De Ocampo Memorial CollegeCollege of Nursing

NATIONAL CENTER FOR MENTAL HEALTH

In partial fulfillment for the requirements on psychiatric nursing

Undifferentiated Schizophrenia

Joeyneil Kenneth M. Licardo

BSN IV – 1

Group 2

Ms. Laarne Dumag-Clinical Instructor-

Introduction

Mental Health and Mental Illness are states of human existence having precise

definitions. Mental Health is a state of emotional, psychological and social wellness evidenced by

interpersonal relationships, effective behavior coping, positive self-concept and emotional stability.

While mental illness is a clinically significant behavioral or psychological syndrome or

patterns that occurs in an individual and that is associated with present distress, associated

with present distress, increased risk of suffering, death, disability and loss of freedom such

disorders are defined by a combination of affective, behavioral, cognitive or perceptual

components, which may be associated with particular functions or regions of the brain

or nervous system, often in a social context. The recognition and understanding of

mental health conditions have changed over time and across cultures, and there are still

variations in definition, assessment and classification, although standard guideline

criteria are widely used. Over a third of people in most countries report problems at

some time in their life which meet criteria for diagnosis of one or more of the common

types of mental disorder.

In our exposure in National Center for Mental Heath in the Philippines (NCMH),

being a student nurse for mental health was great lifetime experience, it fulfills our

career as a health provider; benefit us and our resident to give best nursing care.

Handling a mentally challenged person was difficult task to do, but with our

determination to cope with this situation, we have support system including our

knowledge, skills and our clinical instructor, to provide us to face the behavior and

stressful events inside the institution. One of the leading mentally disorder is

Undifferentiated Schizophrenia. Residents in this condition have the characteristic of

positive and negative symptoms of schizophrenia but do not meet the specific criteria

for the paranoid, disorganized, or catatonic subtypes.

Objectives:

Main Goal

To be able to utilize appropriate psychiatric management in order to lessen

the sign and symptoms, and to decrease in the secondary illnesses in the

existing condition.

Specific Objectives

To be able to establish therapeutic nurse-patient interaction to collect data

and history about the resident, and will contribute to the nurse and to the

resident.

To be able to apply the nursing process to the fullest extent of their

capabilities.

To establish problem-solving approach to develop nursing care plan.

To be able to apply the support system, including individuals, families and

community groups are assisted to achieve satisfying and productive patterns

of living through health teaching.

To be able to participate in environmental structure to establish and maintain

a therapeutic milieu.

1. Resident Identificationa. Age: 47 yrs old

b. Ethnicity: Pilipino

c. Gender: Female

2. Medical Historya. Chief Complaint: “Nahilo ako dahil sa gutom nuong naglalakad ako sa

harap ng hotel tapos ay umupo ako saglit tapos nakita ako ng tanod na

inaatake ako ng epilepsy” as verbalized by the resident. October 31, 1997,

the resident stated false statement, she was brought by Lita Merino of

Bulacan, a barangay health worker due to disturb behavior.

b. History of present illness: the resident was brought by a barangay health

worker named Lita Merino of Bulacan, due to disturbed behavior. She

stated that she was hungry and tired, and then she suffered epilepsy. One

day prior to confinement, she hacked her daughter on the neck that

motivates the barangay health worker to report the resident in the police

station, and referred to the national center for mental health due to

disturbed mental condition.

c. Past Medical/Psychiatric History: the resident stated that when she was 8

yrs old she already suffers epilepsy but did not consult and take

medications. But she remembered that her father gave her sambong after

the epilepsy occurred. When she drink sambong juice, her headache was

reduced the effect.

d. Family Medical History: Denies any family history of the disease.

e. Physical AssessmentGeneral Survey

Resident is active, coherent, ready to participate and approachable.

