Psych Case Study

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Our Lady of Fatima UniversityPsychiatric Nursing

Introduction

Mrs. Hydilyn Compuesto Esteban is a 39 years old female. She was born on May 13,

1972 in Bulacan. She is a Filipino and a Roman Catholic. She was married to Francisco Esteban

and they have 4 children, 3 sons and a daughter. She graduated elementary and has an

educational attainment of 2nd year high school. She was residing at Hydro San Mateo, Bulacan

before she was admitted in the National Center for Mental Health. Her mother is Maura Lucas

and her father is Felix Compuesto.

In Bulacan, at a government owned agency where she was working as a vendor, the

client stated that she was cooking rice and she forgot to turn off the stove which started the

fire. She claimed that it was an accident, but because of the incident she was charged with

Criminal Case no. 48-M-2009 (Arson). She was brought by escorts at the forensic psychiatry

service of the National Center for Mental Health and was admitted on August 12, 2011 per

court order for further evaluation and management. Based on the history, examination and

observation, the patient was found to be suffering from psychosis classified as

undifferentiated schizophrenia. At present, the patient has remained in unimproved state and

is therefore deemed incompetent to stand the rigors of court trial.

Upon assessment, the client verbalizes difficulty of sleeping at night wherein

she manifested restlessness, irritability, fatigability, anxiety, inability to concentrate, slowed

reaction and day time drowsiness. Just like food and water, adequate sleep is also very

essential to the human body. Therefore, I focused on the client’s problem of sleep

deprivation. Because sleep deprivation leads to such problems like mental impairment and

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mental health complications. If there is insufficient rest, some of our faculties like the ability to

think, stress handling and the maintenance of a healthy immune system are all affected.

Pathophysiology

Undifferentiated schizophrenia is a mental disorder which is part of the family of

disorders broadly known as “schizophrenia.” There are a number of subcategories of

schizophrenia including paranoid schizophrenia, catatonic schizophrenia, disorganized

schizophrenia, residual schizophrenia, and schizoaffective disorder; undifferentiated

schizophrenia is often defined as a form in which enough symptoms for a diagnosis are

present, but the patient does not fall into the catatonic, disorganized, or paranoid

subcategories. Schizophrenia is characterized by a lack of grounding in reality, known as

psychosis. People in a state of psychosis can experience hallucinations, delusions, and other

events in which they break from reality. Individuals with schizophrenia experience psychosis

and can also develop symptoms such as disorganized speech, lack of interest in social

interactions, a flat affect, inappropriate emotional responses to situations, confusion, and

disorganized thinking. Patients with undifferentiated schizophrenia do not experience the

paranoia associated with paranoid schizophrenia, the catatonic state seen in patients with

catatonic schizophrenia, or the disorganized thought and expression observed in patients with

disorganized schizophrenia. However, they do experience psychosis and a variety of other

symptoms associated with schizophrenia, including behavioral changes which may be

noticeable to family and friend.

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Causes

There are many factors that may cause schizophrenia. Scientists are still working on trying to

identify all of them. The most common causes of the mental illness are genetic and

environmental.

Genetic cause of schizophrenia usually lies in a person’s having immediate relatives

with a history of schizophrenia or other psychiatric diseases (schizoaffective disorder,

bipolar disorder, depression).

Some researchers consider schizophrenia to be highly heritable (some estimates are as high as

70%). A recent review of the genetic evidence has suggested a 28% chance of one identical

twins developing schizophrenia if the other already has the psychological disorder.

The research results list seven genes as likely to be involved in the inheritance of

schizophrenia, or the risk of developing the disease. Scientists suggest that multiple

chromosomal regions are inherited by, and transmitted to people who are later diagnosed as

having schizophrenia.

Environmental cause. There is considerable evidence indicating that stress may trigger

episodes of schizophrenia psychosis. For example, emotionally turbulent families and

stressful life events have shown to be some of the risk factors for the relapses or

triggers of schizophrenia episodes. Abuse as a child and early traumatic experience are

also among the risk factors for developing schizophrenia later in life.

