A Case Study On

SCHIZOPHRENIA, PARANOID TYPE

In Partial Fulfillment of the Requirements In NCM 102- R ! Psy"hiatri" Nursin# Rotation

Su$mitted to% Prof& Samuel F& Mi#allos' RN' MAN Clini"al Instru"tor (ohn Paolo or"a' St&N& Ro$ert Paul Namua# III' St&N& )ernan Pel*inosas' St&N& Pra"ti"in# Clini"al Instru"tors Su$mitted $y% +atue"on Calim*o' St& N& +onna,ie +ana"' St& N& I,y -aridan' St& N& (ohn Roland Patayan' St& N& +ana Pon"ardas' St& N& Ayesha .uil$an' St& N& Peter Paul Rafosala' St& N& Sheena Mae Raran##ol' St& N& Marie Rose Ra/o' St& N& (ulian Ale0ander Remo' St& N& (an Mi#uel Rodri#ue/' St& N& Ann- Sherlee Serrano' St& N& Mi"hael 1idanes (r&' St& N& Adrian 1i,as' St& N& Ri/a oreine 2an#' St& N& 3SN-4)- -rou* 4 Fe$ruary 4' 2005

6A3 ! OF CON6!N6S

Pa#e num$er

Introdu"tion O$7e"ti,es Personal +ata -eno#ram Anamnesis +efinition of +ia#nosis Mental Status !0amination Pro#ress Notes Psy"hodynami"s +ifferential +ia#nosis +ia#nosti" !0ams Medi"al Mana#ement +ru# Studies Nursin# Mana#ement )ealth 6ea"hin#s Re"ommendations Pro#nosis 3i$lio#ra*hy

4 8 5 11 19 28 42 91 94 82 8: 55 109 1;4 159 15< 200 204

IN6RO+=C6ION

>Ne,er e0*e"t thin#s to ha**en' stru##le and ma?e them ha**en& Ne,er e0*e"t yourself to $e #i,en a #ood ,alue' "reate a ,alue of your o@nA - Anonymous 6he Borld )ealth Or#ani/ation defines mental health as a state of @ell-$ein# @herein the indi,idual reali/es his or her o@n a$ilities' "an "o*e @ith the normal stresses of life' "an @or? *rodu"ti,ely and fruitfully' and is a$le to ma?e a "ontri$ution to his or her "ommunity& 6his means that *eo*le @ho "an "arry out their roles in so"iety and @hose $eha,ior is a**ro*riate and ada*ti,e are ,ie@ed as healthy& )o@e,er' mental illnesses also e0ist in the so"iety today& It is defined $y the Ameri"an Psy"hiatri" Asso"iation as a "lini"ally si#nifi"ant $eha,ioral or *sy"holo#i"al syndrome or *attern that o""urs in an indi,idual and is asso"iated @ith *resent distress or @ith a si#nifi"antly in"rease ris? of sufferin# death' *ain' disa$ility' or an im*ortant loss of freedom& One "ommon e0am*le of this is s"hi/o*hrenia& S"hi/o*hrenia is a se,ere mental disorder' "hara"teri/ed $y *rofound disru*tions in thin?in#' affe"tin# lan#ua#e' *er"e*tion' and the sense of self& It often in"ludes *sy"hoti" e0*erien"es' su"h as hearin# ,oi"es or delusions& It "an im*air fun"tionin# throu#h the loss of an a"quired "a*a$ility to earn a li,elihood' or the disru*tion of studies& 6his is a se,ere form of mental illness affe"tin# a$out : *er thousand of the adult *o*ulation' mostly in the a#e #rou* 1;4; years& 6hou#h the in"iden"e is lo@ C4-1000D' the *re,alen"e is still hi#h due to "hroni"ity& It affe"ts a$out 29 million *eo*le @orld@ide& 6y*i"ally' it $e#ins in early adulthood' $et@een the a#es of 1; and 2;& Men tend to de,elo* s"hi/o*hrenia sli#htly earlier than @omen' @hereas most males $e"ome ill $et@een 18 and 2; years old' most females de,elo* sym*toms se,eral years later' and the in"iden"e in @omen is noti"ea$ly hi#her in @omen after a#e 40& 6he a,era#e a#e of onset is 1< in men and 2; in @omen& 6he onset is quite rare for *eo*le under 10 years of a#e' or
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o,er 90 years of a#e& 6he *re,alen"e rate for s"hi/o*hrenia is a**ro0imately 1&1E of the *o*ulation o,er the a#e of 1< or' in other @ords' at any one time as many as ;1 million *eo*le @orld@ide suffer from s"hi/o*hrenia and it ran?ed amon# the to* 10 "auses of disa$ility in de,elo*ed "ountries @orld@ide& 6he #rou* had "hosen Mr& eonardo Ara*o" as the su$7e"t for the "ase study $e"ause his "ondition allo@s the #rou* to $e interested in ?no@in# @hat $rou#ht a$out his illness& 6he family of Mr& Ara*o" also allo@ed us to "ondu"t this study so that the #rou* and other health teams @ill $e a$le to see the *ro#ress of the treatment and @hat are the *ossi$le or other thera*ies to $e done& At the same time' the #rou* sho@s interest to learn more a$out s"hi/o*hrenia $y relatin# @hat had $een tau#ht in the "lass and the a"tual o$ser,ation of the "ondition& 6his im*lies that as a student nurse' @e should a""e*t the *erson re#ardless of his $eha,ior $y o$ser,in# the #uidelines and *rin"i*les $ein# tau#ht in the "lasses& 6hrou#h this study' @e "an fo"us on stren#thenin# the *ersonFs a$ility to $oun"e $a"? from ad,ersity and to mana#e the ine,ita$le o$sta"les en"ountered in life $y im*ro,in# the *ersonFs resilien"y' and his a$ility to "o*e @ith the *ro$lems' stress and strains of e,eryday li,in#&

O3(!C6I1!S

-eneral O$7e"ti,e 6hat @ithin our 9-@ee? nursin# "are' @e' the mem$ers of 3SN4)- -rou* 4 @ill $e a$le to *resent a "om*rehensi,e and detailed "ase study on S"hi/o*hrenia Paranoid 6y*e' its dia#nosis and its mana#ement& S*e"ifi" O$7e"ti,es 6he follo@in# are the s*e"ifi" o$7e"ti,es formulated to #uide the mem$ers of the #rou* in attainin# the main #oal% aD 6o *resent an o,er,ie@ of our "lientFs "ase and the si#nifi"an"e of its study to nursin# resear"h' edu"ation and *ra"ti"eG $D to esta$lish a #ood and trustin# relationshi* @ith our "lient and his relati,esG "D to tra"e the "lientFs maternal and *aternal linea#e @ith a -eno#ram and relatin# this to our "lientFs *resent "onditionG dD to #ather *ertinent information re#ardin# our "lient from his family and other si#nifi"ant *eo*le @ho are ?no@led#ea$le of his "onditionG eD to o$7e"ti,ely assess our "lient u*on orientation *hase @ith the use of the Mental Status !0amination toolG fD to monitor our "lientFs *ro#ress and $eha,ior durin# the "ourse of the rotationG #D to list the s*e"ifi" etiolo#ies' *re"i*itatin# and *redis*osin# fa"tors that *otentially "aused the onset of our "lientFs illnessG hD to *resent the details of the "ourtshi* of our "lientFs *arents to his *resent de,elo*mental sta#e in a s"hemati" dia#ramG iD to follo@ the e,ents durin# our "lientFs #ro@th and de,elo*ment that are ,ital to the de,elo*ment of his illnessG
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7D to e,aluate the de,elo*mental tas?s *erformed $y our "lient #rounded on the theories of !ri? !ri?son and Si#mund FreudG ?D to formulate a differential dia#nosis $ased from the data #athered as #uided $y the "riteria set $y the +SM-I1G lD to ta$ulate the features' ideal results and inter*retation of our "lientFs a"tual and *ossi$le dia#nosti" e0aminationsG mD to dis"uss the medi"al mana#ement of our "lient @hi"h in"ludes *sy"hothera*y and *harma"olo#y of his "onditionG nD to formulate effe"ti,e nursin# "are *lans and a**ro*riate "are on the nursin# *ro$lems identified in our "lientG oD to *ro,ide health tea"hin#s that are ne"essary to the $etterment of our "lientFs "ondition throu#h his familyG *D to *ro,ide re"ommendations to the indi,idual' family and "ommunity on the im*ro,ement of our "lientFs @ell-$ein#G and qD to e,aluate our "lientFs a$ility to re"o,er to a fun"tional mem$er of the so"iety as #uided $y : "hara"teristi"s and #i,in# its 7ustifi"ations and im*li"ations&

P!RSONA +A6A

Name%

eonardo >+odon#A

Se0% A#e% 3irthday Address% Ci,il Status% Reli#ion% !du"ational Attainment% O""u*ation% FatherFs Name% !du"ational Attainment% O""u*ation% MotherFs Name% !du"ational Attainment% O""u*ation% Num$er of Si$lin#s% +ate Admitted% Physi"ianFs +ia#nosis%

Male 99 years old& No,em$er 8' 158; !"oland' +a,ao City Sin#le Roman Catholi" 1o"ational Course -raduate C2-year "ourseD +iesel Me"hani" !u#enio -rade 8 !lementary le,el Self-!m*loyed Cresen"ia -rade 4 !lementary le,el )ouse@ife 8 No,em$er 2<' 2009 S"hi/o*hrenia Paranoid 6y*e

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-!NO-RAM
Mot)er*s %ide !ga"ito #a$an
Francisca B laco, #roco"io !ra"oc

Fat)er*s %ide
Florencia !ra,-ara,

Celestino %era"eon Roberta Catalino Ra&$ ndo, 84

Cresencia, 82

Marcelo . genio, 83 Cerelina #or+eria !necita !s ncion 1 Ma dit), 47 !li"ia relia,

/eonardo, 43

11
2il+redo, 42

/ 0, 53

Marcos, 78 Ma. Magdalena, . gene, 51 'i(encio, 71

Montano, 69 67 Rosario,

Cle$ente Roberto,

/.3.456

deceased

alco)olic

)&"ertension

diabetes

s$o7er

client

$ale

NARRA6I1! -!NO-RAM

+e$ale

A#a*ito Paman' eonardoFs maternal #randfather' married Fran"is"a 3ula"o& 6hey $ore 12 "hildren& 6he first "hild is Celestino @ho died $e"ause of >*asmoA as ,er$ali/ed $y Cresen"ia Paman& Sera*eon the 2nd "hild' died at the a#e of <2 due to a "ondition "hara"teri/ed $y a se,ere stoma"ha"he& Ro$erta' the 4rd "hild' died due to a dia$etes "om*li"ation& Catalino the 9th "hild' 85 years old' li?e the se"ond "hild' died $e"ause of a "ondition "hara"teri/ed $y a se,ere stoma"ha"he& 6he ;th "hild is Raymundo' no@ <9 years old and resides in 3ohol& Cresen"ia' no@ <2 years old and the 8th "hild of the family' li,es in +a,ao City& Clemente the :th "hild died at the

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a#e of 4 due to "holera& Mar"os the <th "hild @as $orn t@o years after& )e is no@ :< years old& 6he 5th "hild' Maria Ma#dalena' :4 years old' has arthritis& 1i,en"io' the 10 th "hild' is :1 years old and is a hy*ertensi,e& Montano' the ne0t "hild' no@ 85 years old is a hy*ertensi,e and al"oholi"& Rosario' the youn#est "hild' no@ 8: years old has hy*ertension& 6heir father died of Malaria at the a#e of 80& Cresen"ia met and married !u#enio Ara*o"& !u#enio Ara*o" is the son of Floren"io Ara@-ara@ and Pro"o*io Ara*o"& 6hey $ore < "hildren namely% Mar"elo' !u#enio' Cerelina' Profesia' Ane"ita' Asun"ion' Maurelia' and Ali*ia& A""ordin# to Cresen"ia' Maurelia died of mi#raine& Cresen"ia does not ?no@ any information a$out the a#e and illnesses of her hus$andFs $rothers and sisters sin"e they are residin# in 3ohol& Cresen"ia and !u#enio $ore 8 "hildren& 6he first "hild is u/' no@ ;4 years old& !u#ene follo@ed& )e is no@ ;1 years old& A""ordin# to Cresen"ia' he is an al"oholi"& Ro$erto' a seaman' is no@ 95 years old& (udith follo@ed 2 years later& After three years' eonardo @as $orn& )e is no@ 99 years old& Bilfredo' the youn#est' is no@ 94 years old& )y*ertension is *resent in Sir eonardoFs maternal linea#e& On his *aternalFs linea#e' there are no ?no@n diseases e0"e*t mi#raine&

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ANAMN!SIS I& INFORMAN6S a& Informant 1 Name% Cresen"ia Address% !"oland +a,ao City Relationshi* to Patient% Mother en#th of time ?no@n to *atient% Sin"e $irth A**arent understandin# of *resent illness of the *atient% As a mother' MaFam Cresen"ia @as the most affe"ted one @ith @hat ha**ened to eonardo& Bhen as?ed of her understandin# a$out the situation she stated' >6in#ali na*asmo na siya su#od aton# #iti#$as si Bilfredo& Pa#$alhin namo na#a?ata@a' sturyasturya& Amon# *atam$alan la#i sa al$ularyo& =sahay ma# in#on na siya na naay tao

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na?a*arade& Sa *a#tuo lan# na niya' dili na tinuod& Sus' ?un# ano na dalhon C*ertainin# to a $oloD' a?o na iyan# *atayon' sa?it *ud ?ay a?on# ana?&A >3ala? namo ?ami nalan# ma#-atiman sa iyaha& Ma#*areseta nalan# mi ta*os ?ami nalan# ma#*a in7e"tion sa iyaha&ANaluoy ?o alan#an ana? nimo' i*asulod nimo sa hos*ital& +ili man unta namo siya i*asulod unya nanum$a# na man' mao to amon# i*a*atrol& Bala man mi mahimo' da@aton nalan#&A Other "hara"teristi"s and attitudes of the informant% Cresen"ia is a s@eet' lo,in#' and "arin# mom to her "hildren& She is also a "arin# #randmother to her #rand"hildren& She @as quite hesitant to lay do@n some information a$out her family u*on first en"ounter $ut throu#hout the inter,ie@' she $e"ame o*en to dis"ussin# her familyFs life e0*erien"es es*e"ially her sonFs "ondition& She is s*ontaneous all throu#hout the "on,ersation& She @as ,ery friendly& $& Informant 2 Name% Bilfredo Address% !"oland' +a,ao City Relation to the *atient% 3rother en#th of time ?no@n to *atient% Sin"e $irth A**arent understandin# of *resent illness of *atient% Bill is thou#hts& >)inay man ?aayo' sa su#od mura# normal lan# an# iyan# #ina*a?ita' sa ulahi mura# da#han na man& ahi na man& )inay man ?aayo' mura# normal *a man& Huyu#?uyo# man mi sa m#a a"ti,ites sa $atan-on sa amoa& Naa na to sa $iente ton# na#su#od siya' mura# lahi na 7ud& +u#ay-du#ay' nao$ser$ahan namo di na na#atulo#' dili na taron#' *as*as na an# hunahuna $a& A?on# na@un# aton# #iti#$as ?o' *uro 7ud to du#o $aI Mao si#uro to iyan# na?it-an& Mura# na#su#od 7ud to ?aton# nai#o ?o $a& Mura# natuman sa iyan# huna-huna $a unsan# nahita$o sa a?o-a& Na#-a*il #ani siya sa a?o-a' #idayun#an ?o *asa?ay sa 7ee*& eonardoFs "losest $rother& 6hey @ere al@ays seen to#ether @hen they eonardoFs *resent state' he @illin#ly shared his @ere youn#er& Bhen as?ed a$out

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Mura# naa na 7ud si#uro nan# iyan# sa?it sauna *a' @ala lan# mi ?a$alo ?ay dili man mi *sy"holo#ist& 3efore *a nahita$o sa a?o-a ton# nati#$as' mura# naa na siya& Hun# *sy"holo#ist na to tin#ali' liti? na toJ Mu#a@as na siya $ali?tad an# sanina' unsaon man lahi man 7ud' naa may di*erensya& Mahalata 7ud nimo na naay di*erensya& Plano #ani namo i*a#a@as siya ?ay an# sala*iI isod ma#-a*as' @ay ayo an# ?@arta& -@a*o man *ud unta i*a$utan# didto ?ay naa 7ud ma#$antay sa iya& Hun# sa $alay @ala& Bala 7ud siya na#-im*ro,e& Hun# sauna 100E na maayo' ?aron 2;E nalan#&A Other "hara"teristi"s and attitudes of the informants% Bill tal?s "on,in"in#ly& )e maintains a "onstant eye "onta"t throu#hout the inter,ie@& Bhene,er questions are raised' he ans@ers immediately and ela$orates e,en more& )e seems to ha,e a""e*ted his $rotherFs *resent "ondition& "& Informant 4 Name% )elen Address% !"oland' +a,ao City Relationshi* to *atient% Sister-in-la@ en#th of time ?no@n to *atient% Sin"e 2004 A**arent understandin# of *resent illness of *atient% )elen is eonardoFs sister-in-la@& She has ?no@n eonardo sin"e Bill $rou#ht her to their house& Bhen as?ed of @hat she ?no@s a$out eonardo% >Ma#-isturya lan# sa iyaha ?alit-?alit ra ta*os ?alit masu?o& Hani 7ud dili na?o ma?alimtan' naa to siyay sore eyes ta*os nan#ita siya u# 3ay#on' @ala na?o #ita#aan unya #i dumtan na diay ?o& Iya da@ ?o# *atiran& Sus' maayo #ani naa a?on# hus$and' tadya?an unta a?on# tiyan& 8 months $untis $iya ?o ato& Haton# +e"em$er 2<' na#@ild na siya ato ta*os #idala sa mental human #i$alhin sa 3a$ista& +ili na man siya ?atulo# human masu?o na siya ?un# sarad-an an# #ate& +umutan niya ?un# ?insa an# ma#sarado sa #ate& I@as na ?o sa iya ?ay ?alit lan# u# ya@ya@& )a*it *ud niya #ila$ay a?on# ana? ?aton# 2004& Maayo nalan# na?a$antay ?o&

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Pa# masu?o #ani na siya' an# iyan# mata lain ?aayo& Pa# su?o na an# tinan-a@an' lain na an# iyan# mata& masu?o na siya $adlun#on ?ay mura# #inaya@ya@an na *ara sa iyaha& Haton# #i-admit na siya' #i*an#utana siya sa nurse ?un# ?aila siya ?insa iyan# ?au$an CmotherD' an# #itu$a# da@ niya% >Am$ot' ?alit lan# man na niadto sa $alay& O? man na siya ?un# dili muto?ar' *alan##a man niya iyan# m#a *a#uman#?on& Sa iyan# tatay lan# siya hadlo?&Haton# uya$ *alan# mi ni Bill' dili na siya mana#ad' a#ia#i lan# sa a?on# atu$an#an&6an-a@ na?o mura# naa 7ud siyay de*erensiya& +ili man na normal uy' ma#sturya ?alit' lahi na man naJA Other "hara"teristi"s and attitudes of the informants% She is a #ood mother and @ife& She is also ni"e to her *arents-in-la@& She seems to $e atta"hed to them& She is a house@ife @ho loo?s after the sari-sari store that her mother-in-la@ o@ns& +urin# the inter,ie@' she tal?ed and ans@ered our questions @ithout any hesitations& d& Informant 9 Name% !r@in Address% Sasa' +a,ao City Relationshi* to *atient% Ne*he@ en#th of time ?no@n to *atient% 20 years A**arent understandin# of the *resent illness of the *atient% Sir !r@in has al@ays ,ie@ed his un"le as someone @ho is aloof& Bhen he @as as?ed a$out his a**arent understandin# of his un"leFs "ondition he ,er$ali/ed% >Naa to time na ?aton# na# $a?asyon mi didto na ni?alit lan# siya u# ?uha u# sundan#& -i#u$a niya an# door ?no$ ?ay ?uhaon niya iyan# m#a #amit ?ay nau#a' nahutdan na da@ u# du#a an# m#a #oma' #i*u#n#an namo *ero iya lan# mi #i@a?li' @ala man siyan# #isum$a# o #iisu#an *ero #adali #yud siya unya dili mamina@ sa amoa&A >+ili *ud to siya mali#o ?un# dili in#nan& -ina*u#os o #ina remind *a siya sa a?on# lola *ero iyan# tu$a# ?ay >unya na lan#AIA

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>Na#a suot *ud siya u# 7um*er sa $alay' #i?an man to sa a?on# tito na seaman' @ala nay la$a la$aA )e also ,er$ali/ed that he had an idea that his un"le mi#ht $e someone @ho is mentally "hallen#ed $ut he isnFt a@are that his un"le is s"hi/o*hreni" until re"ently& 6his is $e"ause a""ordin# to him' his un"le is still fun"tional des*ite the fa"t that his un"le is sym*tomati" e,ery time he #ets to ,isit him& Other "hara"teristi"s and attitude of the informant% 3ein# a student nurse also' Sir !r@in is *arti"i*ati,e in the inter,ie@& )e is @arm and @el"omin# in ans@erin# our questions& )e e,en mana#ed to insert 7o?es as @e @ent on our inter,ie@& Also' he res*e"ts his un"le des*ite of his "ondition& )e treats his un"le li?e ho@ he treats a normal *erson and res*e"ts him nonetheless li?e his mother and his #rand*arents does& )e #ets to meet sir he @as not a$le to see him sin"e& e& Informant ; Name% Mer,in Address% Matina' +a,ao City Relationshi* to Patient% Nurse on +uty en#th of time ?no@n to *atient% : 2ears A**arent understandin# of *resent illness of the *atient% Sir Mer,in has ?no@n the "lient sin"e he @as 18 years old& 6hey @ere nei#h$ors sin"e then& Bhen as?ed @hat ?ind of *erson the "lient @as $a"? then' he said' >Hana si sir eonardo' $a#on# li*at *a na sila li?i na na& Na#ala?a@-la?a@ siya lan# isa na @alaFy *adulun#an and then ?un# ta@a#an nimo siya' dili na siya mutu$a# mas?in# unsaon& Bala 7ud na siyaFy ?au$an or ami#o ato na time then da#han ?aayo u# na#asun#o# sa iya u# $uan#& A?o mao$ser,e 7ud na?o na ?ay a*il ?o sa m#a na#asun#o#& Nahos*itali/ed na siya aton# #isum$a# niya an# iyan# mama na na$ua? an# *ustiso u# na $la"? eye& Haron ?ay si sir eonardo ?ay dili na #inaadtuan sa iyan# *amilya& 6an-a@ na?o dili na siya #ina?uha ?ay ma#samo? samo? lan# na siya u# dili *a 7ud muinom u# tam$al& Haron dili eonardo durin# holidays' $irthdays and on summer ,a"ations $efore sir eonardo @as admitted in N+RC& After admission' ho@e,er

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na siya #ina*ainom u# tam$al *ara sa iyan# hy*ertension u# dia$etes ?ay mali*on# da@ siya' $ale e,o na lan# iyan# #ina inom& Haron siya ?ay dili 7ud na#a so"ial intera"t' dira na lan# na siya ma#istam$ay sa isa ?a lu#aran then na#ahallu"inate u# na#ata@a siya lan# isa& Other "hara"teristi"s and attitudes of the informants% Sir Mer,in is "urrently a staff nurse in N+RC& As a staff nurse' he ?ne@ and he has o$ser,ed the "lient& 6hey also ha,e $een nei#h$ors sin"e he @as 18 years old& )e said that he has $een a *art of the so"ial stressor of eonardo& )e teased and al@ays mo"?ed the "lient e,ery time they met& )e fully understands the "lientFs situation and de,elo*ment' thus ma?in# his statements rele,ant& )e ans@ered our questions "learly and he shared his idea a$out @hat the "lient is "urrently fa"in#&

II& FAMI 2 )IS6OR2 a& Maternal and Paternal -rand inea#e 3asin# on the family tree of the "lient' the Ara*o" and Paman "lan ha,e no *ast re"ords of $ein# dia#nosed of or admitted due to mental illness' as ,er$ali/ed $y Cresen"ia Paman& +elinquen"y' dru# addi"tion' sui"ide ideation' de*enden"y' "hroni"