General Appearance Resident is not in distress Relax Coordinated Attentive

Vital Signs

Temperature: 36.2 Respiratory rate: 21bpmPulse Rate: 80bpm Blood Pressure: 110/70

Body Parts Inspection Actual Findings Normal Findings Analysis

Skin: General

Color

Texture

Moisture

Head: Size,

Shape and Symmetry

Hair: Distribution

Color

Texture

Inspection and Palpation

oLight to dark brown skin color, and feels warm,(+) lesions, rashes and scars

oRough and Soft

oSkin is dry and has flakes

oface is symmetrical,centered-head position

oEqual distribution of hair

oBlack color

oSmooth

oBrown and uniform skin color with no lesions.

oSmooth and Soft

oNo signs of dryness and flaking.

o face is symmetrical,centered-head position

oEqual distribution of hair

oBlack color

oSmooth

Eyes: Pupil

Eye lids

Sclera

Iris

Ears: Outer Ears

Inner Ears

Nose:

Color

Appearance

Internal Nose

Mouth: Lips

Buccal Mucosa

Inspection

Inspection

Inspection

Inspection

opupil is equally roundand reactivated tolight accommodation

opinkish dark color

osemi dark color

osmooth and moist

osymmetrically appearance and equally in size

ono discharge, clear ear canal, no obstructed object

o same color of the face

osymmetrically appearance

ono redness in nasal mucosa

odarkish pink in color, no flakes, no lesions.

oMoist with no lesions

opupil is equally roundand reactivated tolight accommodation

opinkish color

owhite in color

osmooth and moist

osymmetrically appearance and equally in size

ono discharge, clear ear canal, no obstructed object

osame color of the face

osymmetrically appearance

ono redness in nasal mucosa

opink in color, no flakes, no lesions.

oMoist with no lesions

Gums

Teeth

Neck:

Active Range of Motion

Color, Size

Thyroid

Extremities:

Upper Extremities

Nails

Palms

Arms

Inspection and Palpation

Inspection and Palpation

odarkish pink in color, no bleeding

o4 remaining teeth, no cavity, no dentures

oSome of teeth were yellowish in color

ocan move flexion, extension, tilt and lateral rotation

obrownish color, no lesions

onon- palpable, no pain when palpate

ono cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

opinkish in color, feels warm, rough, (+) tremors, no lesions.

oDominant in right arm, weak at left arm (5/10 muscle force)

opink in color, no bleeding

o32 complete teeth no cavity, no dentures

oWhitish color of Teeth

ocan move flexion, extension, tilt and lateral rotation.

obrownish color, no lesions

onon-palpable, no pain when palpate

ono cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

opinkish in color, feels warm, rough, no lesions.

o10/10 muscle force, no muscle weakness

Lower Extremities

Nails

Feet

Leg

oBilateral pulses are strong, and equal(radial pulse)

o(+) lesions, scars, and rashes.

oSymmetrical in size

ono cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

opinkish dark color on the palm of the feet, no lesions

oDominant in right leg, no muscle weakness

o(+) lesions, scars, and rashes.

oSymmetrical in size

oBilateral pulses are strong, and equal(radial pulse)

oNo lesions, scars, and rashes.

oSymmetrical in size

ono cyanosis, no clubbing, pinkish in color, 2 seconds capillary refill

opinkish color on the palm of the feet, no lesions

ono muscle weakness

ono lesions, scars, and rashes.

oSymmetrical in size

f. Review of SystemsGeneral:

(+) Fever

Skin:(+) Itching

(+) Scabies

(+) Dryness

(+) Rashes

(+) Change Color

Head:(+) Headache

(+) Head Injury

Eyes:(+) Nearsighted

Mouth:(+) Dry Mouth

(+) Four Teeth

Respiratory:(+) Cough

Gastrointestinal: (+) Diarrhea

Vascular:(+) Varicose Veins

Neurologic:(+) Seizures

(+) Tremors

Psychiatric:(+) Depressed Mood

(+) Stress

(+) Disturbing thoughts

(+) Memory Loss

g. Mental Status Examination1. General Description

Appearance- the resident was well groomed, she combed her hair

carefully and she applies face powder, in stooping position.

Behavior and Psychomotor activity- She had good eye contact

whenever she answered a question and sometimes she looking in other

patient when she asked to answer a question. She had a short attention

span while in conversation. She had a mannerism of scratching her finger.

Attitude toward examiner- the resident was approachable and

cooperative and able to do anything that was asked her to do. She acts

what she say when she tells her story.

2. Mood and Affect Mood- the resident looks depressed when she was alone, and no one

calling her attention. When she asked about her daughter she feels

depressed because of the past event, that her husband kills her daughter

after she gave birth.

