A Case Study on Schizophrenia

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In Partial Fulfillment of the Requirement In Psychiatric Nursing

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Presented to the Faculty of the College of Nursing

-------------------------------------------------------------------Submitted by Rico !iguel "ouis #$ %amala Pamela Irene &$ %ampos 'micron (

)* !arch )++,

TABLE OF CONTENTS

I$ Introduction ----------------------------------------------------------------------------------------------------------------------II$ 'b.ecti/es ------------------------------------------------------------------------------------------------------------------------0 III$ Nursing Assessment 1$ Personal 2istory 1$1 Patient3s Profile ------------------------------------------------------------------------------------------, 1$1$1 !ental Status 45am-----------------------------------------------------------------------6 1$) "e/el of 7ro8th and &e/elopment------------------------------------------------------------------9 1$)$1 Normal &e/elopment of the :oung Adults-------------------------------------------9 )$ &iagnostic Results -------------------------------------------------------------------------------------------------1) -$ Pathophysiology and Rationale -$1 Normal Anatomy and Physiology------------------------------------------------------------------1-$) Classical and Clinical Symptoms of Schizophrenia------------------------------------------- )+ -$- Psychopathology---------------------------------------------------------------------------------------)* -$* Schematic &iagram on the Psychopathology of the &isease-------------------------------); -$0 Psychodynamics----------------------------------------------------------------------------------------+ <#$ Nursing Inter/ention----------------------------------------------------------------------------------------------------------) 1$ Care guide-------------------------------------------------------------------------------------------------------------* )$ Actual Patient Care--------------------------------------------------------------------------------------------------0 )$1 =runs8ic> "ens !odel---------------------------------------------------------------------------------0 )$) Nursing Care Plan--------------------------------------------------------------------------------------, )$- &rug %herapeutic Record----------------------------------------------------------------------------*)$* S'API4 Chart-------------------------------------------------------------------------------------------** )$0 Process Recording-------------------------------------------------------------------------------------*, )$, 2ealth %eaching Plan---------------------------------------------------------------------------------,, #$ 4/aluation and Recommendation-----------------------------------------------------------------------------------------,; #I$ 4/aluation and Implication------------------------------------------------------------------------------------------------ 6+ #III$ =ibliography -----------------------------------------------------------------------------------------------------------------6)

I. Introduction %hroughout recorded history? the disease 8e no8 >no8 as schizophrenia has been a source of be8ilderment$ %hose suffering from the illness once 8ere thought to be possessed by demons and 8ere feared? tormented? e5iled or loc>ed up fore/er$ In spite of ad/ances in the understanding of its causes? course and treatment? schizophrenia continues to confound both health professionals and the public$ It is easier for the a/erage person to cope 8ith the idea of cancer than it is to understand the odd beha/ior? hallucinations or strange ideas of the person 8ith schizophrenia$ As 8ith many mental disorders? the causes are poorly understood$ Friends and family commonly are shoc>ed? afraid or angry 8hen they learn of the diagnosis$ 45pectations become more realistic as schizophrenia is better understood as a brain disease that requires ongoing treatment$ &emystification of the illness? along 8ith recent insights from basic neuroscience? gi/es ne8 hope for finding more effecti/e treatments for an illness that pre/iously carried a gra/e prognosis$ Schizophrenia is a mental illness$ %he first acute episode can be a de/astating e5perience? particularly as both the person e5periencing the illness and those close to him 8ill be unprepared$ About one in a hundred people 8orld-8ide e5perience at least one such episode at some time during their li/es? although the highest incidence is in the late teens and early )+@s$ About a quarter of people 8ho de/elop schizophrenia reco/er 8ithin fi/e years$ Appro5imately t8o-thirds of those 8ho de/elop the condition e5perience fluctuating symptoms o/er many years$ About ten to fifteen percent e5perience se/ere long term incapacity$ In about one quarter of cases there is e/entually a full reco/ery$ %he ma.ority 8ill ha/e long periods of good functioning? 8ith occasional problems$ %he recent disco/ery of ne8 forms of treatment may lead to further impro/ement in rates of reco/ery? particularly if e/eryone in/ol/ed? for instance? both the person 8ith schizophrenia and their family? learns to understand ho8 to cope$ In schizophrenia the acti/ity of chemical messengers at certain ner/e endings in the brain is unusual and this may be a clue to the causes of the disorder$ &uring 8hat is sometimes referred to as Aan acute episodeA the mental processes of e5periencing and thin>ing become distorted$ Bhen se/ere this can lead to intense panic? anger? depression? elation or o/er acti/ity? perhaps punctuated by periods of 8ithdra8al$ It is not surprising that other people? particularly family and friends? find the changes incomprehensible and are themsel/es de/astated$ 'ne common misconception is that schizophrenia is the result of @split personality@$ In fact @multiple personality@? the correct term? is /ery rare and has nothing to do 8ith schizophrenia$ %he mista>e comes from the fact that the name @schizophrenia@ 8as coined from t8o 7ree> 8ords meaning @split@ and @mind@$ It 8as intended to represent the fact that processes of thought? feeling and intention? guiding the person@s actions? no longer interact to form a coherent 8hole$

%he sub.ect matter is a #isayan -;-year-old male patient 8ho is around 03*C in height 8ith a fair comple5ion? medium-built and appro5imately 8eighting 1*0 lbs? !arcelino !arcos? also >no8n as Catalino =agayo$ 2is being approachable? recepti/e? composed and tranquil prompted the student nurse to choose him as the sub.ect of the case study$ Aside from that? the sub.ect is controllable D open as 8ell$ In general? he understands simple statements and instructions and ans8ers most of the questions the student nurse as>ed him$ %he student nurse3s e5pectation in conducting this case study is to achie/e more >no8ledge? attitude and s>ills on dealing 8ith patients ha/ing schizophrenia? its /arious theories and etiologiesE e/aluate the effecti/eness of anti psychotic medications on the client and describe supporti/e and rehabilitati/e needs of the client$ !ost importantly? the student nurse 8ants to pro/ide teaching to client and client3s significant others to increase >no8ledge and understanding of schizophrenia$

II. Objectives Student Nurse After ) 8ee>s of student-nurse-client interaction? the student nurse 8ill be able to 1$ apply the nursing process to care of clients 8ith psychosocial responses 8hich occur across the life span$ )$ demonstrate therapeutic relationships 8hen interacting 8ith clients and groups$ -$ establish a therapeutic relationship 8ith a selected client$ *$ formulate a care guide and a comprehensi/e nursing care plan 8ith appropriate nursing inter/entions for a Schizophrenic patient using the nursing process 0$ demonstrate accountability for nursing actions related to psychiatricFmental health nursing in hospital and community en/ironments$ ,$ demonstrate and implement beginning s>ills for the encouragement of acceptable patterns of actions for instance in ,$1 remoti/ation therapy ,$) sensory stimulation ,$- morning stretch ,$* socialization 6$ con/ey health teaching to client and significant others ;$ relate findings from research to the nursing care of clients in a /ariety of mental healthFpsychiatric settings$ 9$ identify personal /alues? ethical and legal issues related to psychiatricFmental health nursing$ Patient After -+-*0 minutes of nurse-client interaction? the client 8ill be able to 1$ maintain rapport 8ith the student nurse )$ introduce self to the student nurse -$ /erbalize her feelings and concerns to the student nurse *$ maintain proper hygiene and grooming -ta>ing a bath -brushing teeth -changing into ne8 clothes e/eryday 0$ e5press desire to socialize 8ith other patients /oluntarily ,$ reduce his an5iety le/el by adapting coping s>ills taught by the student nurse 6$ set contract 8ith the student nurse as to 8hat place? time and date of the ne5t interaction and termination date$

III. Nursing Assessment 1. Persona !istor" 1.1 Patient#s Pro$i e Name !arcos? !arcelino a$>$a$ =agayo? Catalino Address Carcar? Cebu Age -; y$o$ Se5 !ale Ci/il status Single Religion Roman Catholic Nationality Filipino 'ccupationFFinancial status None Significant others According to the patient? both parents died 8hile siblings are present but had lost contact 8ith him$ &ate of Admission February 0?)++0 ImpressionF&iagnosis Schizophrenia Physician &r$ #alencia

1.1.1 %enta Status E&am I$ 7eneral &escription a$ Appearance !r$!arcelino !arcos is a -; year old male patient 8ho 8as around 03*C in height 8ith a fair comple5ion? medium-built and appro5imately 8eighting 1*0 lbs$ No tattoos are present in his body$ 2e has short hair$ %eeth are aligned but 8ith yello8 stains$ 2is nails are not trimmedE he has a /ery flat affect but maintains eye contact$ b$ !otor Acti/ity %he patient has difficulty in mo/ing his body parts and needs constant guidance in performing daily e5ercises$ Although he is still able to perform gross motor s>ills 8ith some assistance? he finds it hard to perform fine motor s>ills such as 8riting or dra8ing$ c$ Speech Problems %he patient@s speech coordination is incomprehensible most of the time$ She has a /ery lo8 /oice 8hich poses a problem to the student nurses$ 2e also mumbles 8ords that are /ery hard to understand$ At times? she does not ans8er the questions as>ed by the student nurses$ 2e also e5periences perse/eration and echolalia and ans8ers in a monotonous /oice tone$ d$ 7eneral Attitude %he patient is /ery manageable$ %hough he can3t ans8er some of the questions or insists of stating the 8rong ans8er? he is easy to moti/ate to perform acti/ities of daily li/ing li>e ta>ing a bath$ %here are times ho8e/er 8hen he is passi/e and doesn3t gi/e too much information$ 2e is easy to be approached as he is non-/iolent$ II$ 4motions !ood

As obser/ed in his actions and facial e5pressions? his passi/eness doesn3t gi/e much data$ 2e does? ho8e/er? cooperate 8ithout question and doesn3t gi/e much of a reaction$ Affect

Patient3s affect is flat$ 2e doesn3t smile or possess any e5pression$ III$ %hough Process Form of thought

Patient manifests perse/eration and echolalia in a 8ay that he has difficulty getting to the point of communication$ Gnrelated topics 8ere introduced by the patient and the original discussion is lost$ Bhen he is as>ed about her family members? he mentioned that his has a t8o sisters and a brother$ Content of thought

Patient e5periences flat affect e5cept during the time he as>ed to be bathed$ I#$ Perceptual &isturbances Patient e5hibits confusion and thin>s his name is Catalino =agayo$ #$ Sensorium and Cogniti/e Ability Patient is not oriented to time? date and place and he is ha/ing a hard time stating his real name$ 2o8e/er? he gi/es unclear ans8ers and sometimes refuses to ans8er questions regarding his memory of the past? before he 8as brought to the psychiatric 8ard$ 2e has difficulty concentrating and cannot do simple math$ #I$ Impulse Control %he patient doesn3t e5hibit any sign of emotion and he participates in acti/ities and ans8ers some questions passi/ely$

1.' Leve o$ (ro)t* and +eve o,ment 1.'.1 Norma (ro)t* and +eve o,ment o$ T*e -oung Adu ts %he age 8hich a person is considered an adult depends on ho8 adulthood is described$ "egally? a person in the Gnited States can /ote at 1; years old$ %he legal age t for alcohol consumption outside the home /aries among states from 1; to )1 years$ Another criterion of adulthood is financial dependence? 8hich is also highly /ariable$ Some adolescents support themsel/es as early as 1, years of age? usually because of family circumstances$ =y contrast? some adults are financially dependent on their families for many years? for e5ample? during prolonged periods of education$ Adulthood may also be indicated by mo/ing a8ay from home and establishing one3s o8n li/ing arrangements$ :et this independence also /aries greatly$ Some adolescents lea/e home because of family problems$ In recent years? ho8e/er? more young adults ha/e been choosing to remain at home$ In addition? many adults under -+ ha/e returned to their parent3s homes to li/e$ %he factors contributing to this trend include high housing costs? high di/orce rates? high unemployment rates? and the many problems resulting from drug abuse$ Some young people 8ho employed full time recei/e only minimum 8age and are unable to earn enough money to be totally self-supporting$ !aturity is the state of ma5imal function and integration? or the stat of being fully de/eloped$ !any other characteristics are generally recognized as representati/e of maturity$ !ature indi/iduals are guided by an underlying philosophy of life$ %hey ta>e many perspecti/es into account and are tolerant to the /ie8s of others$ A comprehensi/e philosophy allo8s a person to ma>e sense out of life and thus helps that person maintain a sense of purpose and hope in the face of human tragedies$ !ature persons are open to ne8 e5periences and continued gro8thE they can tolerate ambiguity? are fle5ible? and can adopt to change$ In addition? mature people ha/e the quality of self-acceptanceE they are able to be reflecti/e and insightful about life and to see themsel/es as others see them$ !ature persons also assume responsibility for themsel/es and e5pect others to do the same$ %hey confront the tas>s of life in a realistic and mature manner? ma>e decisions? and accept responsibility foe those decisions$ :oung adults are typically busy people 8ho face many challenges? they are e5pected to assume ne8 roles at 8or>? in the home? and in the community? and to de/elop interests? /alues? and attitudes related to these roles$ Physical &e/elopment In contrast to the minimal physical changes? psychosocial de/elopment of the young adult is great$ %hey face a number of ne8 e5periences and changes in lifestyle as they progress to8ard maturity$ Choices must be made about education and employment? about 8hether to marry of remain single? about starting a home? and about rearing children$ Social responsibilities include forming ne8 friendships and assuming some community acti/ities$ 'ccupational choice and education are largely inseparable$ 4ducation influences occupational opportunitiesE con/ersely? an occupation? once chosen? can determine the education needed and sought$ 4ducation enhances