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unem*loyment and other traits of ineffi"ien"y is not *resent in their linea#e e0"e*t for al"oholism& Montano Paman is an al"oholi"& eonardo #re@ u* @ith his mother and father $y his side& )is #ro@th and de,elo*ment @ere not influen"ed $y any of his #rand*arents or other relati,es as he #re@ u* in Mlan#' @hile his relati,es li,e in 3ohol& $& Father !u#enio' eonardoFs father is a dis"i*linarian ty*e of *erson& )e doesnFt smo?e nor #am$le $ut o""asionally drin?s& )e dis"i*lines his "hildren $y first threatenin# to hit them @ith a $elt and if the "hild @ill not listen he @ill really hit them& Another form of dis"i*line im*osed $y the father @ould $e lettin# his "hildren ?neel $efore the altar& A""ordin# to Bilfredo' after @or?' their father does not hu# them nor say s@eet @ords to them& )e has ne,er $een a s@eet father to them& !u#enio is "ontent of @hat he has ho@e,er he reminds his "hildren to study hard' finish s"hool' do their $est in your @or?' and stay hum$le& !u#enio #raduated only of elementary edu"ation& )e @as not a$le to *ro"eed to )i#h s"hool or "olle#e& )e a"quired his land from as an inheritan"e from his *arents& It is a 1;-he"tare *ie"e of land& As a family man' he @a?es u* at 4 oF "lo"? in the mornin# to ha,e his $rea?fast then *ro"eed to the farm to tend for his "ro*s& )e #oes $a"? home to ta?e his lun"h then return to the farm a#ain& 3y ; oF "lo"? in the afternoon' he #oes home to rest& )e ta?es his su**er to#ether @ith his @ife and "hildren& A""ordin# to Cresen"ia' he $onds @ith his "hildren $y tal?in# to them and #i,in# them ad,i"es& On Sundays' he ma?es u* from not $ein# @ith his "hildren $y doin# re"reational a"ti,ities li?e $as?et$all and ,olley$all at the ne0t $arrio& "& Mother Cresen"ia' eonardoFs mother' is also a "arin# and lo,in# mother& She is also an o""asional drin?er $ut didnFt use to$a""o or en#a#e in any form of #am$lin#& She follo@s the same form of dis"i*linary measures as im*osed $y her hus$and&

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Cresen"ia has only rea"hed #rade 4& >I#o lan# #ud ma?a$asa u# ma?asulat'A as ,er$ali/ed& +urin# her teena#e years' she @or?ed as a "oo? for the farmers& She "oo?ed meals to $e sold to them& Bhen she #ot married' she stayed home all day& She tends for their *oultry and "leans the yard& At 4 oF "lo"? in the mornin#' she @a?es u* to "oo? $rea?fast then starts her usual tas?s& She ta?es "are of her "hildren from mornin# until e,enin#& She hel*s her "hildren in *re*arin# for s"hool and sometimes hel*s them @ith their home@or?s& "& Si$lin#s A""ordin# to Bilfredo' they are not "lose as si$lin#s& 6hey do not o*en u* their feelin#s to ea"h other& 6hey are not li?e some families @ho tal? a$out *ro$lems& Instead' they ?ee* it to themsel,es& Amon# the si$lin#s' (udith has the unusual attitude& u/ and (udith had a "onfli"t $et@een them for a""ordin# to Bilfredo and Cresen"ia' (udith al@ays @ants to #et @hat she @ants& III& P!RSONA I62 )IS6OR2 a& Prenatal Cresen"ia and !u#enio @as ready to raise a family& 3earin# a $a$y either e0*e"ted or une0*e"ted' means a $lessin# for them& Cresen"ia had a #ood outloo? of the *re#nan"y& She @as a@are of the *ro*er nutrition and needed immuni/ations& 6hey @ere @ell-a@are of the health "are ser,i"es offered ho@e,er $e"ause of their remote lo"ation' they @ere not a$le to #ain a""ess to these hen"e the la"? of needed immuni/ation and "he"?-u*s& +es*ite the la"? of health "are ser,i"es' she @as ,i#ilant of the *ro*er nutrition& She al@ays ate three meals a day' *lus merienda and ne,er fails to s?i* any of her diet @hi"h "onsists of fruits and ,e#eta$les li?e ?alamun##ay' alu#$ati' saluyot' $anana' and many more& Mil? is not *art of her *renatal diet& She does not smo?e "i#ar $ut she o""asionally drin?s a #lass of "o"onut @ine& As a form of e0er"ise' she s@ee*s the floor and ?ee*s the "leanliness of their house& $& 3irth

21

eonardo @as $orn full term on No,em$er 8' 1589 at late afternoon& =nusual in"idents attendin# $irth @ere not e0*erien"ed& eonardo @as deli,ered normally @ith the hel* of a lo"al hilot& )e @as $orn at their o@n home @ith the "are *ro,ided $y his father& Cuttin# of the "ord @as done @ith the use of a $am$oo sti"? and the "ut "ord @as immediately thro@n a@ay& Chan#e to *ra"ti"es after #i,in# $irth @ere done li?e $athin# of the $a$y& "& Infan"y and Child Chara"teristi"s eonardo @as e0"lusi,ely $reastfed for 9 months and @eanin# @as #radually started& Bhene,er he "ried' Cresen"ia immediately $reastfed him& Semi-solid foods li?e lu#a@ @ere introdu"ed durin# his ;th month and @eanin# @ith the use of *anya@an @as done& ea,es of this *lant @as *la"ed in the motherFs $reast& Pro*er $ur*in# @as At his 8th month' his eru*ted and he started to de,elo* the ha$it of thum$su"?in#& Cresen"ia @as the *rimary "are#i,er of eonardo sin"e they didnFt ha,e a hel*er& )er time @as de,oted to "uddlin# her $a$y& At a#e 1' he started to @al? and tal?& )is teeth @ere "om*leted at that same a#e& Bhene,er he needs to defe"ate' his mom $rin#s her to the C&R& )e sto**ed thum$su"?in# at 1 year of a#e& )e "ontra"ted measles at the same a#e& Four months later' he e,entually sto**ed $reastfeedin#& Sin"e they @ere li,in# in a remote area' he didnFt re"ei,e any needed immuni/ation& At the a#e of 4' he e0*erien"ed an e*ile*ti"-li?e sym*tom "hara"teri/ed $y mus"le s*asms' "on,ulsion' frothin# in the mouth and eyes rollin# $a"? at the head as a result of sli**in# off a "orn #rinder and hittin# his head thereafter& 6hen his *arents sa@ him at that state' he @as immediately rushed to the nearest hos*ital @hi"h @as an <?ilometer 7ee*ney ride from their home or a**ro0imately 40 minutes a@ay& eonardo suffered a trauma on the ri#ht-side of the head& 6he attendin# *hysi"ian dia#nosed hi of e*ile*sy and @as #i,en a medi"ation& )is *arents sto**ed #i,in# the medi"ations after a month& eonardo has not e0*erien"ed the same sym*toms sin"e& o$ser,ed $y his *arents&

22

6antrums @ere o$ser,ed as his @ants @ere not met& )e does not tal? to his *arents and does not listen to them& )e e,entually tal?s to them @hene,er he feels to& 3y this a#e' he already @al?s on a steady #ait& 6oilet trainin# @as introdu"ed $y his *arents at the a#e of ;& Bhene,er he defe"ates on the floor' his *arents as? him to #o to the C&R& and defe"ate there& )e started learnin# ho@ to read ad @rite at the same a#e @ith the #uidan"e of his mother& d& Psy"hose0ual )istory eonardo #ained se0ual a@areness at the a#e of 4& )e @as a$le to distin#uish the differen"e $et@een #enders& eonardo @as "ir"um"ised at the a#e of 12 throu#h an old method "alled Pa?an#& )is mother has no idea @hether he mastur$ates or not& eonardo is not o*en to dis"ussin# his se0ual life ho@e,er he admitted that he @at"hed *orno#ra*hi" mo,ies to#ether @ith his $rother& e& Play ife +urin# eonardoFs infan"y' he did not ha,e any toys to *lay @ith& Family intera"tion @as the only ty*e of *lay he had& +urin# his toddlerhood' he has a *ush-and*ull toy tru"? and a $all& )e only *layed @ith his si$lin#s sin"e their lo"ation does not *ermit them to intera"t @ith their nei#h$ors& In"reased intera"tion @ith *eers @as si#nifi"ant durin# his *res"hool years& )e usually *lays @ith his "lassmates& )e $e"ame a "hess *layer @hen he @as in #rades"hool and he *arti"i*ated in tournaments& )e @as also an a,id fan of $as?et$all @hi"h he *lays to#ether @ith his nei#h$ors and ?uya& )e formed a "ir"le of friends in s"hool and s*ent most of his time @ith them& )e *referred to *lay @ith his a#e #rou* and #ender& !,en thou#h he @as fond of *layin#' he $alan"es @or? and *lay& f& S"hool )istory )e started s"hoolin# at the a#e of :& )e @as in #rade 1 @hen he entered Nue,a 1ida elementary s"hool& )e @as friendly at that time& )e #re@ "lose @ith one of his tea"hers and a"ti,ely *arti"i*ates $oth in "lass and s"hool a"ti,ities& )is #rades @ere a,era#e& )is fa,orite su$7e"t @as math&

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+urin# his hi#h s"hool years' he @as still a"ti,ely *arti"i*atin# $oth in "lass and s"hool a"ti,ities& +urin# dismissal' he immediately #oes home to do his home@or?& At the a#e of 18' he #raduated from hi#h s"hool and immediately *ro"eeded to a diesel me"hani"s ,o"ational "ourse& After 2 years of s"hoolin#' he finished the ,o"ational "ourse and @as ready to start a 7o$ as a me"hani"& #& Reli#ious and So"ial Ada*ta$ility )e has many friends at their nei#h$orhood @ho he li?es to *lay @ith& 6hey usually *lay $as?et$all and han#-out "hattin# @ith ea"h other& >Huyu#-?uyo# man sa m#a a"ti,ities sa $atan-on sa amoa& 3as?et$all *a #ani to& Naa *a #ani mi team sa una& i#a-li#a' ?uyu#-?uyo# sa m#a youth youth na a"ti,ity&A )e @as de,oted to his reli#ion& )e #oes to mass e,ery Sunday and *rayed e,eryday& )e @as e,en a mem$er of a youth #rou* in their nei#h$orhood& h& O""u*ational )istory Bhen eonardo @as still in )i#h S"hool' he does a *art time 7o$ in Stanfil"o at Mlan#& Sometimes' he does not attend "lasses for he #oes @ith the dri,er deli,erin# $ananas to A#usan and Suri#ao& +es*ite this' he ne,er failed his su$7e"ts& After )i#h S"hool' he @or?ed on their farm hel*in# his father tend for their ru$$er trees& At a#e 24' in +a,ao City' he too? a ,o"ational "ourse in +I6!' 3an#?al 3ran"h& )e too? the "ourse for 2 years& After finishin# his "ourse' he @as offered a 7o$ $y his $rother-in-la@' Ale7andro Corinales at +a,ao Car$on Chemi"al Cor*oration& )e @or?ed there for a month only for a""ordin# to Bill' eonardo ,er$ali/ed' >Sa$a ?aayo' da#han na#asturya' si#eF# ya@ya@A& )e stayed home and a""e*ted @eldin# 7o$s from nei#h$ors sin"e& i& Marital )istory eonardo is not o*en to dis"ussin# his lo,e life& )e @as ne,er married' and a""ordin# to his mother he did not ha,e any #irlfriends& A""ordin# to Bill' eonardo "ourted a fe@ #irls $efore $ut he ne,er had any relationshi* @ith the o**osite se0& 7& Onset of Present Illness

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At the a#e of 24' si#ns and sym*toms of *sy"hosis a**eared& )e @as lau#hin# $y himself and @hen his mother as?ed him @hy he @as lau#hin#' he ans@ered that he is seein# a dan"in# *oli"e offi"er $ehind a $anana tree& One ni#ht' he told his mother that he @ants the doors o*ened $e"ause they @ill $e ha,in# a ,isitor& )e ne,er sto**ed @antin# to #o out of the #ate des*ite it $ein# lo"?ed& +ay after day' si#ns and sym*toms "ontinued to manifest su"h as refusal to ta?e a $ath and tal?in# to himself& )e #oes out of the house and @anders around the ,illa#e& 6he family @as a@are of the sym*toms $ut i#nored it until the time eonardo $e"ame hostile& On +e"em$er 2<' 2004' eonardo @o?e u* at da@n& She immediately @al?ed to the #ate @antin# to #o outside& )is mother sto**ed him& )e "ontinued to insist to ha,e the lo"?s o*ened& And @hen his mother "ontinued to de"line' he *un"hed her in the eye& 6he family "alled for hel* From the nei#h$ors $ut they only said to "all 511 sin"e at that time' eonardo @as a $i# man& Bhen 511 *oli"e arri,ed' eonardo @as $rou#ht to +a,ao Mental )os*ital and @as admitted for 8 days& )e @as a""om*anied $y Bilfredo throu#hout those times& On (anuary 4' 2009' he @ent home& )e remained to $e hostile so the family de"ided to ha,e him admitted at Ne@ +ay Re"o,ery Center&

25

+!FINI6ION OF +IA-NOSIS A& S"hi/o*hrenia 1& 6he natural *ro#ression of s"hi/o*hrenia is usually des"ri$ed as deterioratin# @ith time' @ith an e,entual *lateau in the sym*toms& Only for elderly *atients @ith s"hi/o*hrenia has it $een su##ested that im*ro,ement mi#ht o""ur& In reality' n one really ?no@s @hat the "ourse of s"hi/o*hrenia @ould $e if *atients @ould ale to adhere to a treatment re#imen throu#hout their li,es& Only re"ently ha,e medi"ations $een relati,ely effe"ti,e' @ith mana#ea$le side effe"ts& 6he "lini"al *i"ture of s"hi/o*hrenia is "om*le0' indi,idual differ from one another' and the e0*erien"e for a sin#le indi,idual may$e different from e*isode to e*isode&

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3i$lio#ra*hy% 3oyd' Mary Ann& Psy"hiatri" Nursin# Contem*orary +ia#nosis& 9 th Philadel*hia' Pennsyl,ania& BB&K 200<& Pa#es <:4

edition&

2& It is one the most "om*le0 and de$ilitatin# mental disorder& It is not a sin#le disorder $ut a syndrome C#rou* diseaseD' @ith a @ide ran#e of se,erity and sym*toms amon# indi,iduals& It is a $rain disease $e"ause sym*toms o""ur from a num$er of fa"tors that affe"ts the $rainFs neurotransmitter system resultin# in im*aired thou#hts' *er"e*tions' "o#niti,e fun"tions' mood and moti,ation CSado"?'et&al'2009D& S"hi/o*hrenia is a uni,ersal disorder that e0ists in all "ultures and in all e"onomi" #rou*s CNational Institute of Mental )ealth' 200;D& It is often "alled a *sy"hoti" disorder meanin# that *eo*le @ith s"hi/o*hrenia ha,e *eriods @hen they lose tou"h @ith reality and e0hi$it ,arious ?inds of *sy"hoti" sym*toms& All sym*toms of s"hi/o*hrenia are de$ilitatin#' $ut not all sym*toms are *sy"hoti"& 6he sym*toms seem to "ome from different me"hanisms' *erha*s $e"ause different $rain re#ions or "ir"uits are affe"ted& 3i$lio#ra*hy% Fortinash' Catherine and Borret' Patri"ia& Psy"hiatri" Mental )ealth Nursin#& 9 th !dition& St& ouie Missouri% Mos$y !lsi,ier&K200<&*a#es 295 4& S"hi/o*hrenia is a syndrome' illness or mental health disorder hetero#eneous in "ause' *atho#enesis' *resentin# *i"ture' res*onse to treatment' and *ro#nosis& Sym*toms #enerally refle"t a *ro#ressi,e deterioration and disor#ani/ation of the indi,iduals *ersonality stru"ture affe"t and "o#nition& 6he +SM-I1-6R lists the follo@in# ty*es *aranoid' "atatoni"' disor#ani/ed' undifferentiated and residual& 3i$lio#ra*hy% Heltner' Norman & et al& Psy"hiatri" Nursin#& ; th edition& Missouri% Mos$y In"& K 200:& * 858 9& S"hi/o*hrenia "auses distorted and $i/arre thou#hts' *er"e*tions' emotions' mo,ements' and $eha,ior& It "anFt $e defined as a sin#le illnessG rather' s"hi/o*hrenia is thou#ht of as a syndrome or a disease *ro"ess @ith many different ,arieties and sym*toms' mu"h li?e the ,arieties of "an"er& Many $elie,ed that those @ith s"hi/o*hrenia needed to $e lo"?ed

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a@ay from so"iety and institutionali/ed& Only re"ently' has the mental health industry "ome to learn and edu"ate the "ommunity at lar#e that s"hi/o*hrenia has many different sym*toms and *resentations and is an illness that medi"ation "an "ontrol& S"hi/o*hrenia usually dia#nosed in late adoles"en"e or early adulthood& Rarely does it manifest in "hildhood& 6he *ea? in"iden"e of onset is 1; L 2; years of a#e for men and 2; -4; years of a#e for @omen& 3i$lio#ra*hy% 1ide$e"?' Sheila & et al& Psy"hiatri" Mental )ealth Nursin#& 4 rd edition&

i**in"ott Billiams M Bil?ins& K 2008& *a#e 2:8& ;& S"hi/o*hrenia is a *sy"hoti" disorder Cor #rou* of disordersD mar?ed $y se,erely im*aired thin?in#' emotions' and $eha,iors& 6he term s"hi/o*hrenia "omes from t@o -ree? @ords that mean Ns*lit mind&N It @as "oined around 150< $y a S@iss do"tor named !u#en 3leuler to des"ri$e the s*littin# a*art of mental fun"tions that he re#arded as the "entral "hara"teristi" of s"hi/o*hrenia& CNote that the s*littin# a*art of mental fun"tions in s"hi/o*hrenia differs from the s*lit *ersonality of *eo*le @ith multi*le *ersonality disorder&D S"hi/o*hreni" *atients are ty*i"ally una$le to filter sensory stimuli and may ha,e enhan"ed *er"e*tions of sounds' "olors' and other features of their en,ironment& Most s"hi/o*hreni"s' if untreated' #radually @ithdra@ from intera"tions @ith other *eo*le' and lose their a$ility to ta?e "are of *ersonal needs and #roomin#& Be$lio#ra*hy% htt*%OO@@@&healthline&"omO#ale"ontentOs"hi/o*hrenia-1O9

3& Paranoid 6y*e S"hi/o*hrenia

1& Paranoid ty*e S"hi/o*hrenia L results in less neurolo#i" and "o#niti,e im*airment and a $etter *ro#nosis for the indi,idual& )o@e,er' in the a"ti,e *hase of the disorder' the affli"ted indi,idual is e0tremely ill and the sym*toms often ma?e the *erson a dan#er to self or others& A""ordin# to the +SM-I1 6R "riteria for s"hi/o*hrenia' a dia#nosis of *aranoid s"hi/o*hrenia must meet t@o of the sym*toms on "riterion A% the *resen"e of
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delusion and hallu"inations& 6he other dia#nosti" "riteria for *aranoid s"hi/o*hreniadisor#ani/ed s*ee"h' $eha,ior' and other ne#ati,e sym*toms- are not *rominent& 6he delusions and hallu"inations must $e *resent for a si#nifi"ant *ortion of time o,er a *eriod of one month& 6his *eriod is shorter of the "ondition is su""essfully treated& Also' if delusions are usually $i/arre or if the hallu"inations in,ol,e "ommandin# or "ommentin# ,oi"es' only one of the "riteria needs to $e met& Paranoid s"hi/o*hrenia often ahs a sudden onset' sometimes tri##ered $y se,ere stressors C fortinash and holoday Borret' 200:G APA' 2009D 3i$lio#ra*hy% Fortinash' Catherine and Patri"ia Borret )olloday& Psy"hiatri" Mental )ealth Nursin#& 9th !dition& St& 290-2;< ouie Missouri% Mos$y !lsi,ier& K200& Pa#es

2& Paranoid s"hi/o*hrenia is "hara"teri/ed $y systemati/ed delusion or auditory hallu"inationsG the indi,idual may $e sus*i"ious' ar#umentati,e' hostile and a##ressi,e& a& 6he indi,idualFs $eha,ior is less a##ressi,e at this ty*e' and he is not as so"ially im*aired& $& Pro#nosis is $etter than that of the other ty*es& 3i$lio#ra*hy% Isaa"s' Ann& Mental )ealth and Psy"hiatri" nursin#& 9 th edition =SA' i**in"ott Billiams and Bil?ins& K 200;& Pa#es ;99- ;80

4& Clients e0hi$itin# *aranoid s"hi/o*hrenia tend to e0*erien"e *erse"utory or #randiose delusions and auditory hallu"inations& 6hey also may e0hi$it $eha,ioral "han#es su"h as an#er' hostility or ,iolent $eha,ior& Clini"al sym*toms may *ose a threat to the safety of self or others& Pro#nosis is more fa,ora$le for this su$ty*e of s"hi/o*hrenia than for other su$ty*es of s"hi/o*hrenia& Clients in @hom s"hi/o*hrenia o""urs in their late 20s and 40s usually ha,e esta$lished a so"ial life that may hel* them throu#h their illness& In addition' e#o resour"es of *aranoid "lients are #reater than those of "lients @ith "atatoni" and disor#ani/ed s"hi/o*hrenia&

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3i$ilio#ra*hy% Shi,es' ouise Re$ra"a& 3asi" Con"e*ts of Psy"hiatri" Mental )ealth Nursin#& 8th edition Philadel*hia& i**in"ott Billiams and Bil?ins K 200;&*# 29;

9& S"hi/o*hrenia' Paranoid ty*e L it is "hara"teri/ed mainly $y the *resen"e of delusions of *erse"ution or #randeur and auditory hallu"inations related to a sin#le theme& 6he indi,idual is often tensed' sus*i"ious and #uarded' and may$e ar#umentati,e' hostile' and a##ressi,e& Onset of sym*toms is usually later C*erha*s in the late 20Fs or 40FsD' and less re#ression of mental fa"ulties' emotional res*onse' and $eha,ior is seen than in the other su$ty*es of s"hi/o*hrenia& So"ial im*airment may$e minimal' and there is some e,iden"e that *ro#nosis' *arti"ularly @ith re#ard to o""u*ational fun"tionin# and "a*a"ity of inde*endent li,in#' is *romisin# CAPA' 200D& 3i$lio#ra*hy% 6o@nsend' Mary C& Psy"hiatri" Mental )ealth Nursin#% Con"e*ts of Care !,iden"e 3ased Pra"ti"e& ;th edition& Philadel*hia' Pennsyl,ania& F&A& +a,is Com*any& K200<& P& 980 ;& In this ty*e of s"hi/o*hrenia' the indi,idual has feelin#s of $ein# *erse"uted or *lotted a#ainst& Affe"ted indi,iduals may ha,e #randiose Co,er-the-to*D delusions asso"iated @ith *rote"tin# themsel,es from the *er"ei,ed *lot& Be$lio#r*ahy% htt*%OO@@@&health"entral&"omOs"hi/o*hreniaO"om*li"ations-1<<1-10<&html

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M!N6A S6A6=S !PAMINA6ION I. PR! !PAMINA6ION -eneral A**earan"e eonardo has a mesomor*hi" $ody $uilt& )e is @earin# a $lue shirt' @hite maon# shorts and a *air of sli**ers& )e is standin# $efore the *ost $ehind the #ate& 6here is no si#n of fa"ial distress& )is hair is "ut in a >s?in headA style& )e loo?s "lean and neat& 3& -eneral Mo$ility 1& Posture and -ait )e has a slou"hed *osition @hen sittin# and standin#& )e has a steady #ait and a**ears rela0ed& )e is a$le to @al? @ithout diffi"ulty& 2& A"ti,ity

32

)y*oa"ti,ity is noted @hen @e ha,e #ames& Same s*eed is also o$ser,ed durin# our art a"ti,ities& Bhen #i,en a question' there is a delayed res*onseG ho@e,er his s*eed in tal?in# is moderate and understanda$le& 4& Fa"ial !0*ression Bhen our to*i" is a$out his lo,e interest' he smiled ho@e,er @hen our to*i" @as a$out his *ast o""u*ation' he @as ,ery serious& Fa"ial e0*ression is a**ro*riate to the a"ti,ity or the e,ent& II. S6R!AM OF 6A H A& Chara"ter )e is deli$erate in ans@erin# our questions& )e ne,er initiates to o*en a to*i"& If @e do not start the intera"tion' @e ne,er "on,erse& Most of the time' he only ans@ers >OoA' >si#eA and >o? lan#A @hi"h are e,iden"es of deli$erate tal?in#& )o@e,er' sometimes he tends to ans@er more than @hat is e0*e"ted from him& )e only ela$orates his ans@ers @hen he is as?ed to do so& 3& Or#ani/ation of 6al? Or#ani/ation of tal? is rele,ant' or#ani/ed and "oherent& )e ans@ers a**ro*riately& )e e0*resses his ideas a""ordin#ly @ith @ords a**ro*riate to @hat he @ants to deli,er to his listener& C& A""essi$ility 6he a""essi$ility is fair $e"ause he easily en#a#es in a "on,ersation @ith others or me& 3ut @hen not "on,ersin# @ith someone' he tends to "o"? his head to a side as if he is listenin# to someone tal?in#& III. !MO6IONA S6A6! AN+ R!AC6IONS A& Mood

33

)is mood is euthymi" as he @as ans@erin# my questions& )e did not manifest e0a##erated mood or si#ns of de*ression as e,iden"ed $y his *arti"i*ation to the a"ti,ities in the *ro#ram& 3& Affe"t )e has an a**ro*riate affe"t on a"ti,ities su"h as the ones in the *ro#ram and durin# our intera"tion& )o@e,er these rea"tions are o $lunt quality sin"e his rea"tions are a**ro*riate $ut @ith less intensity than @hat are to $e e0*e"ted& C& +e*ersonali/ation and +ereali/ation +e*ersonali/ation and dereali/ation @ere not *resent on our "lient&

