Stack Sullivans Theory: Interpersonal Theories

This theory emphasized the importance of interpersonal relations. He insisted that

personality is shaped almost entirely by the relationships we have with other people.

Sullivans principal contribution to personality theory was his conception of

developmental stages.

At this stage the patient need for special sharing relationship shifts to the opposite

sex, and if the self-esteem is intact, areas of concern expand to include values, ideals,

career decisions, and social concerns.
http://www.answers.com/topic/human-relations?nafid=22http://www.answers.com/topic/personality-theory?nafid=22http://www.answers.com/topic/personality-theory?nafid=22http://www.answers.com/topic/human-relations?nafid=22


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Observation:

With my patient, she is close to her sister and brother. She often talks a lot of her

older sister and how her sister helped her during the time of her illness. I also observed

that my patient showed changes in her mood every day, sometimes she shows happy

emotions but sometimes she just kept silent as an indication that she was not happy

and was not in the mood but even though she just kept silent she participates in the

activity.

Robert Havighursts Theory: (Middle Age)

He believed that learning is basic to life that people continue to learn throughout life.

He describe growth and development as occurring during six stages, each associated

with six to ten task to be learned. At this stage the client will establishing and

maintaining an economic standard of living, relating oneself to ones spouse as a

person, Accepting and adjusting to the physiologic changes of middle age.

Observation:

I observed with my patient that she wants to explore something in her life and that

even though she is alone but she tried to relate herself with other people and with her

co residents as her family. Every time we gave her an activity to perform she does well

on it and she was able to answer my questions most of the time.


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Assessment

PSYCHIATRIC HISTORY AND ASSESSMENT TOOL

Identifying/Demographic Information

Name: Carmencita Salucana Room No. Female ward

Primary Care Provider: Saint Dymphna Drop in Center

DOB: June 4, 1955 Age: 57 Sex: Male Female

Race: Filipino Ethnicity: filipino

Marital Status: Married No. Marriages: 1

Highest Educational Level: Elementary Graduate

Religious Affiliation: none

City of Residence: Gingoog

Name/Phone # of Significant Other: NONEPrimary Dialect/Language Spoken: bisayan

Accompanied by:

Admitted from: house

Previous Psychiatric Hospitalizations (#): none

Chief Complaints: Talks but doesnt make sense

DSM-IV TR Diagnosis (previous/current) : substance abuse:amphetamine with cooccurrence of

psychiatric psychosis

Family Members/Significant Others Living in Home

NAME RELATIONSHIP AGE OCCUPATION/GRADELuis Pacudan Husband

Samson Son

Roel David Son

Past Psychiatric Treatments / Medications

It is important to obtain a history of any previous psychiatric hospitalizations, the number of

hospitalizations and dates, and to record all current/past psychotropic medications, as well asother medications the client may be taking. Ask the client what has worked in the past, and also

what has not worked, for both treatments and medications.

Current Psychotropic Medications/ Other Medications

Name Dose/Dosages Treatment Length Response Comments

fluphenazine 0.5 cc IM Deep

chlorpromazine 100 mg 1 tab


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MENTAL STATUS ASSESSMENT AND TOOL

Presenting Problem: Resident was addicted to prohibited drugs amphetamine and shows signs and

symptoms of psychosis. Her sister admitted her because he walks and rooms around the city with no

food and dirty outfit.

APPEARANCE(Describe) Day 1 Day 2 Day 3 Day 4 Day 5

Grooming/dress Well

groomed

Well

groomed

Well

groomed

Well

groomed

Well

groomed

Hygiene Neat &

Clean

Neat &

Clean

Neat &

Clean

Neat & Clean Neat &

CleanEye contact Direct eye

contact

Direct eye

contact

Direct eye

contact

Direct eye

contact

Direct eye

contact

Posture Stoop Stoop Good Good Good

Identifying features

(marks/scars/tattoos)

With scars With scars With scars With scars With scars

Appearance versus stated age Congruent Congruent Congruent Congruent congruent

Overall appearance Good Good Good Good Good

NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help the

client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion with:

Tell me more. A less direct and more conversational tone at the beginning of the interview may help

reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship.

BEHAVIOR/ACTIVITY(Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Hyperactive

Agitated

Psychomotor retardation

Calm

Tremors

Unusual movements/gestures

Catatonia

Akathisia

Rigidity

Facial movements (jaw/lip smacking)

Other specify:


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SPEECH(Describe) Day 1 Day 2 Day 3 Day 4 Day 5

Slow/Rapid Normal Normal Normal Normal Normal

Pressured

Tone Normal Normal Normal Normal Normal

Volume (loud/soft) Normal Normal Normal Normal Normal

Fluency

(mute/hesitation/latency

of response)

Direct

response

Direct

response

Direct response Direct

response

Direct

response

Other specify:

ATTITUDE

Is client: (Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Cooperative

Uncooperative

Warm/friendly

Distant

Suspicious

Combative

GuardedAggressive

Hostile

Aloof

Apathetic

Other specify:

MOOD & AFFECT

Is client: (Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Elated

SadDepressed

Irritable

Anxious

Fearful

Guilty

Worried


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Angry

Hopeless

Labile

Mixed (anxious & depressed)

Is Clients affect :

Flat

Blunted or diminished

Appropriate

Inappropriate/incongruent

Other specify:

THOUGHT PROCESS(Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Concrete Thinking

Circumstantiality

Tangentiality

Loose Association

Echolalia

Flight of Ideas

Perseveration

Clang association

Blocking

Word Salad

Derailment

Others Specify:

THOUGHT CONTENT

Does client have: (Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Delusions

a. Grandioseb. Persecutory

c. Reference

d. Somatic

Suicidal thoughts

Homicidal thoughts

If Homicidal, towards whom? To people who


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speaks bad to her

Obsessions

Paranoia

Phobias

Magical Thinking

Poverty of SpeechOthers Specify:

NOTE: Questions around suicide and homicide need to be direct. For instance, are you thinking of

harming yourself/another person right now? (If another, who?) Clients will usually admit suicidal

thoughts if asked directly but will not always volunteer this information. Any threat to harm someone

else requires informing the potential victim and the authorities.

PERCEPTUAL DISTURBANCES

Is client experiencing: (Check if present) Day 1 Day 2 Day 3 Day 4 Day 5

Visual Hallucinations

Auditory Hallucinations

a. Commenting

b. Discussing

c. Commanding

d. Loud

e. Soft

f. Other

Other Hallucination (olfactory/tactile)

Illusions

DepersonalizationOthers Specify:

MEMORY/COGNITIVE

Day 1 Day 2 Day 3 Day 4 Day 5

Orientation (YES/NO)

a. Time Yes Yes Yes Yes Yes

b. Place Yes Yes Yes Yes Yes

c. Person Yes Yes Yes Yes Yes

Memory (Good/Poor)

a. Recent Good Good Good Good Goodb. Remote Good Good Good Good Good

c. Confabulation (Y/N) No No No No No

Level of Alertness Good Good Good Good Good

INSIGHT and JUDGMENT

Day 1 Day 2 Day 3 Day 4 Day 5


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Insight (Awareness of the

nature of the illness)

Aware Aware Aware Aware Aware

Judgment (Good/Poor) Good Good Good Good Good

Impulse Control

(Good/Poor)

Good Good Good Good Good

Concentration(Good/Poor) Good Good Good Good Good

Attention (Good/Poor) Good Good Good Good Good

Others Specify:

NOTE: It is helpful to ask the client to talk about him/herself and to ask open-ended questions to help

the client express thoughts and feelings; e.g.: Tell me why you are here? Encourage further discussion

with: Tell me more. A less direct and more conversational tone at the beginning of the interview may

help reduce the clients anxiety and set the stage for the trust needed in a therapeutic relationship.

ANALOGY

Patient C symbolizes a house, a new built house. But like any other house, once the

one foundation is removed, the whole house would fall apart. Like when a one pillar is

removed in the house, its stability will no longer be the same as before. Compare this to

patient Ks life, they started with a very good life. Good foods, good clothes and they

almost get everything they want until everything slowly fall apart when their financial

stability was shaken. They still able to survive but not the way it were before when their

financial status was stable. Relate it to a house, the house will still stand, but not as

stable as when the foundation was shaken. Then other aspects will affect the house

stability, like the infestation of termites. The termites will slowly ingest the wood inside

the house, breaking more the foundation of the house. Like what happened in Ks life,

he was influenced by his peers to take drugs. His peers became parasites who infested

his mind to do bad things like termites do which is devouring the wood inside the house.

Then a house without care and maintenance would worsen its condition. Dust, bacteria,

insects would inhibit the house and slowly destroy the house. Like in patient Ks life, his


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siblings doesnt treat him as an older brother. He gets depressed so much and affects

his level of functioning.

Then, an unstable house if hit by a storm would totally destroy foundation of the house.

Like when patient K was hit in the head by someone, that incident totally lost his mind.

The well structured house was slowly destroyed with different factors.


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IV. Psychodynamics

Schematic Presentation

BIOLOGIC FACTOR

Genetics

PSYCHOSOCIAL FACTOR

Infancy Toddler Preschool School age Adolescence

Trust Autonomy Initiative Industry Identity

vs. vs. vs. vs. vs.

mistrust shame and doubt guilt inferiority role confusion

Young adult

Intimacy vs. isolation

Excessive trust

was developed

overly achieved a

sense of control

or autonomy

Havent learned to

managed conflict

and anxiety; guilt

was developed

Role

confusion;(wrong

choice of friends)

Developed the

sense of inferiority

Developed

isolation.