employment opportunities and usually ensures economic sur/i/al$ As the role of 8omen has changed? many 8omen no8 choose to assume acti/e careers and ci/ic roles in society in addition to their roles as mother andFor 8ife$ Remaining single is becoming the lifestyle of more and more young adults$ !any people choose to remain single? perhaps to pursue and education and then to ha/e the freedom to pursue their chosen to li/e 8ith another person of the opposite or same se5 and share li/ing arrangements and certain e5penses$ Some people 8ho are gay or lesbian commit themsel/es legally to a partner as in marriage$ Although nontraditional lifestyles are becoming more acceptable in society? attitude to8ard these /arious lifestyles can contribute social pressures that lead to stress responses$ %he multiple roles of adulthood Hcitizen? 8or>er? ta5payer? homeo8ner? 8ifeFhusband? daughterFson? brotherFsister? partner? friend? and so onI may also create stress as a result of role conflict$ Cogniti/e &e/elopment Piaget belie/es that cogniti/e structures are complete during the formal operations period, from roughly 11 to 10 years$ From that time? formal operations Hfor e5ample? generating hypothesisI characterize thin>ing throughout adulthood and are applied to more areas$ 4gocentrism continues to declineE ho8e/er? according to Piaget these changes do not in/ol/e a change in the structure of thought? only a change in its content and stability$ Recently? researchers in the field of psychology ha/e suggested that Piaget3s formal operational stage is not the last stage of human de/elopment$ Some ha/e proposed a concept pf post-formal thought$ Post-formal thought, Sometimes called the problem finding stage? is characterized by Jcreati/e thought in the form of disco/ered problems? the raising of general questions from ill-defined problems? the use intuition? insight? and hunches? and the de/elopment of significant scientific thoughtC$ In addition to the adolescent ability to thin> in abstract terms? post-formal thin>ers posses an understanding of the temporary or relati/e nature of >no8ledge$ %hey are bale to comprehend and balance arguments created by both logic and emotion$ !oral &e/elopment :oung adults 8ho ha/e mastered the pre/ious stage of (ohlberg3s theory of moral de/elopment no8 enter the precon/entional le/el$ At this time? the person is able to separate self from the e5pectations and rules of others and to define morality in terms of personal principles$ Bhen indi/iduals percei/e a conflict 8ith society3s rules or la8s? they .udge according to their o8n principles$ For e5ample? a person may intentionally brea> the la8 and .oin a protest group to stop hunters from >illing 8ild animals? belie/ing that the principle of 8ildlife conser/ation .ustifies the protest action$ %his type of reasoning is called principled reasoning. 7illigan argues that as indi/iduals approach young adulthood? men and 8omen tend to define moral problems some8hat differently$ !en often use an Jethic of .usticeC and define moral problems in terms of rules and rights$ Bomen? in contrast? often define moral problems in terms of obligation to care and to a/oid hurt$ Spiritual &e/elopment According to Fo8ler? the indi/idual enters the indi/iduating-reflecti/e period sometime after 1; years of age$ &uring this period? the indi/idual focuses on reality$ A )6-year-old adult may as> philosophic questions regarding

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spirituality and may be self-conscious about spiritual matters$ %he religious teaching that the young adult had as a child may no8 be accepted or redefined$

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'. +iagnostic .esu ts None

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/. Pat*o,*"sio og" and .ationa e /.1 Norma Anatom" and P*"sio og" o$ t*e S"stem A$$ected =asic >no8ledge about brain chemistry and its lin> to schizophrenia is e5panding rapidly$ Neurotransmitters? substances that allo8 communication bet8een ner/e cells? ha/e long been thought to be in/ol/ed in the de/elopment of schizophrenia$ It is li>ely? although not yet certain? that the disorder is associated 8ith some imbalance of the comple5? interrelated chemical systems of the brain? perhaps in/ol/ing the neurotransmitters dopamine and glutamate$ Signi$icant Loss o$ Brain (ra" %atter0 Indi/iduals 8ith schizophrenia? including those 8ho ha/e ne/er been treated? ha/e a reduced /olume of gray matter in the brain? especially in the temporal and frontal lobes$ Recently neuroscientists ha/e detected gray matter loss of up to )0K Hin some areasI$ %he damage started in the parietal? or outer? regions of the brain but spread to the rest of the brain o/er a fi/e-year period$ Patients 8ith the 8orst brain tissue loss also had the 8orst symptoms? 8hich included hallucinations? delusions? bizarre and psychotic thoughts? hearing /oices? and depression$ En arged 1entric es in t*e Brain0 Indi/iduals 8ith schizophrenia? including those 8ho ha/e ne/er been treated? typically ha/e enlarged /entricles in the brain? as demonstrated in o/er 1++ studies to date$ En arged Am"gda a0 Indi/iduals ha/e an enlarged amygdala and increased numbers of 8hite matter hyper intensities$ Neuro ogica Abnorma ities0 Indi/iduals 8ith schizophrenia and manic-depressi/e disorder? including those 8ho ha/e ne/er been treated? ha/e more neurological abnormalities$ +ecreased Pre$ronta Brain Function0 Indi/iduals 8ith schizophrenia? including those 8ho ha/e ne/er been treated? sho8 decreased function of the prefrontal area? an area of the brain that 8e use for planning and thin>ing about oursel/es$ Appro5imately 0+ percent of indi/iduals 8ith schizophrenia and manic-depressi/e disorder? including those 8ho ha/e ne/er been treated? ha/e impaired a8areness of their o8n illness$ %his has been sho8n in at least 0+ different studies$ Such indi/iduals do not realize that they are sic>? and they 8ill? therefore? usually not accept treatment /oluntarily$

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Studies suggest that this impaired a8areness is probably related to the decreased function of the prefrontal area of the brain$ Anatomica S"stem Basa gang ia A region consisting of - clusters of neurons Hcalled the caudate nucleus? putamen? and the globus pallidusI located at the base of the brain that are responsible for in/oluntary mo/ements such as tremors? athetosis? and chorea$ %he basal ganglia are abnormal in a number of important neurologic conditions including Par>inson disease and 2untington disease$ %he term Abasal gangliaA refers to the fact that this region is in the AbasementA of the brain$ %he basal ganglia are subcortical nuclei deri/ed from the Telencephalon$ %hey are concerned 8ith comple5 aspects of motor control and consist of t8o ma.or di/isions the 1I Corpus Striatum? and )I Amagdyloid nuclear comple5$ Additionally? there are close relationships of these 8ith the Substantia nigra and the Subthalamic region$ Cor,us Striatum Consists of t8o distinct parts the neostriatum HCaudate nucleus and PutamenI and the paleostiatum Hglobus pallidusI. %he Neostriatum recei/es afferent stimulation from telencephalon? thalamus and portions of the amagdyla? primarily$ %he Paleostriatum? the globus pallidus? pro/ides efferent to thalamic and cortical Hmotor and otherI and brainstem centers$ %here are no direct efferents to the spinal cord$ Amagd" oid Appears to ha/e intimate association 8ith the limbic system and olefactionE also recei/es dopaminergic input from substantia nigra; stimulation pro/ides a 8ide /ariety of somatic? /isceral? endocrine and beha/ioral effects$ A direct role in the coordination of motor acti/ity is not clear to this author$ Substantia nigra "ies dorsal to the crus cerebri? /entral to the tegmentum and lies throughout the course of the mesencephalon$ Is belie/ed to pro/ide source of dopamine to the basal ganglia and is belie/ed to underlie some metabolic disturbances manifest as Par>inson@s disease$%here are many efferent pro.ections from the substantia nigra$ %his discussion 8ill not elaborate on them

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Limbic S"stem It sets the emotional tone of the mind? filters e5ternal e/ents through internal states Hemotional coloringI? tags e/ents as internally important? stores highly charged emotional memories? modulates moti/ation? controls appetite and sleep cycles? promotes bonding? directly processes the sense of smell? modulates libido Prob ems !oodiness? irritability? clinical depression? increased negati/e thin>ing? percei/e e/ents in a negati/e 8ay? decreased moti/ation? Flood of negati/e emotions? appetite and sleep problems? decreased or increased se5ual responsi/eness? social isolation %he deep limbic system lies near the center of the brain$ Considering its size -- about that of a 8alnut -- it is po8er-pac>ed 8ith functions? all of 8hich are critical for human beha/ior and sur/i/al$ From an e/olutionary standpoint? this is an older part of the mammalian brain that enabled animals to e5perience and e5press emotions$ It freed them from the stereotypical beha/ior and actions dictated by the brain stem? found in the older reptilian brain$ %he subsequent e/olution of the surrounding cerebral corte5 in higher animals? especially humans? ga/e the capacity for problem sol/ing? planning? organization and rational thought$ :et? in order for these functions to occur one must ha/e passion? emotion and desire to ma>e it happen$ %he deep limbic system adds the emotional spice? if you 8ill? in both positi/e and negati/e 8ays$ %he deep limbic system? along 8ith the deep temporal lobes has also been reported to store highly charged emotional memories? both positi/e and negati/e$ If you ha/e been traumatized by a dramatic e/ent? such as being in a car accident or 8atching your house burn do8n? or if you ha/e been abused by a parent or a spouse? the emotional component of the memory is stored in the deep limbic system of the brain$ 'n the other hand? if you ha/e 8on the lottery? graduated magna cum laude? or 8atched your child@s birth? those emotional memories are stored here as 8ell$ %he total e5perience of our emotional memories is responsible? in part? for the emotional tone of our mind$ %he more stable? positi/e e5periences 8e ha/e the more positi/e 8e are li>ely to feel$ %he more traumas in our li/es the more emotionally set 8e become in a negati/e 8ay$ %hese emotional memories are intimately in/ol/ed in the emotional tagging that occurs$ %he deep limbic system also affects moti/ation and dri/e$ It helps get you going in the morning and encourages you to mo/e throughout the day$ '/er acti/ity in this area? in our e5perience? is associated 8ith lo8ered moti/ation and dri/e? 8hich is often seen in depression$ %he deep limbic system? especially the hypothalamus? controls the sleep and appetite cycles of the body$ 2ealthy sleep and appetite is essential to maintaining a proper internal milieu$ =oth of these components are often a problem 8ith limbic abnormalities$ %he deep limbic structures are also intimately in/ol/ed 8ith bonding and social connectedness$ Bhen the deep limbic system of animals is damaged they do not properly bond 8ith their young$ In one study of rats? 8hen

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the deep limbic structures 8ere damaged mothers 8ould drag their offspring around the cage as if they 8ere inanimate ob.ects$ %hey 8ould not feed and nurture the young as they 8ould normally do$ %his system affects the bonding mechanism that enables you to connect 8ith other people on a social le/elE your ability to do this successfully in turn influences your moods$ 2umans are not li>e polar bears? 8andering the tundra alone ele/en months out of the year$ Be are social animals$ Bhen 8e are bonded to people in a positi/e 8ay 8e feel better about our li/es and oursel/es$ %his capacity to bond then plays a significant role in the tone and quality of our moods$ %he deep limbic system directly processes the sense of smell$ %he olfactory system is the only one of the fi/e sensory systems that goes from the sensory organ to directly 8here it is processed in the brain$ %he messages from all the other senses Hsight? hearing? touch and tasteI are sent to a Arelay station?A the thalamus? before they are sent to their final destination in different parts of the brain$ =ecause your sense of smell goes directly to the deep limbic system it is easy to see 8hy smells can ha/e such a po8erful impact on our feeling states$ %he multibillion-dollar perfume and deodorant industries count on this fact beautiful smells e/o>e pleasant feelings and dra8 people to8ard you? 8hereas unpleasant smells cause people to 8ithdra8$ 45pensi/e perfumes and colognes can ma>e you beautiful? se5y and attracti/e to others? 8hereas a disagreeable body odor can ma>e the other person 8ant to rush to the far side of the room$ %he deep limbic system? especially the hypothalamus at the base of the brain? is responsible for translating our emotional state into physical feelings of rela5ation or tension$ %he front half of the hypothalamus sends calming signals to the body through the parasympathetic ner/ous system$ %he bac> half of the hypothalamus sends stimulating or fear signals to the body through the sympathetic ner/ous system$ %he bac> half of the hypothalamus? 8hen stimulated? is responsible for the fight or flight response? a primiti/e state that gets us ready to fight or flee 8hen 8e are threatened or scared$ %his Ahard-8ired responseA happens immediately upon acti/ation? such as seeing or e5periencing an emotional or physical threat$ In this response the heart beats faster? breathing rate and blood pressure increases? the hands and feet become cooler to shunt blood from the e5tremities to the big muscles Hto fight or run a8ayI and the pupils dilate Hto see betterI$ %his Adeep limbicA translation of emotion is po8erful and immediate$ It happens 8ith o/ert physical threats and also 8ith more co/ert emotional threats$ %his part of the brain is intimately connected 8ith the prefrontal corte5 and seems to acts as a s8itching station bet8een running on emotion Hthe deep limbic systemI and rational thought and problem sol/ing 8ith our corte5$ Bhen the limbic system is turned on - emotions tend to ta>e o/er$ Bhen it is cooled do8n? more acti/ation is possible in the corte5$ Current research on depression indicates increased deep limbic system acti/ity and shut do8n in the prefrontal corte5? especially on the left side$