+& Sui"idal Potential )e has no sui"idal *otential as e,iden"ed $y a$sen"e of sui"idal threats and sui"idal #estures& IV. 6)O=-)6 CON6RO A& Per"e*tion Auditory hallu"inations are *resent as e,iden"ed $y turnin# his head to the other side& )e loo?s li?e listenin# and murmurin# to someone& Most often' his ,oi"e is not audi$le @ith only the li*s mo,in# durin# the *resen"e of the said hallu"ination& )e suddenly s*o?e to himself one time'>O la#e' *aundan#on na?o sila' *aundan#on na?o silaA & 3& +elusions )e has no delusions durin# our intera"tion& C& Ideas of Referen"e

34

Ideas of referen"e @ere not e,ident durin# our intera"tion& +& Pre-O""u*ations and Ruminations Preo""u*ation and rumination are not e,ident throu#hout the "ourse of the assessment& !& +Q7R ,u and (amais ,u +Q7R ,u and (amais ,u @ere not e,ident& )e is familiar @ith the e,ents that had ha**ened and are ha**enin# to him at the moment&

1&

N!=RO1!-!6A6I1! +2SF=NC6ION A& Slee* )e has no diffi"ulty in fallin# a slee*' no midni#ht and early mornin# a@a?enin#& )is slee*in# *attern is normal& 3& A**etite )e has a ,ery #ood a**etite& On the first @ee? of our duty he "onsumed 2 sio*aos' 2 *lates of s*a#hetti on the se"ond day and 4 "hi"?en sand@i"hes in the third day& 3ut he said that if he is feelin# full' he @ill sto* eatin#& C& +iurnal ,ariation +iurnal ,ariation is a$sent to him as his mood remains the same throu#hout the day& =rination and defe"ation is normal as ,er$ali/ed $y the "lient& +& Bei#ht

35

Be are not a$le to assess and o$tain the @ei#ht of our "lient for @e did not ha,e a @ei#hin# s"ale& F& i$ido -eneral ener#y le,el is normal' as e,iden"ed $y @illin#ness to *arti"i*ate and "oo*erate& Se0ual li$ido is not a"ti,e& 6here is no manifestation of se0ual *reo""u*ation& !,en if he has no @ife and no #irlfriend he still #ets interested to #irls&

-!N!RA S!NSORI=M A& Orientation )e is oriented @ith the time' *la"e' date and his name as e,iden"ed $y the ans@ers >2%00 *m' 3a$ista' (anuary 1;' 2005 and eonardo&A )e "urrently ?no@s @hat the e,ents of the day @ere $e"ause he reads ne@s*a*er e,eryday as he said& 3& Memory )e "ould re"all immediate' re"ent and e,en remote e,ents& In immediate' he re"alls that he ate >la@-uyA for lun"hG in re"ent he re"alls that lst Bednesday he @as handled $y MA6S student nursesG and in remote' he re"alled that he had his ,o"ational "ourse in +I6! s"hool @ith the "ourse of >me"hani"A C& Attention s*an )is attention s*an is fair& )e *arti"i*ates in the a"ti,ities li?e in sin#in#& Bhen the son# started *layin#' he sin#s ,ery @ell at the $e#innin# $ut @hen it is already in the middle and sees someone @ho is not sin#in#' he @ill sto* and fa"es the floor instead or @orse he @ill manifest auditory hallu"inations& As o$ser,ed' the more he is stimulated the more he *arti"i*ates and manifests #ood attention s*an& +& -eneral information Bhen @e as?ed him on @ho is the "urrent *resident' he ans@ered -loria Arroyo& )e is u*dated to "urrent e,ents&
36

!& A$stra"t thin?in# a$ility )e has #ood a$stra"t thin?in# a$ility as e,iden"ed $y ans@erin# 1< from the "om*utation of 10S<& And also he told us a$out their >*alayanA or field& )e said' they left the field $e"ause !l nino is ha**enin# in Mlan# that time' the ri,er dried u* and thereFs no rain& So @e as?ed' >n#ano man diay sir ?un# @alay ulanTA' then he ans@ered' >@ala ulan' @ala *alayan' @ala ?ita' @ala ma?aon&A F& (ud#ement and reasonin# It is unim*aired $e"ause he is a$le to e0*lain thin#s to us' su"h situation a$out his *ast @or?& )e said that he filed a "om*lain a#ainst his $oss so @e as?ed @hy and then he said >?ay @ala naman mi #ina s@eldohan' isa ?a $ulan ra&A Also he thin?s $efore he a"ts as e,iden"e $y the $ead ma?in# a"ti,ity& )e thin?s on @hat @ill $e the *attern or the order of the "olors first $efore insertin# it to the thread& INSI-)6 )is insi#ht is im*aired $e"ause he *er"ei,es this admission as a seminar required $y the "om*any @here he *re,iously @or?ed&

37

S=MMAR2 OF M!N6A S6A6=S !PAMINA6ION +istur$an"e in% CU D Presentation CU D Stream of tal? CU D 6hou#ht "ontrol eonardo is hy*oa"ti,e and "an $e ,ery slo@ in "om*rehension& In re#ards to "on,ersin#' he is deli$erate in ans@erin# questions& )e also manifests auditory hallu"inations $ut "an still $e "ontrolled if his attention is di,erted& )e has an im*aired insi#ht $e"ause he *er"ei,es his admission as *urely a seminar& 6he quality of his affe"t is $lunted $e"ause @hen he rea"ts the rea"tion is less intensified and returns his flat fa"ial e0*ression after a@hile& +IA-NOS6IC CA6!-OR2 Our "lient is "ate#ori/ed as fun"tional sin"e he "an do his a"ti,ities of daily li,in#& )e @as not de*endent to student nurses or to the staff $ut he is "onsidered *sy"hoti"& +SM I1 +IA-NOSIS APIS I- s"hi/o*hrenia' *aranoid ty*e APIS II-none APISIII-none APIS I1- so"ial stressor' trauma APIS 1 - Current -AF ;1-80 CU D Insi#ht CU D !motional state and rea"tion

38

PRO-R!SS NO6!S

(anuary 1;' 2005 C6hursdayD It @as the first day in our rotation in *sy"hiatri" nursin# @hen @e first met Sir eonardo' he a**ears "lean and neat& 6he first day of our a"ti,ity #i,es us the "han"e to ?no@ our "lient and ha,e a first im*ression on him& +urin# our first a"ti,ity @e noti"ed that our "lient' Mr& eonardo Ara*o" or Sir eonardo has a e0*ression less fa"e' althou#h he res*onded to our questions he tends to ha,e a short attention s*an& Bhen the a"ti,ity *ro#resses' @e had o$ser,ed that Sir eonardo
39

*arti"i*ated on ea"h a"ti,ity and follo@s ea"h instru"tions $ut his hallu"inations most of the time interferes @ith the a"ti,ity& Also @e noti"ed that he eats too mu"h sometimes 4 times of the usual ser,in#& (anuary 18' 2005 CFridayD On the se"ond day of our a"ti,ity it seems that Sir eonardo en7oyed ea"h a"ti,ity that @e *re*ared& From $ein# e0*ressionless he started to smile es*e"ially durin# the #ame >Shoot the 3allA& In this *arti"ular #ame alone our "lient manifested that en7oyment that he had @hen *layin# the #ame& Not only the smiles $ut also he "an "on,erse in lon# statements rather than sin#le @ord ans@er& Still eonardoFs hallu"inations *ersisted' if left undistra"ted he ?ee*s on tal?in# to himself li?e murmurin# to someone& 6he only thin# that remains the same @as his $i# a**etite& (anuary 1:' 2005 CSaturdayD On the third day of our first @ee? e0*osure in *sy"hiatri" nursin# in Ne@ +ay Re"o,ery Center' thin#s @ent quiet @ell from nothin# to somethin#& As @e esta$lished ra**ort @ith our "lient it seems that he re"i*ro"ate it @ith $etter res*onse @ay $etter than on the *re,ious days& )e *arti"i*ates and en#a#ed on a"ti,ities mu"h li,elier and ans@ers ea"h questions @ith more sense& 6he fa"t that he eats to mu"h' li?e after re"ei,in# a to?en of a**re"iation he then o*ens it and shared the food to someone&

(anuary 22' 2005 C6hursdayD In this day our #rou* de"ided to ha,e a remoti,ational thera*y usin# the mo,ie > Hasal' Hasali' HasaloA a "omedy-drama #enre as the film of "hoi"e& Be noti"ed that durin# the time that @e @at"hed the mo,ie there @ere tines that he "on"entrates on @at"hin# the mo,ie and also there @ere times that his hallu"inations ta?es o,er& Sometimes his eyes seem to s"an the @hole *la"e and loo? to the other residents& After the mo,ie sir eonardo @as as?ed on @hat he feels a$out the mo,ie he said >naa' ?ata@-ananA (anuary 24' 2005 CFridayD

40

Nutrition day' the main theme @as all a$out ha,in# a healthy $ody and ?ee*in# the $ody healthy& In this day' sir eonardo *arti"i*ated @ell in all a"ti,ities @hi"h in,ol,e eatin#& Also @e noti"ed that he smiles a lot durin# "on,ersations and he s*ea?s in lon# *hrases not as often as @hat he sho@ed on the first of our duty& Also he follo@s @ell ea"h instru"tion that @as told $y the student nurse on ea"h #ame he *layed& 6he only thin# that $others us the most is his $lood *ressure' sometimes his $lood *ressure raises u* to 1;0O100 mm)#& 3efore the a"ti,ity and after ea"h a"ti,ity his $lood *ressure is "onstantly "he"?ed for monitorin#& (anuary 29' 2005 CSaturdayD Re"allin# the e,ent that ma?es the "lient thin? of their most memora$le ha**y e0*erien"e "an $e thera*euti"G this ma?es the "lient tem*orarily for#et his *ro$lems and his hallu"inations& 6he theme of that day @as >PeryaA or "arni,al& Be noti"ed that @hile *layin# the #ame our "lient should the e0*ression of ha**iness and 7ust li?e on the *ast days of the @ee? he seems to $e more in,ol,e and "urious of the a"ti,ity $y as?in# >unsaon manaTA sho@in# that he is really interested on the #ame& After the #ame he e0*resses his feelin# $y tellin# to the em"ees that his most fa,orite #ame @as the >rin# tossA or thro@in# ea"h rin# in a *lasti" $ottle& After the a"ti,ity his $lood *ressure @as "he"? for any a$normalities& (anuary 25' 2005 C6hursdayD Rela0ation thera*ies #reatly hel* "lients @ith mental illness to di,ert their attention and let #o of their *ro$lems e,en 7ust for a @hile& Sir eonardo stated that he has not e0*erien"e #oin# to a SPA' and may$e that is one of the reasons @hy durin# the thera*y he res*onded @ell on the questions thro@n to him and ans@erin# them in *hrases @ith mu"h @ith sense than the *re,ious a"ti,ities& And also @e noti"ed that durin# the thera*y he $e#un thro@in# questions $a"? to the student nurse @hi"h @as ,ery un"ommon to him& +urin# the $a"? massa#e thera*y our "lient sho@ed that he is en7oyin# the a"ti,ity' @hen as?ed on @hat he feels a$out the $a"? massa#e he ans@ers > amiA @ith his fa"e smilin#& (anuary 40' 2005 CFridayD 6he *ast fe@ days sho@ed #reat *ro#ress on our "lientFs "ondition' from $ein# e0*ressionless and al@ays hallu"inatin# to a ha**y smilin# and *arti"i*ati,e *erson& 6he

41

thera*ies of the *ast @ee?s seems hel*in# the "lient to re"o,er& Sur*risin#ly the "ondition of our "lient @as not the same "om*arin# to last @ee?Fs and e,en to yesterdays "ondition& After re"ei,in# our "lient his res*onse seems to #o $a"? from the ,ery start' early on the a"ti,ity he started to hallu"inate and ans@ers ea"h questions in a sin#le @ord res*onse& Also his attention s*an $e#un to lessen and it $e"ome hard for the student nurse to di,ert his attention es*e"ially @hen hallu"inatin#& It ta?es more than fe@ "alls and tou"hin# sir eonardo to di,ert his attention $a"? to the nurse& (anuary 41' 2005 CSaturdayD 6odayFs main theme is =nited Nations day& !a"h "lient re*resents a "ountry of their "hoi"e and @e ha,e de"ided to *i"? the "ountry India for sir eonardo& +urin# this day' mostly art and *lay thera*ies @ere used to im*ro,e the "lientFs "ondition& Bith the aid of his student nurse he *arti"i*ated @ell on the i"e$rea?er >sha##idi sha##idi sh*o*oA @ere he @as teamed-u* @ith his student nurse& 3ut durin# the "on,ersation time' in the nurse-*atient-intera"tion there is still that short attention s*an that sho@ed yesterday& Also his hallu"inations #ot @orse and it $e"ome hard for the student nurses to di,ert his hallu"inations& Still he ans@ers in a sin#le @ord ans@er and suddenly $e#ins to hallu"inate&

42

PS2C)O+2NAMICS A& 6a$ular form of Predis*osin# and Pre"i*itatin# Fa"tors Predis*osin# Fa"tor eonardo @as 24 years old @hen Most *eo*le @ho e0*erien"e he first e0*erien"ed the *sy"hoti" s"hi/o*hrenia ha,e the disorder A#e manifestations& It *ro#ressed until dia#nosed in late adoles"en"e he rea"hed the a#e of 4<' @hi"h and Ne@ +ay Re"o,ery Center& early adulthood& $e#ins Bhen earlier @as the time of his admission to s"hi/o*hrenia Presen"e Rationale

then a#e 2; years' sym*toms seem to de,elo* more #radually and ne#ati,e sym*toms
43

*redominate "ourse of

throu#hout the

the

disease&

+isru*tions o""ur in milestone e,ents of early adulthood' su"h as a"hie,in# in edu"ation' @or?' and lon#-term relationshi*s& Sin"e our *atient is a male he is Men tend to $e dia#nosed -ender more *redis*osed to ha,e the $et@een the a#es of 1< and 2;& disease& Bomen are dia#nosed most frequently $et@een the a#es of 2; and 4;& Males may ha,e more se,ere manifestations of s"hi/o*hrenia' mar?ed in"ludin# an earlier a#e of onset' more neuro*atholo#i" a$normalities' *oorer res*onse to treatment and less fa,ora$le out"ome& -eneti"s A""ordin# to his mother in their Relati,es of indi,idual @ith family linea#e she ne,er ?ne@ s"hi/o*hrenia ha,e mu"h hi#her someone @ho had mental illness& *ro$a$ility of de,elo*in# the disease than does the #eneral *o*ulation& lifetime ris? Bhereas of the de,elo*in#

s"hi/o*hrenia is a$out 1 *er"ent in most *o*ulation studies' the si$lin#s of offs*rin# of an identified "lient ha,e a ; to 10 *er"ent ris? of de,elo*in# s"hi/o*hrenia& Family and t@in studies sho@ the tenden"y to
44

de,elo* s"hi/o*hrenia is at least 80 *er"ent inherited& A *erson has a 10 *er"ent "han"e of de,elo*in# s"hi/o*hrenia if a *arent 3io"hemi" al or si$lin# has s"hi/o*hrenia& 6he do*amine do*amine-de*endent s"hi/o*hrenia& a"ti,ity may$e 6his

hy*othesis neuronal e0"ess to

su##ests that an e0"ess of a"ti,ity in the $rain may "ause related

in"rease *rodu"tion or release of the su$stan"e at ner,e terminals' in"rease re"e*tor sensiti,ity to too many do*amine re"e*tors or a Physiolo#i "al "om$ination of these me"hanisms& Bith the use or neurolo#i"al te"hnolo#ies' stru"tural $rain a$normalities s"hi/o*hrenia& enlar#ement "onsistent atro*hy is findin#G are also ha,e $een o$ser,ed in indi,iduals @ith 1entri"ular the most ho@e,er re*orted& is

sul"i enlar#ement and "ere$ral 1entri"ular fun"tionin#' treatment and enlar#ement

asso"iated @ith *oor *remor$id ne#ati,e "o#niti,e

45

sym*toms' *oor res*onse to

im*airment& Studies @ith MRI ha,e rea"hed in a *ossi$le and also de"rease "ere$ral Studies

intra"ranial si/e in "lients @ith s"hi/o*hrenia& si/e& sho@ a de"rease in frontal lo$e

Pre"i*itatin# So"io"ultural

Presen"e Rationale +urin# the time his mom @as -reater num$ers of indi,idual *re#nant she did not re"ei,e any from the lo@er so"ioe"onomi" immuni/ations and o$stetri"al "lasses e0*erien"e sym*toms e,aluation' e,en so she ,er$ali/ed asso"iated @ith s"hi/o*hrenia that she ate adequate nutritious than those from the hi#her foods su"h as ,e#eta$les and so"ioe"onomi" in 3arrio Nue,a 1ida Mlan# in"lude farm and @ith 7ust fe@ nei#h$ors su"h the family& as the "on#ested #rou*s& "onditions housin# fruits& 6hey li,e in a remote area !0*lanations of this o""urren"e North Cota$ato& 6hey li,e in their asso"iated @ith li,in# in *o,erty around them& 6his farm su**orts a""ommodations' inadequate

nutrition' a$sen"e of *renatal "are' fe@ resour"es for dealin# @ith stressful situations' and feelin# of ho*elessness for

+isease 6rauma

and

"han#in# oneFs life of *o,erty& Bhen he @as still 4 years old he Some studies su**ort that fell do@n from an ele,ated "orn s"hi/o*hrenia #rinder& )is mother @as not sure de,elo*mentally related is to

if he had hit his head& 6hey 7ust disease and trauma o""urrin# found him as ha,in# an e*ile*ti" durin# *renatal *eriod or in li?e e*isode& )e then @as $rou#ht early adulthood& Com*li"ations to the nearest hos*ital @ith a that *ossi$ly in"rease ris? for
46

tra,ellin# time of 40 minutes& )e s"hi/o*hrenia @as #i,en @ith medi"ines and infe"tions

in"lude

,iral

durin#

*re#nan"y' and

too? it for a$out a month& On the rhesus in"om*ati$ility' maternal same a#e he also e0*erien"ed *ree"lam*sia' then' he @as treated and had fully Stressful e,ents re"o,ered& life 1& BBhen he @as still 20 years !n,ironmental stress *rodu"in# old his $rother Bilfredo had e,ents and situations are al@ays an a""ident& )e @as hit @ith a *resent& 6he life e,ents and $olo @hen a nei#h$or had an su$sequent stress in"rease >amo?A e*isode& )e @as the do*aminer#i" transfer and "ause one @ho sa@ and res"ue his a hi#h-le,el arousal' leadin# to se,erely in7ured $rother @ho s*e"ifi" e*isodi" re"urren"e of had re"ei,ed multi*le dee* the illness& 6he hi#h le,el of @ound in7uries at the ne"? arousal and arms& results in intense hallu"inatory e0*erien"e& It is anemia measles' fe,er and diarrhea& 3ut +ia$etes mellitus&

2& B)e *er"ei,es himself' as the ,ery *ro$a$leG ho@e,er that one res*onsi$le in earnin# stress may "ontri$ute to the money for the family& 6his is se,erity and "ourse of the $e"ause he ,ie@s his $rother illness& It is ?no@n that e0treme Bil as an in"a*a"itated *erson stress "an *re"i*itate *sy"hoti" and "annot hel* their *arents& e*isodes& Stress may indeed 6his made him to #i,e more *re"i*itate effort in @or?in# than @hat he indi,idual usually does& #eneti" sym*toms @ho ,ulnera$ility in an a to *ossesses

s"hi/o*hrenia&

47

3& S"hemati" +ia#ram

Father6 . genio !ra"oc !ge6 83 &ears old 8cc "ation6 Far$er 9 :e is disci"linarian and ses cor"oreal t&"e o+ " nis)$ent 9 :e is easil& contented ,it) ,)at t)e& )a(e as long as t)eir +a$il& is )a""&

Mother6 Cresencia !ra"oc !ge6 82 &ears old 8cc "ation6 :o se,i+e 9 %)e is a lo(ing and caring $ot)er 9 %)e is easil& contented ,it) ,)at t)e& )a(e as long as t)eir +a$il& is )a""&

48

Courtship and Marriage Cresencia ,as 27 &ears old ,)en s)e +irst $et . genio, 28 &ears old ,)o ca$e +ro$ #anglao, Bo)ol ,)ile Cresencia ca$e +ro$ ; bigon, Bo)ol. ;)e& $et in Barrio 4 e(a 'ida Mlang 4ort) Cotabato. %)e ,or7ed in t)e +ar$ o+ )is brot)er, ,)ic) is ad<acent to Mr. . genio*s )o se. %)e sed to bring +ood +or t)e tenants o+ t)eir +ar$, and at ti$es also )el"s in t)e +ar$ acti(it&. Mr. . genio +re= entl& sees )er and beca$e attracted to )er. Mr. . genio started to co rt )er b& going to t)eir )o se toget)er ,it) )is +riends and serenade )er. !+ter 6 $ont)s o+ " rs ing )is lo(e Cresencia acce"ted )i$. !+ter 3 $ont)s o+ being toget)er t)e& got $arried last 4o(e$ber 10, 2009 at >ida"a,an Cit&. ;)e& )ad t)eir eldest c)ild a &ear a+ter t)e& got $arried. ;)e& are no, li(ing toget)er +or 54 +r it+ l &ears and blessed ,it) 6 c)ildren.

1st Child: / 0 !ra"oc

2nd Child: . gene !ra"oc 3rd Child: Roberto !ra"oc

4th Child: 1 dit) !ra"oc

5th Child: Leonardo Arapoc 49

6th Child: 2il+redo !ra"oc

Prenatal Cresencia*s +i+t) "regnanc& ,as nor$al and bearing anot)er c)ild $eans anot)er blessing +or t)e$. B t, s)e ne(er )ad a co$"lete obstetrical s "er(ision since t)e& li(e in a re$ote area in Mlang 4ort) Cotabato. ;)o g) s)e 7no,s abo t t)e a(ailabilit& o+ t)e reso rces in t)e cit& "ro"er, s)e ne(er )ad an& i$$ ni0ation d ring )er "regnanc&. %)e eats a lot o+ +r its and (egetables ,)ic) ca$e +ro$ t)eir +ar$. %)e reall& too7 care o+ )er )ealt) d ring )er "regnanc&. %)e gets ade= ate rest and slee" since s)e ,as < st sta&ing in t)eir )o se and too7 care o+ )er c)ildren. ?nstead o+ going to t)e )ealt) center s)e resorted to a @)ilotA in ,)ic) according to )er co ld )el" to "osition t)e bab& ,ell to +acilitate eas& and sa+e deli(er&.