Neuroleptic malignant syndrome


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Chronic (persistent) psychotic disorders

Chronic (persistent) psychotic disorders* - F29# (Clinical term: Schizophrenia

Eu20). Includes schizophrenia, schizoaffective disorders, schizotypal disorder,

persistent delusional disorders, induced delusional disorder, other non-organic

psychotic disorders

*Chronic psychosis has become a pejorative term: persistent psychosis embraces the

possibility of recovery.

Presenting complaints

Many patients will have an established history of psychosis; others, however, may be

unknown to specialized services, particularly those with more insidious presentations or

those who have disengaged or are homeless.

Patients may present with the following:

difficulties with thinking or concentrating (eg they think that the television is

talking to them, or that their thoughts are being read)

reports of hearing voices or seeing visions

strange beliefs (eg having supernatural powers or being persecuted)

extraordinary physical complaints (eg strange sensations or having unusual

objects inside their body)

problems or questions related to antipsychotic medication

problems in managing work, studies or relationships

physical health care problems (eg weight, respiratory or cardiac problems)


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lack of energy or motivation and an inability to feel emotion

Depression or suicidal thinking.

Families might seek help because of apathy, withdrawal, poor hygiene, or strange

behaviour.

Diagnostic features

Persistent problems with the following features:

social withdrawal and/or poor social integration

low motivation, interest or self-neglect

disordered thinking (exhibited by strange or disjointed speech).

Periodic episodes of:

depression (co-existing depression is a common, and is sometimes a serious

consequence of persistent psychosis; there is a serious risk of suicide)

agitation or restlessness

bizarre behaviour

hallucinations (false or imagined perceptions, eg hearing voices)

delusions (firm beliefs that are often false, eg patient is related to royalty,

receiving messages from the television, being followed or persecuted)

Intense fear, anxiety and distress.


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Differential diagnosis and co-existing conditions

Depression - F32# (if low or sad mood, pessimism and/or feelings of guilt; co-

morbid depression is common).

Bipolar disorder - F31 (if symptoms of mania excitement, elevated mood,

exaggerated self-worth is prominent).

Alcohol misuse - F10 or Drug use disorders - F11#. Chronic intoxication or

withdrawal from alcohol or other substances (stimulants, hallucinogens) can

cause psychotic symptoms. Patients with persistent psychosis might misuse

drugs and/or alcohol.

Essential information for patient and family

Agitation and strange behavior can be symptoms of a mental disorder.

Symptoms may come and go over time.

Medication should be part of an overall holistic and multi-axial approach to care

and can help by reducing current difficulties and the risk of relapse.

Stable living conditions (eg stable accommodation, adequate income, daily work

or activities) are a pre-requisite for effective rehabilitation and recovery.

It is important for family/careers to work with the doctors to learn to recognize

early warning signs of relapse and for an advance agreement to be established

with the patient and family/careers on how crises should be managed. (see Early

warning signs form)

Voluntary organizations can provide valuable information, support and self-

management courses to the patient and careers


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General management to patient and family

Remain optimistic and emphasize the patients strengths and abilities rather than

deficits.

Recovery often takes place in small steps and, for the patient, being engaged in

an activity that is meaningful to them might be as important as symptom control.

Discuss a treatment plan with the patient, in line with NICE good practice; (ref 5)

provides information on the condition, treatment choices and informed

discussion. The treatment plan should include recognition of early warning signs

and the agreed management of crises should be clearly recorded in the medical

records. A copy of the plan should be given to the patient and, with their

permission, to the family/career.

Explain that drugs help prevent relapse, and discuss information on effects and

side effects with the patient.(see Coping with the side effects of medication)

The DVLA must be notified in all cases. Advise patient to inform DVLA: driving

should cease until patient has been stable and well for at least three years and

has insight into his/her condition (LGV/PSV driver) (ref 3)

Support patient to function in the areas that are important to him/her (eg work,

recreation, relationships). It is important proactively to offer patients the same

health promotion and prevention measures as the general population (eg

smoking cessation, weight control, screening for diabetes and sexual health).

Substance misuse (seen in over 30% of cases) will increase the chance of

relapse.


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Psychological therapies for both the patient and family/careers might help

prevent relapse, promote recovery, and are increasingly available in local

services. Encourage the patient to engage with psychological therapies where

available (eg cognitive behavioral therapy, family therapy, problem-solving

interventions).

Family interventions or problem-solving work might help improve patient and

career health.

Therapeutic alliances build on respect and feeling valued. Encourage the patient

to build relationships with key members of the practice team, for example by

seeing the same doctor or nurse at each appointment. Use the relationship to

discuss the treatment plan including medication advantages of medication and to

review the effectiveness of the care plan (see Social and living skills checklist).

Refer to Acute psychotic disorder - F23 for advice on the management of

agitated or excited states.

If care is shared with the Community Mental Health Team, agree who is to do

what.

Support of the career is essential for effective treatment and rehabilitation. An

assessment of the patients needs and those of the career (under the Careers

Recognition and Services Act) can be requested from the local Social Services

department.