Affect- the resident has an appropriate response affect about the topic of

the conversation. Sometimes she has no emotion when talked about her

father.

Appropriateness- the resident can answer the questions, but some were

false statement.

3. Speech- the resident was quite, if she asked a question then that’s the time she

talk and continue to give a data.

4. Perceptual Disturbance- the resident had a memory loss because of the

existing mental disorder that she pretends that her husband kills her daughter but

truth was she hacked her daughter seen by the barangay health worker.

5. Thoughta. Process or Form of thought- the resident had overabundance of

thoughts. She gave a false data about her daughter but she tells a lot of

everything about her past.

b. Context of Thought- denies any hallucination and illusions, also

homicidal ideation. 6. Sensorium or Cognition

a. Alertness and level of consciousness- The resident was alert and

attentive.

b. Orientation- The resident was oriented to time, date, place and names of

person around her.

c. Memory- Recent – she remembers what they eat and what household

she do in the morning, Immediate- she can’t remember 3 words/items that

she asked to memorized, in every 5 minutes, Remote- when she was still

a child she remembers when her father got drunk, her father hurt her

mother, Recent Past Memory- she can’t remember the recent president,

and she always saying that Pacquio was the recent president

d. Concentration and Attention- the resident had difficulty in subtracting 3

from 100, but she can count up to 1000.

e. Capacity to read and write- she can read more on tagalog words, and

had difficulty in English word. In her writing, it quite understandable, and

can copy the word that was written in a piece of sheet, and can write one

sentence more on tagalog but can’t write in English word.

f. Visuospatial Ability- the resident can draw the images that asked to her,

and she can copy an image by herself.

g. Abstract Thinking- She can’t identify the similarities of 2 objects given to

her.

h. Fund of Information and Intelligence- She knows what year and her

age when she confined in the institution but she don’t know when she had

a incident report five times in the isolation room, but if it was told to her

she remembers the incident.

7. Judgment and Insight- The resident was asked what she will do, if she saw a

mother and a child, and the mother was choking her child, she said that, she will

go to the mother then asked what was happening, then she will try to help to

solve the problem about the mother and the child. She was aware that she had a

mental disorder.

3. Psychosocial Historya. Personal History

i. Marital and relationship history- the resident claimed that she’s

only 13 years old when her father sell her to a “magjuejueteng” a 28

years old to become her husband. After 1 year, they were

separated but not married because of a family problem. When she

was 18 years old, she met a 30 years old guy who works in the

bakery with two kids and widow, and then they have a relationship

for one year and not married. According to the resident, she had a

daughter in her second husband but apparently her husband kill the

baby after she gave birth and they were separated by the family of

her husband because she did not finish her high school.

ii. Sexual History and Preference- according to the resident when

her first husband came from work and drunk, her husband abuse

her but did not report to the authority. After she was confined in the

mental institution she had no longer sexually active.

iii. Educational History- she was under graduate, she finished up to

grade III elementary.

iv. Occupational History- when she was a child she stop going to

school, because she want to help her mother to earn money, she

sells “kakanin” in Manila. When she was 10 years old, she travelled

to Manila from Quezon to find a job, she said that she was excellent

in doing household chores, and apply as a maid.

v. Socioeconomic Status- she claimed that they are in middle class.

Her father was a fisherman and her mother sells “kakanin”.

vi. Religious Affiliations- she said that she is Roman Catholic but not

able to go to church to pray because of her status but she always

pray at night before she sleep.

vii. Place of Birth- the resident claimed that she is from Caluag,

Quezon, but her chart showed that she is from Sitio Katulad Pulong

Sampaloc Dona Remedious Trinidad Bulacan.

viii. Legal History- she had a record on police before she referred to

the mental institution.

4.Medical Management

Name of Drug(Classification) Dosage Action Indication Side-effect Interpretation

Nursing Consideration

Haloperidol (Haldol)-Antipsychotics

10 mg. ODStarted: 4/18/99Ended: 6/30/08

• Alters the effects of dopamine in the CNS• Also has anticholinergic and alpha-adrenergic blocking activity.• Diminished signs and symptoms of psychoses

•Organic Psychoses• acute psychotic symptoms• Relieve hallucinations, delusions, disorganized thinking• severe anxiety• seizures

•CNS: extrapyramidal symptom such as muscle rigidity or spasm, shuffling gait, posture leaning forward, drooling, masklike facial appearance, dysphagia, akathisia, tardive dyskinesia, headache, seizures.