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Pre$ronta Corte& S"stem P.EF.ONTAL CO.TE2 S-STE% %he most e/ol/ed brain system Functions Attention span? Perse/erance$ Planning? Ludgment? Impulse control? 'rganization? Self-monitoring and super/ision? Problem sol/ing?Critical thin>ing? For8ard thin>ing? "earning from e5perience and mista>es? Ability to feel and e5press emotions? Influences the limbic system? 4mpathy? Internal super/ision

Prob ems Short attention span? &istractibility? "ac> of perse/erance? Impulse control problems? 2yperacti/ity? Chronic lateness? poor time management? Poor organization and planning? Procrastination? Gna/ailability of emotions? !isperceptions? Poor .udgment? %rouble learning from e5perience? Short term memory problems? Social and test an5iety? "ying? !isperceptions

Nervous S"stem Pat*)a"s Cerebe um %he portion of the brain that coordinates mo/ements of /oluntary Hs>eletalI muscles$ It contains about half of the brain@s neurons? but these particular ner/e cells are so small that the cerebellum accounts for only 1+K of the brain@s total 8eight$ %he cerebellum operates automatically? 8ithout intruding into consciousnessE motor impulses from the cerebrum are organized and modulated before being transmitted to muscle$ As the muscle tissue responds? its sensory ner/e cells return information to the cerebellum$ %hus? throughout periods of muscular acti/ity? the cerebellum ad.usts speed? force? and other factors in/ol/ed in mo/ement$ %he o/erall effect is a smooth? balanced muscular acti/ity$ If the cerebellum is in.ured? an acti/ity li>e 8al>ing becomes spasmodic the muscles in/ol/ed contract too much or too little and operate out of sequence$ !aintaining muscle tone is also a function of the cerebellum$ Filling most of the s>ull behind the brain stem and belo8 the cerebrum? the human cerebellum appro5imates an orange in size and consists of t8o hemispherical lobes$ %he groo/ed surface of the cerebellum is gray matter? composed chiefly of ner/e cells$ %he interior? dense 8ith ner/e fibers? ma>es up the 8hite matter$ Fi/e different ner/e cell types ma>e up the cerebellum stellate? bas>et? Pur>in.e? 7olgi? and granule cells$ %he Pur>in.e cells are the only ones to send a5ons out of the cerebellum$ %hree main ner/e tracts lin> the

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cerebellum 8ith other brain areas$ In.ury to the cerebellum usually results in disruption of eye mo/ements? balance? or muscle tone$ Cerebra Corte& Language S"stem %he language system is located almost completely in the left hemisphere? 8here there are three regions that mediate the capacity to communicate =roca3s area? Bernic>e3s area and the auditory corte5$ Broca#s area? 8here speech is produced? contains information about the 8ords that connect the thought content$ 3ernic4e#s area 8hich is referred to as the auditory association corte5 and the meaning of 8ords is achie/ed thru comparisons in Bernic>e3s area$ 3ernic4e#s a,*asia produces impo/erished speech sometimes referred as J8ord saladC$ Broca#s a,*asia produces impo/erished speech and decreased /erbal cogniti/e functions such as a /erbal intelligence quotient measuring lo8er than the performance IM and impairment as determined by language test$ %emor" S"stem !easures of /erbal memory and learning are found in the left-medial-temporal area$ Any symmetry in the tempero hippocampal area 8ill significantly affect the memory$ Functional Divisions of the Cerebral Cortex %he cerebral corte5 is responsible for many Ahigher-orderA functions li>e language and information processing$ "anguage centers are usually found only in the left cerebral hemisphere$ Cortica Area Prefrontal Corte5 !otor Association Corte5 Primary !otor Corte5 Primary Somatosensory Corte5 Sensory Association Area Sensory Association Area #isual Corte5 Function Problem Sol/ing? 4motion? Comple5 %hought Coordination of comple5 mo/ement Initiation of /oluntary mo/ement Recei/es tactile information from the body Processing of multisensory of /isual

information Comple5 processing

information &etection of simple /isual stimuli

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Bernic>e@s Area Auditory Association Area Auditory Corte5 Speech H=roca@s AreaI Center

"anguage comprehension Comple5 processing of auditory information &etection of sound quality

Hloudness? toneI Speech production and articulation

Brain Stem %he lo8er e5tension of the brain 8here it connects to the spinal cord$ Neurological functions located in the brainstem include those necessary for sur/i/al Hbreathing? digestion? heart rate? blood pressureI and for arousal Hbeing a8a>e and alertI$ !ost of the cranial ner/es come from the brainstem$ %he brainstem is the path8ay for all fiber tracts passing up and do8n from peripheral ner/es and spinal cord to the highest parts of the brain$ %idbrain %he midbrain ser/es as the ner/e path8ay of the cerebral hemispheres and contains auditory and /isual refle5 centers$ Pons %he pons is a bridge-li>e structure 8hich lin>s different parts of the brain and ser/es as a relay station from the medulla to the higher cortical structures of the brain$ It contains the respiratory center$ %edu a Ob ongata %he medulla oblongata functions primarily as a relay station for the crossing of motor tracts bet8een the spinal cord and the brain$ It also contains the respiratory? /asomotor and cardiac centers? as 8ell as many mechanisms for controlling refle5 acti/ities such as coughing? gagging? s8allo8ing and /omiting$

/.' C assica and C inica S"m,toms o$ Sc*i5o,*renia C assica S"m,toms POSITIVE SYMPTOMS C inica S"m,toms .ationa e Current opinion tends to fa/our a scenario 8here an early perinatal brain insult leads to dormant CNS damage 8hich

19

4motional Ambi/alence Not !anifested

particularly manifests in the de/eloping brain at or after adolescence$ Source !urray et al? 199)

Associati/e "ooseness

!anifested Fragmented or poorly related thoughts and ideas as e/idenced by irrele/ant ans8ers to questions

%he onset of schizophrenia is associated 8ith reacti/e synaptic regeneration occurring in brain regions recei/ing degenerating temporal lobe pro.ections$ %he frontal corte5 is an associati/e memory neural net8or> 8hose input synapses represents incoming temporal pro.ections$ %his hypothesized pathological synaptic changes result in ad/erse side effects reminiscent in delusions and hallucinations seen in schizophrenia spontaneous? stimulusindependent retrie/al of stored memories$ %hese could account for the occurrence of schizophrenic delusions? hallucinations and looseness of association 8ithout any apparent e5ternal trigger? and for their tendency to concentrate on a fe8 central cogniti/e and perceptual themes$ Source Ste/ens3 H199)I %he onset of schizophrenia is associated 8ith reacti/e synaptic regeneration occurring in brain regions recei/ing degenerating temporal lobe pro.ections$ %he frontal corte5 is an associati/e memory neural net8or> 8hose input synapses represents incoming temporal pro.ections$ %his hypothesized pathological synaptic changes result in ad/erse side effects reminiscent in delusions and hallucinations seen in schizophrenia spontaneous? stimulusindependent retrie/al of stored memories$ %hese could account for the occurrence of schizophrenic delusions? hallucinations and looseness of association 8ithout any apparent e5ternal trigger? and for their tendency to concentrate on a fe8 central cogniti/e and perceptual themes$ Source Ste/ens3 H199)I 7ray matter loss is implicated in schizophrenia and is also >no8n to occur in adolescence detailed spatiotemporal maps of these loss processes 8as created$ %his technique unco/ered a dynamic 8a/e of accelerated gray matter loss? spreading from parietal cortices at disease onset to encompass temporal and frontal regions later in the disease It suggests a dynamic structural basis for early prodromal symptoms and for the positi/e and negati/e deficit symptoms obser/ed clinically$ Source =ird? 2$ D Alu8ahlia? S$ H19;-I Arch. Gen. Psychiatry *+? 1));-1)Conceptual disorganization 8as related to the sequencing of comple5 motor acts and to the Neurological 4/aluation Scale total score? suggesting both a possible specific frontal dysfunction and a more global impairment$ Source Ro8e 4B? Shean 7 Card-sort performance and syndromes of schizophrenia$ 7enet Soc 7en Psychol

&elusion

Not !anifested

4chopra5ia

Not !anifested

Flight of Ideas

Not !anifested

20

!onogr 1996E 1)- 196N)+9 2allucination !anifested HauditoryI patient is obser/ed mumbling to himselfE tal>ing to an unseen person %he onset of schizophrenia is associated 8ith reacti/e synaptic regeneration occurring in brain regions recei/ing degenerating temporal lobe pro.ections$ %he frontal corte5 is an associati/e memory neural net8or> 8hose input synapses represents incoming temporal pro.ections$ %his hypothesized pathological synaptic changes result in ad/erse side effects reminiscent in delusions and hallucinations seen in schizophrenia spontaneous? stimulusindependent retrie/al of stored memories$ %hese could account for the occurrence of schizophrenic delusions? hallucinations and looseness of association 8ithout any apparent e5ternal trigger? and for their tendency to concentrate on a fe8 central cogniti/e and perceptual themes$ Source Ste/ens3 H199)I Current opinion tends to fa/our a scenario 8here an early perinatal brain insult leads to dormant CNS damage 8hich particularly manifests in the de/eloping brain at or after adolescence$ Source !urray et al? 199) =ecause gray matter loss is implicated in schizophrenia and is also >no8n to occur in adolescence detailed spatiotemporal maps of these loss processes 8as created$ %his technique unco/ered a dynamic 8a/e of accelerated gray matter loss? spreading from parietal cortices at disease onset to encompass temporal and frontal regions later in the disease$ %he rates and temporal sequencing of cortical gray matter loss 8as mapped in the teenage years and 8as found to be greatly accelerated in diseased relati/e to healthy teenagers matched for age? gender? and demographics$ %he final profile 8as consistent 8ith the loss pattern in adult schizophrenia$ It suggests a dynamic structural basis for early prodromal symptoms and for the positi/e and negati/e deficit symptoms obser/ed clinically$ Source =ird? 2$ D Alu8ahlia? S$ H19;-I Arch. Gen. Psychiatry *+? 1));-1)-1

Ideas of Reference

Not !anifested

Perse/eration

!anifested Stating the same ans8er o/er and o/er again e/en if questions are different

NEG TIVE SYMPTOMS Alogia !anifested Spea>s /ery little and con/eys litts substance of meaning !anifested No feeling of .oy or pleasure from life or any acti/ities or relationships Possibly a mi5ture of biological? genetic and en/ironmental factors$ Source Alloy? "$=$E Acocella? L$? D =ootzin? R$R$ H199,I$ Abnormal psychology sometimes too much dopamine causes anhedonia &opamine appears to be more closely related to moti/ation than anhedonia$ Source American Psychiatric Association H199*I$

Anhedonia

21

Apathy

Not !anifested

%he chief symptoms of schizophrenia include apathy? a blunting of emotions? delusions and the hearing of internal /oices$ 'nce these symptoms begin? they typically 8a5 and 8ane for the rest of a person@s life$ Source American Psychiatric Association H199*I$ A physical interaction bet8een p"76) and &AA' 8as confirmed in vitro by column binding and glutathione Stransferase pull do8n$ Source Lohnson? L$ B$ D Ascher? P$ H19;6I &iseases that affect the basal ganglia? such as 2untington3s disease and Par>inson3s disease? are associated 8ith affecti/e disturbances and psychosis$ In/oluntary mo/ements? affecti/e disturbance? and catatonia in schizophrenia are phenotypically similar to symptoms found in basal ganglia disorders? suggesting the possibility of basal ganglia pathology in schizophrenia$ Postmortem studies suggest both abnormally high and abnormally lo8 basal ganglia /olumes in schizophrenia and some but not all magnetic resonance imaging H!RII studies ha/e sho8n lo8 caudate /olumes in antipsychotic-nai/e patients$ Se/eral longitudinal !RI studies of basal ganglia /olumes in schizophrenia during treatment 8ith typical or atypical antipsychotic ha/e been described$ Source Am L Psychiatry 199A physical interaction bet8een p"76) and &AA' 8as confirmed in vitro by column binding and glutathione Stransferase pull do8n$ Source Lohnson? L$ B$ D Ascher? P$ H19;6I =ecause gray matter loss is implicated in schizophrenia and is also >no8n to occur in adolescence detailed spatiotemporal maps of these loss processes 8as created$ %his technique unco/ered a dynamic 8a/e of accelerated gray matter loss? spreading from parietal cortices at disease onset to encompass temporal and frontal regions later in the disease$ %he rates and temporal sequencing of cortical gray matter loss 8as mapped in the teenage years and 8as found to be greatly accelerated in diseased relati/e to healthy teenagers matched for age? gender? and demographics$ %he final profile 8as consistent 8ith the loss pattern in adult schizophrenia$ It suggests a dynamic structural basis for early prodromal symptoms and for the positi/e and negati/e deficit symptoms obser/ed clinically$ Source =ird? 2$ D Alu8ahlia? S$ H19;-I Arch. Gen. Psychiatry *+? 1));-1)-1