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Medication

Antipsychotic medication may reduce psychotic symptoms (BNF section 4.2.1).

Some patients remain stable on the older medications (eg trifluoperazine,

chlorpromazine). If effective and well tolerated, NICE guidance suggests the drug

should be continued (ref 5). If ineffective or poorly tolerated, NICE guidance

suggests an atypical medication should be considered (ref 5).

Atypical antipsychotics, for example olanzapine (510 mg a day) or risperidone

(2-4 mg per day), should be considered as a first-line treatment (ref 5).

Inform the patient that continued medication helps reduce risk of relapse. In

general, antipsychotic medication should be continued for at least one year.

The dose should be the lowest possible for relief of symptoms and effective daily

functioning.

If, after team support, the patient is reluctant or erratic in taking medication,

injectable long-acting antipsychotic medication could be considered in order to

ensure continuity of treatment and reduce risk of relapse (ref 59). It should be

reviewed at 4-6 monthly intervals, and a weight gain and physical annual heath

check is essential to decrease the risk of cardiac and respiratory effects of

medication and a sedentary lifestyle. Doctors and nurses who give depot

injections in primary care need training to do so (ref 60). If available, specific

counseling about medication is also helpful (ref 61). As part of the shared care

plan, decide who is to contact the patient should he/she fail to attend an

appointment.


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Discuss the potential side-effects with the patient. Common motor side-effects,

particularly with older antipsychotics, include the following:

Acute dystonias or spasms and parkinsonian symptoms (eg tremor and

akinesia), which can be managed with antiparkinsonian drugs (eg orphenadrine

[50 mg three times a day] ); (BNF section 4.9)

withdrawal of antiparkinsonian drugs should be attempted after 2-3 months

without symptoms, as these drugs are liable to misuse and may impair memory.

Akathisia (severe motor restlessness) can be managed with dosage reduction, or

betablockers (eg propranolol at 3080 mg a day) (BNF section 2.4). A change in

medication might be necessary

Tardive dyskinesia is a particularly important side-effect for which to monitor. It is

associated with longer-term use of traditional antipsychotic medication, is

severely disabling and can be irreversible.

Other side-effects can include glucose intolerance, weight gain, galactorrhoea

and photosensitivity. Patients suffering from drug-induced photosensitivity are

eligible for sunscreen on prescription.

Avoid poly-pharmacy, particularly concurrent prescribing of typical and atypical

antipsychotics, and prescribing in excess of BNF guidelines.

References

5 National Institute for Clinical Excellence. Schizophrenia: Core

Interventions i.


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Name of Drug Dateordered

Classification Recommended Dose &Frequency

Why givento patient inrelation to

themechanism

of action

Contraindication Sideeffects/Toxic

effects/Drug-druginteraction

Stabilityof thedrug

NursCons

ratio

Generic brand Therapeutic Pyoric andduodenalobstruction,myasthenia

gravis,hypotensionHepatic or renalimpairmentAlcoholismAlzheimersdisease

Checkvital sigspeciaBP bef

giving.

Biperidine 5/25/11 Anti-parkinsondrug

Adults:2 mg 3-4times per dayto maximumof 16 mg/day

Syntheticcholinergictremor mayincrease asspasticity isrelieved, slightrespiratory &

cardiovascu-lar effects

Agitated

Blurredvision

Constipa-tion

Dizziness

Drowsiness

Lightheadedness

Drymouth

Dry nose& throat

Nausea

Nervous

Store inclosedlightresistantcontainerat 15-30

oC (59-

86oC)

Avoidactivitthatrequirmentaalertn


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Dose/Frequency prescribed

Pharmacologic Indication: GI upset

2 mg 1 tabCholinergicblocking agents

Parkinsonism

Relief ofsymptoms of EPS


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themechanism

of action


effects/Drug-druginteraction

Stabilityof thedrug

NursinConsid

ration

Generic brand Therapeutic Comatose,severelydepressedstate

Circulatorycollapse

Liver damage

CAD

Chlorpromazine 5/25/11 Anti-psychotic Adults:100 mg3 to 4x perday or 2-3times per day

Hassignificantanti-emetichypotensiveand sedative

effect

Constipation

Drowsiness

Blurredvision

Decreasedsweating

Tremor Difficulty

urinating

Dark urine

Dizziness

Increaseappetite

Swollenbreast

Avoidalcoholand anyother Cdepressts

Avoidtemperatureextreme


Pharmacologic Indication:


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100 mg 1 tab HS Schizophrenia




themechanism

of action


effects/

Stabilityof thedrug

NursingConsid

ration

Generic brand Therapeutic Comatose,severely

depressedstate

Circulatorycollapse

Liver damage

CAD


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Fluphenazine 5/25/11 Anti-psychotic Adults;12.5-25 mg(0.5-1ml)