Infancy C0.1 Dear oldE Natal #s&c)osocial 5e(elo"$ent t)eor&6

#s&c)oanal&tic t)eor&6 8ral stage !ccording ;r st ,asto ac)ie(ed ,)en t)e client ,as 5odong ,as deli(ered + ll ter$ on 4o(e$ber 6, 1964 in t)eir )o se. )is $ot)er Mrs. !ra"oc still an in+ant #s&c)osocial t)eor&6 ;r st '%. Mistr st t)ere ,ere no signi+icant n s al incidents t)at )a""ened d ring t)e deli(er&. %)e ,as assisted b& a @)ilotA %igni+icant "ersons6 #ri$ar& caregi(er, $ot)er s (aginal deli(er&. ;)e ;)e sed "ri$ar& caregi(er didstic7 not +ail to tgi(e / 0 #analan d ring )er nor$al s"ontaneo @)ilotA a s)ar" ba$boo to c 'irt e6 )o"e lo(e and attention to t)e client t)e $bilical cord. !""roBi$atel& 7 da&s a+ter )e ,as deli(ered t)e re$aining "art o+ t)e cord ,as ;as7 learned6 /o(e and be lo(ed ;as76 re$o(ed +ro$ t)e c)ild. ?n+ants ,)ose needs are $et ,)en t)ose 'ie,ing t)e ,orld as sa+e and reliable needs arise, ,)ose disco$+orts are 'ie,ing relations)i" as n rt ring, stable, and = ic7l& re$o(ed, ,)o are c ddled, "la&ed de"endable ,it) co$e to (ie, t)e ,orld as a sa+e #ri$ar& caregi(er is )is $ot)er "lace and "eo"le as )el"+ l and Fed b& $ot)er ,)en ) ngr& de"endable. C ddled d ring +eeding and ,)en cr&ing .Bcl si(e breast+eeding +or 4 $ont)sF breast+eeding contin ed " to a &ear and 4 $ont)s. %e$i-solid +oods introd ced at 5 $ont)s 2eaning ,as started at 5 $ont)s b t ,as grad all& done till 1 &ear old First toot) er "ted at 6 $ont)s ;) $b s c7ing started at 12 $ont)s 2al7ing started at 12 $ont)s #s&c)oanal&tical 5e(elo"$ental t)eor&6 2eaning ,as done earl& at 5 $ont)s b t ,as done grad all& .arl& ,eaning $a& ca se one to be 50 and narcissistic, de"endent, de$anding orall& +iBated ,)ile late ,eaning $a& ca se one to be o(erl& o"ti$istic gi(ing

Toddlerhood C1-3 &ears oldE #s&c)oanal&tic t)eor&6 !nal stage #s&c)osocial t)eor&6 ! tono$& '%. %)a$e and 5o bt %igni+icant "ersons6 #arents 'irt e6 2ill ;as76 !c)ie(ing a sense o+ control and +ree ,ill M sc lar control %e$i-solid +oods introd ced at 5 $ont)s %tarted to tal7 babbled ,ords d ring 3 &ears old 2eaning ,as started at 5 $ont)s b t ,as grad all& done till 1 &ear old ;oilet training started at 1 &ear old and till t)e age o+$ont)s 5. 2)en )e "rogressed First toot) er "ted at 6 de+ecates )is nder,ear )e ,as not scolded ,as told to in+or$ $ot)er i+ )e instead ;) $b)e s c7ing started at 12)is $ont)s ,ants to de+ecate and e(ent all& bro g)t to co$+ort roo$. t)e 2al7ing started at 12 $ont)s %tarted ,al7ing at 1 &ear o+ age. ;) $b s c7ing ,as still "resent ntil )e is 1 &ear old. :e )ad $easles ,)en )e ,as 1 &ear old and ,as treated :e +ell +ro$ an ele(ated corn grinder and )ad an e"ile"tic li7e e"isode. 5 ring t)is stage )e ,as s"an7ed e(er& ti$e )e insists t)e t)ings )e ,anted and i+ )e $ani+ests tantr $s, b t )e is not i$$ediatel& )it b t instead < st t)reatened

51

#s&c)osocial 5e(elo"$ent t)eor&6 :e ,as able to ac)ie(e a "ositi(e resol tion +or )e ,as able to eBert sel+control ,it)o t sel+ estee$ and t)e abilit& to coo"erate and to eB"ress one*s sel+ :e eB)ibited negati(istic acts s c) as6 ;antr $s b t )is $ot)er did not tolerate t)is and occasionall& " nis)ed )i$ t)ro g) s"an7ing. #s&c)oanal&tical de(elo"$ental ;)eor&6 ;oilet training ,as not t)at rigidl& i$"le$ented Controlling and eB"elling +eces "ro(ide "leas re and sense o+ control. ;oilet training s)o ld be a "leas rable eB"erience Rigid toilet training $a& ca se co$" lsi(e need to be clean, orderl& and +r gal

52

#s&c)oseB al de(elo"$ent t)eor&6 Pre !chool C3-6 &ears oldE #s&c)oanal&tic t)eor&6 #)allic stage #s&c)osocial t)eor&6 ?nitiati(e '%. 3 ilt %igni+icant "ersons6 Basic +a$il& 'irt e6 # r"ose ;as76 Beginning de(elo"$ent o+ conscience and learning to $anage con+lict and anBiet& 5e(elo"s loco$otion :e ,as able to do basic acti(ities o+ dail& li(ing ,it) t)e g idance o+ )is $ot)er. %tarted to go to sc)ool at 7 &ears o+ age, grade one at 4 e(a 'ida .le$entar& sc)ool :e "la&s ,it) sa$e seB +riends at sc)ool and is $ore o+ a +ollo,er t)an a leader :e "la&s o tdoor ga$es at sc)ool b t co$es )o$e i$$ediatel& a+ter class C ts, br ises and lacerations ,ere co$$on at t)is age #re+erred ga$es ,ere tag and )ide and see7 #la&s $ore ,it) siblings inside t)e )o se Cor"oreal disci"linar& $eas res ,ere obser(ed b& bot) "arents !l,a&s +ollo,s t)e co$$ands o+ bot) "arents :e ,as able to eB)ibit e(al ation o+ o,n asserti(eness and control "resenting as an e(idence o+ "ositi(e resol tion !ble to initiate acti(ities s c) as6 5ressing and ndressing Br s)ing teet) B t ,it) t)e g idance o+ t)e $ot)er ntil )e ,as able to do so inde"endentl& !ccording to #illiteri, t)ose ,)o do not de(elo" initiati(e $a& later de(elo" li$ited brain stor$ing and "roble$ sol(ing s7ills, t)e& $a& ,ait +or cl es or g idance +ro$ ot)ers be+ore acting

#s&c)oanal&tical de(elo"$ent t)eor&6 Mot)er )ad not ca g)t )i$ $ast rbating %eB a,areness at 3 &ears old ;)e c)ild identi+ies ,it) t)e "arent o+ t)e o""osite seB and later ta7es on a lo(e relations)i" o tside t)e +a$il&.

53

#s&c)osocial de(elo"$ent t)eor&6 :e ,as able to ac)ie(e a "ositi(e resol tion on t)e con+lict since )e )ad de(elo"ed a sense o+ co$"etence and "erse(erance

!ccording to #illiteri, in t)is "eriod, c)ildren are interested in learning t)ings ,ell. C)ildren can alread& acco$"lis) s$all tas7s inde"endentl&. C)ildren ,)ose sense o+ ind str& )as been destro&ed at )o$e $a& be re(itali0ed at sc)ool. de(elo"$ent t)eor&6 #s&c)osocial :e ,as able to )as )a(e in sense t)e o+ %ir 5odong aa,ards co)erent co$"etition )e <oined. sel+ and )as "lans to act ali0e one*s "lans abilities. #s&c)oanal&tical de(elo"$ent t)eor&6 !chool "ge C7- 12 &ears oldE #s&c)oanal&tic t)eor&6 /atenc& stage #s&c)osocial t)eor&6 ?nd str& '%. ?n+eriorit& %igni+icant "ersons6 %c)ool ac= aintances 'irt e6 Co$"liance ;as76 .$erging con+idence in o,n abilities 5e(elo" co$"etence and "erse(erance ;a7ing "leas re in acco$"lis)$ents :ad )is sc)ooling in 4 e(a 'ida .le$entar& sc)ool at t)e o+ 7 :e ,as a c)ess "la&er ,)en )e ,as still in grade 5 and <oined a "ro(incial c)ess co$"etition and )e ,on. :e did not )a(ing an& +ailing grades t)o g) )e is not an )onor st dent b t still )e eBcels in )is st dies :is +a(orite s b<ect ,as $at)e$atics :e ,as circ $cised ,)en )e ,as 12 &ears old. :e )el"s )is +a$il& b& doing so$e )o se)old c)ores li7e going to t)eir +ar$ and gets so$e (egetables. ;)ere are +o to r $ain ins,)ic) %ir 5odong li7es "la& areas ga$es c) as adolescents $ st gain to s ccess+ bas7etball to en)ance gross, +ine, and ll& $ental s7illsa sense o+ identit&6 ac)ie(e :e able toa di(ert )is libido into concrete is Ma7ing career decision ,as t)ings s c) as "la&ing ga$es re= iring ac)ie(ed as e(idenced b& )is desire bot) +ine and gross $otor s7ills. to beco$e a diesel $ec)anic since )is )ig) sc)ool da&s .stablis)ing ,)at 7ind o+ "erson )e ,ants to be ,as ac)ie(ed as e(idenced b& )i$ +inis)ing )is (ocational co rse ,it)o t )a(ing an& second t)o g)ts. .$anci"ation +ro$ "arents ,as not &et ac)ie(ed since )e ,as still li(ing ,it) )is "arents )e is still de"endent on t)e$ on $ost as"ects o+ )is li+e. ;)e last one is also ac)ie(ed as )e alread& acce"ted )is o,n bod& i$age "erce"tion. ?dentit& is not + ll& ac)ie(ed t)o g) 3 a$ong t)e 4 areas are $et.

#s&c)oseB al de(elo"$ent t)eor&6 5odong )ad cr s)es, co rted a girl b t ne(er )ad a girl+riend Mat re seB alit& is ac)ie(ed as ")&sical gro,t) is co$"leted and relations)i" ,it) ot)ers occ54 rs. Main e(ents o+ t)is "eriod incl des establis)$ent o+ ne, seB al ai$s.

"dolescence C12-20 &ears oldE #s&c)oanal&tical t)eor&6 3enital stage #s&c)osocial t)eor&6 ?dentit& '%. Role con+ sion %igni+icant "ersons6 #eers 'irt e6 Fidelit& ;as76 For$ late as sense o+ sel+ and belongingness :e ,as able to )a(e +riends b t not reall& close b ddies :ad cr s)es and is attracted to t)e o""osite seB. :e )ad a )istor& o+ co rts)i" #la&s bas7etball and c)ats at sc)ool ,it) ot)er sc)ool$ates 5ran7 li= or ,it) +riends occasionall& 'oice c)angeF "itc) is lo,ered at age 14.

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#oung "dulthood C18-25 &ears oldE #s&c)osocial ;)eor&6 ?nti$ac& '%. ?solation Cogniti(e t)eor&6 For$al o"erational ;as76 ;o de(elo" inti$ate and lasting relations)i", sense o+ res"onsible and career de(elo"$ent :e sed to co rt t)eir neig)bor and ,)en t)e& go to t)eir )o se t)e +at)er o+ t)e girl o++ers t)e$ cocon t ,ine. :e is a silent t&"e o+ "erson :e )ad no close +riends or bar7ada :e goes to c) rc) eit)er at %t.#a l or %an #edro Cat)edral #s&c)osocial de(elo"$ent t)eor&6 ?nti$ac& is lesser t)an isolation as e(idenced b& li$ited close inter"ersonal relations)i". 5odong )ad di++ic lt& o+ b ilding close relations)i"s ,it) t)e o""osite seB. !ccording to #illiteri "eo"le cannot o++er lo(e and +riends)i" i+ t)e& do not )a(e con+idence t)at can co"e " ,it) re<ection.

Middle "dulthood C30 G 60 &ears oldE #s&c)osocial t)eor&6 3enerati(it& '%. %tagnation ;as76 3 iding &o nger generation and gi(ing bac7 to t)e ,orld brings "leas re :e said t)at )e ga(e ad(ice to )is niece and ne")e,s to +inis) t)eir st dies in order to )el" t)eir +a$il& 2)en )e ,ill go o t +ro$ 45RC )e ,ants to ,or7 again and s ""ort )is +a$il& :e said )e is not read& to engage in an inti$ate relations)i" #s&c)osocial de(elo"$ent t)eor&6 %igns o+ "ositi(e resol tion o+ t)e con+lict are "resent as e(idenced b& )is concern +or )is ne")e,s to +inis) t)eir st dies. !lso )is "lans o+ ret rning to ,or7 a+ter disc)arge +ro$ t)e instit tion. :o,e(er )e did )a(e a c)ance to act ali0e t)ese "lans as )e ,as con+ined in t)e instit tion d ring t)e onset o+ t)is de(elo"$ental stage. %till )e is not &et read& to engage in an inti$ate relations)i" as (erbali0ed.

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#redis"osing Factor6 !. !ge B. 3ender C. 3enetics 5. Bioc)e$ical

#reci"itating Factor6 !. %ocioc lt ral B. 5isease and tra $a C. %tress+ l li+e e(ents

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First ad$ission at 4e, 5a& Reco(er& center6 :e ,as +irst ad$itted to Babista )o$e care +or "s&c)iatric "atients ,)ic) is t)e +or$er na$e o+ 45RC. B t t)en disc)arged and sent )o$e. :e ,as also ad$itted to insig)t reco(er& center +or a ,ee7 and seen b& 5r. C nanan Fro$ 5ece$ber 28, 2004 to 1an ar& 3, 2005 )e ,as ad$itted to 5a(ao $edical center. !+ter a ,ee7 o+ ad$ission +ro$ 5MC t)e& bro g)t )i$ to 4e, 5a& Reco(er& center at 1an ar& 5, 2005 :e eB)ibited be)a(ioral c)anges s c) as6 ;al7ing to )i$sel+, la g)ing alone, di++ic lt&

Medications ,ere gi(en li7e6 Ris"eridone !7ineton /e(o$e"ro$a0ine Bis"eriden :C/ 8t)er orders ,ere $ade6 !d$it to "s&c)iatric ,ard 5iet as tolerated 'ital signs c)ec7 initiall& onl& #R4 4#? ,)en a$endable For ro tine laborator& eBa$ /e(o$e"ra0one 100 $g H tab B?5 Bi"eriden :C/ 2$g tab 1 tab B?5 +or .#% % icidal, )o$icidal and esca"e "reca tion Re+er accordingl& to doctor ?gnas

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Client co$"lies ,it) )is treat$ent regi$en and )as good relations ,it) ot)er clients in t)e instit tion as ,ell as t)e sta++. !+ter se(eral $ont)s )e ,ill be disc)arged against $edical ad(ice

?+ treated6

?+ not treated6 Rela"se o+ illness

Medical Manage$ent !d< ncti(e Manage$ent Re$oti(ation t)era"& 8cc "ational t)era"& Recreational t)era"& M sic t)era"&

Rec rrence o+ t)e signs and s&$"to$s o+ t)e disorder

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&$$' P%$&N$!I!

P$$% P%$&N$!I!

C& NARRA6I1! PS2C)O+2NAMICS !u#enio Ara*o"' 2< years of a#e' a farmer in Nue,a 1ida Mlan# North Cota$ato first met Cresen"ia Paman' 2: years old @ho also @or?s at the farm of his $rother in Cota$ato lo"ated ad7a"ent to the farm o@ned $y !u#enio& )e often sees her in the farm $e"ause Cresen"ia sends food for the tenants in their farm' and hel*s in the @or? in the farm& After that he @as attra"ted to her and started to "ourt Cresen"ia& )e ,isits her in their house to#ether @ith his friends and offers her a serenade& After 8 months of *ursuin# his lo,e' Cresen"ia a""e*ted it and they #ot married after three months& 6hey #ot married last No,em$er 10' 15;8 at Hida*a@an City& 6heyF,e $een li,in# to#ether for a$out ;9 yearsG they are $lessed @ith 8 "hildren& 6hey ha,e a small farm in their *la"e @hi"h su**orts their family& 6heir eldest "hild is u/' she finished a "ommer"e de#ree and is "urrently @or?in# in an offi"e at +a"udao& !u#ene is the se"ond "hildG he is a tea"her in Nue,a 1ida Mlan# North Cota$ato& )e used to #uide sir eonardo @hile he @as still studyin# in their 3arrio& Ro$erto' the third "hild is a Seaman @or?in# in a "ar#o shi*& (udith' the fourth "hild finished a 3a"helor of
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s"ien"e in $iolo#y and "urrently @or?s at Stanfil"o $anana *lantation& eonardo' the fifth "hild' finished a 1 year ,o"ational "ourse at +I6! he used to @or? at +CC $ut then he sto**ed due to o$ser,ed $eha,ioral "han#es& 6he youn#est "hild is Bilfredo' he finished a se"retarial "ourse and @or?s as a radio te"hni"ian& Sir eonardo and Bilfredo used to $e "losest to ea"h other they used to #o out to#ether a lot and share their se"rets& +urin# Infan"y' trust @as a"hie,ed @hen eonardo @as an infant& )is *rimary "are#i,er is his mother& She "uddles him durin# feedin# and @hen hun#ry& )e @as $reastfeed e0"lusi,ely for 9 months and lasted until he rea"hed 1 V year old& Beanin# @as quite early' it started @hen he @as ; months old and #radually done till he rea"hed 1 year of a#e they used >Panya@anA *lant in @eanin# him& Semisolid foods @ere introdu"ed at ; months @ith the use of *orrid#e& First tooth eru*ted at 8 months' thum$ su"?in# started at 12 months and he started @al?in# @hen he @as 12 months old& 6hum$ su"?in# @as not dis"oura#ed instead his mother said that it is 7ust normal for a "hild to thum$ su"?' teethers @ere not *ro,ided for oral stimulation& +urin# 6oddlerhood' eonardo started to tal? $a$$led @ords @hen he @as 4 years old and started to @al? @hen he @as 1 year old& 6oilet trainin# @as not ri#idly im*osed& A""ordin# to his mother' e,ery time he defe"ates or @ets his under@ear the a,aila$le "are #i,er $rin#s him immediately to the "omfort room to "han#e his under@ear& At times @hen he a""identally defe"ates' he is not re*rimanded $ut instead' instru"ted to tell his mother @hene,er he @ants to defe"ate or urinate to *re,ent him from defe"atin# or urinatin# in ina**ro*riate *la"es& 6hum$ su"?in# @as *resent until he is 1 year old& Also' he had measles' fe,er and diarrhea @hen he @as three years old and @as treated& )e fell from an ele,ated "orn #rinder and had an e*ile*ti"- li?e sym*toms& +urin# this sta#e he @as s*an?ed e,ery time he insists the thin#s he @anted and if he manifests tantrums' $ut he is not immediately hit $ut instead 7ust threatened so that he @ill $eha,e& A""ordin# to Pilliteri' @hen "are #i,ers are im*atient and do e,erythin# for them' this enfor"es shame and dou$t& If "hildren lea,e this sta#e @ith less autonomy than shame and dou$t' they "an $e disa$led in their attem*ts to a"hie,e inde*enden"e and may la"? "onfiden"e in their a$ilities to a"hie,e @ell into adoles"en"e and adulthood& +urin# his *res"hool years' he @as a$le to e0hi$it *ositi,e "onfli"t resolution $e"ause e,er sin"e he @as still a toddler he @as tau#ht $y his mother to do some a"ti,ities of daily li,in# @hi"h resulted for him to $e dis"i*lined and to $e a$le to @or? inde*endently @ith minimal assistan"e from his mother& )e started to #o to s"hool at : years of a#e' #rade one at Nue,a 1ida

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!lementary s"hool& )e *lays @ith same se0 friends at s"hool and is more of a follo@er than a leader& )e *lays outdoor #ames at s"hool $ut "omes home immediately after "lass& Cuts' $ruises and la"erations @ere "ommon at this a#e& Preferred #ames @ere ta# and hide and see?& )e *lays more @ith si$lin#s inside the house& Cor*oreal dis"i*linary measures @ere o$ser,ed $y $oth *arents& Furthermore he al@ays follo@s the "ommands of $oth *arents +urin# his s"hool a#e years' he had studied in Nue,a 1ida !lementary s"hool at the a#e of :& )e @as a "hess *layer @hen he @as still in #rade ; he 7oined a *ro,in"ial "hess "om*etition and he @on& 6hou#h not an honor student' Sir eonardo ne,er failed in any of his su$7e"ts& )is fa,orite su$7e"t @as mathemati"s& )e @as "ir"um"ised @hen he @as 12 years old @ith use of a traditional method "alled >*a?an#A& )e also de,elo*ed interests in s*orts s*e"ifi"ally $as?et$all and *lays e,ery after "lass& )e also hel*s his family $y doin# some household "hores li?e #oin# to their farm and #ets some ,e#eta$les& 6his fa"ilitates the de,elo*ment of his fine and #ross mus"le a"ti,ity and @ell as de,elo*in# a sense of "om*eten"e and *erse,eran"e& Bhene,er he #ets #ood #rades he @ill $e *raised $y his *arents& )e @as not that #ood in @ritin# and dra@in#' thou#h he e0"els in math& )e @as a$le to a"hie,e a sense of industry sin"e he @as a$le to en#a#e in #ross motor de,elo*ment @hi"h is fostered $y $all s*orts' startin# ho$$ies and *layin# $oard #ames& Co#niti,e #ro@th is fa"ilitated $y readin# and ma?in# s"hool @or?s& +urin# eonardoFs adoles"ent years' he @as a$le to ha,e friends $ut not really "lose $uddies& )is ,oi"e "han#ed into a lo@er *it"h at the a#e 19& )ad "rushes and is attra"ted to the o**osite se0& )e had a history of "ourtshi*& Plays $as?et$all and "hats at s"hool @ith other s"hoolmates& )e also dran? liquor @ith friends o""asionally& )e is also a"ti,e @ith the a"ti,ities of the youth in their 3arrio' he used to 7oin $as?et$all #ames to#ether @ith his $rother' Bilfredo& )is $rother said > si-a@ man na siya' na#a 7o?e siya sa amon# m#a ?a $ar?ada' na#a a*il #ani mi u# m#a li#a sa $as?et$all saunaA& )e en7oys the "om*any of his friends as @ell as his $rother& Sir eonardo has a "oherent sense of self and has *lans to a"tuali/e oneFs *lans a$ilities& 6here are four main areas in @hi"h adoles"ents must #ain to su""essfully a"hie,e a sense of identity% Ma?in# a "areer de"ision @as a"hie,ed as e,iden"ed $y his desire to $e"ome a diesel me"hani" sin"e his hi#h s"hool days& !sta$lishin# @hat ?ind of *erson he @ants to $e @as a"hie,ed as e,iden"ed $y him finishin# his ,o"ational "ourse @ithout ha,in# any se"ond thou#hts& !man"i*ation from *arents @as not yet a"hie,ed sin"e he @as still li,in# @ith his *arents he is still de*endent on them on most as*e"ts of his life& 6he last one is also a"hie,ed as he already

62

a""e*ted his o@n $ody ima#e *er"e*tion& Identity is not fully a"hie,ed& Sin"e out of the four areas @as not a"hie,ed the tas? @as not yet "om*leted @hi"h may affe"t him in a"hie,in# his tas?s for the ne0t de,elo*mental le,el& +urin# his youn# adulthood' )e used to "ourt their nei#h$or and @hen they #o to their house the father of the #irl offers them "o"onut @ine& )e is a silent ty*e of *erson& )e #ot no "lose friends or $ar?ada& A""ordin# to his mother she allo@s him to #o out from their house and #o to#ether @ith her friends $ut' he *refers to stay at home than #oin# out& Althou#h at times he #oes to#ether @ith their nei#h$or and *lay $as?et$all' intima"y is lesser than isolation as e,iden"ed $y limited "lose inter*ersonal relationshi*& eonardo had diffi"ulty of $uildin# "lose relationshi*s @ith the o**osite se0& A""ordin# to Pilliteri *eo*le "annot offer lo,e and friendshi* if they do not ha,e "onfiden"e that "an "o*e u* @ith re7e"tion& +urin# the sta#e of his middle adulthood it @as the time that he @as admitted to Ne@ +ay Re"o,ery Center @hi"h #reatly influen"es the resolution and a"hie,ement of the tas?s he needs to ha,e at this sta#e& )e said that he #a,e ad,i"e to his nie"e and ne*he@s to finish their studies in order to hel* their family& Bhen he @ill #o out from N+RC he @ants to @or? a#ain and su**ort his family& )e said he is not ready to en#a#e in an intimate relationshi* Predis*osin# Fa"tors eonardo @as 24 years old @hen he first e0*erien"ed *sy"hoti" manifestations& )e @as first admitted to 3a$ista home "are for *sy"hiatri" *atients @hi"h is the former name of N+RC& he stayed there for a month and @as dis"har#ed& )e @as sent home and stayed in their house for 2 years @ith medi"ations to $e ta?en $ut he sto**ed ta?in# it and e,entually his $eha,ior $e"ame @orse& )e @as then $rou#ht to Insi#ht Reha$ilitation Center and @as e0amined $y +r& Cunanan& )e stayed there for a @ee? and then dis"har#ed after' still @ith medi"ations #i,en' $ut as he @ent home he sto**ed ta?in# his medi"ines a#ain& On +e"em$er 2<' 2009 at ;%40 am he $e"ame hostile and hit his mother on the head' $e"ause he @anted to #o out from their house and his mother did not a#ree' he loo?ed for the ?ey from her $ut his mother did not @ant too& 6hey $rou#ht him to +a,ao Medi"al Center and @as admitted from +e"em$er 2<' 2009 to (anuary 4' 200;& After that he @as $rou#ht $a"? to their house $e"ause they donFt @ant him to stay in +MC $e"ause his situation mi#ht #et @orst& After 2 days' they $rou#ht him to Ne@ +ay Re"o,ery Center and @as admitted on (anuary ;' 200; until *resent& 6he a#e of onset of the disease is

63

a**ro0imately from 1<-2; years of a#e& Sin"e our *atient is a male he is more *redis*osed to ha,e the disease& In their family linea#e there is no ?no@n relati,e ha,in# mental illness& 3io"hemi"al "han#es @ere not assessed as @ell as *hysiolo#i"al "han#es in his $rain anatomy& Pre"i*itatin# Fa"tors So"io"ultural differen"e is one of the fa"tors @hi"h may *re"i*itate the o""urren"e of the "ondition& It in"ludes the en,ironment @here they li,e' adequate *renatal "are' so"ioe"onomi" status' inadequate nutrition and the a,aila$ility of resour"es in their *la"e& As @hat @e had assessed durin# the *re#nan"y of his mother she did not re"ei,e any immuni/ations or medi"al "are @hi"h may "ontri$ute to the o""urren"e of the disease& +isease and trauma' it @as re*orted that @hen he @as 4 years old' he fell do@n from an ele,ated "orn #rinder and he had an e*ile*ti" li?e sym*toms& )e @as $rou#ht to the nearest hos*ital a$out 40 minutes a@ay from their house& After that in"ident their family mo,ed to -eneral Santos City& )e frequently e0*erien"e fe,er and diarrhea @hi"h @as a""ordin# to her mother @as "aused $y the dirty @ater they are drin?in# from the @ater @ell& )e also had measles durin# that time' $ut e,entually mana#ed& After that they @ent $a"? to North Cota$ato $e"ause his mother thou#ht that stayin# there @as mu"h $etter& 6hey li,e in an area in @hi"h the ma7or sour"e of in"ome is farmin#' they ha,e 1; he"tares of land' ha,in# "o"onut trees' ru$$er trees and root "ro*s& 6@o of the ma7or stressful life e,ents that ha**ened in his life @as @hen he @as still 20 years old his $rother Bilfredo had an a""ident& )e @as hit @ith a $olo @hen a nei#h$or had an >amo?A e*isode& )e @as the one @ho sa@ and res"ue his se,erely in7ured $rother @ho had re"ei,ed multi*le dee* @ound in7uries at the ne"? and arms& )e *er"ei,es himself' as the one res*onsi$le in earnin# money for the family& 6his is $e"ause he ,ie@s his $rother Bill as an in"a*a"itated *erson and "annot hel* their *arents& 6his made him to #i,e more effort in @or?in# than @hat he usually does&