•CV: tachycardia, arrhythmias, hypertension, orthostatic hypertension.•EENT: blurred vision, glaucoma• GI: dry mouth, anorexia, nausea, vomiting, constipation, diarrhea, weight gain.• GU: urinary frequency, urine retention, impotence, enuresis, amenorrhea, gynecomastia

• Assess mental status prior to and periodically during therapy.

• Monitor BP and pulse prior to and frequently during the period of dosage adjustment. May cause QT interval changes on ECG.

• Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded.

•Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of

• Hematologic: anemia, leucopenia, agranulocytosis• Skin: rash, dermatitis, phtosensitivity

dehydration.

• Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK.

• Advice patient to take medication as directed. Take missed doses as soon as remembered, within remaining doses

evenly spaced throughout the day. May require several weeks to obtain desired effects. Do not increase dose or discontinue medication without consulting health care professional. Abrupt withdrawal may cause dizziness, nausea and vomiting, GI upset, trembling, or uncontrolled movements of mouth, tongue or jaw.

Dilantin (Phenytoin)

100mg  Phenytoin is used to prevent and control seizures (also called an anticonvulsant or antiepileptic drug). It works by reducing the spread

Phenytoin is indicated for use as an anticonvulsant drug in people of all ages. Evidence supporting efficacy of phenytoin as an anticonvulsa

 Headache, nausea, vomiting, constipation, dizziness, drowsiness, trouble sleeping, or nervousness may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.Phenytoin may cause swelling and bleeding of the gums. 

Take this drug exactly as prescribed, with food to enhance absorption and reduce GI upset, or without food—but maintain consistency in the manner in which you take it; be especially careful not to miss a dose if you are on

ofseizure activity in the brain.OTHER This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is listed in this section only if it has been so prescribed by your health care

nt was derived from active drug-controlled studies that enrolled patients with the following seizure types:

Partial seizures

Primary generalized tonic-clonic seizures (grand mal)

Phenytoin is best used for partial-onset seizures. It generally is not effective against generalized-onset absence seizures or infantile

Immediately if any of these unlikely but serious side effects occur: unusual eye movements, loss of coordination, slurred speech, confusion, muscle twitching, double or blurred vision, tingling of the hands/feet, facial changes (e.g., swollen lips, butterfly-shapedrash around the nose/cheeks), excessive hair growth, increased thirst or urination, unusual tiredness, bone or joint pain, easily broken bones.A small number of people who take anticonvulsants for any condition (such as seizure, bipolar disorder, pain) may experience depression, suicidal thoughts/attempts, or other mental/mood problems. 

once-a-day therapy.

Do not discontinue this drug abruptly or change dosage, except on the advice of your prescriber.

Maintain good oral hygiene (regular brushing and flossing) to prevent gum disease; arrange frequent dental checkups to prevent serious gum disease.

Arrange for frequent checkups to monitor your response to this drug.

Monitor your blood or urine sugar regularly, and report any abnormality to

professional.This drug may also be used to treat certain types of irregular heartbeats.

spasms. Phenytoin

has limited value in clonic, myoclonic, and atonic seizures and in the Lennox-Gastaut syndrome. It may control the tonic-clonic component of the syndrome.

your health care provider if you have diabetes.

This drug is not recommended for use during pregnancy. It is advisable to use some form of contraception other than hormonal contraceptives.

Wear a medical alert tag so that any emergency medical personnel will know that you have epilepsy and are taking antiepileptic medication.

Chlorpromazine(Thorazine)

-Antipsychotic

100g Block dopamine receptors in the brain; also alter dopamine release and turnover.

Acute and chronic psychoses, particularly when accompanied by increased

CNS: neuroleptic malignant syndrome, sedation, extrapyramidal reactions, tardive dyskinesia

CV: hypotension (increased with IM, IV)

Assess mental status prior to and periodically during therapy.

Monitor BP and pulse prior to and frequently during

Prevention of seizures

psychomotor activity. Nausea and vomiting.

Also used in the treatment of intractable hiccups.