Anticholiner-gic effects

Drowsiness

Dizziness

Lethargy

Nausea

Anorexia

Blurredvision

Dry mouth

Constipa-tion

Store atroomtemperature andavoidfreezingthe elixir

Avoidactivitiesthatrequiresmentalalertnessuntil drueffectstakesplace

Periodtubs, ho

shower,and bathas low Bmay occ

Avoidalcohol,CNSdepressts andOTCdrugs orcoughremedie



1.0 mL deep IMDopaminergicBocker

Psychosisdisorder

Schizophrenia


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themechanism

of action


effects/

Stabilityof thedrug

NursingConsid

ration

Generic brand Therapeutic

Diphenhydramine

Anti-histamine Adults:25 -50 mg PO3-4 times perday

Competitivelyblocks theeffects ofhistamine atH1- receptorsites, hasatropine-like,anti-pruritic,and sedativeeffects

Younger than 5years old

Asthesia

Constipa-tion

Dizziness

Diarrhea Drowsine

ss

Headache

Drymouth

Dry nose& throat

Nausea &vomiting

Nervous

GI upset

Store inclosedlightresistantcontainerat 15-30oC (59-86

oC)

Avoid thuse ofalcoholand any

other CNdepressts



1 tab at H.S.H1 receptorantagonist

Night time sleep aid


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Nursing Diagnosis: Dysfunctional family processes r/t lack of problem solving skills.

Cause analysis: psychosocial and physiological function of the family unit are

disorganized, which leads to conflict, resistance to change, ineffective problem solving

and series of self perpetuating crises.

Cues Planning Intervention Rationale Evaluation

Subjective:makalagot judkayo ang akongmga igsoon kaydili agpatoo saako.

Objectives: Inappropriate

expressionof anger;blaming,criticizing

Triangulatingfamilyrelationships

Inability toadapt

change;inability todealconstructively withtraumaticexperiences.

Lto:At the end of3 days, the ptwill:

Participateinindividualtreatment

programs. Take

action tochangebehaviorsthatcontributeto clientssubstanceabuse.

Sto:At the end of8 hours, ptwill:

Verbalizeunderstanding ofdynamicsofcodepende

nce

Review familyhistory,explores rolesof familymembers andcircumstancesinvolvingsubstance

abuse. Mutually agree

onbehaviors/responsibilities fornurse andclient.

Provideinformationregardingeffects of

addiction onmood/personality of theinvolvedperson.

Identify use ofmanipulativebehaviors anddiscuss ways toavoid/prevent

thesesituations.

Maximizesunderstandingof what isexpected toeachindividual.

To enhancethe therapeuticrelationship.

Helps familymembersunderstandand cope with

negativebehaviorswithout being

judgmental orreactingangrily.

Manipulationhas the goal ofcontrollingothers andwhen family

membersaccept selfresponsibilityand commit tostop using it,new healthybehaviors willensue.

Lto:At the end of3 days, thept:

Participated inindividualtreatment

programs. Took

someactions tochangebehaviorsthatcontributeto clientssubstanceabuse.

Goal waspartially met

Sto:At the end of8 hours, pt:

Verbalizedunderstan

ding ofdynamicsofcodependence.

Goal wasmet.


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Discuss theimportance ofrestructuringlife activities,work or leisure

activities.

Collaborative:1. Encourage

involvement to self-helpgroups.

2. Provide

bibliotherapy asappropriate.

Previouslifestyle/relationshipssupportedsubstance

abuse use,requiringchange topreventrelapse.

1. To provideongoingsupport andassist withproblem

2. To promote

wellness.


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Nursing diagnosis: Ineffective coping r/t difficulty handling new situations.

Cause analysis: inability to form a valid appraisal of the stressors


dili jud namumadawat angnahitabo sa amupapa nga nahimosya nga naa saconstruction workergikan sa iyangpagkasupervisor sacompanya.

Objectives:

Destructive selfbehaviortowards self(use of drugabuse)

Behavioralchanges (e.g.,frustration,discouragement,irritability,impatience)

Use of forms ofcoping thatimpede adaptivebehavior(including inappropriateuse of defensemechanisms,verbalmanipulation).

Lto:

At the end of 5days, the ptwill:

Meetpsychological needs asevidencedbyappropriateexpressionsof feelings,identificationofresources.

Assess thecurrentsituationaccurately.

Sto:

At the end of 2days, pt will:

Verbalizefeelingscongruentwithbehavior

Verbalizeawarenessof owncopingabilities.

1.Evaluateability tounderstandevents, providerealisticappraisal ofsituation.2. Note speechandcommunicatingpatterns andobservebehaviors inobjective terms.3.explaindiseaseprocess/procedures/in a simpleconcise manner.

4. confront clientwhen behavioris inappropriate,pointing outdifferencesbetween wordsand actions.5. treat clientwith courtesyand respect.Converse atclients level,

providingmeaningfulconversationwhile performingcare.6. Help clienthow to

1. todeterminedegree ofimpairment.