=lunted Affect

!anifested Restricted emotional feeling? tone and mood$ Not !anifested

Catatonia

Flat Affect

"ac> of #olition

!anifested by patient$ Passi/e facial e5pression and monotonous /oice during e/ery inter/ie8 !anifested &ue to patient3s passi/ity? there is an absence of 8ill and dri/e to ta>e action or accomplish tas>s$

22

/./ Ps"c*o,at*o og" +iagnostic Criteria -At least 1 of the follo8ing - for at least one 8ee>

23

1$ Prominent hallucinations of a /oice )$ =izarre delusions -$ At least ) out of 0 of a$&elusions b$Prominent hallucinations c$ Incoherence or mar>ed loosening of associations d$Catatonic beha/ior e$Flat affect or grossly inappropriate affect -!ar>ed deterioration in functioning after the onset of the disturbance -Schizoaffecti/e &isorder and !ood &isorder 8ith Psychotic Features ha/e been ruled out At least 1 of the follo8ing ) a$ Psychotic for at least si5 months b$ Continuous signs of the disturbance for at least si5 months -If not psychotic for at least si5 months? must ha/e at least ) out of the follo8ing for at least si5 months around the time of the psychosis a$!ar>ed social isolation or 8ithdra8al b$!ar>ed impairment in role functioning c$ !ar>edly peculiar beha/ior d$!ar>ed impairment in personal hygiene and grooming e$=lunted or inappropriate emotion f$ &isorganized speech g$'dd beliefs or magical thin>ing h$Gnusual perceptual e5periences i$ !ar>ed lac> of initiati/e? interests? or energy -Absence of e/idence that an organic factor initiated and maintained this psychotic disturbance Associated Features a$"earning Problem

24

b$2ypoacti/ity c$ Psychotic d$4uphoric !ood e$&ysphoric !ood f$ SomaticFSe5ual &ysfunction g$2yperacti/ity h$7uiltF'bsession i$ Se5ually &e/iant =eha/ior .$ 'ddF4ccentricFSuspicious Personality >$ An5iousFFearfulF&ependent Personality l$ &ramaticF4rraticFAntisocial Personality T",es 1. Catatonic Sc*i5o,*renia A type of Schizophrenia in 8hich the clinical picture is dominated by any of the follo8ing for at least one 8ee> aICatatonic stupor or mutism bICatatonic negati/ism cICatatonic rigidity dICatatonic e5citement eICatatonic posturing '. +isorgani5ed Sc*i5o,*renia A type of Schizophrenia in 8hich the follo8ing occurred for at least one 8ee> aIIncoherence? mar>ed loosening or associations? or grossly disorganized beha/ior bIFlat affect or grossly inappropriate affect &oes not meet the criteria for Catatonic Schizophrenia /. Paranoid Sc*i5o,*renia A type of schizophrenia in 8hich? for at least one 8ee>? there is aIPreoccupation 8ith one or more systematized delusions or 8ith frequent auditory hallucinations related to a single theme bINone of the follo8ing

25

cIIncoherence dI!ar>ed loosening of associations eIFlat affect fI 7rossly inappropriate affect gICatatonic beha/ior hI7rossly disorganized beha/ior 6. 7ndi$$erentiated Sc*i5o,*renia A type of schizophrenia in 8hich? for at least one 8ee>? at least one of the follo8ing occurs a$Prominent delusions b$2allucinations c$ Incoherence d$7rossly disorganized beha/ior - &oes not meet the criteria for Paranoid? Catatonic? or &isorganized %ype$ 8. .esidua Sc*i5o,*renia A type of schizophrenia in 8hich there are a$Absence of the follo8ing aIProminent delusions bI2allucinations cIIncoherence dI7rossly disorganized beha/ior b$Continuing e/idence of the disturbance? as indicated by t8o or more of the follo8ing aI!ar>ed social isolation or 8ithdra8al bI!ar>ed impairment in role functioning cI!ar>edly peculiar beha/ior dI!ar>ed impairment in personal hygiene and grooming eI=lunted or inappropriate emotion fI &isorganized speech gI'dd beliefs or magical thin>ing hIGnusual perceptual e5periences iI !ar>ed lac> of initiati/e? interests? or energy

26

%he course of illness /aries from client to client? and thus the APA has specified fi/e courses of the illness 1$ Sub chronic- the time from the beginning of the disturbance? 8hen the person first began to sho8 signs of

the disturbance more or less continuously? is less than ) years? but at least , months$ )$ -$ Chronic- same as sub chronic? but more than ) years Sub chronic 8ith acute e5acerbation- reemergence of prominent psychotic symptoms in a person 8ith sub

chronic 8ho has been in the residual phase of the disturbance *$ Chronic 8ith acute e5acerbation- reemergence of prominent psychotic symptoms in a person 8ith chronic

8ho has been in the residual phase of the disturbance 0$ In remission- 8hen a person 8ith a history of schizophrenia is free of all signs of the disturbance? in

remission should be cooled$

/.6 Sc*ematic +iagram on t*e Ps"c*o,at*o og" o$ t*e +isease Premorbid Personality Patient is non-alcoholic? does not abuse substances and does not smo>eE she 8as contented as a child but not until she reached adolescenceE patient 8as not physically abused by her family or by anyone$ Predis,osing Factors0 "o8 educational attainment

27

SocialFoccupational dysfunction- For a significant portion of the time since the onset of the disturbance? one or more ma.or areas of functioning such as 8or>? interpersonal relations? or self-care are mar>edly belo8 the le/el achie/ed prior to the onset Hor 8hen the onset is in childhood or adolescence? failure to achie/e e5pected le/el of interpersonal? academic? or occupational achie/ementI$ !alnutrition Childhood rearing en/ironment 7enetic epidemiology of schizophrenia Se5 differences in schizophrenia %he question of 8hether schizophrenia is more common among males is contro/ersial$ Already in (raepelin@s material? females H06KI outnumbered males H*-KI H(raepelin 1919? p$ )-1I$

Age at onset of schizophrenia %he pea> age at onset of schizophrenia occurs in early adulthood H(raepelin 1919 p$ ))*? =leuler 1911 p$ -*1? Sham et al 199*? Castle et al 1990I$ Females tend to ha/e a later age at onset than males HCastle et al 1990I and a different age at onset distribution that among males sho8s a single mar>ed pea> in the early t8enties? 8hile the distribution among females is bimodal 8ith a second pea> in the *0-0*-year age group 7eographical /ariation in the occurrence of schizophrenia %he pre/alence of schizophrenia has been repeatedly obser/ed to be higher in urban than rural areas? but pre/iously this 8as assumed to be caused by social drift - patients 8ith schizophrenia AdriftA into urban areas as a consequence of their illness or its prodromal symptoms HFreeman 199*? %orrey D =o8ler 199+I$

Preci,itating Factors &ysfunctional Family System =eha/ioral Changes Neutral affectE sometimes obser/es eye contact 8ith the student nurseE decreased interest in self-care acti/itiesE pro.ects loose associations? sometimes illogical 8hen spea>ing$

Coping =eha/ior Patient sho8ed suppression? pro.ection? rationalization? denial during the inter/ie8 8hen as>ed about her family$ Signs and S"m,toms

28

Patient manifested emotional ambi/alence? auditory hallucinations? associati/e looseness and slight autism$ No signs of echopra5ia? catatoniaE

/.8 Ps"c*od"namics Bioc*emica $actors %he main biochemical e5planation for schizophrenia is the dopamine hypothesis$ %his idea is based on the role of chemical messengers bet8een ner/e cells called neurotransmitters$ %here seems to be a chemical imbalance in the action of the neurotransmitter dopamine in the brains of those 8ith schizophrenia$ 4/idence for the dopamine hypothesis &rugs Antipsychotic or neuroleptic drugs are >no8n to dampen the effects of dopamine? by bloc>ing dopamine receptors$ %hese help to relie/e symptoms of hallucinations and delusions in many sufferers$ !ore e/idence for

29

the dopamine hypothesis comes from drugs that increase the release of dopamine? for e5ample? amphetamines$ An o/erdose produces symptoms li>e those of schizophrenia$ %his is >no8n as amphetamine psychosis$ Bio ogica causes o$ sc*i5o,*renia A. (enetics %he more closely related the person? the greater the chance that he or she 8ill ha/e schizophrenia$ In addition? the greater the number of relati/es 8ith schizophrenia? the greater is the chance that one 8ill ha/e schizophrenia$ B. Brain abnorma ities Schizophrenics tend to sho8 abnormalities in particular structures in the brain as 8ell as abnormal acti/ity in particular areas of the brain$ %he frontal lobes of many schizophrenics sho8 e/idence of atrophyE and the frontal lobes tend to sho8 reduced acti/ity$ %he frontal lobes are /ery important for reasoning and planning actions$ People 8ith damage to the frontal lobes sho8 many problems 8ith staying on tas> and concentrating$ %he limbic systems of many schizophrenics also sho8 disturbances$ %he limbic system is an area important for emotions? memory formations? and biological dri/es Hsuch as hunger and se5I$ %he amygdala is a structure in the limbic system that is important for emotions such as fear and anger$ It is smaller in many schizophrenics$ %he hippocampus is another structure in the limbic system that is smaller in many schizophrenics$ It is important for the formation of long-term memories$ %here is no structure in the ner/ous system? ho8e/er? that is damaged in all Hor e/en most schizophrenicsI$ Furthermore? many schizophrenics sho8 no ob/ious problems in the brain$ C. Brain bioc*emistr" &opamine acti/ity has been lin>ed to schizophrenia$ %his is because drugs that increase the acti/ity of dopamine tend to produce symptoms of schizophrenia? and drugs that reduce dopamine acti/ity tend to reduce symptoms of schizophrenia$ Schizophrenia and physical brain defects Studies ha/e sho8n enlargement of the cerebral /entricles Hfluid-filled spaces of the brainI in some? but not all people 8ith schizophrenia$ Post-mortem studies ha/e sho8n changes in the amount and distribution of brain cells in some people 8ith schizophrenia$ Researchers thin> these changes might occur before people are diagnosed 8ith the disease - schizophrenia could be a disorder in the 8ay the brain de/elops$ 4rrors in brain de/elopment may remain dormant for years$ %his theory is supported by the fact that schizophrenia is usually diagnosed in young adults before the age of *0? but not in children$ Ps"c*o ogica and socia $actors People diagnosed 8ith schizophrenia come from all types of social bac>grounds? but most are clustered in the lo8er socio-economic groups and li/e in the poorest areas of cities$ %his has led to suggestions that social factors might be important$ %he sociogenic hypothesis suggests that poor social conditions create stresses that trigger schizophrenia in some people$ %he social drift hypothesis suggests that people 8ith schizophrenia are unable to function normally? lose their .obs and drift into lo8er social classes? and poor areas of cities$ Some psychologists suggest that dysfunctional family relationships 8ith Oabnormal3 communication may play a part?

30

creating highly stressful en/ironments$ 2o8e/er? this might be due to difficulties in coping 8ith a member of the family 8ho is mentally disturbed? not the reason for the illness$ Nature and nurture 2eredity is important in most cases of schizophrenia$ Probabi it" o$ +eve o,ing Sc*i5o,*renia Around 0K to 1+K of the biological first-degree relati/es Hparents? children? brothers? and sistersI of a person 8ith schizophrenia also ha/e symptoms$ In the case of a child 8ith t8o schizophrenic parents this rises to around *+K$ A similar rate H-+K to 0+K I holds bet8een the identical t8ins of schizophrenics? but this drops to around 1+K to 10K rate in fraternal t8ins$ =io-mar>ers such as 4ye !o/ement dysfunction are present in 0+K of the relati/es of people 8ith schizophrenia$ %hese indi/iduals carry the mar>er 8ith little of no o/ert symptomatology suggesting that the basis of the disorder may be highly heritable but ha/e /ariable penetrance and are highly dependent on circumstances and epigenetic effects for its e5pression$ Socio ogica T*eories Apart from heredity? other causes of schizophrenia remain little understood$ +iscredited Ideas Schizophrenogenic mothering$ Conflicting messages$ Psychodynamic notions of conflict resolution$

I1. N7.SIN( INTE.1ENTIONS Ps"c*osocia Treatments Antipsychotic drugs ha/e pro/en to be crucial in relie/ing the psychotic symptoms of schizophrenia N hallucinations? delusions? and incoherence N but are not consistent in relie/ing the beha/ioral symptoms of the disorder$ 4/en 8hen patients 8ith schizophrenia are relati/ely free of psychotic symptoms? many still ha/e e5traordinary difficulty 8ith communication? moti/ation? self-care? and establishing and maintaining relationships 8ith others$ !oreo/er? because patients 8ith schizophrenia frequently become ill during the critical career-forming years of life He$g$? ages 1; to -0I? they are less li>ely to complete the training required for s>illed 8or>$ As a result?