64

65

+IFF!R!N6IA +IA-NOSIS

S"hi/o*hrenia' Paranoid 6y*e 6he "lient manifested sym*toms that meet the dia#nosti" "riteria for s"hi/o*hrenia s*e"ifi"ally' *aranoid ty*e& A""ordin# to +SM I1-6R "riteria' S"hi/o*hreni" differentiated ty*e *atient @ould ha,e the follo@in# si#ns and sym*toms% +SM I1 Criteria for S"hi/o*hrenia 1& Chara"teristi" sym*toms Cat least t@o of the follo@in# are metD +elusions )allu"inations' +isor#ani/ed s*ee"h' -rossly disor#ani/ed or "atatoni" $eha,ior' Ne#ati,e sym*toms&

2& So"ial or o""u*ational dysfun"tion @here an indi,idual is e0*erien"in# inter*ersonal' self-"are alteration& 4& +uration% si#ns of distur$an"e must $e o$ser,ed "ontinuously for at least 8 months&
66

9& S"hi/oaffe"ti,e and mood disorders should not $e *resent and are not res*onsi$le for the si#ns and sym*toms& ;& Should not $e "aused $y su$stan"e a$use or a #eneral medi"al disorder&

Paranoid 6y*e% A& Preo""u*ation @ith one or more delusions or frequent auditory hallu"ination& 3& None of the follo@in# is *rominent% disor#ani/e s*ee"h' disor#ani/e $eha,iour' flat or ina**ro*riate affe"t' "atatoni" $eha,iour&

+isor#ani/ed 6y*e% A& All of the follo@in# are *rominent% disor#ani/e s*ee"h' disor#ani/e $eha,iour' flat or ina**ro*riate affe"t& 3& +oes not meet the "riteria of the "atatoni" ty*e&

Catatoni" 6y*e% At least t@o of the follo@in# are *resent& A& Motori" immo$ility' @a0y fle0i$ility or stu*or& 3& !0"essi,e motor a"ti,ity C*ur*oselessD C& !0treme ne#ati,ism of mutism& +& Pe"uliar mo,ement stereoty*y of mo,ements' *rominent mannerism' or *rominent #rima"in#& !& !"holalia or e"ho*ra0ia&

=ndifferentiated 6y*e% Chara"teristi"s sym*toms A& +elusions

67

3& )allu"ination C& +isor#ani/ed s*ee"h +& -rossly disor#ani/ed or "atatoni" $eha,iour !& Ne#ati,e sym*toms Alo#ia Aner#ia Anhedonia Aso"ial $eha,iour Attention defi"its A,olition 3lunted affe"t Communi"ation diffi"ulties +iffi"ulty @ith a$stra"tions Passi,e so"ial @ithdra@al Poor #roomin# and hy#iene Poor ra**ort Po,erty of s*ee"h

A& Criterion A are *resent' $ut "riteria for *aranoid' "atatoni"' or disor#ani/ed su$ty*es are not met&

Residual 6y*e% A& Chara"teristi" sym*toms are no lon#er *resentG "riteria are unmet for *aranoid' "atatoni" and disor#ani/ed su$ty*e& 3& 6here is "ontinuin# e,iden"e of distur$an"e' su"h as *resen"e of ne#ati,e sym*toms or "riterion A sym*toms' in an attenuated form Ce&#& old $eliefs' unusual *er"e*tual e0*erien"esD&

68

Be @ei#hed thin#s and used our rationality to 7ud#e his a"tions and his story for us to "ome u* @ith a dia#nosis& After a lon# term o$ser,ation' "hart-readin#' and inter,ie@s' @e stron#ly $elie,e and stand that our dia#nosis for our "lient' eonardo' @ould $e S"hi/o*hrenia Paranoid ty*e& +elusions and hallu"inations @ere *resent for a si#nifi"ant *ortion of time durin# a one month *eriod& As ,er$ali/ed $y his mother' he suddenly heard *eo*le s"reamin# @hi"h is a *rominent auditory hallu"ination so he headed home& Self-"are defi"it @as o$ser,ed $y family mem$ers at home& )e doesnFt ta?e a $ath& 6here @ere times @hen he only too? a $ath on"e in a @ee?& S"hi/oaffe"ti,e and mood disorders are not *resent& )is disorder is also not "ause $y any su$stan"e a$use or a #eneral medi"al disorder& 6herefore' @e "onsidered him as a s"hi/o*hreni" disorder& Si#ns of distur$an"es @ere "ontinuously manifested for almost 21 years& It @as ei#ht years after the onset of his si#ns and sym*toms @hen he @as su$mitted to a *hysi"ian for a medi"al e,aluation& 6hey also tried to "onsult and >al$ularyoA or a qua"?do"tor $e"ause as they say medi"ations re"ei,ed $y Sir eonardo @ere ineffe"ti,e& +es*ite of those medi"ations and different thera*ies' si#ns and sym*toms @ere still *resent& After he ,iolently *un"hed his mother at home' the family de"ided to su$mit him for reha$ilitation at N+RC& In his fi,e years of admission at the institution' *rominent auditory hallu"inations and delusions are still *resent' $ut no disor#ani/ed s*ee"h @as o$ser,ed @hi"h fits him to the dia#nosis of s"hi/o*hrenia' *aranoid ty*e&

69

70

71

+IA-NOS6IC !PAMS

+A6! +e"em$er 9' 2009

3ASIC 6!S6O Normal 1alues )ematolo#y% )emo#lo$in C14;-180 #O D

RA6IONA !

R!S= 6

C INICA SI-NIFICANC!

N=RSININ6!R1!N6ION 6ell the *atient that the test requires a $lood sam*le& !0*lain that he may feel dis"omfort *un"ture& Inform the "lient that he from the tourniquet and the needle

6o assess for the *resen"e of anemia or *oly"ythemia 6o monitor the *atientFs res*onse to thera*y

19: #O

NORMA

Bhite 3lood Cell C;-10 W 1000 #O D Se#menter s C0&;;0&8;D

6o determine infe"tion or inflammation 6o determine the need for further tests su"h as $one marro@ $io*sy

8&<

NORMA

doesnFt need to restri"t food and fluids for the test& A**ly dire"t *ressure to the ,eni*un"ture site until $leedin# sto*s& If a lar#e

6o monitor res*onse to thera*ies 6o e,aluate the $odyFs

0&8:

In"reased% infe"tions' is"hemi" ne"rosis' meta$oli"

hematoma de,elo*s at the ,eni*un"ture site' monitor *ulses distal to the site&

68

"a*a"ity to resist and o,er"ome infe"tion ym*ho"y tes C0&2;0&90D 6o determine the sta#e and se,erity of an infe"tion 6o distin#uish ,iral from $a"terial infe"tions& 0&22

disorders' stress res*onse' inflammatory disease +e"reased% se,ere de$ilitatin# illness' defe"ti,e lym*hati" "ir"ulation

Mono"yte s C0&020&08D !osino*hil s C0&010&0;D 6o e,aluate aller#i" air@ay inflammation in "lients&

0&08

NORMA

0&0;

NORMA

Platelets C1;045; W 1001O 6o e,aluate *latelet

Adequate

NORMA

0&99

NORMA
69

)emato"rit C0&90-0&9<D Clini"al Chemistry%

*rodu"tion 6o aid in the "al"ulation of erythro"yte indi"es :&55 In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress O$ser,e "lients& 6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume s*e"imen @ithdra@n& <2&: NORMA diet after has the $een or hematoma formation& A**ly *ressure for si#ns in of

-lu"ose C4&<5;&<9 mmolO D 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia

C)i#hD

hy*o#ly"emia

fastin#

Creatinine C;45: mmolO D

70

It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e 2: NORMA

)-P6 C0-91 mmolO D

$et@een "reatinine formation and e0"retion&

=rinalysis% 2ello@ Color *) Al$umin S*e"ifi" -ra,ity Su#ar Pus S 1 *lus 6o determine the *resen"e of #enitourinary diseases& Mon7torthe effe"ts of *hysi"al or emotional stress Monitor the res*onse to dru# thera*y and e,aluate undesired rea"tions to dru#s that may im*air renal fun"tion 0-1Oh*F NORMA Ne#ati,e NORMA 1&02; NORMA Ne#ati,e NORMA A"idi" NORMA NORMA

Inform

"lient

that

"olle"tion ta?es *al"e fro ;-10 minutes& Instr"ut the male *atient to thofou#h @ash the hands' "lean the meatus' ,oid small amount to the toilet and ,oid dire"tly to the s*e"imen $ottle&

71

Mu"us S 1 *lus !*ithelial "ells In"reased% 01-04-0; Cast Chest P-ray M =ltrasound% 6o e,aluate ?no@n or sus*e"ted *ulmonary disorders' or "ardi,as"ular disorders& !le"tro"ardio#r a*hy C!H-D% 6o dete"t arrhythmias as e,iden"ed $y a$normal @a,e defle"tions& Sinus ta"hy"ardia S 1 *lus Radio#ra* hy% Ne#ati,e Chest C-D O$tain ,ital so#ns Pla"e *atient in su*ine *osition& !0*ose and dra*e the "hest' arms and le#s& Bhen *ro"edure is done' instr"ut *hysi"ian *atient if to "hest notify *ain' hy*ertension NORMA

o""urs or "han#es in *ulse rate or shortness of $reath&

72

02-2<-0;

Clini"al Chemistry% -lu"ose C4&<5;&<9 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia :&81 mmol In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress O$ser,e "lients& 6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume s*e"imen @ithdra@n& diet after has the $een or hematoma formation& A**ly *ressure for si#ns in of

hy*o#ly"emia

fastin#

04-0<-0;

Clini"al Chemistry% -lu"ose C4&<5;&<9 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia 8&<< mmol In"reased% +ia$etes mellitus' O$ser,e for si#ns in of

hy*o#ly"emia

fastin#
73

hy*ertension' infe"tions'in7ury' stress

"lients& 6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume s*e"imen @ithdra@n diet after has the $een or hematoma formation& A**ly *ressure

09-02-0;

B3C +ifferential Count% Bhite 3lood Cell C9&8-10&2 W 10 !qO D ym*ho"ytes C0&8-4&9D

6o assist in determini#n the "ause of an infe"tion& 6o monitor the effe"ts of *hysi"al and emotional stress 6o monitor the res*onse to dru# thera*y NORMA 4&2 91&0E
74

NORMA :&5

MI+ C0&0-1&<D

0&4 4&2E

NORMA

-ranulo"ytes 09-09-0; C2&0-8&5D Clini"al Chemistry% -lu"ose C4&<5;&<9 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia

9&9 ;;&<E -

NORMA

;&< mmol

NORMA

Cholesterol C4&5-8&1< mmolD 6ri#ly"erides C0-2&2; mmolD )i#h +ensity i*o*rotein

6o determine the ris? of "ardio,as"ular disease

;&8 mmol CNormalD 2&02 mmol CNormalD 0&84 mmol C o@D

NORMA

Instru"t *atient to fast for12 hours $efore s*e"imen "olle"tion&

NORMA

!nsure that *atient "om*lied @ith dietary restri"tions& O$ser,e the ,eni*un"ture site

+e"reased%

for $leedin#& A**ly *ressure

Sedentary lifestyle' $anda#e&

75

)+ C1&18-1&9; mmolD o@ +ensity i*o*rotein + C0-9&0 09-12-0; mmolD )ematolo#y% )emo#lo$in C120-190 #OlD 6o assess for the *resen"e of anemia or *oly"ythemia 6o monitor the *atientFs res*onse to thera*y 19: #O 9&0; mmol

un"ontrolled dia$etes' hy*ertension NORMA

6ell the *atient that the test requires a $lood sam*le& In"reased% )emo"on"entratio n from *oly"ythemia or dehydration !0*lain that he may feel dis"omfort *un"ture& Inform the "lient that he doesnFt need to restri"t food and fluids for the test& A**ly dire"t *ressure to the ,eni*un"ture 0&85 In"reased% infe"tions' site until $leedin# sto*s& If a lar#e hematoma de,elo*s at the ,eni*un"ture site' monitor
76

from

the

tourniquet and the needle

Bhite 3lood Cell C;-10 W 1000 #O D Se#menters C0&;;-0&8;D

6o determine infe"tion or inflammation 6o determine the need for further tests su"h as $one marro@ $io*sy

<&: W 1000 #O

NORMA

6o monitor res*onse to thera*ies 6o e,aluate the $odyFs "a*a"ity to resist and o,er"ome infe"tion

is"hemi" ne"rosis' meta$oli" disorders' stress res*onse' inflammatory disease 0&22 +e"reased% se,ere de$ilitatin# illness' defe"ti,e lym*hati" "ir"ulation

*ulses distal to the site&

ym*ho"yte C0&2;-0&90D

6o determine the sta#e and se,erity of an infe"tion 6o distin#uish ,iral from $a"terial infe"tions&

Mono"yte C0&02-0&08D !osino*hil C0&01-0&0;D 3aso*hil C0&00&0;D Platelet C1;0-

0&0;

NORMA

0&04

NORMA

0&01

NORMA

adequate

NORMA
77

45; W100 #O D )emato"rit C0&4:-0&9;D =rinalysis% Color Rea"tion Chara"ter 2ello@ A"idi" Sli#htly a"idi" Ne#ati,e C-D 1&010 Ne#ati,e C-D
78

6o e,aluate *latelet *rodu"tion 6o aid in the "al"ulation of erythro"yte indi"es 0&99 NORMA

6o determine the *resen"e of #enitourinary diseases& Mon7torthe effe"ts of *hysi"al or emotional stress Monitor the res*onse to dru# thera*y and e,aluate undesired rea"tions to dru#s that may im*air renal fun"tion

NORMA NORMA NORMA

Al$umin S*e"ifi" #ra,ity Su#ar

NORMA NORMA NORMA

Pus Cells

2-9 O)*f

In"reased% =rinary tra"t infe"tion

R3C

1-2 O)*f

In"reased% =rinary tra"t infe"tion

Mu"us

S 2 *lus

NORMA

3lood Chemistry% Creatinine C;:52 mmolD It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e $et@een "reatinine formation and e0"retion& <;&0: mmol NORMA

79

05-08-0;

3lood Chemistry% Creatinine C;:52 mmolD It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e $et@een "reatinine formation and e0"retion& 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia <8 mmol NORMA

01-40-08

-lu"ose C4&<5;&<9 mmolD

12&8 mmol

In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress

O$ser,e "lients&

for

si#ns in

of

hy*o#ly"emia

fastin#

6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume s*e"imen @ithdra@n&
80

or

hematoma

formation& A**ly *ressure diet after has the $een

0<-19-08

Fastin# 3lood Su#ar% -lu"ose C9&208&90 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia 8&2< mmol NORMA

0<-25-08

Fastin# 3lood Su#ar% -lu"ose C9&20 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia 6o "onfirm or rule out intestinal *arasiti" infe"tion Color Consisten"y and disease& Assist in dia#nosin# -I $leedin# or dru# thera*y that leads to $leedin# Formed no $lood nor intestinal found NORMA 3ro@n NORMA 8&2< mmol NORMA !0*lain to the *atient that it dete"ts infe"tion& It the *atient has diarrhea' assess re"ent dietary Inform the *atient of the *ro"edure s*e"imen' of "olle"tin# the
81

05-1;-08

8&90 mmolD Fe"alysis%

intestinal

*arsiti"

in"ludin#

im*ortan"e Pus "ells Red $lood "ells 0&1 O)*f 4-; O)*f C)i#hD 3a"teria Ne#ati,e C-D 10-08-08 Clini"al Chemistry% F3S -lu"ose C9&208&90 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia 11&59 mmol In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress O$ser,e "lients& for In"reased% Inflammatory disorders NORMA

of

#ood

hand@ashin# te"hniques&

si#ns in

of

hy*o#ly"emia

fastin#

6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# or hematoma formation& A**ly *ressure
82

$anda#e& Resume s*e"imen @ithdra@n& Creatinine C;45: mmolD It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e $et@een "reatinine formation and e0"retion& 1;2&9 umol In"reased% dia$etes mellitus' "on#esti,e heart fai?ure' dru#s in"ludes do*amine A,oid e0essi,e e0er"ise for < hours and a,oid e0"essi,e red meat inta?e for 29 hours $efore the test& !0*lain to the *atinent that it is used to e,aluate ?idney fun"tion& !0*lain to the *atient that he may e0*erien"e from sli#ht the dis"omfort *un"ture& diet after has the $een

tourniquet and the needle

83

12-21-08

Fastin# 3lood Su#ar% -lu"ose C9&208&90 mmolD 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia :&45 mmol C)i#hD In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress O$ser,e "lients& 6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume s*e"imen @ithdra@n& diet after has the $een or hematoma formation& A**ly *ressure for si#ns in of

hy*o#ly"emia

fastin#

<-40-0:

3lood Chemistry% 8&0 -lu"ose C9&1;&5 mmolO D 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia mmolO In"reased% +ia$etes mellitus' hy*ertension' O$ser,e "lients&
84

for

si#ns in

of

hy*o#ly"emia

fastin#

infe"tions'in7ury' stress Alanine Aminotransfera se A 6 C21-:2 =O D Monitor li,er dama#e resulyin# from he*atoto0i" dru#s 45&0 =O NORMA

6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume @ithdra@n diet after the s*e"imen has $een or hematoma formation& A**ly *ressure

<-41-0:

)$ A1" C9&2E8&0:ED

;&<E

10-05-0:

-lu"ose C9&1;&5 mmolD

6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia

:&1 mmolO

In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress

O$ser,e "lients&

for

si#ns in

of

hy*o#ly"emia

fastin#

6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion&

85

O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume @ithdra@n 01-0:-0< =rine Analysis% Color -lu"ose Protein =ro$ilino#en 3iliru$in Hetone 6o determine the *resen"e of #enitourinary diseases& Mon7torthe effe"ts of *hysi"al or emotional stress Monitor the res*onse to dru# thera*y and e,aluate undesired rea"tions to dru#s that may im*air renal fun"tion Normal Ne#ati,e Ne#ati,e S1 In"reased% +ia$eti" *atients NORMA NORMA NORMA Ne#ati,e NORMA 2ello@ NORMA diet after the s*e"imen has $een or hematoma formation& A**ly *ressure

86

A**earan"e S*e"ifi" -ra,ity 3lood *) Nitrite eu?o"yte Pus Cells Clini"al Chemistry% -lu"ose C9&1;&5 mmolO 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia

Clear 1&01; Ne#ati,e 8&0 Ne#ati,e Ne#ati,e 0-1 Oh*f

NORMA NORMA NORMA NORMA NORMA NORMA NORMA

8&5 mmolO C)i#hD

In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress

O$ser,e "lients&

for

si#ns in

of

hy*o#ly"emia

fastin#

6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for
87

$leedin# $anda#e& Resume Bithdra@n Creatinine C82144 =molO D It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e $et@een "reatinine formation and e0"retion& 190 =molO In"reased% dia$etes mellitus' "on#esti,e heart fai?ure' dru#s in"ludes do*amine

or

hematoma

formation& A**ly *ressure diet after the

s*e"imen has $een A,oid e0essi,e e0er"ise for < hours and a,oid e0"essi,e red meat inta?e for 29 hours $efore the test& !0*lain to the *atinent that it is used to e,aluate ?idney fun"tion& !0*lain to the *atient that he may e0*erien"e from sli#ht the dis"omfort *un"ture& A 6 C21-:2 =O D Monitor li,er dama#e resulyin# from he*atoto0i" 4: =O NORMA

tourniquet and the needle

88

dru#s

09-0;-0<

Clini"al Chemistry% -lu"ose C9&1;&5 mmolO 6o hel* dia#nose dia$etes mellitus and hy*o#ly"emia :&< mmolO C)i#hD In"reased% +ia$etes mellitus' hy*ertension' infe"tions'in7ury' stress O$ser,e "lients& 6he *atient should $e fastin# at least 12 hours $efore the s*e"imen "olle"tion& O$ser,e ,eni*un"ture site for $leedin# $anda#e& Resume diet after the s*e"imen has $een Bithdra@n&
89

for

si#ns in

of

hy*o#ly"emia

fastin#

or

hematoma

formation& A**ly *ressure

Creatinine C82144 =molO D

It hel* to determine a slo@in# of the #lomerular filtration rate and $alan"e $et@een "reatinine formation and e0"retion&

14< =molO

In"reased% dia$etes mellitus' "on#esti,e heart fai?ure' dru#s in"ludes do*amine

A,oid e0essi,e e0er"ise for < hours and a,oid e0"essi,e red meat inta?e for 29 hours $efore the test& !0*lain to the *atinent that it is used to e,aluate ?idney fun"tion& !0*lain to the *atient that he may e0*erien"e from sli#ht the dis"omfort *un"ture&

tourniquet and the needle A 6 C21-:2 =O D Monitor dru#s li,er dama#e :: =O NORMA

resulyin# from he*atoto0i"

90

POSSI3 ! +IA-NOS6IC !PAMINA6IONS

Name of the 6est

+es"ri*tion

Method It is a *ro"edure in @hi"h a ima#es 6he

It "an ,isuali/e the $rain *re"ise 0-ray $eam ta?es Com*uter 6omo#ra*hy or Com*uter A0ial 6omo#ra*hy soft tissues' so C6 is used to "ross-se"tional dia#nose *rimary tumors' layer-$y-layer&

metastases' and effusions "om*uter re"onstru"ts the and to determine the si/e of ima#es on a monitor and the ,entri"les of the $rain& also stores ima#es on ma#neti" ta*e or film& A ty*e of a $ody s"an' an ener#y field is "reated @ith a hu#e ma#net and radio @a,es& 6he ener#y field is "on,erted to a ,isual ima#e

MRI *rodu"es more tissue Ma#neti" Resonan"e Ima#in# detail and "ontrast than C6 and "an sho@ $lood flo@ *atterns and tissue "han#es su"h as edema& Positron !mission 6estin#

or s"an 6his is used to e0amine the 6he radioisoto*es used in fun"tion of the $rain& P!6 P!6 ha,e ,ery short half uses "ar$on' and *ro"esses $y other unique nitro#en' to the in isoto*es li,es those "om*ared to nu"lear CParti"ularly fluorineD of "on,entional

o0y#en medi"ine radioisoto*es Cin study the order of minutesD& P!6 $ody radioisoto*es Ca emit a *ositi,ely

im*ossi$le to demonstrate *ositron means&

A"ti,e "har#ed ele"tronD in the

tissues @ithin the $ody' *ro"ess of de"ay& Bhen this su"h as tumors' the $rain' *ositron "ollides @ith an the heart and inflammation ele"tron' the 2 *arti"les may $e ,isuali/ed as these annihilate ea"h other' and @ill ta?e u* more #lu"ose *rodu"e 2 *hotons tra,elin#
93

in o**osite dire"tions& 6@o dete"tors *ositioned o**osite one another "an $e used to dete"t the e,ent& Many su"h in e,ents are "olle"ted "om*uter

memory' and are used to ma?e u* a 4 dimensional ima#e than other tissues& of the ori#inal distri$ution of tra"er @ithin the *atient& 3y *la"in# a rin# of dete"tors around the *atient' and mo,in# the dete"tor assem$ly alon# the a0is of a *atient it is *ossi$le to "onstru"t a 4 dimensional ima#e of the or#an emittin# the *hoton *air& A test of ,isual motor 6he "lient is as?ed to "o*y "oordination that is most time useful -ender-#estalt 6est *resen"e im*airment& @ith of adults s"reenin# de,i"e to dete"t *a*er' se*arate one at the #eometri" a time& is an as desi#ns unto *lain @hite "lient after

or#ani" Sometimes from

as?ed to dra@ the desi#n memory inter,al of 9;-80 se"onds&

94

A *ro7e"ti,e test used in 6he "lient is as?ed first to $oth adults and "hildren to dra@ a human fi#ure and eli"it information on the later to dra@ a *erson of the "lientFs +ra@ A Person 6est $ody ima#e or o**osite se0& 6he test *er"e*tion of self and the may$e e0*anded $y as?in# "lientFs relationshi* to the the "lient to dra@ a *i"ture en,ironment& It is also used of a house and a tree as @ell as a s"reenin# de,i"e to C"alled )ouse-6ree *erson dete"t *resen"e of or#ani" 6estD or CFi#ure dra@in#D an im*airment& animal or a family&