2. To validatedata accordingto what pt.assertcompare tohow pt .act.

3. may help toexpressemotions,graspsituation, andfeel more incontrol.4.providesexternal locusof control,enhancingsafety.

5. enhancestherapeuticrelationship.

6. Provideopportunity to

Lto:

At the end of5 days, thept:

Meetpsychological needsasevidencedbyappropriateexpressions offeelings.

Assessthecurrentsituationnot soaccurate.

Goals weremet.

Sto:At the end of2 days, pt:

Verbalizefeelingscongruentwithbehavior

Verbalizeawareness of owncopingabilities.


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substitutepositivethoughts fornegative ones.

Collaborative:1. Refer to atherapist asappropriate.2. giveinformationabout purposes,side effects ofmedications andtreatments.

increase pt.self esteem.

1. To discusspt.s concerns.

2. Makes thepatient feelimportance.

goals wasmet.


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Nursing diagnosis: ineffective role performance r/t inadequate support system

Cause analysis: patterns of behavior and self expression that do not match the

environmental context, norms and expectations.


Subjective:Ang akong mgaigsoon dili kogapaminawun,burag dili ko nilamaguwang, asverbalized by thepatient.

Objectives:

Inadequateexternalsupport forroleenactment

Systemconflict

Inadequate

adaptationto change.

At the end of 5days, pt will:

Developrealistic plansfor adaptingto rolechanges.

At the end of 3days, pt. will:

Verbalizeunderstanding of roleexpectationsandobligations.

1. determineclientperceptions/concerns aboutsituation.

2.maintainpositive attitudetoward the client.

3.provideopportunities forthe client toexercise controlover as many asdecisions aspossible.

4.use thetechniques of rolerehearsal to helpthe client developnew skills.5. makeinformationavailable for clientto learn about roleexpectations/demands that mayoccur.

Collaborative:1. Interview SO(s)

regarding theirperceptionsandexpectations.

2. Refer to

1. Toassesspatientsfeelingsaboutsituation.

2. Topromoteclientscomfort.

3. enhacesselfconceptandpromotescommitment togoals.

4. To copewithchanges.

5. Providesopportunity to beproactivein dealingwithchanges.

1. mayinfluenceclients viewof self.2. providesongoing

At the end of5 days, pt:

Developsomerealisticplans foradaptingto rolechanges.

Goal waspartially met.

At the end of3 days,pt:

Verbalizedunderstanding ofroleexpectations andobligations


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supportgroups,counseling andpsychotherapy,as appropriate.

support tosustainprogress.


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Nursing diagnosis: disturbed thought process r/t drug abuse.

Cause analysis: effect of the substance abuse that results to a disturbed thought

process.


Subjective:pirmi ko kadungogsa mga music ngakusog kayo,ganahan komaminaw.

Objectives:

hallucinations

Inappropriateinterpretation ofstimuli

Distractibility

Hypervigilance

Lto:at the end of 5week, the ptwill:

Maintainusual realityorientation

Demonstrate behaviorsthat willminimize/preventchanges inmentation

Identifyinterventions to dealeffectively

withsituation.Sto:

At the end of 2days, the potwill:

Verbalizeunderstanding ofcausativefactors.

1.assessattention spananddistractibilityand ability tomakedecisions orproblem solve.2.test ability toreceive, sendandappropriatelyinterpretcommunication3.notebehavior suchas untidypersonalhabits andslurredspeech.Noteoccurrence ofparanoia anddelusions4. orient thept. to person,place andtime.

5.have theclient writenameperiodically.6.reduceprovocative

1.determinesability toparticipate inplanning/executing care.

2.to assessdegree ofimpairment.

3.Indicatesseverity ofillness.

4.to see ptscognition andassessment ofcurrent situation

5.forcomparisonpurposes.

6.To avoid thefight and flights

Lto:at the end of 5week, the ptwill:

Maintainusualrealityorientation

Demonstrate behaviorsthat willminimize/preventchanges inmentation

Identifyinterventions to deal

effectivelywithsituation.

Goal was met

Sto:At the end of2 days, thepot will:Verbalizeunderstandingof causativefactors.


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stimuli,negativecriticisms,argumentsand

confrontations.Collaborative

1. assist inidentifyingongoingtreatmentneeds forthe pt.

2. promotesocializatio

n withinindividuallimit.

3. Refer toappropriaterehabilitation provider.

response

1.to maintaingains andcontinueprogress.

2.to promotewellness.

3.to have acontinuousapproach tocare.


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Nursing diagnosis: risk for others directed violence r/t history of violence against

others.

Cause analysis: at risk for behaviors in which the individuals demonstrate that he canbe physically harmful to others.


Subjective:nakapatay kosa una og taokay ila man kogipareglahan,nanimalos ko

sailing gibuhatako syanggidunggab, asverbalized by thepatient.