31

many 8ith schizophrenia not only suffer thin>ing and emotional difficulties? but lac> social and 8or> s>ills and e5perience as 8ell$ It is 8ith these psychological? social? and occupational problems that psychosocial treatments may help most$ Bhile psychosocial approaches ha/e limited /alue for acutely psychotic patients Hthose 8ho are out of touch 8ith reality or ha/e prominent hallucinations or delusionsI? they may be useful for patients 8ith less se/ere symptoms or for patients 8hose psychotic symptoms are under control$ Numerous forms of psychosocial therapy are a/ailable for people 8ith schizophrenia? and most focus on impro/ing the patient3s social functioning N 8hether in the hospital or community? at home? or on the .ob$ Some of these approaches are described here$ Gnfortunately? the a/ailability of different forms of treatment /aries greatly from place to place$ .e*abi itation =roadly defined? rehabilitation includes a 8ide array of non-medical inter/entions for those 8ith schizophrenia$ Rehabilitation programs emphasize social and /ocational training to help patients and former patients o/ercome difficulties in these areas$ Programs may include /ocational counseling? .ob training? problemsol/ing and money management s>ills? use of public transportation? and social s>ills training$ %hese approaches are important for the success of the community-centered treatment of schizophrenia? because they pro/ide discharged patients 8ith the s>ills necessary to lead producti/e li/es outside the sheltered confines of a mental hospital$ Individua Ps"c*ot*era," Indi/idual psychotherapy in/ol/es regularly scheduled tal>s bet8een the patient and a mental health professional such as a psychiatrist? psychologist? psychiatric social 8or>er? or nurse$ %he sessions may focus on current or past problems? e5periences? thoughts? feelings? or relationships$ =y sharing e5periences 8ith a trained empathic person N tal>ing about their 8orld 8ith someone outside it N indi/iduals 8ith schizophrenia may gradually come to understand more about themsel/es and their problems$ %hey can also learn to sort out the real from the unreal and distorted$ Recent studies indicate that supporti/e? reality-oriented? indi/idual psychotherapy? and cogniti/e-beha/ioral approaches that teach coping and problem-sol/ing s>ills? can be beneficial for outpatients 8ith schizophrenia$ 2o8e/er? psychotherapy is not a substitute for antipsychotic medication? and it is most helpful once drug treatment first has relie/ed a patient3s psychotic symptoms$ Fami " Education #ery often? patients 8ith schizophrenia are discharged from the hospital into the care of their familyE so it is important that family members learn all they can about schizophrenia and understand the difficulties and problems associated 8ith the illness$ It is also helpful for family members to learn 8ays to minimize the patient3s chance of relapse N for e5ample? by using different treatment adherence strategies N and to be a8are of the /arious >inds of outpatient and family ser/ices a/ailable in the period after hospitalization$ Family Jpsychoeducation?C 8hich includes teaching /arious coping strategies and problem-sol/ing s>ills? may help families deal more effecti/ely 8ith their ill relati/e and may contribute to an impro/ed outcome for the patient$ Se $9!e , (rou,s

32

Self-help groups for people and families dealing 8ith schizophrenia are becoming increasingly common$ Although not led by a professional therapist? these groups may be therapeutic because members pro/ide continuing mutual support as 8ell as comfort in >no8ing that they are not alone in the problems they face$ Selfhelp groups may also ser/e other important functions$ Families 8or>ing together can more effecti/ely ser/e as ad/ocates for needed research and hospital and community treatment programs$ Patients acting as a group rather than indi/idually may be better able to dispel stigma and dra8 public attention to such abuses as discrimination against the mentally ill$ Family and peer support and ad/ocacy groups are /ery acti/e and pro/ide useful information and assistance for patients and families of patients 8ith schizophrenia and other mental disorders$ A list of some of these organizations is included at the end of this document$

1.Care (uide o$ Patients )it* Sc*i5o,*renia Influencing the client@s disturbances of thin>ing deciphering meaning reinforcing reality promoting clarifications Interrupting the client@s disturbances of feelings role modeling de/eloping tolerance

33

&iminishing the client@s social or beha/ioral disturbances de/eloping trust encourage self-care dealing hostility

Inter/entions for delusions do not argue 8ith the patient establish and maintain reality 8ith the patient teach client positi/e self-tal> and positi/e thin>ing

Inter/entions for hallucinations help present and maintain reality by frequent contact and communication elicit description of hallucination engage client in reality-based acti/ities

%each client social s>ills needed for interaction? such as maintain eye contact 8ith the person you are con/ersing 8ith listen attenti/ely to the spea>er ta>e turns in tal>ing proper table manners and etiquette

'. Actua Patient Care '.1 BL%

34

'.' NCP Needs:,rob ems:c ues 1$ Psychologi c deficit A$ Altered thought processes Nursing +iagnosis Altered thought process paranoid delusions related to In schizophrenia? client3s thought processes becomes N7.SIN( CA.E PLAN Scienti$ic Objectives Basis o$ Care After ) 8ee>s of nurse N patient interaction ? the patient Nursing Actions !easures to de/elop trust 1$ con/ey acceptance of client3s need for 1$ the client must understand that you do not /ie8 the idea .ationa e

35

Patient is unable to remember significant e/ents in his life before admission in Psychiatric 8ard$ Student nurse Jpila mo >abuo> imo igsuonPC Patient J igsuonPC Student nurse Jo? mga pila manP "imaPC Patient JlimaC Student nurse Jlima or onomPC Patient JonomC 4asily gets distracted &emonstrat es flat affect

inability to trust others? possible hereditary or biochemical factors

disoriented the continuity of thoughts and information process is disoriented$ %he client may suddenly stop tal>ing in the middle of a sentence and remain silent for se/eral seconds to a minute$ %he client may state that she belie/es others can hear her thoughts or that others are placing thoughts in client3s mind against her 8ill$ Clients 8ith schizophrenia usually e5periences delusions Qfi5ed false beliefs that ha/e no basis in realityR in the psychotic phase of the illness$ Source

8ill be able to 1$ begin to de/elop trust in student nurse as e/idenced by patient3s /erbalization of feelings and concerns$

false beliefs but that you do not share the belief$ )$ do not argue or deny the belief

as real HPsychiatric !ental 2ealth Nursing )nd edition by !ary C$ %o8nsend? page 1)1I )$ arguing or denying the belief ser/es no useful purpose as delusional ideals are not eliminated by this approach HPsychiatric !ental 2ealth Nursing )nd edition by !ary C$ %o8nsend? page 1)1I

-$ reinforce and focus on reality? tal> about real people and real e/ents

-$ discussions that focus on the false beliefs are purposeless and useless and may e/en aggra/ate the symptom of psychosis HPsychiatric !ental 2ealth Nursing )nd edition by !ary C$ %o8nsend? page 1)1I

*$ a/oid physical contact? a/oid laughing? 8hispering? or tal>ing quietly 0$ do not ma>e promises feedbac> that

*$ to pre/ent the client from feeling threatened HPsychiatric !ental 2ealth Nursing )nd edition by !ary C$ %o8nsend? page 1)1I 0$ bro>en promises reinforce the client3s mistrusts of others

36

Psychiatric !ental 2ealth Nursing by Sheila #idebec> page -+;

you cannot >eep

HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -10I

,$ gi/e positi/e feedbac> for client3s success

,$ to enhance client3s sense of 8ell being HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -10I

6$ be consistent in setting e5pectations? enforcing rules and so forth

6$ clear? consistent limits pro/ides a secure structure for the client HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -10I

Needs: Prob ems: Cues =$ Impaired #erbal Communic ation patient speech is incomprehensible

Nursing +iagnosis Impaired #erbal Communication perse/eration and echolalia related to neurologic

N7.SIN( CA.E PLAN Scienti$ic Objectives Basis Impaired /erbal for the schizophrenic? language is primarily a means of self e5pression? o$ Care )$ e5press ideas? needs? concerns as e/idenced by minimal looseness of association?

Nursing Actions b$ measures to promote /erbalization of ideas? needs and concerns clearly 1$ attempt to

.ationa e

1$these techniques

37

patient >eeps on saying C!arcosC upon ans8ering many questions patient 8as able to maintain an eye to eye contact 8ith the student nurse during the con/ersation patient mumbles 8ords that the student nurse cannot understand patient sometimes refuses to ans8er questions as>ed

impairment secondary to schizophrenia

rather than means of communication %he schizophrenics characteristics bizarre speech results from the interaction of /arious factors or cogniti/e processes$ Source Comprehensi/e te5tboo> of PsychiatryF I#E * edition page ,;,
th

neologisms and concrete thin>ing

decode incomprehensi ble communication patterns? see> /alidation and clarification )? maintain non N /erbal communication is not /ery successful

re/eal ho8 the client is being percei/ed by others HPsychiatric !ental 2ealth Nursing by !ary C$ %o8nsend page 1))I )$presence of nurse is a contact 8ith reality for the client and can also demonstrate the nurse3s interest and care for the client HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -1-I

-$ call client by name? ma>e references to the day and time and comment on the en/ironment

-$they3re all helpful 8ays to continue to contact 8ith a client ha/ing problems 8ith reality orientation and /erbal communication HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -1-I *$clients 8ho are left

*$ maintain frequent contact and spent time 8ith client

alone for long eriods of time become more deeply in/ol/ed in their psychosis HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -1-I

38

0$to promote 0$ listen for themes? or recurrent atatements? as> clarifying questions or cues ,$ let client >no8 that her meaning is not clear increased understanding HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -1-I ,$it is ne/er useful to pretend to unrestand it /iolates the trust relationship bet8een client and nurse HPsychiatric !ental 2ealth Nursing by Sheila #idebec> page -1-I

Needs: Prob ems: Cues C$Sensory N perceptual Alteration Patient reports auditory an /isual hallucinations Onaa bayay 8a>8a>

Needs: Prob ems: Cues Sensory N Perceptual Alteration AuditoryF /isual hallucinations relate to constant e5posure to o/er8helming

N7.SIN( CA.E PLAN Needs: Needs: Prob ems: Cues Schizophrenic patients see unable to sort out and process the great mass of sensory information to Prob ems: Cues -$ /erbalize description of perception

Needs: Prob ems: Cues C$ promote /erbalization of description of perceptions 1$ nurse must determine 8hat the client

Needs: Prob ems: Cues

1$this 8ill increase nurse3s understanding of the nature of the

39

>abalo >a anaPC Patient easily get distracted

sensory stimuli

8hich all of us are constantly e5posed$ As a result? stimuli o/er8helm the meager resources the person has for information processing$

is e5periencingE 8hat the /oices are saying or 8hat the client is seeing )$ obser/e client for signs of hallucination

client3s feeling and beha/ior HPsychiatric mental 2ealth Nursing by Sheila "$ #idebec> page -1*I )$early inter/ention may pre/ent aggressi/e response to command hallucinations$ HPsychiatric !ental 2ealth Nursing by Sheila "$ #idebec> page -1*I

-$ a/oid touching client 8ithout 8arning

-$client may percei/e touch as threatening and may respond in an aggressi/e manner HPsychiatric !ental health Nursing by Sheila #idebec> page -+9I

*$demonstrate an attitude of acceptance 8ill encourage the client to share the concepts of the hallucination 8ith the nurse 0$ do not reinforce the

*$to pre/ent possible in.ury to client or others from command hallucinations HPsychiatric !ental 2ealth Nursing by !ary C$ %o8nsend page *+;I

0$client must accept the perception as

40

hallucination$ "et the client >no8 that you do not share the perception ,$2elp client understand the connection bet8een an5iety and hallucination 6$ try to distract the client a8ay from hallucination li>e focusing on a sub.ect 8here is interested 8ithE read her stories she li>e to listen

unreal before hallucination can be eliminated HPsychiatric !ental 2ealth Nursing by S$ #idebec> page -10I ,$if client can interrupt escalating an5iety? hallucinations may be pre/ented HPsychiatric !ental 2ealth Nursing )nd edition by !ary C$ %o8nsend page *+;I 6$in/ol/ement in interpersonal acti/ities and e5planation$ HPsychiatric !ental 2ealth Nursing? )nd edition by !ary C$ %o8nsendI

41

'./ +T. +rug: +ose: .oute : Fre;uenc" Chlorproma N zine H %horazineI 1++ mg 1 tab 2$S p$o ,pm Actions %hese drugs are C assi$ication: %ec*anism o$ Action Classification Antipsychotic dimenthyl -amino type phenothiazine +.7( T!E.APE7TIC .ECO.+ Indications: Contraindica9 Princi, es o$ Care tions: Side E$$ects Indications 1$ obtain baesline 1$ hourly monitoring )$ monitor /ital signs *$ instruct patient to a/oid ta>ing alcohol treatment Eva uation

management of manifestations measures of blood of psychotic disordersE control pressure before of manic phase of manic N depressi/e illness?relief of preoperati/e restlessnes? and apprehensions? ad.unct in treatment of tetanus? se/ere and monitor regularly )$ alcohol should not be ta>en or used

starting the therapy -$ full diet

42

+rug: +ose: .oute : Fre;uenc"

C assi$ication: %ec*anism o$

+.7( T!E.APE7TIC .ECO.+ Indications: Contraindica9 Princi, es o$ Care tions: Side E$$ects

treatment

Eva uation

Action thought to 8or> by beha/ioral problems in children -$ relie/e dry mouth bloc>ing post receptors in the basal ganglia? hypothalamus? limbic system? brainstem and medulla$ Also demonstrates cholinergic? alpha adrenergic? and histamine receptors$ Antipsychotic Contraindication 8ith sugarless gum or hard candy synaptic dopamine allergy to chlorpromazine?

comatose or se/erly depressed *$ use of sun bloc>? state? bone marro8 depression? sunglasses?and circulatory collapse?par>insons protecti/e clothing? disease Side 4ffects CNS dro8siness? insomia? /ertigo? headache? ata5ia? C# hypotension? orthostatic hypotension?tachycardia? bradycardia 44N% nasal congestion? glaucoma? blurred /ision to a/oid photosensiti/ity reactions 0$ protect oral concentrate from light

/erifyingaffinity for slurring

effects may also be 4N&'CRIN4 related to inhibition lactation? breast engorgement? of dopamine N mediated transmission of the synapses$ '.6 SOAPIE C*arting &ate 1)+,+, SOAPIE 1 S ' - J ablihi >o<C -Patient seen 8al>ing bac> and forth inside the (amagong Bard? he still loo>s dirty and ha/en@t ta>e a bath yet? his nails are uncut? he smells bad and has dirty fingers galactorrhea? changes in libido 7I dry mouth? sali/ation? nausea? /omiting? anore5ia incontinence? male impotence

neutral impulses at 7G urinary retention? polyuria?