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Factors such as poverty and discrimination may also be involved in increasing the risk of

having a schizophrenic episode due to the high levels of stress that these lifestyles harbor. The

"social drift hypothesis" suggests that people affected by schizophrenia may be less able to

hold steady, demanding, or high-paying jobs. As a result, low income and problems increase

stress levels and leave such people susceptible to lapsing into a schizophrenic episode.

Signs and Symptoms

Schizophrenia symptoms are divided into positive and negative according to their impact on

treatment and diagnosis.

Positive Symptoms of Schizophrenia

Positive schizophrenia symptoms are caused by an excess or distortion of normal functions.

The diagnosis of schizophrenia requires observing two or more positive symptoms for at least

a month. If hallucinations or delusions are very intense, they alone are enough to justify a

diagnosis of schizophrenia.

The positive symptoms of schizophrenia include:

Delusions. Delusions are inflexible misleading beliefs. They appear as a result of

exaggerations or distortions of reasoning, as well as false interpretations of things and

events. For example, one can think that some book was written especially for him/her.

Hallucinations. Hallucinations are exaggerations or distortions of senses. Auditory

hallucinations, when one can hear non-existent imaginary sounds, especially voices,

are the most widely observed.

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Disorganized speech/thinking. This symptom is usually assessed based on the person’s

speech. Disorganized thinking that results in disorganized, improperly associated, or

inconsistent speech and poor communication abilities is a sign of the thought disorder.

Disorganized behavior. This type of schizophrenic behavior is expressed when a person

has difficulty performing everyday actions and activities. The individual’s behavior is

unpredictable, silly, or strange; the odd behavior is usually caused by delusional

beliefs.

Catatonic behavior describes a lack of reaction to the external stimuli or events.

Catatonic behavior includes absence of any reaction, inactivity, rigid and strange

postures as a reaction to an external stimulus.

Other symptoms of schizophrenia are less common and when seen alone, these symptoms

are not sufficient to diagnose schizophrenia. They include inappropriate reactions to a

situation or stimuli, unusual motor behavior (inane pacing or rocking), depersonalization,

derealization, and somatic preoccupations.

Negative Symptoms of Schizophrenia

Negative schizophrenia symptoms are those that reflect a decrease in normal functions, or a

loss of them. They may be observed in the lives of people with schizophrenia during the

periods when positive symptoms are absent or poorly expressed.

Negative symptoms of schizophrenia are difficult to evaluate because they are not as

apparent or as "abnormal" as positive symptoms.

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Affective flattening is usually expressed by the absence or reduction of emotional

expression, such as mimicry, voice tone, eye contact and body language.

Alogia is present when a person speaks very little and unproductively, or gives short

and meaningless replies to questions due to slow or blocked thinking processes.

Avolition is the absence of goal-oriented behavior. A person loses interest to the

surrounding world, doesn't do anything, and sits doing nothing for long periods of

time.

The symptoms of schizophrenia may be controlled with cognitive therapy intervention and

medication that varies in price and individual effectiveness.

History

On her 11th HD the patient was referred to the female medical infirmary because of the

Physical Examination finding upon admission of an anterior neck mass. She was examined by

the surgical and medical infirmary section and ordered the following workup Ft3, Ft4, TSI 1,

Thyroid scan. She had a 3x2x5 cm nodular anterior neck mass that moves with deglutition and

was goiterous in origin. Thereafter she was diagnosed to have a Nodular Goiter.

Client’s medication were Clozapine, Chlorpromazine and Fluphenazine Decanoate.

Clozapine is an anti-psychotic medication that works by blocking receptors in the brain

for several neurotransmitters (chemicals that nerves use to communicate with each other)

including dopamine type 4 receptors, serotonin type 2 receptors, norepinephrine receptors,

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acetylcholine receptors, and histamine receptors. Unlike traditional anti-psychotic agents,

such as chlorpromazine (Thorazine) and haloperidol (Haldol) as well as the newer anti-

psychotics, risperidone (Risperdal) and olanzapine (Zyprexa), clozapine only weakly blocks

dopamine type 2 receptors. Clozapine is use in the management of psychotic

disorders including schizophrenia. Because of concern for the side effect of agranulocytosis

(see side effects), clozapine should be reserved for patients who have failed to respond to

other standard medications or who are at risk for recurring suicidal behavior.