EENT: blurred vision, dry eyes, lens opacities

GI: constipation, dry mouth, anorexia, hepatitis, ileus

GU: urinary retention Hematologic: agranulocytosis, leucopenia

Skin: photosensitivity, pigment changes, rashes

the period of dosage adjustment. May cause QT interval changes on ECG.

Observe patient carefully when administering medication, to ensure that medication is actually taken and not hoarded.

Monitor I&O ratios and daily eight. Assess patient for signs and symptoms of dehydration.

Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis,

hypertension or hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder control. Report symptoms immediately. May also cause leukocytosis, elevated liver function tests, elevated CPK.

CONCEPT MAPPING

Undifferentiated Schizophrenia

Disturbed Thought Processes

Risk for SuicidalRisk for Other-Directed Violence

Disturbed Personal Identity

Name: Ms. L.Z. Age: 48 years old Gender: FemaleReligion: Roman Catholic Ethnicity: PilipinoDiagnosis: Undifferentiated Schizophrenia

Priority No. 1

Nursing Diagnosis: Risk for other-directed violence

At risk for behaviors in which an individual demonstrate that she can be physically, emotionally and/or sexually harmful to others.

Data Outcome Intervention Rationale EvaluationSubjective:

“Kapag nag aaway ang mga engot(Mentally Retarded) nag aawat ako, pero nung nasaktan ako, sinaktan ko na din sila” as verbalized by the patient.

Objective: History of hitting

others: she had an 5 incident report

History of Hitting family members: she hack her daughter

History of Childhood abuse: when she got married with the age of 13 years old

History of conflictual family background:

After of 8 hours of duty, the resident will expressed her own realistic evaluation and demonstrate self-control.

Developed therapeutic nurse-client relationship.

Observed for early cues of distress/increasing anxiety

Identified condition such as psychomotor seizures activity

Asked directly if the person was thinking of acting on thoughts/feelings

Accepted client’s anger without reacting on emotion basis. Give permission to express angry feeling in acceptable ways and let

Promotes sense of trust, allowing client to discuss feeling openly.

To give appropriate management.

to control own behavior

to determine violent intent

to promotes acceptance and sense of safety

After of 8 hours of intervention, the resident were expressed her own realistic evaluation and demonstrated self-control as evidenced by:

expressed calmness when someone hurt him, and will tell to the nurse on duty

not joining the argue, and stayed in the conner.

her father hit them, when her father got drunk.

client know that staff will be available to assist in maintaining control.

Helped client identify more approachable solution/behavior

to lessen sense of anxiety and associated physical manifestation

Name: Ms. L.Z. Age: 48 years old Gender: FemaleReligion: Roman Catholic Ethnicity: PilipinoDiagnosis: Undifferentiated Schizophrenia

Priority No. 2

Nursing Diagnosis: Diarrhea

Unformed stool

Data Outcome Intervention Rationale EvaluationSubjective:

“Kapag lagi akong kumakain ng giniling at nilagang baboy ay sumasama ang tiyan ko at nagnatatae ako ” as verbalized by the patient.

Objective: hyperactive bowel

sounds History of taking drugs

for diarrhea three loose liquid

stools per day

After of 8 hours of duty, the resident will maintain normal pattern of bowel function.

Monitored Vital signs and intake and output.

Auscultated abdomen

Restricted solid food intake as indicated

Promoted use of relaxation technique

Increased oral fluid intake and return to normal diet as tolerated.

Reviewed causative factors and appropriate intervention.

To know the baseline data.

To know presence, location, and characteristics of bowel sounds.

To allow for bowel rest/reduced intestinal workload

To decrease stress/anxiety

To prevent dehydration.

To prevent recurrence.

After of 8 hours of intervention, the resident was maintained normal pattern of bowel function.

Math homework help

https://www.homeworkping.com/

Homework Help

https://www.homeworkping.com/

Math homework help

https://www.homeworkping.com/

Research Paper help

https://www.homeworkping.com/

Algebra Help

https://www.homeworkping.com/

Calculus Help

https://www.homeworkping.com/

Accounting help

https://www.homeworkping.com/

Paper Help

https://www.homeworkping.com/

Writing Help

https://www.homeworkping.com/

Online Tutor

https://www.homeworkping.com/

Online Tutoring

https://www.homeworkping.com/