43

-Self N care deficit bathing? grooming related to perceptual or cogniti/e impairment secondary to schizophrenia

P I 4

-%o promote proper hygiene -encouraged client to perform independently as many self N care acti/ities as possible pro/ide positi/e reinforcement for independent accomplishments pro/ided assistance 8ith bathing and grooming e5plained to patient the negati/e effects of poor hygiene -%he patient 8as participati/e in performing self - care acti/ities$

&ate 1)+6+, SOAPIE ' S ' -J ligo >o<C -Patient 8as seen sitting do8n at one side of the 8ard$ 2e can be obser/ed 8earing a red %-shirt 8ith blue slee/es? a pair of blac> shorts and a pair of green slippers$ 2is facial hair has been >ept short but still someho8 loo>s rough$ Gpon 8al>ing? he slumps on his shoulders and mo/es slo8ly$

44

-Impaired #erbal Communication Perse/eration related to neurologic impairment secondary to schizophrenia

P I

-%o promote proper /erbal communication -Called client by nameE ma>e references to the day and time and comment on the en/ironmentE demonstrated an attitude of acceptance to the patient to encourage him to share his thoughtsE maintained frequent contact and time spent 8ith patientE listened attenti/ely to 8hat the patient saysE as>ed the client 8hen its meaning is not clear or clarify on 8hat he saysE student nurses focuses on a con/ersation of a topic that interests him

-Patient 8as able to e5press thoughts and feelings in a safe manner 8ith minimized flight of ideas$

'.8 Process .ecording Patient !arcelino !arcos a$>$a$ Catalino =agayo HFebruary 0? )++)I Age -; yrs old Se5 !ale Chief Complaints Schizophrenia? Perse/eration P.OCESS .ECO.+IN( 1 '=L4C%I#4S &ate 1)+,+,

45

7eneral 'b.ecti/es After ) 8ee>s of holistic student nursing-client interaction? the patient 8ill be able to de/elop trust 8ith the student nurse? impro/e hisFher capabilities of performing normal acti/ities of daily li/ing? increase ability of social interaction and utilize coping s>ills in dealing 8ith stressful situations$ Specific 'b.ecti/es After -+-*0 minutes of holistic student nurse-client? the patient 8ill be able to 1$ introduce himself to the student nurse $ )$ share little information about himself to the student nurse$ -$ cite the rules and purpose of the interaction$ *$ agree 8ith the nurse regarding the time? date and location of the ne5t interaction$ 0$ e5press his feelings after the interaction$ SETTIN( &ate &ecember ,? )++, %ime +9 -0-+9 *) "ocation (amagong Bard? #icente Sotto !emorial !edical Center Psych Bard

APPEA.ANCE !r$!arcelino !arcos is a -; year old male patient 8ho 8as around 03*C in height 8ith a fair comple5ion? medium-built and appro5imately 8eighting 1*0 lbs$ 2e 8as in the (amagong Bard together 8ith - other patients$ 2e 8as 8earing a blue %-shirt 8ith many stains and a pair of dar> bro8n shorts$ 2e hasn3t ta>en a bath yet and he loo>s /ery messy$ %here are crusts on his eyes? his fingernails and toenails 8ere long and dirty? and his arms? hands and feet 8ere greasy$ 2e has no physical deformities or 8hatsoe/er$

BE!A1IO.

46

%he patient? as 8e 8ere tal>ing? 8as al8ays holding on the grilled door of the 8ard$ 2e doesn3t mo/e that much from his position but he stares at people a lot$ Although he tries to ans8er the questions being as>ed? his ans8ers 8ere irrele/ant because he 8as repeating his name o/er and o/er again$ 2e doesn3t pay attention and instead forces me to open the 8ard door$ 2e 8as stubborn at the time and /ery persistent$ CO%%7NICATION %he patient 8as responsi/e but he had unusual speech patterns$ 2e 8as e5periencing perse/eration of his name J!arcosC 8ith 8hich he repeatedly uttered e/ery time a question 8as as>ed$ %he client 8as incoherent and he spea>s moderately loud? though 8ith a lo8 and hus>y /oice ma>ing it difficult to communicate$ I%PLICATION %he patient needs to undergo remoti/ation therapy to be reoriented 8ith the time and surroundings for him to be more participati/e and coherent$ Constant remoti/ation 8ill enable the patient to be more a8are about himself? the en/ironment and current situations$ INTE.ACTION Student9Nurse#s 1erba and Non91erba Communications !aayong buntag >animo manoy? a>o di-ay si Rico !iguel "ouis #$ %amala$ A>o imohang student nurse gi>an sa Cebu &octors3 Gni/ersity$ HSmiling and loo>ing at patient in the eyeI !anong? mangutana unta >o? unsa di-ay imong pangalanP !arcosP Gnsa di-ay imong completing pangalan manongP !arcos !arcos See>ing information RestatingF See>ing clarification and /alidation %his is to confirm his identity and Repeating 8ords can encourage the patient to tal> and 8ill let him feel that someone is listening to him$Clarify things 8hich are to be /erified$ Hpatient stared at the student nurseI Patient#s 1erba and Non9 1erba Communications T*era,eutic Communications: +e$ense %ec*anisms 7i/ing recognition 7reeting and recognizing the patient is a 8ay of establishing a good interaction$ Ana "sis

47

AhhhS pila di-ay atong edad >aron !anong !arcosP

!arcos

See>ing information

Patient gi/es out 8rong information about the question

!anong !arcos? >anus-a >a nata8o di-iayP

!arcos lagi

See>ing information

As>ing questions in a different aspect might unloc> the ans8er

Nya? >umusta man atong pamati >aron !aonongP

!arcos< Ablihi >o diri bi<

4ncouraging e5pression

As>ing the patient ho8 he feels 8ill let him >no8 somebody cares for him$

A8? dili man gud a>o ang tig abli !anong$ Gnsa di-ay ang hinungdan nganung gisulod >a ani nga 8ardP Cge !anong? bali>on lang ti>a unya$ Salamat !anong ha AF%4R A S2'R% L'S2GA 7' !aayong buntag >animo manoy? a>o di-ay si Rico !iguel "ouis #$ %amala$ A>o imohang student nurse gi>an sa Cebu &octors3 Gni/ersity$ HSmiling and loo>ing at patient in the eyeI (umusta na imong pamati !anongP Cge !anong !arcos? bali> lang nya ta og istorya ugma

Ablihi >o biS

45ploring

%his 8ill help the patient >no8 the reason 8hy the patient 8as detained

Hstared at student nurseI

7i/ing information

%his 8ill let the patient >no8 that you 8ill return in a short 8hile$

B2I"4S N'B BI%2

%24 C'!PAN:

'F !R$

Ablihi ning purtahan bi Hstaring at the student nurseI

7i/ing recognition

Attempting to re-inter/ie8 the patient after a short 8hile of failed attempts may change the patient3s cognition and perception

Ablihi >o diri bi

4ncouraging e5pression

%he patient 8as still unresponsi/e %his 8ill inform the patient of the ne5t interaction

Hblunt affect on the face of patientI

7i/ing information

48

ha mga ingon-aron gihapon orasa mga alas 9 y medya$ Salamat >ayo sa imong oras ug pagtubag !anong !arcos$ Hsmiling at patientI

E1AL7ATION0 %he ob.ecti/es set by the student-nurse 8ere not carried on due to the patient3s present beha/ior$ Attempts of establishing rapport 8ith the patient failed and 8ill need to be done again during the ne5t interaction$ No rele/ant data 8as collected during the acti/ity$ %he patient 8as also e5cluded from the usual morning acti/ities such as the morning stretch due to inappropriate beha/ior 8hich includes manipulation of student nurses? se5ually harassing them and other patients$ Patient is no8 inside the (amagong Bard and classified as unmanageable$

Patient !arcelino !arcos a$>$a$ Catalino =agayo HFebruary 0? )++)I Age -; yrs old Se5 !ale Chief Complaints Schizophrenia P.OCESS .ECO.+IN( ' '=L4C%I#4S Specific 'b.ecti/es After -+-*0 minutes of holistic student nurse-client? the patient 8ill be able to

&ate 1)+6+,

49

1$restate hi name to the student nurse )$/erbalize his feelings to8ards the inter/ie8 to the student nurse -$share information about himself *$reaffirm the rules and purpose of the interaction$ 0$agree 8ith the nurse regarding the time? date and location of the ne5t interaction$ ,$articulate his feelings after the interaction$ SETTIN( &ate &ecember 6? )++, %ime +9 -)-+9 *+ "ocation !ale acti/ity grounds? #icente Sotto !emorial !edical Center Psych Bard

APPEA.ANCE %he patient no8 had already ta>en his bath$ 2is nails? both in his hands and feet? are no8 trimmed do8n and neat$ 2e can be obser/ed 8earing a red %-shirt 8ith blue slee/es? a pair of blac> shorts and a pair of green slippers$ 2is facial hair has been >ept short but still someho8 loo>s rough$ Gpon 8al>ing? he slumps on his shoulders and mo/es slo8ly$ BE!A1IO. %he patient still has poor cognition and thought process$ As obser/ed during the morning stretch? he can hardly catch up 8ith the e5ercises performed by the other patients$ =ut impro/ement has been noted do8n since he is no8 more manageable compared to yesterday$ %hough he has difficulty in follo8ing instructions conducted by the student nurse? he is still 8illing to .oin the art therapy spearheaded by !edina College$

50

CO%%7NICATION Communication has impro/ed a little since he no8 ans8ers some of the questions e/en though the data he pro/ides is quite different from 8hat has been charted$ 2e spea>s in a lo8? rough /oice that can be barely heard and needs follo8-up questions to be confirmed$ I%PLICATION %he patient needs to be constantly e5posed and reoriented 8ith the date? time and place? and to /arious stimuli to enhance his cognition and perception$ compared to staying inside the 8ard$ INTE.ACTION Student9Nurse#s 1erba and Non91erba Communications !aayong buntag >animo manoy$ (aila pa>a na>oP A>o di-ay si Rico !iguel "ouis #$ %amala? ang imohang student nurse gi>an sa Cebu &octors3 Gni/ersity$ HSmiling and loo>ing at patient in the eyeI !anong? mangutana unta >o? unsa di-ay imong pangalanP Ah =agayo? >umusta man imong pamati >aron parti sa atong pag-istorya >aronP Gnya? =agayo mangutana >o? pila naman imong edadP AhhS sing>8enta na di-ay >aP &ili >o mutu-o oi$ =atanon pa lagi >a ug na8ng$ =agayo? taga-asa di-ay >aP %aga Carcar See>ing '? sing>8enta sing>8enta See>ing information RestatingF/oicing doubt !aayo raman =agayo See>ing information 45ploring %his is to confirm his identity and %his 8ill help the patient /erbalize his feelings to8ards the acti/ity %his 8ill as> the patient as basis for baseline data 45pressing uncertainty as to the reality of the client3s perceptions As>ing basic questions can Regular e5posure may significantly impro/e the patient3s condition

Patient#s 1erba and Non9 1erba Communications Hsmiles to student nurseI

T*era,eutic Communications: +e$ense %ec*anisms 7i/ing recognition

Ana "sis

7reeting and recognizing the patient is a 8ay of establishing a good interaction$

51

information

assess for memory and cognition

Nya? >abalo >a unsa adla8a >aron =agayoP

Hsmiles to student nurseI

See>ing information

%o >no8 if the patient is a8are of basic information uch as date today$

(abalo >a =agayoP

Bala Hstared at student nurseI

Restating

%his is to confirm if patient has heard the question as>ed by the student nurse

I>a-pito ron sa &isyembre? )++, =agayo$ Cge!anong? muapil ta >aron sa Art therapy ha$ Salamat >ayo sa imong oras$ !agistorya lang nya ta ug bali> ugma ha$ !ga ingon aron gihapon orasa$ Alas 9 y medya$ E1AL7ATION0