Chlorpromazine is used to treat certain mental/mood disorders (such as schizophrenia,

psychotic disorders, manic phase of bipolar disorder, severe behavioral problems in children).

Chlorpromazine helps you to think more clearly, feel less nervous, and take part in everyday

life. It can reduce aggressive behavior and the desire to hurt yourself/others. It may also help

to decrease hallucinations (hearing/seeing things that are not there). Chlorpromazine is a

psychiatric medication that belongs to the class of drugs called phenothiazine antipsychotics.

It works by helping to restore the balance of certain natural substances in the brain.

Chlorpromazine is also used to control nausea/vomiting, relieve prolonged hiccups, relieve

restlessness/anxiety before surgery, and help treat tetanus.

Fluphenazine decanoate belongs to the family of medications known as antipsychotics,

more specifically, the phenothiazines. This medication is used to treat schizophrenia. It is

thought to work by reducing dopamine (a chemical messenger) in certain areas of the brain.

The effects of this medication on symptoms of schizophrenia begin to appear within 48 to 96

hours after being injected.

http://www.medicinenet.com/script/main/art.asp?articlekey=470



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Nursing Physical Assessment

Client is neatly and appropriately dressed. She already took a bath and her hair is well

groomed. She has a medium body built and she appeared her stated age. She was able to

maintain an adequate eye contact, though she sometimes bows her head when avoiding

some questions. Client’s motor activity appears normoactive but manifests resting hand

tremors. Her facial expression is calm. Client is cooperative during nurse patient interaction,

but she sometimes appear avoidant and evasive. She is well oriented to place, time and

person. Her concentration and attention were both adequate but she sometimes becomes

aloof. She denied any hallucination experiences. She denied any pre occupation, illusions or

phobias. Depersonalization and derealization was not present on the client. She sometimes

manifests loose association and thought blocking. Client’s affect is appropriate. Immediate

and recent memory is not impaired, but his remote memory is somewhat partially impaired.

The organization of her speech is relevant and coherent. Client manifests repression as her

defense mechanism. She has a moderate level of self esteem. Client has sleep deprivation.

She has no difficulty in defecating and voiding as verbalized. She has no leisure time activities,

no regular exercise and activities of daily living are not done.

Related Treatment

Since schizophrenia may not be a single condition and its causes are not yet known,

current treatment methods are based on both clinical research and experience. These

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approaches are chosen on the basis of their ability to reduce the symptoms of schizophrenia

and to lessen the chances that symptoms will return.

Some available medications for treating schizophrenia are:

• chlorpromazine (Thorazine)

• clozapine (Clozaril)

• haloperidol (Haldol)

• risperidone (Risperdal)

• olanzapine (Zyprexa)

• quetiapine (Seroquel)

• aripiprazole (Abilify)

Antipsychotics medications reduce the psychotic symptoms of schizophrenia and usually

allow the patient to function more effectively and appropriately. Antipsychotic drugs are the

best treatment now available, but they do not “cure” schizophrenia or ensure that there will be

no further psychotic episodes. The large majority of people with schizophrenia show substantial

improvement when treated with antipsychotic drugs.

Sometimes when people with schizophrenia become depressed, other symptoms can

appear to worsen. The symptoms may improve with the addition of an antidepressant

medication.

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Rehabilitation

Rehabilitation programs may include vocational counseling, job training, problem-

solving and money management skills, use of public transportation, and social skills training.

These approaches are important for the success of the community-centered treatment of

schizophrenia

Individual Psychotherapy

Individual psychotherapy involves regularly scheduled talks between the patient and a

mental health professional such as a psychiatrist, psychologist, psychiatric social worker, or

nurse. Recent studies indicate that supportive, reality-oriented, individual psychotherapy, and

cognitive-behavioral approaches that teach coping and problem-solving skills, can be beneficial

for outpatients with schizophrenia. However, psychotherapy is not a substitute for

antipsychotic medication, and it is most helpful once drug treatment first has relieved a

patient’s psychotic symptoms.