Objectives:

Familybackground(conflict,chaotic)

Directingangrymessagesanddisappointments at asignificantothers whohas rejectedthe patient.

Emotional

problems(anger)

Lto:At the end of5 days, ptwill:

Participatein care

and meetin ownneeds inanassertivemanner.

Acknowledgerealities ofthesituation

Demonstrate selfcontrol asevidencedbyrelaxed,nonviolentbehavior.

Sto:

At the endof 8 hours,ptwill:

Verbalizeunderstanding ofwhybehavior

1. ascertainclientsperception ofself andsituation.2.

observe/listenfor early signsof distressincreasinganxiety(irritability, lack ofcooperation).3.ask directly ifthe person isthinking onactingthoughts/feelings.4.assess clientcopingbehavioralreadypresent.

5.develop atherapeuticnurse-clientrelationship.Provideconsistentcaregiver whenpossible.6.be truthful indealing withclient and

1.to assess thesituation.

2.May indicate

possibility ofloss of controlandintervention atthis point canprevent a blowup3.to determineviolent intent.

4.clientbelieves thatthere are noalternativesother thanviolence.5.promotessense of trustallowingclients feelingto discussopenly.

6.builds trustand enhancingtherapeutic

Lto:At the end of 5days, pt will:

Participated incare and meetin own needs

in an assertivemanner.

Acknowledgedrealities of thesituation

Demonstratedself control asevidenced byrelaxed, nonviolentbehavior.

Goals were met.

Sto:At the end of 8hours, pt will:

Verbalizedunderstanding of whybehavioroccurs

Goal was met.


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occurs. givinginformation7.give positivereinforcementsfor clients

behaviors.

Collaborative:1.prescribedantipsychoticmedications.

2.discussclients reasonof behavior so

significantothers.Determinedesiredcommitment ofinvolvedparties tosustain currentrelationship.3.identifysupportsystems(family, friends)

relationship.7.encouragescontinuation ofdesiredbehaviors.

1.the chemistryof the brain ischanged byearly violenceand had beenknown torespond toserotonin, as

well as relatedneurotransmitters system,which play arole inrestrainingaggressiveimpulses.2.to maximizeplan of care

3.those aroundhim need tolearn how tobe positive rolemodels anddisplay abroader arrayfor resolvingproblems


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Discharge Planning

Exercise

o Encourage client to exercise every day for at least 30 mins, preferably early in

the morning. This is to stimulate blood circulation in the body, move and exercise

muscles and joints.

Medication

o Patient should be instructed to take medication regularly at the right time and a

right dose.

Foods

o Certain foods should be avoided this is to prevent aggravating the patients mood

like foods containing caffeine, like colas, sodas, cakes, sweets and chocolates.

Support system

o Provide support for decision to stop substance use.

o Promote family involvement in rehabilitation program.

o Plan to maintain substance-free life formulated.


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Prognosis and Recommendation

Recommendation for Mr. K is to encourage him to do morning care and take his

prescribed medications properly. Continue exercise and eat nutritious food and avoiding

foods like energy drinks, caffeine beverages and chocolates. Encourage him to

participate in any therapy that well enhances his knowledge.

A. criteria for prognosis basing from the

following:

a. Onset of illness: Fair

b. Duration of illness: Poor

c. Precipating factors: Poor

d. Mood and Affect: Good

e. Attitude towards taking medication: Good

f. Any depressive feature: None

g. Family support: Poor

Resident K prognosis overall is fair because as you can see at the tabulation

onset of illness is fair because his illness was detected early because he manifested

symptoms. The duration of illness is poor because he started this illness at the age of

16. And for Precipating factors is poor because of their socioeconomic situation. For

attitude towards taking of medication is good because he took his prescribed drug on


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time. And for the family support, its poor because no one ever visited him at St.

Dymphna for quite a long time now, not even by his family.

Nurse-Resident-Interaction: Day # 1

Physical Description of the Client: Client appears happy but grooming and hygiene is

poor.

Physical Description of the Setting:Setting is within the clients room.

Objective:

Nurse TherapeuticCommunication

Done

Resident Interpretation/Analysis

maayong buntag,

kumusta man ka?

pwede istoryahanko nimumahitungod saimungkaugalingon?

wala may tao diha

sa imung kamot

ako si MaamLovely Grace.

mura man ka ugnaulaw?

kung naa kaymga gusto ngaiistorya pwede kamuistorya saamua.

Giving recognition

Exploring

Presenting reality

Giving information

Making observation

Offering self

Silence

maayong buntag

mga maam,Kendal akongngalan asverbalized by theclient.

maulaw man koninyoasverbalized by theclient.

naa diri o, naasila duhanagtinan-awasilaas verbalizedby client.

patient noddedand repeats myname.

Patient smiles

Patient smiles withgood eye contact.

To indicate awareness.

To examine the issuemore fully.

To indicate what is real.