Senten"e Com*letion 6est

+esi#ned to eli"it "ons"ious 6he

"lient

is

as?ed

to

asso"iation to s*e"ifi" areas "om*lete s*ontaneously a of fun"tionin# to illustrate senten"e as % >I feelI&A' the fears' *reo""u*ations' >My motherI&A' am$itions of the "lient& >Sometimes I @ishedI&A 6hemati" A**er"e*tion 6est 6est offerin# a standardi/ed 6he "lient is sho@n a series set of stimuli e0*lorin# the of am$i#uous *i"tures of "lientFs emotional life& *eo*le in ,arious si#nifi"ant 6hemes and inter*ersonal situations and is as?ed to *ro$lems emer#e in the res*ond $y as?in# @hat is "lientFs res*onses& Beshier Memory S"ale ha**enin# in the *i"ture and tellin# the story a$out it& A *sy"holo#i"al test for 6he "lient is as?ed to do immediate' short term and se,en lon# term memory& in"ludin# information' mental $a"?@ard' "ontrol' memory test' "urrent orientation' lo#i"al ,isual

memory' di#its for@ard and re*rodu"tion' and asso"iate

95

learnin#&

A of

memory or#ani"

quotient s"ore is useful in determination im*airment&

A test @hi"h assesses the Stimulus "ards of different a$stra"t fle0i$ility sol,in#& Bis"onsin Card Sortin# 6est reasonin# in Persons and "olor' form' and num$er are @ith into #rou*s a""ordin# to *ro$lem *resented to *atients to sort

dama#e to the frontal lo$es *rin"i*le esta$lished $y the or to the "audate and some e0aminer $ut un?no@n to *ersons @ith s"hi/o*hrenia the *atient& As the *atient #i,e a$normal res*onses& sorts the "ard' he is told @hether the res*onses is "orre"t or not' and the num$er of trials required to a"hie,e "orre"t ten "onse"uti,e is res*onses

re"orded& Bhen the *atient has mastered the tas?' the *rin"i*le of sortin# and the trial required to a"hie,e "orre"t sortin#&

96

A test to assess *resen"e of 6he *atient is required to ri#ht hemis*here or $ilateral identify failure Fa"ial Re"o#nition 6est lesions& to those @ith ,ie@& is *hoto#ra*h lesions& Results are often *resented in front or side *osterior ri#ht hemis*here Performan"e #enerally in *atients @ith left hemis*here lesions' and in *atients @ith s"hi/o*hrenia&

97

M!+ICA MANA-!M!N6

)os*itali/ation In*atient units must *ro,ide ra*id assessment' sta$ili/ation of sym*toms and dis"har#e *lannin# and they must a""om*lish #oals qui"?ly& A "lient-"entered multi-dis"i*linary a**roa"h to a $rief stay is essential& Clini"ians hel* "lient re"o#ni/e sym*toms' identify "o*in# s?ills and "hoose dis"har#e su**orts& On"e the "lient is safe and sta$le' the "lini"ians and the "lient identify lon#-term issues for the "lient to *ursue in out-*atient thera*y& 6he N+RC team hel*s to#ether in *ro,idin# the needs of the "lient as @ell as to a"hie,e the latterFs #oal' the re"o,ery from *resent illness& Psy"ho*harma"olo#y
98

Medi"ation mana#ement is "ru"ial issue that #reatly influen"es the out"ome of the treatment for many *atients @ith mental disorders& 6he *sy"hiatri" mental health nurseFs ?no@led#e of *sy"ho*harma"olo#y and its asso"iated thera*euti" a#ents is a si#nifi"ant fa"tor in "ontem*orary *ra"ti"e& 6he *sy"hiatri" nurse has a "ru"ial role in assistin# "lients to in"or*orate *sy"ho*harma"olo#i"al a#ents into their efforts to re"o,er and maintain health and *re,ent ne#ati,e sequelae and rela*se& 6he nurse is res*onsi$le for assessin# the thera*euti" dosa#es' do"umentin#' administration' and edu"atin# the "lient and family mem$ers a$out the *sy"ho*harma"olo#i"al a#ents $ein# used in the treatment re#imen& Milieu 6hera*y It is the use of the total en,ironment as the thera*euti" a#ent& It is the use of *eo*le' resour"es and e,ents in the "lientFs immediate en,ironment to *romote the "lientFs o*timal fun"tionin#' inter*ersonal #ro@th' and ada*tation to life outside the hos*ital& It may $e thera*euti"' neutral or non-thera*euti"G it is sha*ed $y the staffFs *ra"ti"es and attitudes' human nature and #rou* dynami"s& It is a dynami" and "ontinuous *ro"ess that in,ol,es "ommitment to maintain and *romote thera*euti" effe"ts @ithin a so"ial "onte0t& Psy"hothera*y CA"tualD Psy"hothera*y is the #lo$al term for the *rofessional hel* to resol,e *ro$lems' *romote *ersonal #ro@th' and redu"e malada*ti,e res*onses& A"hie,in# an understandin# of their feelin#s and $eha,iors is a ma7or #oal for *eo*le @ho underta?e *sy"hothera*y& It is a ,alua$le form of treatment in @hi"h the nurse and "lient en#a#e in an intera"tional relationshi* that *romote ada*ti,e "han#es' en"oura#es insi#ht' and fa"ilitates o*tional fun"tionin#& 1& -rou* 6hera*y It is the modality of more than one *erson& 6he *ur*oses in"lude en"oura#in# so"ial in,ol,ement' de,elo*in# ra**ort $et@een "lients and staff' ena$lin# "lients to demonstrate su**ort for ea"h other and *arti"i*ate in mutual *ro$lem-solin# and *romotin# the de,elo*ment of a sense of solidarity as a #rou* of indi,iduals in the hos*ital situation& A"tual% -rou* Colla#e Ma?in#- (anuary 41' 2005

99

2& Play 6hera*y It #i,es a sym$oli" @ay to e0*ress their feelin#s' an0iety' a##ressions and self-dou$t& It is a form of thera*y that $rin#s fun and a form of e0er"ise' so"iali/ation @ith others' "oo*eration' di,ertin# *atientFs attentionG *romote s*ortsmanshi* and healthy "om*etition amon# the *atients& It ena$les the indi,idual to ha,e a unique o**ortunity to dis"har#e stron# emotions in a se"ure atmos*here& A"tual% )e*-he* hooray- (anuary 1;' 2005 Pera o $ayon#- (anuary 1;' 2005 Fruit O$sta"le Ra"e- (anuary 24' 2005 -ame ?n$- (anuary 24' 2005 -arter #ame L (anuary 40' 2005 Cu*side do@n- (anuary 40' 2005 4& Musi" 6hera*y Musi" thera*y is a ty*e of *sy"hothera*y in @hi"h the *atient is en"oura#ed to utili/e musi" to im*ro,e inter*ersonal and "ommuni"ation s?ills in @ays that re#ular dialo#ue is limited& Forms of musi" thera*y #enerally are $ased around "o#niti,eO$eha,ioral' humanisti" or *sy"hoanalyti" frame@or?s or a mi0ture of a**roa"hes& 6here are usually $oth a"ti,e and re"e*ti,e *arts of the thera*y' meanin# that at times musi" is listened to and at other times there is the use of musi"al im*ro,isation or "reation& A"tual% >Remem$er Me 6his BayA 9& +an"e 6hera*y It is a method of *sy"holo#i"al treatment in @hi"h mo,ement and dan"e are used to e0*ress and deal @ith feelin#s and e0*erien"es $oth *ositi,e and ne#ati,e& 6he em*hasis in dan"e thera*y is on free mo,ement' not restri"ti,e ste*s' and e0*ressin# oneFs true emotions& A"tual% >Saya@an na 6ayoA Sto* +an"e- (anuary 40' 2005 ;& O""u*ational 6hera*y

100

6hese are a"ti,ities that are use to *romote health and inde*enden"e& 6his also used to restore *hysi"al fun"tion and de,ise @ays to hel* those @ith *ermanent limitations "arry out e,eryday fun"tions& A"tual% 3ead Ma?in#- (anuary 1:' 2005 Pastil Ma?in#- (anuary 24' 2005 Personali/ed )ome +e"oration- (anuary 40' 2005 8& Art 6hera*y It is a *ro"ess of lettin# the *atient e0*resses hisOher feelin#s and thou#hts throu#h ,arious artisti" means *arti"ularly s?et"hin#' dra@in#' and "olorin#& It is a form of e0*ression $y @hi"h emotionally ill "lient "an "ommuni"ate their *ro$lems $y e0*ressin# it throu#h dra@in#s and *aintin#s& 6his thera*y "an enhan"e the *atientFs interest and stren#th' and de,elo* hisOher sense of "reati,ity& A"tual% Calendar Ma?in#- (anuary 18' 2005 My Summertime- (anuary 40' 2005 My Most =nfor#etta$le !0*erien"e- (anuary 1:' 2005 :& Remoti,ational 6hera*y It is a te"hnique of ,ery sim*le #rou* thera*y of an o$7e"ti,e nature used in an effort to rea"h the un@ounded areas of the *atients *ersonally and #et them alon# mo,in# in the dire"tion of reality& Remoti,ation te"hnique stimulates *atients to thin? a$out somethin# and tal? a$out himG de,elo* the a$ility to "ommuni"ate and share idea and e0*erien"es @ith othersG and de,elo* feelin#s of a""e*tan"e and re"o#nition& A"tual% N+RC S*a +ay- (anuary 25' 2005 Hasal' Hasali' Hasalo Cthe mo,ieD- (anuary 22' 2005 Peryahan sa N+RC- (anuary 29' 2005 Psy"hothera*y CPotentialD 1& Co#niti,e 6hera*y Co#niti,e thera*y hel*s "lients re"o#ni/e their distorted "o#nitions and malada*ti,e $eha,iors& Ma7or strate#ies in"lude home@or? assi#nments' interru*tion of irrational $elief
101

systems' and redu"tion of feelin#s #enerated $y distorted "o#nitionCsD& (ohnston C1550D asserted that the "a*a"ity to form a "olla$orati,e nurse-"lient relationshi* and the "lientFs moti,ation to "han#e determine the su""ess of "o#niti,e thera*y& It ena$les the nurse to esta$lish a nonthreatenin# "limate that hel*s the "lient re"o#ni/e irrational $elief systems that distort reality and there$y #enerate distress& 2& Su**orti,e Psy"hothera*y Su**orti,e *sy"hothera*y ena$les "lient to maintain and im*ro,e their ada*ti,e "o*in# $eha,iors& Pro$lem-sol,in# s?ills are diffi"ult for these "lients @hen under stress& Inter,ention in,ol,es #i,in# the "lient the o**ortunity to "om*are and "ontrast @ays in @hi"h he or she has "o*ed @ith "ertain situation and hel*s him or her to re,ie@ stren#ths and rene@ sense of *ersonal *o@er& 3y 7ust merely en"oura#in# the "lient to "are for himself is another inter,ention that hel*s the "lient to "o*e& 4& !C6 C!le"tro-Con,ulsi,e 6hera*yD Resear"h su##ests that !le"tro"on,ulsi,e thera*y C!C6D has a modest $ut definite role to *lay in the treatment of s"hi/o*hrenia des*ite the ad,erse *u$li"ity it has re"ei,ed& & In !uro*ean "ountries it has $een used more @idely for the treatment of s"hi/o*hrenia than in the =nited States&

102

+R=- S6=+2

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

+e"em$er ;' 2009 $i*eriden A?ineton Choliner#i" $lo"?in# dru#' anti*ar?inson dru# 3i*eriden )Cl 2m# 6a$ 1ta$ 3I+ for !PS Par?insonism Adults% 2m# 4-9 times *er day' to a ma0imum of 18m#Oday +ru#- indu"ed e0tra-*yramidal effe"ts

A"tion

Adults% 2m# 1-4 times *er day& Ma0imum daily dose% 18m#& 3lo"?s "holiner#i" a"ti,ity in the CNS' @hi"h is *artially res*onsi$le for the sym*toms of Par?insonFs +isease& Restores the natural $alan"e of neurotransmitters in the CNS& 6hera*euti" !ffe"ts% Redu"tion of ri#idity and tremors& Ad7un"ti,e treatment of all forms of Par?insonFs disease' in"ludin# dru#-indu"ed e0tra*yramidal effe"ts and a"ute dystoni" rea"tions&
103

Indi"ation

Contraindi"ation

)y*ersensiti,ity' narro@-an#le #lau"oma' myasthenia #ra,is' -IO -= o$stru"tion' me#a"olon' an0iety' stenosin# *e*ti" ul"ers' *rostati" delusions' in"oheren"e' hy*ertro*hy& CNS% "onfusion' hallu"inations'

Side !ffe"ts

restlessness' sedation'

irrita$ility'

heada"he'

de*ression'

di//iness' eu*horia' tremors' memory loss C1% *al*itations' ta"hy"ardia' *ostural hy*otension' $rady"ardia !!N6% $lurred ,ision' *hoto*ho$ia' dilated *u*ils' diffi"ulty s@allo@in#' mydriasis' in"reased intrao"ular tension' an#le-"losure #lau"oma -I% dryness of mouth' "onsti*ation' nausea' ,omitin#' a$dominal distress -=% hesitan"y' retention' dysuria Inte#umentary% rash' urti"aria' dermatoses Mis"ellaneous% in"reased tem*erature' flushin#' de"reased s@eatin#' num$ness of fin#ers Ad,erse !ffe"ts +ru# Intera"tions MS% @ea?ness and "ram*in# -I% *aralyti" ileus Mis"ellaneous% hy*erthermia or heat stro?e Antihistamines' *henotiha/ines' quinidine' diso*yramide' tri"y"li" antide*ressants% additi,e "holiner#i" effe"ts @ith dru#s sharin# anti"holiner#i" *ro*erties& 3ethani"ol% "ountera"ts "holiner#i" effe"ts of the dru# Anta"ids or anti-diarrheals% may de"rease a$sor*tion An#elFs Nursin# Res*onsi$ility 6rum*et' (imson Beed and s"o*olia% in"rease anti"holiner#i" effe"ts 1& Administer @ith food or immediately after meals to minimi/e #astri" irritation& 2& -i,e at $edtime to a,oid daytime dro@siness& 4& Store at room tem*erature& 9& Assess for e0tra*yramidal sym*toms su"h as restlessness' or desire to ?ee* mo,in#' ri#idity' tremors' *ill rollin#' mas?-li?e
104

fa"e' shufflin# #ait' mus"le s*asms' t@istin# motions' diffi"ulty s*ea?in# or s@allo@in#' loss of $alan"e "ontrol $efore and after thera*y& ;& Assess $o@el fun"tion daily& Monitor for "onsti*ation' a$dominal *ain' distention or the a$sen"e of $o@el sounds& 8& Monitor inta?e and out*ut ratios and assess *atient for urinary retention& :& Bithhold dru# and notify *hysi"ian or other health "are *rofessionals if si#nifi"ant $eha,ioral "han#es o""ur& <& 6ea"h *atient to use "aution in hot @eather& 5& 6ea"h *atient not to dis"ontinue this dru# a$ru*tlyG to ta*er off o,er 1 @ee? to *re,ent @ithdra@al sym*toms Csu"h as insomnia' in,oluntary mo,ements' an0iety and ta"hy"ardia& 10& Caution *atient to rise from sittin# or re"um$ent *osition slo@ly to minimi/e orthostati" hy*otension&

105

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Mar"h 40' 200; quetia*ine fumarate Seroquel Anti*sy"hoti" .uetia*ine 100m# 1ta$ 3I+ S"hi/o*hrenia Adults% initially' 2; m# PO 3I+G in"rease in"rements of 2;- ;0 m# 3I+ or 6I+ on days 2 and 4 as tolerated& 6ar#et dosa#e ran#e is 400-900 m# daily' di,ided into 2 or 4 daily doses $y day 9& 6hen ma?e further dosa#e ad7ustments at inter,als of not less than 2 days& +osa#e "an $e in"reased or de"reased $y 2;;0 m# 3I+ $ased on res*onse& Safety of doses a$o,e <00 m# daily hasnFt $een e,aluated& Monothera*y and ad7un"t thera*y @ith lithium or di,al*roes for the short-term treatment for a"ute mani" e*isodes asso"iated @ith 3i*olar I disorder& Adults% initially' ;0m# PO 3I+& In"rease dosa#e in in"rements of 100m# *er day in 2 di,ided doses to 200 m# PO 3I+ on day 9& May in"rease dosa#e in in"rements not #reater than 200m# *er day' u*to <00m# *er day $y day 8& =sual dose' 900 to <00 m# daily& +e*ression in $i*olar disorder& Adults% On day1' #i,e ;0 m#& On day 2' 100m#& On day4' 200m#& 6hen on day 9 and thereafter' #i,e 400m# daily& 6hen #i,e dru# at $edtime& Ad7ust a dose for *atients @ith he*ati" im*airment' initially #i,e 2; m# PO daily& In"rease in"rements of 2; to ;0 m# daily to an effe"ti,e dose' de*endin# on the *atientFs res*onse and toleran"e& Me"hanism un?no@n& 3ut may a"t as an anta#onist on do*amine + 2 and serotonin ; )62 re"e*tors& 6hen side effe"ts may $e due to
106

A"tion

anta#onism of other re"e*tors Ce&#& )istamine )1' do*amine +1' Indi"ation Contraindi"ation Adrener#i" al*ha1 and al*ha2' and serotonin ;)61aD& S"hi/o*hrenia and $i*olar mania Contraindi"ated in *atients hy*ersensiti,e to dru# or any of its in#redients& =se "autiously in *atients @ith C1 disease or "ondition that *redis*ose them to hy*otensionG in those @ith history of sei/ure or "onditions that lo@er sei/ure thresholdG in those at ris? for as*iration *neumoniaG and in those @ho "ould e0*erien"e "onditions in @hi"h "ore $ody tem*erature may $e ele,ated& Side !ffe"ts CNS% Also use "autiously in *atients @ho are de$ilitated& !PS' *seudo*ar?insonism' a?athisia' dystonia' tardi,e

dys?inesia' dro@siness' insomnia' a#itation' an0iety' heada"he' sei/ure' di//iness C1% orthostati" hy*otension -I% nausea' anore0ia' "onsti*ation' a$dominal *ain' dry mouth Inte#umentary% rash Mis"ellaneous% asthenia' $a"? *ain' fe,er' ear *ain Ad,erse !ffe"ts +ru# Intera"tions Res*iratory% Rhinitis CNS% neurole*ti" mali#nant syndrome C1% ta"hy"ardia Antihy*ertensi,es% may in"rease dru# effe"ts& Monitor $lood *ressure& Car$ama/e*ine' #lu"o"orti"oids' Pheno$ar$itals' *henytoin' rifam*in' thiori/adine% may in"rease quetia*ine "learan"e& In"rease dose if needed& Cimetidine' erthyromy"in' flu"ona/ole' itra"ona/ole' ?eto"ona/ole% may de"rease quetia*ine "learan"e& =se to#ether "autiously& +o*amine A#onists' le,odo*a% may anta#oni/e effe"t of these dru#s& Monitor *atient for effe"ts& CNS de*ressant% may in"rease CNS effe"ts& =se to#ether "autiously& Nursin# Res*onsi$ility ora/e*am% may redu"e lora/e*am "learan"e& Monitor *atient& 1& PO @ith full #lass of @ater' mil?G or #i,e @ith food to
107

de"rease -I u*set& 2& Store in airti#ht' li#ht resistant "ontainer& 4& Assess mental status& 9& Che"? that *atient s@allo@s all PO medi"ations& 6hen "he"? for hoardin# or #i,in# of medi"ation to other *atients& ;& Monitor I and O ratio' *al*ate $ladder if lo@ urinary out*ut o""urs& 8& Monitor 3P @ith *atient in sittin#' standin#' and lyin# *osition& :& Che"? for di//iness' faintness' *al*itations' ta"hy"ardia on risin#G se,ere orthostati" hy*otension& <& Identify for neurole*ti" mali#nant syndrome& 5& Assess for !PS in"ludin# a?athisia' tardi,e dys?inesia' *seudo*ar?insonismG an anti-*ar?inson dru# should $e *res"ri$ed& 10& Caution *atient to a,oid ha/ardous a"ti,ities until dru# res*onse is determinedG di//iness' $lurred ,ision may o""ur&

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose

A*ril 8' 200; "lo/a*ine Clo/aril 6ri"y"li" di$en/odia/e*ine deri,ati,e' anti*sy"hoti" Clo/a*ine day 1-4% 2;m# 1ta$ )S day 9-8% 2;m# 1ta$ 3I+ day :-5% 100m# V ta$ 3I+ Adults% PO 12&; m# daily or 3I+G may in"rease $y 2; to ;0m# *er dayG normal ran#e 400 to 9;0 m# *er day after 2 @ee?sG do
108

Su##ested +ose

not in"rease dosa#e more than 2 times *er @ee?G do not e0"eed A"tion 500m# *er dayG use lo@est dose to "ontrol sym*toms& Interferes @ith do*amine re"e*tors $indin# @ith !PS and tardi,e dys?inesiaG also a"ts as an adrener#i"' "holiner#i"' histaminer#i"' and Indi"ation serotoner#i" anta#onist& S"hi/o*hrenia unres*onsi,e to or intolerant of standard thera*y @ith other antiX*sy"hoti"s& 6o redu"e re"urrent sui"idal $eha,ior in Contraindi"ation s"hi/o*hreni" *atients& Contraindi"ated in *atients ta?in# dru#s that su**ress $one marro@ fun"tion and in those @ith *aralyti" ileus& =n"ontrolled @ith e*ile*sy' history of dru#-indu"ed a#ranulo"ytosis' or se,ere CNS de*ression or "oma& B3C "ount less than 4;00O"u& mm& =se "autiously in *atients @ith *rosthati" hy*er*lasia' urinarty retention' or an#le-"losure #lau"oma $e"ause dru# has *otent anti"holiner#i" effe"t& Also use in *atients re"ei,in# #eneral Side !ffe"ts anesthesia and those @ith he*ati"' renal or "ardia" disease& CNS% sedation' sali,ation' di//iness' heada"he' tremors' slee* *ro$lems' a?inesia' fe,er' s@eatin#' a?athisia' "ontusion' fati#ue' insomnia' de*ression' $lurred s*ee"h' an0iety and a#itation C1% ta"hy"ardia' hy*otension' hy*ertension' "hest *ain' !C"han#es' orthostati" hy*otension !!N6% $lurred ,ision -I% nausea' anore0ia' "onsti*ation' a$dominal dis"omfort' dry mouth' ,omitin#' droolin# or e0"essi,e sali,ation' diarrhea' @ei#ht #ain' heart$urn' dys*e*sia' -!R+ -=% urinary a$normalities' in"ontinen"e' e7a"ulation dysfun"tion' frequen"y' ur#en"y' retention' dysuria MS% @ea?nessG *ain in $a"?' ne"?' le#sG s*asm and ri#idity Res*iratory% dys*nea' nasal "on#estion Ad,erse !ffe"ts Res*iratory% Rhinitis CNS% neurole*ti" mali#nant syndrome' sei/ures
109

+ru# Intera"tions

)ematolo#i"% leu"o*enia' neutro*enia' a#ranulo"ytosis' eosino*hilia Anti"holiner#i"s% may in"rease anti"holiner#i" effe"ts of "lo/a*ine& A,oid use to#ether& Antihy*ertensi,es% may in"rease hy*otension effe"ts& Monitor $lood *ressure& 3one marro@ su**ressants% may in"rease $one marro@ to0i"ity& +onFt use to#ether& Citalo*ram% may si#nifi"antly in"rease "lo/a*ine le,el and ad,erse effe"ts& A,oid use to#ether& +i#o0in' @arfarin' other hi#hly *rotein-$ound dru#s% may in"rease le,els of these dru#s& Monitor *atient "losely for ad,erse rea"tions& Psy"hoa"ti,e dru#s% may *rodu"e additi,e effe"ts& =se to#ether "autiously& 1& -i,e @ith full #lass of @ater' mil?G or #i,e @ith food to de"rease -I u*set& 2& Store in airti#ht' li#ht resistant "ontainer& 4& +e"rease dosa#e in elderly sin"e meta$olism is slo@ed& 9& Assess mental status& ;& Che"? for s@allo@in# of PO medi"ation& 6hen "he"? for hoardin# or #i,in# of medi"ation to other *atients& 8& Monitor I and O ratio' *al*ate $ladder if lo@ urinary out*ut o""urs' es*e"ially in elderlyG urinalysis re"ommended $efore' durin# *rolon#ed thera*y& :& Monitor 3P @ith *atient in sittin#' standin#' and lyin# *osition& <& Che"? for di//iness' faintness' *al*itations' ta"hy"ardia on risin#& 5& Assess for neurole*ti" mali#nant syndrome& 10& Assess for !PS in"ludin# a?athisia' tardi,e dys?inesia' *seudo*ar?insonismG an anti-*ar?inson dru# should $e *res"ri$ed& 11& Caution *atient to a,oid ha/ardous a"ti,ities until dru#
110

Nursin# Res*onsi$ility

res*onse is determinedG di//iness' $lurred ,ision may o""ur& 12& 6ea"h *atient to a,oid O6C *re*arations unless a**ro,ed $y *res"ri$er' sin"e serious dru# intera"tion may o""ursG a,oid al"ohol&