Family Education

Very often, patients with schizophrenia are discharged from the hospital into the care of

their family; so it is important that family members learn all they can about schizophrenia and

understand the difficulties and problems associated with the illness.

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Self-Help Groups

Family and peer support and advocacy groups are very active and provide useful

information and assistance for patients and families of patients with schizophrenia and other

mental disorders.

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Nursing Care Plan

ASSESSMENT PLANNING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective“Nahihirapan ako makatulog sa gabi, kagapi nga hindi ako nakatulog ng maayos, ano ba gagawin ko?” as verbalized by the patient

Objective Restlessness Irritability Fatigue Anxiety Inability to

concentrate Slowed reaction Day time

drowsiness

DiagnosisSleep deprivation related to inadequate day time activity and uncomfortable sleep environment as manifested by verbalization of difficulty of sleeping or staying asleep

Short term goalAfter 3 hours of nursing intervention the patient will verbalize understanding of sleep disorder and she will be able to acquire knowledge on the interventions that can promote sleep

Long term goalAfter 1-2 weeks of nursing intervention the patient will report improvement in her sleep pattern and she will have increase sense of well being and feeling rested

Independent1. Assess causative

factors on why the patient has difficulty of sleeping. Note the environmental factors affecting sleep.

2. Explain and give information about sleep disorder to promote client’s knowledge on the area of concern

3. Determine client’s usual sleep pattern and expectations to provide as a comparative baseline

4. Encourage client to restrict intake of stimulating substances like caffeine from late afternoon to evening and avoid eating large evening or late night meals because these factors are known to disrupt sleep pattern

5. Promote adequate physical exercise activity during the day to enhance expenditure of energy so that client

After 3 hours of nursing intervention the patient had verbalized understanding of sleep disorder and had acquired knowledge on the interventions that can promote sleep

After 1-2 weeks of nursing intervention the patient had report improvement in her sleep pattern and she will have increase sense of well being and feeling rested as manifested by decrease restlessness, irritability, fatigability, anxiety, day time drowsiness and increase in ability to concentrate

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feels ready for sleep during the night

6. Suggest abstaining from day time naps because they impair ability to sleep at night

7. Provide calm quiet environment and manage controllable sleep disrupting factors (ex. Noise, light)

Collaborative8. Administer

sedatives such as benzodiazepines as ordered by the doctor and note patient’s response to induce sleep

Recommendations

She is advised to take part in complying with the treatment; the medication and

therapeutic regimen designed for his rehabilitation. She should realize the importance

of complying with her medication and the benefits this practice would bring to the

improvement of his well-being.

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Because recovery from schizophrenia is a lifelong process. It doesn’t mean she won’t

experience any more challenges from the illness or that she’ll always be symptom-free. What it

does mean is that she is continuing to work toward her goals, learning to manage symptoms,

developing the support needed, and creating a satisfying, purpose-driven life.

Successful treatment for schizophrenia aims to relieve current symptoms, prevent

future psychotic episodes, and restore the ability to function and enjoy a meaningful life. A

treatment plan that combines medication with supportive services and therapy is the most

effective approach.

My Autobiography

My name is Suzaine Marie Ferrer Suarez. I’m 19 years of age. I was born on the 8th of

May on the year 1992 at the University of Sto. Tomas Hospital. I am currently residing at

Potrero, Malabon City, where I live with my dad, my mom, my cousin, my tito and his wife. I’m

the only child of my parents. My dad is a lawyer and he’s currently working at BDO. While my

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mom is the one in charge of our business, in which we breed mostly small dogs like Shih Tzu

and Yorkshire Terrier. We also breed big dogs like English Bulldogs and German Shepherds. I

spent my elementary years at St. Augustine School at Iba, Zambales. Then I attended and

graduated higschool at La Consolacion College – Caloocan. I am now a 3rd year college student

at Our lady of Fatima University in an effort to obtain my bachelors degree in Nursing. My