Giving informationbuilds trust with theclient.

Sometimes clientcannot verbalize ormake themselvesunderstood.

So that the client doesnot have to respondverbally to get thenurses attention.

Encourages the client toverbalize provided that


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..

sige padayon,unsa pa man?

kanus-a maninahitabo?

unsa nga patay.

nodding

General leads

Placing event intime

Translating intofeelings

Accepting

Client went ontelling his

experiences.

client continues totalk.

high school pako.

gipatay naku saakong huna-huna.

is interested andexpectant.

Indicates that the nurseis listening and

following.

To see some things thatis not related.

To understand theclients word.

To indicate that thenurse has heard and

followed the train ofthought.


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Physical Description of the Client: Client is sweaty looks anxious.

Physical Description of the Setting: setting is inside the room together with other

clients and student nurses.

Objective:


Done


Good morning

Kendal.

naa kay gustoiistorya?

unsay nahitaboman?

Unsa man imunggibati nga

nagtherapy ka?

gasinguta manlage ka kendall?

wala may mapadiha kanang imunakita dili natinuod.

Giving recognition

Broad opening

Encouragingdescription ofperceptions

Encouragingexpression

Makingobservations

Presenting reality

Good morning

as verbalized.

No response

No response

Smiling

igang man kauasverbalized by theclient.

toa o Luzon, toaang visayaasverbalized.


Stimulate the patient totake the initiative.

To relieve the tensionthe client is feeling.

Encourages the client tomake his own appraisal

rather than to acceptthe opinion of others.

To make the self of theclient be understood.



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Physical Description of the Client: client has unusual movements and appears clean

and well-groomed.

Physical Description of the Setting: inside the administration room sitting on chair

with client facing us.

Objective: to gather necessary information/data and know what other factors that is

bothering the client and what is his past experiences and to build rapport.


Done


Good morningKendal.

istoryahe mi saimung mgakaagi?

Nodding.

sige padayon.

unsa man imunggibati mahitungodsa atong therapy?

naa kay gustoiistorya?

unsa man imupasabot dana?

Giving recognition

Exploring

Accepting

General leads

Encouragingexpressions

Broad opening

Encouragingdescription ofperception.

Good morningwith matchingsmile asverbalized.

Client sharedstories about hispast life.

Client continued

telling his stories.Client continuedtelling his stories.

Smiling.

No response justhaving physical

movements.

wala man koypasabotasverbalized.


To examine the issuemore fully.

To indicate that nurse

has followed the train ofthoughts.

Encourages the client tomake his own appraisalrather than to acceptthe opinion of others.

Stimulate the patient totake the initiative.

To relieve the tensionthe client is feeling.


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Physical Description of the Client: client appears clean but smells bad.

Physical Description of the Setting: we stayed in the administration office.

Objective:


Done


Good morningKendal.

unsa man imunggibati sa therapy?

nodding.

sige padayon

gasinguta manlage ka?

wala man minakita sa imungkamot (palad).

Giving recognition

Encouragingexpression

.

Accepting

General lead

Makingobservations

Presenting reality

Good morningas verbalized with

matching smile.

mayo nalingaw kokay nakadaug mitungod naku asverbalized.

Client continuedhis drawing.

Client continuedhis drawing.

Silence.

sa imu wala manpero sa akoa naaas verbalized.


Encourages client tomake his own appraisalrather than to acceptthe opinion of others.

To indicate that nursehas followed the train ofthoughts.

To indicate that thenurse listened andfollowed.

To make the self of theclient be understood.



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Bibliography

Nursing drug guide, Karch, Amy M.,Lippincott William & Wilkins(2009)

Psychiatric mental health nursing, Videbeck, Sheila L.,5th Edition, Lippincott William &

Wilkins (2011)

Nurses Pocket Guide, Doenges, Marilyn et.al, 11 th edition,LA Davis Company (2008)

Diagnostic and statistical Manual of Mental disorders-TR, 4th Edition,Washington DC,

American Psychiatric Association (2000)

Medical-surgical nursing,Black, Joyce M. & Hawks, Jane Hokanson, Eight

edition,Elsevier, Inc (2009)

http://www.mentalneurologicalprimarycare.org/

3 Driver and Vehicle Licensing Agency. At a Glance Guide to Medical Aspects of

Fitness to Drive.

URL http://www.dvla.gov.uk. Further information is available from The Senior Medical

Adviser,

DVLA, Driver Medical Unit, Longview Road, Morriston, Swansea SA99 ITU, Wales.

5 National Institute for Clinical Excellence. Schizophrenia: Core Interventions in the

Treatment
http://www.mentalneurologicalprimarycare.org/http://www.mentalneurologicalprimarycare.org/http://www.mentalneurologicalprimarycare.org/


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and Management of Schizophrenia in Primary and Secondary Care. Clinical Guideline

1.

December 2002. URL http://www.nice.org.uk. (AI)

Case Study Psych

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