' Hnods slo8ly as if agreeing to student nurseI ' Hpatient nodsI

7i/ing recognition

%his 8ill reorient the patient 8ith today3s date

7i/ing information

%he acti/ity 8as ended and patient 8as briefed 8ith the ne5t acti/ity

Rapport has been established 8ith the patient and the con/ersation has significantly impro/ed$ Speech pattern has no8 returned to normal? though? the data the patient has gi/en is still incomplete$ Constant e5posure and reorientation is still required to further impro/e the patient3s condition and thought process$ Patient !arcelino !arcos a$>$a$ Catalino =agayo HFebruary 0? )++)I Age -; yrs old Se5 !ale Chief Complaints Schizophrenia? echolalia? P.OCESS .ECO.+IN( / '=L4C%I#4S Specific 'b.ecti/es After -+-*0 minutes of holistic student nurse-client? the patient 8ill be able to &ate 1)1)+,

52

1$ articulate feelings of loneliness )$ cite factors that precipitate to feelings of loneliness -$ identify coping acti/ities on the e/ent of stressful situation *$ /erbalize feelings especially 8ith regards to his stay in this institution 0$ agree on the time? place and date of the ne5t interaction SETTIN( &ate &ecember 6? )++, %ime +; 1;-+9 *) "ocation !ale acti/ity grounds? #icente Sotto !emorial !edical Center Psych Bard

APPEA.ANCE =efore ta>ing a bath %he patient 8as seen standing near the large bathing quarters$ 2e 8as 8earing a filthy yello8 shirt and underneath it is the shirt he 8as 8earing yesterday$ 2e 8as also 8earing the same short pants he 8as 8earing the day before$ 2is s>in 8as dirty and he had a urine-li>e smell$ After ta>ing a bath %he patient no8 8as cleaner$ 2e 8as no8 8earing a pin> long-slee/ed polo? grey pants and a ne8-loo>ing pair of grey slippers$ BE!A1IO.

53

!r$ !arcos 8as /ery obedient from the time I bathed him until the time 8e finished conducting the interaction together 8ith fello8 student nurse? !s$ (athrina Nisnisan$ 2e 8as compliant and /ery manageable$ Also? he 8as /ery passi/e and depended on the information that has to be gi/en to him$ Still? his cognition and thought process is lo8 but progress has been obser/ed$ Coordination has been noted do8n as lo8 also$ CO%%7NICATION It has been obser/ed that he ans8ers questions 8ell if he understands it but tends to repeat the questions if he didn3t quite understand them? a manifestation of echolalia$ 2e spea>s in a lo8 /oice and most of the time? 8as /ery responsi/e$ I%PLICATION Constant grooming and hygiene impro/ements can help the patient from de/eloping sic>ness? infection and other disorders$ Also? reorientation and remoti/ation 8ill assist in de/eloping his thought process$ =oth passi/e and acti/e e5ercises must be performed to ensure the patient3s muscle function$

INTE.ACTION Student9Nurse#s 1erba and Non91erba Communications Inside 2all8ay !aayong buntag dira !arcos? nag-unsa man >a dihaP 7anahan >a maligoP Hstudent nurse smiling at patientI Ah o>

Patient#s 1erba and Non9 1erba Communications

T*era,eutic Communications: +e$ense %ec*anisms %a>en a bath 7i/ing recognitionFSee>ing information

Ana "sis

=efore patient had !aligo >o Hloo>ing at other patients ta>ing a bathI

7reeting and recognizing the patient is a 8ay of establishing a good interaction$

accepting

Ac>no8ledgement of the patient3s request

After Nya unsa may nabati nmo >aron noy nga nahuman na>ag >aligoP

%a>ing !ayo na a>ong pamati >aron

A See>ing information

=ath %he patient 8as satisfied after ta>ing a bath

54

!anoy !arcos? >umusta naman imong pamilyaP (aila pa>a sa imong pamilya !anoy !arcosP

HmuteI

See>ing information

As>ing about families can sho8 if the patient is lonely As>ing the patient can help assess his memory and if he3s longs for them

(aila

See>ing information

Cge? pila mo >abuo> sa pamilyaP >insa man claP

&aghan

45ploringF7i/ing general leads

%o del/e into a patient 8ith a superficial le/el of communication

!ga pila !anoyP !ga limaP

"ima

45ploringF See>ing clarification

%his is to confirm patient3s ans8er %his is to confirm patient3s ans8er An alternate method to ma>e sure of the patient3s ans8er is to cross e5amine them

"ima or onomP

'nom

See>ing clarification

A8? mao baP Cge? >insa may mga pangalan sa imong mga igsuonP

Si Nelia? si Luana ug si Lerome

See>ing information

Gnya !anoy !arcos? giminga8 na>a nilaP

7iminga8 nasad

See>ing information

%his is to let the patient /erbalize about his feelings of loneliness and if his family is one of the factors

Asa na diay to sila !arcosP

Naa sa dagat

See>ing information

%o repeat the main idea of 8hat the client has said %his is to assess patient3s memory of his parents

Naa sila sa dagatP Nag-unsa man sila ngadtoP Nya? imong mama ug papa !arcos? asa naman silaP

Naa sila sa dagat

Restating

Naa sa tulay

See>ing information

%o identify patient3s coping mechanisms to loneliness and to >no8 if he has been performing this to relie/e himself of stress

55

Naa ba >ay buhaton >ung ma>abati >a ug >aminga8 Noy !arcosP Naa >ay buhaton marcos >ung minga8on >a sa imong pamilyaP

HmuteI

See>ing information

%his to agree 8ith patient3s idea

7iminga8

Restating

%his is to as> for patients memory on his stay I the institution and as a preparatory in as>ing for his feelings during his stay

A8 o cge

) >a tuig

Accepting

%his is to >no8 ho8 the patient feels inside the psych 8ard$

Pila na>a >atuig diri NoyP

!ayo raman$ giminga8 sad

See>ing information

%his 8ill inform the patient of the ne5t interaction

Nya Noy? sa imong ) >a tuig nga naa >a diri? unsa man imong gibatiP Gnsa man imong pamina8 aning lugara ug sa mga tao diriP Ahh o cge !anoy !arcos$ Salamat >ayo sa imong oras$ !ag-istorya lang nya ta ug bali> ugma ha$ !ga ingon aron gihapon orasa$ Alas 9 y medya$ 4#A"GA%I'N

' cge

See>ing informationF 45ploring

AcceptingFgi/ing information

%he patient? though still manifesting disorganized thoughts? sho8ed feelings of loneliness inside the institution$ %he patient still >no8 a little about his family and seemed to yearn for them$ 2e still has problems concerning coordination and a8areness therefore constant remoti/ation must be performed$ Gnusual speech pattern no8 included echolalia in 8hich the patient tends to repeat the question of the student nurse$

56

Patient !arcelino !arcos a$>$a$ Catalino =agayo HFebruary 0? )++)I Age -; yrs old Se5 !ale Chief Complaints Schizophrenia? echolalia? P.OCESS .ECO.+IN( 6 '=L4C%I#4S Specific 'b.ecti/es After -+-*0 minutes of holistic student nurse-client? the patient 8ill be able to

&ate 1)1)+,

57

1$share his e5periences inside the institution )$/erbalize his feelings to8ards the routine acti/ities -$impart about his relationships 8ith the other patients *$articulate his feelings after performing and benefiting from daily acti/ities 0$agree on the time? place and date of the ne5t interaction SETTIN( &ate &ecember 1)? )++, %ime +; 1)-+9 -6 "ocation !ale acti/ity grounds? #icente Sotto !emorial !edical Center Psych Bard

APPEA.ANCE %he patient 8as seen under another patient3s bed$ 2e loo>ed filthy and 8ore the same clothes that he 8as 8earing yesterday 8hich included a pin> polo and grey shorts$ After ta>ing a bath? he 8as 8earing a clean grey shirt? a pair of purple slippers and clean 8hite shorts$ BE!A1IO. %he patient 8as /ery obedient$ %hough he had slo8? passi/e mo/ements? he still complied 8ith the request of the student nurse$ 2e 8as manageable and easy to be 8ith$ Perception 8as impro/ing especially 8ith regards to pain$ 2e reported about pain in his patellar region$ CO%%7NICATION

58

%he client is communicati/e and responsi/e but still manifests unusual speech patterns such as echolalia and /erbigeration$ 2e still tends to repeat after the student nurse 8hen he doesn3t quite understand the question$ 2e had a less than audible /oice no8 compared to yesterday 8hich 8as 8ell-modulated$ I%PLICATION Constant interaction 8ith people can help the patient a lot$ Remoti/ating therapies and reorientation programs? as much as possible? should be ma5imized to ensure patient3s slo8 progression to promote a8areness and cognition$ INTE.ACTION Student9Nurse#s 1erba and Non91erba Communications !aayong buntag !anoy !arcos? >amusta naman atong pamati >aronP 7anahan >a maligoP Hsmiling at patientI After Nya noy !arcos? unsa man atong pamati >aron na nahuman na>a ug >aligoP Nya !arcos? mangutana >o nimo? >amusta naman ang imong ) >a tuig sa sulod aning institutionP Nganong na>asulti man >ag mayo ra !arioP !ayo ra 45ploring &el/ing deep into the patient3s idea 8ill help him /erbalize his feelings Sa imong ) >a tuig diri !ario? daghan na>a ug amigoP &aghan na See>ing information %his as>s the patient more about the relationships 8ith other !ayo ra See>ing information %a>ing !ayo lang A See>ing information =ath As>ing the patient ho8 he3s doing 8ill let him /erbalize 8hat he3s feeling %his 8ill assess about the patient3s e5periences in the institution !aligo >o Hstanding up from beneath another patient3s bedI

Patient#s 1erba and Non9 1erba Communications

T*era,eutic Communications: +e$ense %ec*anisms 7i/ing recognitionFSee>ing information

Ana "sis

7reeting and recognizing the patient is a 8ay of establishing a good interaction$

59

patients (insa man imong mga amigo diri !arcosP Amigo See>ing information

!arcos? unsa man buhaton ninyo dri >ada adla8P (anang gi>an sa buntag hantod hapon$ Gnsa paP

!angaon ng>a buntag

See>ing information

%his is in preparation for the patient to be as>ed later ho8 he feels about the daily acti/ities

!aligo

'ffering general leads

%he patient ans8ered in fragments thus the need to be follo8ed up

Cge unsa pa lainP

HmuteI

'ffering general leads

&iba !arcos mag-e5ercise man sad moP Nya !arcos? lami imong gi>aon ganihaP Gnsay sudanP

!ag-e5ercise

7i/ing information

%his helps the patient remember other ideas$

"ami ang utan

See>ing information

%his lets the patient /erbalize ho8 he feels about the meals ta>en in the morning

Ahh lami diayP

Nalinga8 ra

Accepting

%his con/eys an attitude of reception and regard

Nya nalinga8 ra>a sa mga bulohaton ninyo >ada buntag diri !arcosP Bala raba >a >apuyi aning mga bulohaton !arcosP

Sa>it a>ong tuhod Hrubs >neesI

See>ing information

%his lets the patient /erbalize ho8 he feels about routine acti/ities

Sa>it man

See>ing information

60

A8 sa>it imong tuhodP Ngano mana !arcosP

Hsits on near the tree and nodsI

RestatingF 45ploring

%his let the patient >no8 that someone cares for them$

A8 cge? a>o lang nyang ingnon ang nurse ha$ "ing>od lang usa diri$ Cge !arcos? >aon sa o nya naa ray tubig dri$ Inom lang$ Hhanding crac>ers to patientsI Nya? unsa may pamati nmo paghuman nimo ug >aonP !arcos? mag>ita lng nya ta ug bali> ugma$ !ga ingon ani gihapon orasa ug diri ghapon$ Storya ta ug bali>$ E1AL7ATION0

Hta>es crac>ers and starts to nibble on themI

7i/ing information

=usog na Hsmiles to student nurseI

%his as>s the patient ho8 he feels after eating

'

See>ing information 7i/ing information

%his 8ill inform the patient of the ne5t interaction

All ob.ecti/es 8ere carried out by the student-nurse$ Gnusual speech patterns still manifested during the interaction and there 8ere times 8hen the ans8ers 8ere /ery difficult to e5tract from the patient$ %hough not much information 8as collected? another problem materialized in the form of .oint pains in the patellar region$ Patient !arcelino !arcos a$>$a$ Catalino =agayo Age -; yrs old Se5 !ale Chief Complaints Schizophrenia? echolalia? /erbigeration? perse/eration P.OCESS .ECO.+IN( 8 '=L4C%I#4S Specific 'b.ecti/es After -+-*0 minutes of holistic student nurse-client? the patient 8ill be able to &ate 1)1-+,