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

May <' 200; trimetho*rim sulfametho0a Cotrimo0a/ole Anti$ioti"' "om$ination Cotrimo0a/ole 900m# 1 ta$ 3I+ 0 : doses =6I Adults% PO 180m# 6MPO e,ery 12 hours 0 10-19 days& Chroni" 3ron"hitis Adults% PO 180m# 6MPO e,ery 12 hours 0 19 days Pneumo"ytis 7iro,e"i *neumonitis Adult% PO 20m#O?# 6MP daily in 9 di,ided doses q 8hours 0 19daysG I1 1;-20 m#O?#Oday C$ased on 6MPD in 4-9 di,ided doses u*to 19 days& Renal +osa#e Adult% redu"tion ne"essary in moderate to se,ere renal

A"tion

im*airment CCCr less than 40mlOminD Sulfametho0a/ole inhi$its $a"terial synthesis at the dihydro"hlori" a"id $y "om*etin# @ith *ara-amino $en/oi" a"id& 6rimetho*rim $lo"?s the *rodu"tion of tetrahydro"hlori" a"id $y inhi$itin# the
111

en/yme dihydrofolate redu"tase& 6hus' this "om$ination $lo"?s 2 "onse"uti,e ste*s in the $a"terial $iosynthesis of essential nu"lei" Indi"ation a"ids and *roteins& 6reatment of% $ron"hitis' shi#ella enteritis' otitis media' *neumo"ystis "arinii *neumonia' =6I' tra,ellerFs diarrhea& Pre,ention of PCP in Contraindi"ation )I1- *ositi,e a#ents& Contraindi"ated in *atients @ith me#alo$lasti" anemia "aused $y folate defi"ien"y' *or*hyria' se,ere renal im*airment CCCr less than 1;mlOminD' or hy*ersensiti,ity to trimetho*rim or sulfonamides& =se "autiously and redu"e dose in *atients @ith he*ati" im*airment' a CCr of 1;-40 mlOmin' se,ere aller#y or $ron"hial Side !ffe"ts asthma' -8P+ defi"ien"y or $lood dys"rasias& CNS% heada"he' dru# fe,er' fati#ue' insomnia' de*ression' an0iety' hallu"ination' ,erti#o' sei/ures' "hills -I% nausea' anore0ia' a$dominal *ain' ,omitin#' diarrhea' stomatitis' #lossitis' *an"reatitis' -=% in"reased 3=N' Creatinine% "rystalluria' Inte#umentary% rash' dermatitis' urti"aria' erythema' *hotosensiti,ity' *ain' inflammation at in7e"tion site& Ad,erse !ffe"ts Res*iratory% "ou#h and shortness of $reath CNS% ase*ti" menin#itis C1% aller#i" myo"arditis -I% he*atitis' entero"olitis -=% renal failure' to0i" ne*hrosis )ematolo#i"% leu"o*enia' neutro*enia' throm$o"yto*enia' a#ranulo"ytosis' hemolyti" anemia' hy*o*rothro$inemia Inte#umentary% to0i" e*idermal ne"rosis +ru# Intera"tions Systemi"% ana*hyla0is' S !' Ste,ens- (ohnson Syndrome Oral Anti"oa#ulants% may in"rease anti"oa#ulant effe"t& Monitor *atient for $leedin# Oral Antidia$eti"s% may in"rease hy*o#ly"emin effe"t& Monitor
112

#lu"ose le,el& Phenytoin% may inhi$it he*ati" meta$olism of *henytoin& Monitor Nursin# Res*onsi$ility *henytoin le,el& 1& -i,e @ith full #lass of @ater to maintain adequate hydration& 2& Store in airti#ht' li#ht resistant "ontainer at room tem*erature& 4& Assess for aller#i" rea"tion& 9& Monitor I and O ratioG note for "olor' "hara"ter' *) of urine if dru# administered for =6IG out*ut should $e <00 m less than inta?eG if urine is hi#hly a"idi"' al?ali/ation is needed& ;& Assess $lood dys"rasia' s?in rash' fe,er' sore throat' $ruisin#' $leedin#' fati#ue' 7oint *ain& 8& 6ea"h *atient to ta?e ea"h oral dose @ith @hole #lass of @ater to *re,ent "rystalluria& :& +rin? <-10 #lasses of @ater *er day& <& Com*lete "ourse of @hole treatment to *re,ent su*erinfe"tion& 5& 6ea"h *atient to a,oid sunli#ht or use suns"reen to *re,ent $urns& 10& 6ea"h *atient to notify *res"ri$er if s?in rash' sore throat' fe,er' mouth sores and unusual $ruisin#' $leedin# o""ur&

113

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

May 5' 200; "e*hale0in Hefle0' Hefta$ Ce*halos*orin' first #eneration Ce*hale0in 900m# 1ta$ 3I+ 0 : Renal dose Adults% CCr less than 90mlOmin q <-12 hoursG CCr ;-10mlOmin q 12 hoursG CCr less than ; mlOmin q 29 hours& Moderate Infe"tion Adults% PO 2;0-;00m# q 8hours& Moderate S?in infe"tions Adult% PO ;00m# q 12hours !ndo"arditis Adult% 2# 1 hour $efore *ro"edure Se,ere Infe"tion

A"tion

Adults% PO ;00m#- 1 # q 8 hours Interferes @ith the final ste* in "ell @all formation Cinhi$ition of mu"o*e*tide $iosynthesisD' resultin# in unsta$le "ell mem$rane that under#o lysis& Also' "ell di,ision and #ro@th are inhi$ited& 6reatment of% s?in and s?in stru"ture infe"tion' *neumonia' otitis media' =6I' $one and 7oint infe"tion' se*ti"emia "aused $y sus"e*ti$le or#anism& Contraindi"ated in *atients hy*ersensiti,e to "e*halos*orins& =se "autiously in *atients hy*ersensiti,e to *eni"illin and in

Indi"ation

Contraindi"ation

Side !ffe"ts

*atients @ith renal im*airment& CNS% heada"he' fe,er' "hills' di//iness' @ea?ness' *aresthesia -I% nausea' anore0ia' a$dominal *ain' ,omitin#' diarrhea' #lossitis' $leedin#' in"reased AS6' A 6' 3iliru$in' +)' Al?aline *hos*hatase -=% in"reased 3=N' *roteinuria' ,a#initis' *ruritus' "andidiasis Inte#umentary% rash' dermatitis' urti"aria
114

)ematolo#i"% Anemia Ad,erse !ffe"ts Res*iratory% dys*nea CNS% sei/ure for hi#h doses -I% *seudomem$ranous "olitis -=% renal failure' ne*hroto0i"ity )ematolo#i"% leu"o*enia' neutro*enia' throm$o"yto*enia' a#ranulo"ytosis' hemolyti" anemia' *an"yto*enia' lym*ho"ytosis' +ru# Intera"tions Nursin# Res*onsi$ility eosino*hilia Pro$ene"id% may in"rease "e*halos*orin le,el& 1& Assess for infe"tion at $e#innin# and durin# thera*y& 2& 3efore initiatin# thera*y' o$tain a history to determine *re,ious use of and rea"tions to *eni"illins or "e*halos*orins& 4& O$tain s*e"imens for "ulture and sensiti,ity $efore initiatin# thera*y& First dose may $e #i,en $efore re"ei,in# results& 9& +o not $rea?' "rush or "he@ "a*sules& ;& -i,e in e,en doses around the "lo"?G if -I us*et o""urs' #i,e @ith foodG dru# must $e ta?en for 10-19 days to ensure or#anism death and *re,ent su*erinfe"tion& 8& Sha?e sus*ension' refri#erate' dis"ard after 2 @ee?s& :& 6ea"h *atient to re*ort sore throat' $ruisin#' $leedin#' 7oint *ain' may indi"ate $lood dys"rasias <& Ad,i"e *atient to notify *res"ri$er of diarrhea @ith $lood' *us' mu"ous' @hi"h may indi"ate *seudomem$ranous "olitis& 5& Instru"t *atient to ta?e all medi"ation *res"ri$ed for the len#th of time ordered& 10& Inform *atient that dru# may $e ta?en @ith meals&

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

+e"em$er 14' 2008 metronida/ole Fla#yl 6ri"homona"ide' ame$i"ide Metronida/ole ;00m# ta$ 6I+ 0 10days 6ri"homoniasis
115

Adults% PO 2;0m# 6I+ 0 :days or 2# in sin#le doseG do not re*eat treatment for 9-8 @ee?s A"tion Refra"tory 6ri"homoniasis Adults% PO 2;0m# 3I+ 0 10 days Ame$i" )e*ati" A$s"ess Adult% PO ;00-:;0 m# 6I+ 0 ;-10 days Intestinal Amoe$iasis Adult% PO :;0 m# 6I+ 0 ;-10 days -iardiasis

Adults% PO 2;0m# 6I+ 0 ; days !ffe"ti,e a#ainst anaero$i" $a"teria and *roto/oa& S*e"ifi"ally inhi$its #ro@th of tri"homonae and amoe$ae $y $indin# to +NA' resultin# in loss of heli"al stru"ture' strand $rea?a#e' inhi$ition of nu"lei" a"id synthesis' and "ell death& 6reatment of% ame$i" he*ati" a$s"ess' intestinal

Indi"ation

ame$iasis'

tri"homoniasis' refra"tory tri"homoniasis' $a"terial infe"tion "aused $y anaero$i" mi"roor#anism' inflammatory *a*ules and *ustules of a"ne rosa"ea' a"ti,e CrohnFs +isease' )& *ylori @ith *e*ti" ul"er Contraindi"ation disease' #iardiasis Contraindi"ated in *atients hy*ersensiti,e to the dru# or other nitroinida/ole deri,ati,es& =se "autiously in *atients re"ei,in# he*atoto0i" dru#s and *atients @ith history of $lood dys"rasias or CNS disorder' Side !ffe"ts retinal or ,isual field "han#es' he*ati" disease or al"oholsim CNS% heada"he' di//iness' *aresthesia' "onfusion' irrita$ility' restlessness' ata0ia' de*ression' fati#ue' dro@siness' insomnia' *eri*heral neuro*athy' in"oordination -I% nausea' anore0ia' "ram*s' ,omitin#' diarrhea' e*i#astri" distress' metalli" taste -=% dar?ened urine' *olyuria' dysuria' "ystitis' de"reased li$ido' in"ontinen"e Inte#umentary% rash' flushin#' urti"aria' *ruritus
116

C1% flat 6-@a,es !!N6% $lurred ,ision' sore throat' retinal edema' dry mouth' furry Ad,erse !ffe"ts ton#ue' stomatitis CNS% sei/ure -I% *seudomem$ranous "olitis -=% al$uminuria' ne*hroto0i"ity +ru# Intera"tions )ematolo#i"% leu"o*enia' $one marro@ de*ression' a*lasia Al"ohol% in"reased disulfiram-li?e rea"tion A/ithio*rine' fluoroura"il% in"reased lue?o*enia Cimetidine' metronida/ole Nursin# Res*onsi$ility Barfarin% in"reased a"tion of @arfarin 1& -i,e @ith or after a meal to a,oid -I sym*toms' metalli" tasteG "rush ta$lets if needed& 2& Store in li#ht resistant "ontainerG do not refri#erate& "hara"teristi" of @ounds& 9& Assess for aller#i" rea"tion& ;& Identify urine out*ut' also "he"? for in"reased 3=N' "reatinine 8& Assess $o@el *attern daily' if se,ere diarrhea o""urs' dru# should $e dis"ontinued& :& 6ea"h *atient to re*ort sore throat' $ruisin#' $leedin#' 7oint *ainG may indi"ate $lood dys"rasias <& Ad,i"e *atient to notify *hysi"ian of num$ness or tin#lin# of e0tremeties& 5& Inform *atient that dru# has a metalli" taste and urine may turn $la"?& 10& Ad,i"e *atient to use si*s of @ater' su#arless #um' "andy for dry mouth& 4& Assess *atient for si#ns and sym*toms of infe"tion in"ludin# Pheno$ar$ital' *henytoin% de"reased effe"t of

117

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose A"tion Indi"ation

Se*tem$er 1' 200; ?eto"ona/ole Ni/oral Imida/ole deri,ati,e' antifun#al Ni/oral 200m# 1ta$ O+ Adults% PO 200-900m# on"e daily for 1-2 @ee?s C"andidiasisD' 8 @ee?s Cfor other infe"tionsDG 900m# 6I+ CProstate Can"erD& Alters "ell mem$rane and inhi$its se,eral fun#al en/ymesG *re,ent *rodu"tion of adrenal sterolsG *re,ent fun#al meta$olism& 6reatment of "andidiasis Cdisseminated and mu"o"utaneousD' "hromomy"osis' "o""idioidomyosis' histo*lasmosis' *ara"o""idioidomyosis& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onents' and in those ta?in# oral mida/olam or tria/olam& =se "autiously in *atients @ith he*ati" disease' and in those
118

Contraindi"ation

Side !ffe"ts

ta?in# other he*atoto0i" dru#s& CNS% heada"he' di//iness' somnolen"e -I% nausea' anore0ia' a$dominal *ain' ,omitin#' diarrhea' -=% #yne"omastia' im*oten"e Inte#umentary% *ruritus' fe,er' "hills' *hoto*ho$ia' rash' dermatitis *ur*ura' urti"aria -I% he*atoto0i"ity )ematolo#i"% leu"o*enia' throm$o"yto*enia' hemolyti" anemia Systemi"% ana*hyla0is Rifam*i"in' rifa$utin' "ar$ama/e*ine' isonia/id' *henytoinG dru#s affe"tin# #astri" a"idity' ritona,ir& 6erfenadine' astemi/ole' "isa*ride' tria/olam' oral mida/olam' quinidine' *imo/ide and dru#s @ith a lo@ thera*euti" inde0& 1& -i,e in the *resen"e of a"id *rodu"ts onlyG do not use al?aline *rodu"ts' *roton *um* inhi$itors' )2 anta#onist or anta"ids @ithin 2hours of dru#& 2& Store in ti#ht "ontainer at room tem*erature& 4& -i,e @ith hydro"hloride if a"hlorhydria is *resent& 9& Assess for si#ns and sym*toms of infe"tion& ;& Monitor for he*atoto0i"ity' in"rease AS6' A 6' al?aline *hos*hatase' $iliru$inG dru# is dis"ontinued if he*atoto0i"ity o""urs& 8& Ad,i"e *atient that lon# term thera*y may $e needed to "lear infe"tion& :& Ad,i"e *atient to a,oid ha/ardous a"ti,ities if di//iness o""urs& <& Instru"t *atient to ta?e 2hours $efore administration of other dru#s that in"rease #astri" *)& 5& Stress the im*ortan"e of "om*lian"e @ith dru# re#imen& 10& Ad,i"e *atient to use sun#lasses to *re,ent *hoto*ho$ia&

Ad,erse !ffe"ts

+ru# Intera"tions

Nursin# Res*onsi$ility

119

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Au#ust 25' 200: a"etylsali"yli" a"id As*irin Non-steroidal anti-inflammatory dru#' anal#esi"' anti*yreti" As*ilet <0m# 1ta$ O+ Arthritis Adults% Initially 2&9- 4&8 #rams PO daily in di,ided doses& Maintenan"e dosa#e is 4&8 to ;&9 # PO daily in di,ided doses& Mild *ain or fe,er Adults% 42; to 8;0 m# PO or PR e,ery 9hours PRN& Pre,ention of throm$osis& Adults% 1&4 # PO daily in 2 to 9 di,ided doses& Redu"tion of MI ris? in *atients @ith *re,ious MI or unsta$le an#ina& Adults% 180 to 42; m# PO daily& -i,e dose immediately @hen a"ute "oronary syndrome is sus*e"ted& Pre,ention of reo""lusion in "oronary re,as"ulari/ation *ro"edures& Adults% 42; m# PO e,ery 8 hours after sur#ery and for 1 year& Pro*hyla0is for 6ransient Is"hemi" Atta"? Adults% ;0- 42; m# PO daily& Rheumati" Fe,er Adults% 9&5 to :&< # PO daily in di,ided doses e,ery 9 to 8 hours
120

for 1 to 2 @ee?s& A"tion Peri"arditis after a"ute MI

Adult% 180 to 42; m# PO daily& !0hi$its anti*yreti"' anti-inflammatory' and anal#esi" effe"ts& 6he anti*yreti" effe"ts are due to an a"tion on the hy*othalamus resultin# in heat loss and ,asodilation of *eri*heral $lood ,essels and *romotin# s@eatin#& 6he anti-inflammatory effe"ts are *ro$a$ly mediated throu#h inhi$ition of "y"lo-o0y#enase' @hi"h results in a de"rease in *rosta#landin synthesis and other mediators of *ain& Also *rodu"es inhi$ition of *latelet a##re#ation $y de"reasin# the synthesis of endo*ero0ides and throm$o0anes& Inflammatory disorders in"ludin#% Rheumatoid

Indi"ation

arthritis'

osteoarthritis& Mild to moderate *ain& Fe,er& As*irin% Pro*hyla0is of Contraindi"ation transient is"hemi" atta"?s and MI& Contraindi"ated in *atients hy*ersensiti,e to the dru# and those @ith -8P+ defi"ien"yG $leedin# disorders su"h as hemo*hilia' ,on Bille$rand disease' and telan#ie"tasiaG or NSAI+-indu"ed sensiti,ity =se "autiously in *atients @ith -I lesions' im*aired renal fun"tion' hy*o*rothrom$inemia' ,itamin ? defi"ien"y' throm$o"yto*enia' throm$oti" throm$o"yto*eni" *u*ura' or Side !ffe"ts se,ere he*ati" im*airment& CNS% stimulation' dro@siness' di//iness' "onfusion' heada"he' flushin#' hallu"inations C1% ra*id *ulse' *ulmonary edema !!N6% tinnitus' hearin# loss !ndo"rine% hy*o#ly"emia' hy*onatremia' hy*o?alemia -I% nausea' ,omitin#' diarrhea' heart$urn' anore0ia )ematolo#y% in"reased *ro-time' P66' $leedin# time Inte#umentary% rash' urti"aria' $ruisin# MS% "ram*s' myal#ia' *ain' stiffness Res*iratory% @hee/in#' hy*er*nea
121

Ad,erse !ffe"ts

CNS% sei/ures' "oma -I% -I $leedin#' he*atitis )ematolo#i"% throm$o"yto*enia' a#ranulo"ytosis' leu?o*enia' neutro*enia' hemolyti" anemia

+ru# Intera"tions

Systemi"% ana*hyla0is' laryn#eal edema Al"ohol' "efamandole' "lo*ido#rel' e*tifi$atide' he*arin' *li"amy"in' ti"lo*idine' tirofi$an% in"reased ris? of $leedin# Ammonium "hloride' ni/atidine% in"reased sali"ylate le,el Insulin' methotre0ate' *henytoin' ,al*roi" a"id' @arfarin% in"reased effe"ts of ea"h s*e"ifi" dru# Nitro#ly"erin% in"reased hy*otension PA3A% in"reased to0i" effe"ts Pro$ene"id% de"reased effe"ts of *ro$ene"id S*ironola"tone' sulfin*yra/one% de"reased effe"ts AC! Inhi$itors% de"reased antihy*ertensi,e effe"t Anta"ids' "orti"osteroid' steroids' urinary al?ali/ers% de"reased effe"ts of as*irin Anti"oa#ulant and throm$olyti"s% in"reased ris? of $leedin# Car$oni" Anhydrase Inhi$itors% in"reased to0i" effe"ts Peni"illin' +iureti"s Cloo* and $eta-$lo"?ersD% de"reased effe"t of ea"h s*e"ifi" dru#& NSAI+s% in"reased #astri" ul"ers Sali"ylates% de"reased $lood #lu"ose le,el =rinary A"idifiers% in"reased sali"ylate le,els 1& Assess for hy*ersensiti,ity to the dru#& 2& Assess for *ain $efore and 1 hour after administration& 4& Assess for ototo0i"ity% tinnitus' rin#in#' roarin# in ears 9& Assess for ,isual "han#es% $lurrin#' halos and "orneal and retinal dama#e ;& Monitor li,er fun"tion or he*atoto0i"ity 8& Instru"t *atient not to e0"eed re"ommended dosa#e $e"ause of the dan#er of a"ute *oisonin#&
122

Nursin# Res*onsi$ility

:& Instru"t *atient to ta?e @ater and seat u*ri#ht for 40 minutes to fa"ilitate *assin# into the stoma"h% a,oid if aller#i" to tartra/ine and dis"ard ta$lets @ith ,ine#ar li?esmen& <& Ad,i"e the *atient of the *ossi$ility for aller#i" rea"tions in *atient @ith other aller#ies' nasal *oly*s and asthma& 5& Re*ort hy*er,entilation' ,isual "han#es and $leedin#& 10& Inform *atient that the thera*euti" res*onse ta?es 2 @ee?s CarthritisDG #i,e half hour $efore *lanned e0er"ise&

+ate Ordered -eneri" Name 3rand Name

Au#ust 25' 200: #li$en"lamide !u#lu"on

123

Classifi"ation Ordered +ose Su##ested +ose

Antidia$eti" -li$en"lamide ;m# 1 ta$ 40minutes $efore $rea?fast Adults% Initially 1&2; to ;m# re#ular ta$lets PO on"e daily @ith $rea?fast& For maintenan"e' 1&2; to 20m# daily as sin#le dose or in di,ided doses& Causes fun"tionin# $eta-"ells in *an"reas to release insulin' leadin# to dro* in $lood #lu"ose le,elsG may im*ro,e insulin $indin# to insulin re"e*tors and in"rease num$er of insulin re"e*tors @ith *rolon#ed administrationG may also redu"e $asal he*ati" #lu"ose se"retionG not effe"ti,e if *atient la"?s fun"tionin# $eta-"ells& Ad7un"t to diet to lo@er #lu"ose le,el in *atients @ith ty*e 2 dia$etes mellitus Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onentsG in those @ith dia$eti" ?etoa"idosis' and in those @ith aller#ies to sulfonamides or thia/ide diureti"s& =se "autiously in *atients @ith he*ati" or renal im*airment and in de$ilitated or malnourished *atients& C1% fa"ial flushin# -I% e*i#astri" fullness' heart$urn' nausea )e*ati"% "holestati" 7aundi"e S?in% Puritus' rash )ematolo#i"% a#ranulo"ytosis' a*lasti" anemia' throm$o"yto*enia Meta$oli"% )y*o#ly"emia Ana$oli" steroids' "hloram*heni"ol' "lofi$rate' #uanethidine' MAOI' *hnyl$uta/one' sali"ylates' sulfonamides% may in"rease hy*o#ly"emi" a"ti,ity& Monitor #lu"ose le,el& 3eta-$lo"?ers% may *rolon# hy*o#ly"emi" effe"t and mas? sym*toms of hy*o#ly"emia& =se to#ether "autiously& Corti"osteroids' #lu"a#on' rifam*in' thia/ide' diureti"s% may de"rease hy*o#ly"emi" res*onse& Monitor #lu"ose le,el& )ydantoin% May in"rease hydantoin le,elG monitor le,el& Oral Anti"oa#ulants% May in"rease hy*o#ly"emi" a"ti,ity or enhan"e anti"oa#ulant effe"t& Monitor #lu"ose le,el P6' and INR& 1& Althou#h most *atients ta?e dru# on"e daily' *atient ta?in#
124

A"tion

Indi"ation Contraindi"ation

Side !ffe"ts

Ad,erse !ffe"ts +ru# Intera"tions

Nursin# Res*onsi$ility

more than 10m# daily may a"hie,e $etter results @ith t@i"edaily dosa#e& 2& +onFt "onfuse #ly$uride @ith #li*i/ide a**ro*riate& 9& 6ea"h *atient a$out dia$etes and the im*ortan"e of follo@in# thera*euti" re#imen $y adherin# to s*e"ifi" diet' @ei#ht redu"tion' e0er"ise and *ersonal hy#iene *ro#rams& ;& !0*lain ho@ to monitor #lu"ose le,els and re"o#ni/e and treat hy*o#ly"emia and hy*er#ly"emia& 8& 6ell *atient not to "han#e dosa#e @ithout *res"ri$erFs "onsent and to re*ort any ad,erse rea"tion& :& Ad,ise *atient not to ta?e O6C dru#s or her$al remedies @ithout first "he"?in# @ith *res"ri$er& <& 6ea"h *atient to ta?e dru# in AM to *re,ent hy*o#ly"emi" rea"tions at ni#ht& 5& 6ea"h *atient that dia$etes mellitus is a life-lon# illnessG that this dru# is not a "ure& 10& Instru"t *atient that all food in"luded in the diet *lan must $e +ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose eaten to *re,ent hy*o#ly"emia& Au#ust 25' 200: amo0"illin Au#mentin Anti$ioti"' *eni"illin Amo0i"illin 100m# 1"a* 6I+ 0 1@? Renal +isease Adults% PO CCr 10-1;ml *er minute e,ery 12 hoursG CCr less than 10ml *er minute dose 29hours& Systemi" Infe"tions Adults% PO :;0m# to 1&; # daily in di,ided doses e,ery <hours& -onorrhea or =6I Adults% PO 4# #i,en @ith 1# *ro$ene"id as sin#le doseG
125