Favorite sports are volleyball and swimming. My hobbies are surfing the net, playing games

online and watching TV or DVDs. I love eating and sleeping during my wee hours. I also love

hanging out with my friends and going out with them. My friends see me as a loud and jolly

person. And they are always there for me and of course I’ll be doing the same to them. I have a

bestfriend, and we love to explore things most especially when it comes to food. My favorite

color is white, pink and purple. When it comes to school, I do my best to maintain a grade not

lower than 2.00, and gladly I can keep up with it. Because I want my dad and mom to be proud

of me. And after I obtain my bachelors degree I am planning to have my Doctor of Medicine as

well or if not I want to go to abroad and practice nursing there and of course earn money to

provide for my family. As time passes by I became wiser and stronger, and I can prove it base

on the experiences I have though I know that I still have a lot to learn but still I’m ready to face

the challenges that life can hand me.

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REMOTIVATION TECHNIQUE

A therapy of very simple group therapy of an objective nature used in an effort to reach the unwounded areas of the patient’s personality & get them moving back into the reality

Indication

Can be used in a ward situation regardless of the length of time the patient has been hospitalized, his age or the reason of his illness & sex.

Objectives

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1. Stimulate patient to be fellow explorer of the real world2. Develop the ability to communicate &share ideas & experience with other3. Develop feeling of acceptance &recognition

Values of the patient

1. Stimulate patient to think about something & talk about himself 2. Gives him reason to value himself &increase his self-respect3. Takes him out of the darkness of the world life4. Makes him part of the group5. Take the patient out of the vegetable class

Duration: 45-60 minutes45 min – 1 hour for once or twice per week

No. of sessions & Evaluation

12 sessions consists a series. The student evaluates the patient’s reactions with the guidance of the CI

Evaluation report is attached to their respective chair of the physicians to note

Subject to be considered

1. Geography2. History3. Science4. Literature5. Industry6. Sports7. Hobbies8. Nature

Subject NOT to be considered

1. Religion2. Politics3. Love4. Sex5. Family Problem

STEPS/ Procedures

1. Climate Acceptance (5min)a. The leader who is at the center of the group introduces him & the rest of the group.b. Leader must ask the patient to introduce themselves.

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c. After the intro., the leader may comment on the weather, the patient’s appearance or may give a pleasant compliment

d. The objective: Create a pleasant& relaxed atmosphere

2. Bridge to Reality (15min)a. Ask bounce questions. Question should be short & easy to answer.b. Then ask for anybody who knows a poem about the topic of discussionc. Questions are from general-specificd. Try to read your poetry to the group & later ask the patients to read it. Show your

visual aid.

3. Sharing the world we live in (15min)a. Stimulating question leading to the topicb. Leader should try to explore the topic under discussion

4. Appreciation of the works of the world (15min)a. The step is blended with step 3b. Be sure to relate the patient so he will be able to think of himself in relation into

certain job

5. Climate of Appreciation (15min)a. Leader should try to ask a summary about the topic w/c has discussedb. Express your appreciation to the patient for coming to the sessions &tell them about

the next session &what topic to be discussed

Interpretation

In a fast rate of music, the patient drew two houses, inside each house she drew a

person. And behind the two house she drew three mountains and a sun rising/setting in it. She

also drew two birds and fences for the two house. She said that these two house represent

their house in Bulacan. While the person inside the house was her and her husband. When she

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was asked on what was the meaning of her drawing, she said that she drew the house and her

husband because she wants to be with her family and she misses her husband.