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1$maintain a good 8or>ing relationship 8ith the student nurse )$articulate a positi/e outloo> to8ards self after all interactions -$e5press feelings about the interactions that 8ere conducted *$e/aluate the student nurse3s performance basing on the care and interactions that 8ere made 0$agree on the time? place and date of the ne5t interaction S4%%IN7 &ate &ecember 1-? )++, %ime +; 1*-+9 +0 "ocation !ale acti/ity grounds? #icente Sotto !emorial !edical Center Psych Bard

APPEA.ANCE %he patient before ta>ing doing his morning bath 8as seen 8earing a grey shirt? a loose 8hite pair of shorts fastened by a long strap 8hich ser/ed as a belt? and a pair of purple slippers$ After bathing him? the patient 8ore a clean 8hite shirt? a pair of green long pants? and his purple sleepers$ 2e 8as in his usual slouching posture$ BE!A1IO. %he patient 8as /ery compliant in obeying commands$ 2e didn3t brea> any rules during the interaction and beha/ed the entire session e/en though he still had slo8? passi/e mo/ements$ 2e 8as /ery manageable and no problems 8ere encountered throughout the acti/ity$ CO%%7NICATION

62

%he same communication problems still occurred during the interaction$ %he client is communicati/e and responsi/e but still manifests unusual speech patterns such as echolalia? perse/eration and /erbigeration$ 2e still tends to repeat after the student nurse 8hen he doesn3t quite understand the question$ As he 8as instructed to ma>e his /oice louder? impro/ements in therapeutic communication 8ere obser/ed$ I%PLICATION 7rooming the patient and encouraging him to participate in routine daily acti/ities 8ill promote independence$ Acti/ities such as remoti/ation therapy and reorientation 8ill help the patient3s a8areness and cognition$

INTE.ACTION Student9Nurse#s 1erba and Non91erba Communications !aayong buntag !anoy !arcos? >amusta naman atong pamati >aronP Hsmiling at patientI Ah ganahan >a maligoP !aligo Restating !aligo Hstanding up from beneath another patient3s bedI Patient#s 1erba and Non9 1erba Communications T*era,eutic Communications: +e$ense %ec*anisms 7i/ing recognitionFSee>ing information 7reeting and recognizing the patient is a 8ay of establishing a good interaction$ %his is to confirm patient3s request Ana "sis

After !arcos? mangutana >o nimo ha$ Sa >aning mga niaging adla8? unsa man imong pamati sa atong mga istoryaP

%a>ing &aghan natabang

A See>ing information

=ath As>ing this question 8ill let the student nurse >no8 ho8 the patient feels after each and e/ery interaction

A8 nalipay >o !arcos na na>atabang >ani >animo$ Hsmiling to8ards patientI

Nalipay

Accepting

An accepting response indicates the nurse has heard and follo8ed the train of thought$

Gnsa pa lain nimo nabati !arcosP

Nalinga8 >o

7eneral lead

%his 8ill let the patient >no8 that the student

63

nurse is listening and follo8ing 8hat he is saying Nganong na>aingon man >a !arcos nga na>atabang >aning storya nato >animoP Ahhh sige$ !ayo nga na>aingon >a na mahitabangon atong pagistorya Sa atong pag-istorya gi>an atong mga niaging adla8 !arcos hantod >aron? nalipay raba >a sa imong pamatiP Cge pa !arcos? unsa paman imong gibatiP &aghan ug na>ata-onan 7eneral leads "ipay >aayo See>ing information &a>og tabang Hsmiles at student nurseI AcceptingF 7i/ing information Na>atabang 45ploring %his is to e5amine 8hy the patient has come up 8ith an ans8er %his ac>no8ledges the patient3s response to8ards the question being as>ed %his is to as> patient to articulate a positi/e outloo> to8ards the interactions %o let the patient e5press more of 8hat he felt during the interactions

Sa imong pamina8 !arcos? ni-uyon raba >a sa mga acti/ities ug sa a>ong serbisyo gihatag >animoP

Ni-uyon ra

See>ing information

%his is to as> for the patient3s comments on the care and interaction gi/en by the student nurse

Gnsa man imong masulti bahin atoP !aayo ra !arcos? o> ra to nimoP

!aayo

45ploring

Nalinga8? nalipay HsmilingI

Restating

Restating confirms the patient3s response

64

Gnya !arcos? unsa man imong gibati >aronP

(atogon

See>ing information

Constantly as>ing the patient ho8 he feels 8ill let the student nurse >no8 the client3s

Bala nato gasa>it imong tuhod Sige !arcos? daghan >aayong salamat$ Ggma mag>ita gihapon ta para magstorya mga ingon aron gihapon orasa ha$ E1AL7ATION0

Bala naman

See>ing information

situation

' sige

7i/ing information

%his 8ill inform the patient of the ne5t interaction

%he ob.ecti/es 8ere accomplished during the interaction$ %he student nurse and the patient had established a good relationship but because of the patient3s condition? he couldn3t e5press that many feelings$ %he 8ith limited output through 8ords due to unusual speech patterns? the patient sho8ed other signs of satisfaction through non/erbal communication$

'.< !ea t* Teac*ing P an Objectives (enera Objectives0 After ) 8ee>s of N-C !EALT! TEAC!IN( PLAN Contents %et*odo og" Eva uation

interaction? the client 8ill be able to de/elop trust 8ith the student nurse and gain insight on the reason of admission$ S,eci$ic Objectives0

65

After

-+-*0

minutes

of

nurse-client interaction? the client 8ill be able to

1$increase positi/e attitude in meeting self-care needs

&aily to

bathing

and

"ecture-discussion

%he patient? too> a bath? 8ore combed clean her clothes? hair and

grooming is important maintain of body to promote cleanliness parts?

brushed her teeth 8ith the student nurse assistance$

good s>in turgor and to eliminate bad odor$ Patient can no8 be a role model for other psych patients 8ho ha/e poor grooming )$ state the importance of sharing one3s emotions and feelings Importance of sharing one3s emotions and feelings - &ecrease an5iety - Increases the feeling of self-8orth - "essens the burden felt inside - 2elps in coping up 8ith the situation -$ acquire adapti/e coping s>ills crisis and mechanisms 8hich are useful in times of Adapti/e mechanisms compensatio n di/ersional acti/ities participating in acti/ities the of coping &iscussion-sharing %he patient is /ery acti/e in participating in different acti/ities held in the 8ard such as morning stretch? culminating remoti/ation sensory stimulation acti/ities? therapy? &iscussion-sharing and demonstration student assistance patient 8ith nurse3s %he patient 8as able to share her emotions and feelings nurse$ to the student

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the 8ard /erbalization of feelings and emotions to others

1. Eva uation and .ecommendation Prognosis Indi/iduals 8ith schizophrenia often de/elop fi/e symptoms that are difficult for the indi/idual? parents? brothers? sisters? professionals and others to deal 8ith$ %he symptoms are paranoia? denial of illness as manifested by !arcelino !arcos a$>$a$ Catalino =agayo? stigma? demoralization? and terror of being psychotic$ Schizophrenia generally can be controlled 8ith treatment and? in more than 0+ percent of indi/iduals gi/en access to continuous treatment and rehabilitation o/er many years? reco/ery is often possible$ As 8ith the case of !arcelino? he has been in the #S!!C Psych Bard for about 0 years$ %hough researchers and mental nurses don@t >no8 8hat causes the disorder? they ha/e de/eloped treatments that allo8 most persons 8ith schizophrenia to 8or> li/e 8ith their families and en.oy friends$ =ut li>e those 8ith diabetes? people 8ith schizophrenia probably 8ill be under medical care for the rest of their li/es$ %he outloo> for people 8ith schizophrenia has impro/ed o/er the last )0 years$ Although no totally effecti/e therapy has yet been de/ised for the researcher3s sub.ect? it is important to remember that !arcelino

67

!arcos a$>$a$ Catalino =agayo has impro/ed enough from being socially 8ithdra8n to being considerably cooperati/e in con/ersations$ As 8e study more about the causes and treatments of schizophrenia? 8e should be able to help the sub.ect achie/e successful outcomes$ &espite difficulties in comparison? birth? marriage? and di/orce rates appear to be not /ery different from those for the general population? although the percentage of married patients is lo8er Has 8ith the situation of the researcher3s sub.ectI$ &eaths 8ould seem greater than e5pected$ Possible reasons for the impro/ed prognosis in schizophrenia are considered to be short initial hospitalization? almost uni/ersal use of phenothiazines Hsub.ect is ta>ing CPT 1++mg 1 tab at bedtimeI? use of de/eloping community ser/ices Hsocial and psychiatricI? and generally good economic conditions$

%here are many different potential outcomes of schizophrenia$ %he sub.ect 8ith schizophrenia finds that her symptoms impro/e 8ith medication? and can achie/e substantial control of the symptoms o/er time$ 2o8e/er? many others e5perience functional disability and are at ris> for repeated acute episodes? particularly during the early stages of the illness$ People 8ith the most se/ere forms of this disorder may remain too disabled to li/e independently? requiring group homes or other long-term? structured li/ing en/ironments$ !ost people 8ith schizophrenia continue to suffer chronically or episodically throughout their li/es$ 4/en bet8een bouts of acti/e illness? lost opportunities for careers and relationships? stigma? residual symptoms? and medication side effects often plague those 8ith the illness$ 'ne of e/ery 1+ people 8ith schizophrenia e/entually commits suicide$ As 8ith !arcelino !arcos a$>$a$ Catalino =agayo? there is an inclination for the disease to de/elop as the anticipation for impro/ement of the sub.ect is reduced 8ith e/ery year of sustained illness? but not at all times to enduring incompetence of the beha/ior$ #ocational rehabilitation and other community support programs may be essential to her community tenure$

68

1I .Eva uation and Im, ication !ental health is the primary focus of this study 8hich is de/oted to the personal mental health? and mental health reco/ery of those 8ho suffer from /arious types of mental illness particularly schizophrenia$ 7i/en the comple5ity of schizophrenia? the ma.or questions about this disorder N its cause or causes? pre/ention? and treatment N must be addressed 8ith research$

A greater comprehension of the stressors that accompany the problem 8ill ta>e place if the client 8ill obtain the trust and support of the nurse$ %his is true in all aspects of nursing care$ It is through holistic nursing care that clients can achie/e a goal of ma5imum health capability$

69

Nursing Practice0 As part of its mission to treat mental illness? nurses 8ho care for those afflicted 8ith any form of mental illness offers to the community psychodynamics? psychosocial and psychobiological inter/entions$ %his case study of schizophrenia is proposed as a recommendation for s>illed registered nurses 8ho are in/ol/ed in psychiatric nursing and as a fundamental copy for the student$

Nursing Education0 Psychiatric nursing education is aimed to8ards the implementation of the aspects of holistic nursing care to psychiatric or schizophrenic clients 8ith the >no8ledge? attitude and s>ills in psychiatric nursing care$ %his educational focus should continue to be in the areas 8here student nurses ha/e a higher degree of comfort such as ha/ing the interest to impro/e the >no8ledge in 8hate/er e5isting measures in order to acquire the goals of the actual nursing practice and education on the area of mental 8ellbeing$ %his increased comfort le/el 8ill help to increase the 8ell being of the client$

Nursing .esearc*0 %he primary aim of the researcher is to contribute to the ongoing articulation? de/elopment and ad/ancement of psychiatric nursing practice in order to strengthen the contribution to enhancing the 8ell being of the patients$ %his case study e5ists to support? be guided by and? 8here necessary? to challenge current nursing practice$ %his belief is? and 8ill continue to be? central to the process and further de/elopment of the research study$ In its quest to recognize? understand and treat mental illness? psychiatric nursing research is also committed to the research of the causes and cures of mental illness$ In particular the causes and cures for schizophrenia$

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1II. Bib iogra,*" Alloy? "$=$E Acocella? L$? D =ootzin? R$R$ H199,I$ Abnormal psychology American Psychiatric Association H199*I$ Am L Psychiatry 199=aron? Chang 2o8ard? !iller? %urner$ Pathophysiology$pgs --0---9 =ird? 2$ D Alu8ahlia? S$ H19;-I Arch. Gen. Psychiatry *+? 1));-1)-1 &a/is? F$ A$ Nurse3s Poc>et 7uide$ 9th edition$ 2alsey$ Collier3s 4ncyclopedia$1961$ pge 0,* Lohnson? L$ B$ D Ascher? P$ H19;6I (ozier? =arbara et al$ Fundamentals of Nursing Concepts? Process and Practice? 6th 4dition$ Singapore Pearson 4ducation South Asia Pte$ "td$? )++* !urray et al? 199) Potter? Perry$ Fundamental of Nursing$ 0th edition$)++)Ro8e 4B? Shean 7 Card-sort performance and syndromes of schizophrenia$ 7enet Soc 7en Psychol !onogr 1996E 1)- 196N)+9

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Shi/es? "ouise Rebraca$ =asic Concepts of Psychiatric-!ental 2ealth Nursing$ 0th 4dition Ste/ens3 H199)I !ary C$ %o8nsend$Psychiatric !ental 2ealth Nursing$ )nd edition #idebec>? Sheila "$ Psychiatric !ental 2ealth Nursing$ )nd 4dition 4ncarta Premium )++, 888$yahoo$com 888$google$com

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