House interpretations are loosely based on research and on the symbolic meaning of

the aspects of the house. They should hopefully be nurturing places with normal levels of detail

and normal size. Too little and the client may reject family life; too big and they may be

overwhelmed by it. Lines and walls represent boundaries and strengths of the ego, thus weak

lines in the structure of the house are weaknesses in the ego, while strong lines are problems

with anxiety and a need to reinforce boundaries. The roof symbolizes the fantasy life, and extra

attention to it can indicate extra attention to fantasy and ideation, while incomplete, tiny, or

burning roofs can indicate avoidance of overpowering and frightening fantasies (think about

fears of ghosts in the attic - these are based on the association for us). Windows, doors, and

sidewalks are all ways that others enter or see into the house, so they relate to openness,

willingness to interact with others, and ideas about the environment. Thus, shades, shutters,

bars, curtains, and long and winding sidewalks indicate some unwillingness to reveal much

about yourself (think about expression like windows to the soul or the door to the mind). Open

doors or many windows could mean strong needs to engage others. Psychotics tends to show

groundlines (their need for grounding), clear visions of the insides of the house (they believe

their thoughts and mind are open to view by others), strange angles (like their strange thought

processes), or a house on the verge of a collapse (like their ego).

The patient used the color pink to drew the house, the fences, the birds, the mountains

and the sun. Pink is the color of universal love. Pink is a quiet color. Pink is a combination of red

and white. The quality of energy in pink is determined by how much red is present. White is the

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potential for fullness, while red helps you to achieve that potential. Pink combines these

energies. Shades of deep pink, such as magenta, are effective in neutralizing disorder and

violence. Some prisons use limited deep pink tones to diffuse aggressive behaviour. Pink

provides feelings of caring, tenderness, self-worth and love, acceptance.

The patient used color blue for the person inside each of the house. Blue is the color of

the sky and of the sea. It is associated with depth and stability, and the ideas of wonder,

freedom and dreams. It symbolizes wisdom, confidence, intelligence, trust, loyalty, faith and

truth. Calm, relaxing and transparent, blue inspires a sense of peacefulness and relaxation. Blue

slows the human metabolism and creates an atmosphere of tranquility. Blue brings beneficial

effects to the mind and body.

Interpretation

In a slow rate of music, the patient drew a coconut tree. She also drew a heart on the

left and on the right side of the of the coconut tree. She said that there are many coconut trees

in her hometown at Bulacan that’s why she drew a coconut tree. While the two hearts

represents her mother and her.

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The patient used the color brown in drawing the coconut tree. People who prefer brown

are often conventional and orderly. The negative meaning of brown can be a repressed

personality or a lazy person. Brown is the color of the earth and is associated with the material

side of life. Brown gives a feeling of solidity, and allows one to stay in the background,

unnoticed. Some shades of brown create a warm, comfortable feeling of wholesomeness,

naturalness and dependability.

The patient used the color red in drawing the hearts. Red is the warmest of all colors.

Red is the color most chosen by extroverts. On the negative side red can mean temper or

anger. Red is the color of Mars. This planet is known as the God of War. Red is associated with

fiery heat and warmth. It can also mean danger (burning). Red is the color of blood, and as such

has strong symbolism as life and vitality. It brings focus to the essence of life and living with

emphasis on survival. Red is also the color of passion and lust.

Related Learning Experience

In

National Center for Mental Health

As a Requirement in Psychiatric Nursing

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Our Lady of Fatima University

Suarez, Suzaine Marie F.Group 8-E

Mrs. Aida I. Bautista RN, MANClinical Instructor

February 2012

REMOTIVATION TECHNIQUE

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Suarez, Suzaine Marie F.BSN 3Y3-8E

Our Lady of Fatima University120 McArthur Hignway, Marulas, Valenzuela City

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CASE STUDYPsychosis classified under Schizophrenia

Suarez, Suzaine Marie F.BSN 3Y3 – 8E

References

Psychiatric Nursing: Contemporary Practice, 4th edition by Mary Ann Boyd

Psychiatric-Mental Health Nursing, 5th edition by Sheila L. Videbeck

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Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales, 11th edition

http://www.medicinenet.com/clozapine/article.htm

http://www.medicinenet.com/chlorpromazine_tablets_liquid-oral/article.htm

http://chealth.canoe.ca/drug_info_details.asp?brand_name_id=1182&rot=4

http://mentalhealth.about.com/od/schizophrenia/a/sz3.htm

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