4& Ma?e sure that and7un"t thera*y' su"h as diet and e0er"ise' is

follo@ed $y tetra"y"line or erythromy"in Chlamydia tra"homatis Adults% PO ;00 m# *er day 0 1@ee? )eli"o$a"ter *ylori Adults% PO 1000m# 3I+ #i,en @ith lan/o*ra/ole 40m# 3I+' "larithromy"in ;00m# 3I+ 0 2@ee?sG or 1000m# 3I+ #i,en @ith ome*ra/ole 20m# 3I+' "larithromyi"n ;00m# 3I+ 0 2 @ee?sG or 1000m# 6I+ #i,en @ith lan/o*ra/ole 40m# 6I+ 0 A"tion 2@ee?s& Interferes @ith "ell @all re*li"ation of sus"e*ti$le or#anism $y $indin# to the $a"terial "ell @allG the "ell @all' rendered osmoti"ally Indi"ation unsta$le' s@ells and $urst from osmoti" *ressure& 6reatment of% s?in and s?in stru"ture infe"tions' otitis media' sinusitis' res*iratory infe"tions' #enitourinary infe"tions& !ndo"arditis *ro*hyla0is& Contraindi"ation Post-e0*osure inhalational anthra0 *ro*hyla0is& Mana#ement of ul"er disease due to )& *ylori& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onents A,oid to *atients @ith *henyl?etonuria& =se "autiously in se,ere renal insuffi"ien"y then infe"tious mononu"leosis' a"ute lym*ho"yti" leu?emia& Side !ffe"ts Patients @ith history of "e*halos*orin aller#y& -I% diarrhea' nausea' ,omitin#' ele,ated li,er en/ymes& )ematolo#y% $lood dys"rasias Inte#umentary% rashes and urti"aria Ad,erse !ffe"ts Mis"ellaneous% aller#i" rea"tions and su*erinfe"tion CNS% sei/ures -I% *seudomem$ranous "olitis +ru# Intera"tions Mis"ellaneous% ana*hyla0is and serum si"?ness Pro$ene"id% in"reased amo0i"illin le,els' de"reased renal e0"retion Barfarin% in"reased anti"oa#ulant effe"ts Nursin# Res*onsi$ility Allo*urinol% may in"rease frequen"y of rash 1& Assess for infe"tion&
126

2& Assess for history of *eni"illin sensiti,ity& 4& Assess for $o@el *atterns& 9& Assess for si#ns of dehydration% if se,ere diarrhea o""urs dru# should $e dis"ontinued& ;& Monitor for $leedin#% e""hymosis' $leedin# #ums and hematuria& 8& Instru"t *atient to ta?e medi"ation around the "lo"? and to finish the dru# "om*letely as dire"ted& :& Ad,i"e to re*ort si#ns of su*erinfe"tion& <& Instru"t *atient to ta?e entire quantity of dru# and not to dou$le dose& 5& 6ea"h *atient to re*ort sore throat' $ruisin#' $leedin#' 7oin *ain and $loody diarrhea& 10& Instru"t *atient to use soft-$ristled tooth$rush&

127

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

(anuary ;' 200< a"etamino*hen Para"etamol Non-nar"oti" anal#esi" Para"etamol ;00m# e,ery 9 hours for fe,er Mild Pain or fe,er& Adults% #i,e 42; to 8;0 m# PO or PR e,ery 9 hours PRN or 1# PO 6I+ or .I+ PRN Mild *ain or fe,er& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onents =se "autiously in *atients @ith history of "hroni" al"ohol a$use $e"ause ha*toto0i"ity may o""ur after thera*euti" doses& CNS% stimulation and dro@siness -I% nausea' ,omitin#' a$dominal *ain Inte#umentary% rash and urti"aria -I% )e*atoto0i"ity and he*ati" sei/ure -=% Renal Failure )ematolo#i"% eu?o*enia' neutro*enia' hemolyti" anemia' throm$o"yto*enia' *an"yto*enia Systemi"% hy*ersensiti,ity 6o0i"ity% "yanosis' anemia' neutro*eina' 7aundi"e' *an"yto*enia' CNS stimulation delirium follo@ed $y ,as"ular "olla*se' "on,ulsions' "oma' death Al"ohol' "ar$ama/e*ine' difloni/al' isonia/id' rifa$utin' rifam*in' suilfin*yra/one% in"reased he*atoto0i"ityG de"reased effe"t Cholesti*ol' "holestyramine% de"reased a$sor*tion of a"etamino*hen
128

Indi"ation Contraindi"ation

Side !ffe"ts

Ad,erse !ffe"ts

+ru# Intera"tions

Nursin# Res*onsi$ility

Barfarin% )y*o*rothrom$inemia 1& Assess *atientFs fe,er or *ain& 2& Assess aller#i" rea"tion& 4& Assess he*atoto0i"ity& 9& Monitor li,er and renal fun"tions& ;& Che"? I and O ratio& 8& Assess for "hroni" *oisonin#& :& -i,e @ith food or mil? to de"rease #astri" sym*toms& <& -i,e 40minutes $efore or 2 hours after meals 5& 6ea"h *atient to re"o#ni/e si#ns of "hroni" o,erdose% $leedin#' $ruisin#' malaise' fe,er' sore throat& 10& 6ell *atient to notify *res"ri$er for *ain or fe,er lastin# for more than 4 days&

+ate Ordered -eneri" Name

Mar"h 9' 200< losartan

129

3rand Name Classifi"ation Ordered +ose Su##ested +ose

Co/aar Antihy*ertensi,e' an#iotensin II re"e*tor anta#onist losartan 100 m# 1ta$ on"e a day Ne*hro*athy in ty*e 2 dia$etes mellitus Adults% ;0m# P&O& daily& In"rease dose to 100 m# daily $ased on $lood *ressure res*onse& )y*ertension Adults% Initially' 2; to ;0 m# P&O& daily& Ma0imum' 100m# daily in one or t@o di,ided doses& 6o redu"e ris? of stro?e in *atients @ith hy*ertension and left ,entri"ular hy*ertro*hy& Adults% Initially' ;0 m# P&O& on"e daily& Ad7ust dosa#e $ased on $lood *ressure res*onse' addin# hydro"hlorothia/ide 12&; m# on"e daily' in"reasin# losartan to 100m# daily' or $oth& If further ad7ustments are needed' may in"rease the daily dose of hydro"hlorothia/ide to 2;m#& Com*etiti,ely $lo"?s the an#iotensin A61 re"e*tor lo"ated in ,as"ular smooth mus"le and the adrenal #lands' thus $lo"?in# the ,aso"onstri"tor and aldosterone-se"retin# effe"ts of an#iotensin II Ca *otent ,aso"onstri"torD& 6hus' 3P is redu"ed& )y*ertension' alone or in "om$inationG ne*hro*athy in ty*e 2 dia$etes' hy*ertension @ith left ,entri"ular hy*ertro*hy& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onents =se "autiously in *atients @ith im*aired ?idney or li,er

A"tion

Indi"ation Contraindi"ation

Side !ffe"ts

fun"tion and in ,olume-de*leted' hy*otensi,e *atients& CNS% di//iness' insomnia' an0iety' "onfusion' a$normal dreams' mi#raine' tremor' ,erti#o' heada"he C1% an#ina *e"toris' 2nd de#ree A1 $lo"? C1A% hy*otension !!N6% $lurred ,ision' $urnin# eyes' "on7un"ti,itis -I% diarrhea' dys*e*sia' anore0ia' "onsti*ation' dry mouth' flatulen"e' #astritis' ,omitin#
130

-=% im*oten"e' no"turia' urinary frequen"y' urinary tra"t infe"tion )ematolo#y% Anemia Inte#umentary% Meta$oli"% -out MS% "ram*s' myal#ia' *ain' stiffness Res*iratory% "ou#h' u**er res*iratory infe"tion' "on#estion' dys*nea' Ad,erse !ffe"ts $ron"hitis C1A% Myo"ardial infar"tion' dysrhythmias -=% renal failure +ru# Intera"tions Inte#umentary% an#ioedema Flu"ona/ole% in"reased antihy*ertensi,e effe"t ithium% in"reased to0i"ity Pheno$ar$ital' rifamy"in% de"reased antihy*ertensi,e effe"t A"onite% in"reased to0i"ity' death Astra#alus' "ola tree% in"reased or de"reased antihy*ertensi,e effe"t 3ar$erry' $etony' $la"? "ate"hu' $la"? "ohosh' $loodroot' $room' $urdo"?' "atFs "la@' dandelion' #oldenseal' Irish moss' (amai"an do#@ood' ?el*' ?hella' mistletoe' *arsley% in"reased antihy*ertensi,e effe"t Nursin# Res*onsi$ility Coltsfoot' #uarana' ?hat' li"ori"e% de"reased antihy*ertensi,e effe"t 11& Assess 3P @ith *osition "han#es' *ulse e,ery 9 hoursG note rate' rhythm' quality& 12& Monitor ele"trolytes% *otassium' sodium "hloride& 14& O$tain $aselines for renal' li,er fun"tion tests $efore thera*y $e#ins& 19& Monitor for edema in feet' le#s daily& 1;& Assess for s?in tur#or' dryness of mu"ous mem$ranes for hydration status& 18& Administer @ithout re#ard to meals& 1:& 6ea"h *atient to a,oid sunli#ht or @ear suns"reen if sunli#htG *hotosensiti,ity may o""ur&
131

alo*e"ia'

dermatitis'

dry

s?in'

flushin#'

*hotosensiti,ity' rash' *ruritus' s@eatin#

1<& Ad,ise *atient to "om*ly @ith dosa#e s"hedule' e,en if feelin# $etter& 15& 6ea"h *atient to notify *res"ri$er of mouth sores' fe,er' s@ellin# of hands or feet' irre#ular heart$eat' "hest *ain& 20& Ad,ise *atient that e0"essi,e *ers*iration' dehydration' ,omitin#' diarrhea may lead to fall in $lood *ressure' "onsult *res"ri$er if these o""ur& 21& Inform *atient that dru# may "ause di//iness' faintin#G li#htheadedness may o""ur& 22& Caution *atient to rise slo@ly to sittin# or standin# *osition to minimi/e orthostati" hy*otension&

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Mar"h 9' 200< #li"la/ide -lu$itor Oral Antidia$eti" A#ent -lu$itor <0 m# 1 ta$ on"e a day 6he usual initial dose is 90-<0 m# daily& +oses more than 180 m# daily are #i,en in di,ided doses& Ad7ust dose a""ordin# to *atientFs indi,idual res*onse& Stimulates insulin release from *an"reati" $eta- "ells Non- insulin de*endent dia$etes mellitus 6y*e 1 dia$etesG dia$etes "om*li"ated @ith ?etosis and a"idosisG dia$eti"s under#oin# sur#eryG hy*ersensiti,ity to sulfonylureas and related dru#s& )y*o#ly"emia'

A"tion Indi"ation Contraindi"ation

Ad,erse !ffe"ts

-I

distur$an"es'

dermatolo#i"al

rea"tions'
132

$io"hemi"al a$normalities' heada"he' sli#ht disulfiram-li?e rea"tions'

+ru# Intera"tions

lassitude Insulin' al*ha-#lu"osidase

inhi$itors'

*yra/olones'

*ro$ene"id'

"oumarin' sali"ylates' $eta-$lo"?er& MAOIs' dihydroer#otamine' "hloram*heni"ol' tetra"y"line' "lofi$rate' e*ine*hrine' adreno"orti"al a#ents' thyroid and folli"le hormones' diureti"s' PYA' IN)' ni"otini" Nursin# Res*onsi$ility a"id' *henothia/ines& Sulfonylureas& 1& +ru# is #i,en $y oral administration& 2& +ru# should $e ta?en *refera$ly @ith meals& 4& Assess for hy*o#ly"emi"O hy*er#ly"emi" rea"tions& 9& Assess for hy*ersensiti,ity of the *atient to medi"ation& ;& Ad,ise *atient that medi"ation is "ontraindi"ated to unsta$le andOor insulin de*endent dia$etes mellitus' ?etoa"idosi' "omaG durin# stress "onditions su"h as serious infe"tion' trauma or sur#eryG in the *resen"e of li,er disease or renal im*airment& 8& Inform *atient that treatment is a su**lement to *ro*er dietary re#imen and not as a su$stitute for diet& :& Ad,ise *atient to inform the *hysi"ian if a loss of adequate $lood #lu"ose-lo@erin# res*onse to #li"la/ide is dete"tedG dru# should $e dis"ontinued& <& Inform *atients of manifestations of hy*o#ly"emia in"ludin# di//iness' la"? of ener#y' dro@siness' heada"he' s@eatin# and @ea?ness' ner,ousness' sha?iness and *aresthesia& 5& Inform *atient that hy*o#ly"emia is more li?ely to o""ur @hen "alori" inta?e is inadequate or after strenuous or *rolon#ed *hysi"al e0er"ise& 10& Inform *atient of dru#s that may indu"e hy*er#ly"emia and may lead to loss of "ontrol of $lood su#ar "ontrolG these in"lude diureti"s Chydro"hlorothia/ide' furosemideD' "orti"osteroids and ni"otini" a"id in *harma"olo#i" doses&

133

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Mar"h 9' 200< metformin Fortamet Antidia$eti"' oralG $i#uanide Metformin ;00m# 1ta$ 6I+ Adult% PO ;00m# 3I+ initially' then in"rease to desired res*onse 1-2 #G dosa#e ad7ustment e,ery 2-4 @ee?s or <;0m# daily @ith mornin# meal @ith dosa#e in"reased e,ery other @ee?' ma0 2;00m#OdayG e0tended release ma0imum of 2000m#Oday Inhi$its he*ati" #lu"ose *rodu"tion and in"reases sensiti,ity of *eri*heral tissue to insulin& Mana#ement of ty*e 2 dia$etes mellitusG may $e used @ith diet' insulin' or sulfonylurea oral hy*o#ly"emi"s& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onentsG those @ith he*ati" disease' renal dysfun"tion' or a"ute or "hroni" meta$oli" a"idosisG and in heart failure *atients @ho need other dru#s& 6em*orarily @ithhold dru# in *atients under#oin# radiolo#i" studies in,ol,in# *arenteral administration or iodinated "ontrast materialsG usin# su"h *rodu"ts may result in a"ute or renal dysfun"tion& If *atient enters hy*o0i" state' sto* dru#& =se "autiously in de$ilitated or malnourished *atients and in
134

A"tion Indi"ation Contraindi"ation

those @ith adrenal or *ituitary insuffi"ien"y $e"ause of Side !ffe"ts in"reased ris? of hy*o#ly"emia& CNS% heada"he' @ea?ness' di//iness' dro@siness' tinnitus' fati#ue' ,erti#o' a#itation !ndo"rine% hy*o#ly"emia -I% nausea' ,omitin#' diarrhea' heart$urn' anore0ia' metalli" taste )ematolo#y% de"reased ,itamin 312 le,els Ad,erse !ffe"ts +ru# Intera"tions Inte#umentary% rash !ndo"rine% la"ti" a"idosis )ematolo#i"% throm$o"yto*enia Cal"ium Channel 3lo"?ers' "orti"osteroids' estro#ens' hormonal "ontra"e*ti,es' isonia/id' ni"otini" a"id' *henothia/ines' *henytoin' sym*athomimeti"s' thia/ide' and other diureti"s' thyroid dru#s% may "ause hy*er#ly"emia& Monitor *atientF#ly"emi" "ontrol& In"rease metformin dosa#e& Cationi" +ur#s Csu"h as amiloride' "imetidine' di#o0in' mor*hine' *ro"ainamide' quinidine' quinine' ranitidine' triamterene' trimetho*rim' ,an"omy"inD% May redu"e metformin "learan"e and in"rease metformin le,el& Monitor *atientFs #lu"ose le,el& Ad7ust Nursin# Res*onsi$ility doses' of needed& 1& +o not $rea?' "rush or "he@ e0tended release ta$lets& 2& Con,ersion from other oral hy*o#ly"emi" a#entsG "han#e may $e made @ithout #radual dosa#e "han#eG monitor serum or urine #lu"ose and ?etones 6I+ durin# "on,ersion& 4& -i,e t@i"e a day @ith meals to de"rease -I u*set and *ro,ide $est a$sor*tion' may also $e ta?en as sin#le dose& 9& -i,e in AM to *re,ent hy*o#ly"emi" rea"tions in PM& ;& Store in ti#ht "ontainer in "ool en,ironment& 8& Assess for hy*o#ly"emi" rea"tions' hy*er#ly"emi" rea"tions soon after meals& :& Monitor for la"ti" a"idosis% malaise' myal#ia' a$dominal distressG ris? in"reases @ith a#e' *oor renal fun"tionG monitor
135

ele"trolytes' la"tate' *yru,ate' $lood *)' ?etones' #lu"ose& <& 6ea"h *atient sym*toms of hy*oOhy*er#ly"emia' @hat to do a$out ea"h& 5& Ad,ise *atients that dru# must $e "ontinued on daily $asisG e0*lain "onsequen"e of dis"ontinuin# dru# a$ru*tly& 10& Ad,ise *atient to a,oid O6C medi"ations unless a**ro,ed $y the *res"ri$er& 11& 6ea"h *atient that all food in"luded in diet *lan must $e eaten to *re,ent hy*o#ly"emia&

136

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Mar"h 9' 200< nifedi*ine Adalat' Pro"ardia Cal"ium Channel 3lo"?er Nifedi*ine 40m# 1ta$ on"e a day 1asos*asti" an#ina Adults% Initially' 10m# Cshort-a"tin# "a*sulesD P&O& 6I+& =sual effe"ti,e dosa#e ran#e is 10 to 20m# 6I+& Some *atients may require u* to 40m# .I+& Ma0imum daily dose is 1<0m#& Ad7ust dosa#e o,er : to 19 days to e,aluate res*onse& Or' 40 to 80m# Ce0tended- release ta$lets' e0"e*t Adalat CCD P&O& on"e daily& Ma0imum daily dose is 120m#& Ad7ust dosa#e o,er : to 19 days to e,aluate res*onse& )y*ertension Adults% 40 or 80 m# P&O& Ce0tended-releaseD on"e daily& Ad7usted o,er : to 19 days& +oses lar#er than 50m# CAdalat CCD and 120m# CPro"ardia P D arenFt re"ommended& Inhi$its "al"ium trans*ort into myo"ardial and ,as"ular smooth mus"le "ells' resultin# in inhi$ition of e0"itation- "ontra"tion "ou*lin# and su$sequent "ontra"tion& Systemi" ,asodilation' resultin# in de"reased $lood *ressure& Coronary ,asodilation' resultin# in de"reased frequen"y and se,erity of atta"?s of an#ina& Mana#ement of% )y*ertension' An#ina *e"toris' 1asos*asti" an#ina& =nla$eled use% Pre,ention of mi#raine heada"he& Mana#ement of C)F or "ardiomyo*athy& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onents& =se "autiously in those @ith heart failure or hy*otension& =se e0tended-release ta$lets "autiously in *atients @ith se,ere -I

A"tion

Indi"ation

Contraindi"ation

Side !ffe"ts

narro@in# $e"ause o$stru"ti,e sym*toms may o""ur& CNS% heada"he' fati#ue' dro@siness' di//iness' an0iety' de*ression' @ea?ness' insomnia' li#htheadedness' *aresthesia' tinnitus' $lurred ,ision' ner,ousness' tremors
137

C1% flushin#' hy*otension' *al*itations' *eri*heral edema !!N6% nasal "on#estion -I% a$dominal dis"omfort' "onsti*ation' diarrhea' nausea& -=% no"turia' *olyuria Inte#umentary% rash' *ruritus' flushin#' hair loss MS% mus"le "ram*s Ad,erse !ffe"ts Res*iratory% "ou#h' dys*nea C1A% Myo"ardial infar"tion' dysrhythmias' heart failure -I% he*atoto0i"ity Meta$oli"% )y*o?alemia +ru# Intera"tions Res*iratory% Pulmonary edema Car$ama/e*ine' "imetidine' "y"los*orine' *henytoin' *ra/osin' ranitidine% in"reased ris? of to0i"ity +i#o0in% in"reased di#o0in le,els' $rady"ardia' C)F .uinidine% de"reased effe"ts Smo?in#% de"reased nifedi*ine le,el Antihy*ertensi,es' $eta-adrener#i" $lo"?ers% in"reased effe"ts NSAI+s% de"reased antihy*ertensi,e effe"ts 3ar$erry' $etel *alm& 3urdo"?' #oldenseal' ?hat' ?hella' lily of the ,alley' *laintain% in"reased effe"t 2ohim$e% de"reased effe"t Nursin# Res*onsi$ility -ra*efruit 7ui"e% in"reased nifedi*ine le,el 1& +o not e0"eed a sin#le dose of 40m#& 2& 3efore in"reasin# dose' "arefully monitor 3P& 4& No re$ound effe"t @hen nifedi*ine dis"ontinued& If dru# to $e dis"ontinued' de"rease dosa#e #radually @ith su*er,ision& 9& Food may de"rease rate $ut e0tent of a$sor*tionG "an $e ta?en @ithout re#ard to meals& ;& Maintain fluid inta?e of 2-4 liters *er day to a,oid "onsti*ation& No "aused for "on"ern if a ta$let "oatin# a**ears in the stool& 8& A,oid a"ti,ities that require mental alertness until dru# effe"ts
138

reali/edG may "ause di//iness or li#htheadedness& :& May ta?e @ith or @ithout food& Should not $e "he@ed' "rushed or di,ided& <& !n"oura#e *atient to re*ort *ersistent heada"he' flushin#' nausea' *al*itations' @ei#ht #ain' di//iness' rash' and la"? of res*onse& 5& 3rush teeth and floss re#ularly to redu"e s@ellin# and tenderness of #ums& 10& Hee* lo# of 3Ps& Perform @ee?ly @ei#hts' note any e0tremeties s@ellin#& 6his may result from arterial ,asodilation *re"i*itated $y nifedi*ine' or the s@ellin# may indi"ate in"reasin# ,entri"ular dysfun"tion and should $e re*orted&

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

Mar"h 9' 200< meto"lo*ramide Plasil -astrointestinal Stimulant Plasil 10m# 1ta$ e,ery < hours for ,omitin# Plasil 1am* for fe@er ,omitin# e,ery < hours 6o *re,ent or redu"e nausea and ,omitin# indu"ed $y "is*latine alone or @ithout other "hemothera*euti"s& Adults% 1-2 m#O?# I1 40 minutes $efore "hemothera*y& 6hen re*eat 2 hours for 2 dosesG e,ery 4 hours for 2 doses& 6o fa"ilitate small $o@el or u**er -I intu$ation and aid in radiolo#i" e0aminations& Adults and "hildren older than a#e 19% -i,e 10m# I1 as sin#le
139

dose o,er 1-2 minutes& +elayed #astri" em*tyin# "aused $y dia$eti" #astro*aresis Adults% 10m# P&O& for mild sym*tomsG slo@ I1 infusion for se,ere sym*toms 40 minutes $efore meals and at $edtime for 2 to < @ee?s de*endin# on res*onse& -!R+ Adults% 10- 1; m# P&O& .I+ PRN 40 minutes $efore meals and A"tion at $edtime& !nhan"es res*onse to a"etyl"holine of tissue in u**er -I tra"t @hi"h "auses "ontra"tion of #astri" mus"les' rela0es *ylori"' duodenal se#ments' in"rease *eristalsis @ithout stimulatin# se"retions' $lo"? Indi"ation do*amine in "hemore"e*tor tri##er /one of CNS& Pre,ention of "hemothera*y indu"ed emesis& 6reatment of *ostsur#i"al and dia$eti" #astri" stasis& Fa"ilitation of small $o@el intu$ation in radio#ra*hi" *ro"edures& Mana#ement of -!R+& 6reatment and *re,ention of *ost-o*erati,e nausea and ,omitin# @hen naso#astri" su"tionin# is undesira$le& =nla$eled use% 6reatment Contraindi"ation for hi""u*s& Ad7un"t mana#ement of mi#raine heada"hes& Contraindi"ated in *atients hy*ersensiti,e to the dru# or any of its "om*onentsG *atient aller#i" to *ro"ainamide& Side !ffe"ts Contraindi"ated in *atients ta?in# dru#s that are li?ely to "ause !PS& In *atient for @hom stimulation of -I motility mi#ht $e dan#erous& In *atient @ith *heo"hromo"ytoma or sei/ure disorder& =se "autiously in *atients @ith history of de*ression'

Par?insonFs disease' hy*ertension or renal im*airment& CNS% sedation' fati#ue' restlessness' heada"he' slee*lessness' dystonia' di//iness' dro@siness' sym*toms of !PS C1% hy*otension -I% dry mouth' "onsti*ation' nausea and anore0ia' ,omitin#' diarrhea -=% de"reased li$ido
140

Ad,erse !ffe"ts

Inte#umentary% urti"aria' rash CNS% sui"ide ideation' sei/ure C1% su*ra,entri"ular ta"hy"ardia )ematolo#i"% neutro*enia' lue?o*enia' a#ranulo"ytosis& A"etamino*hen' as*irin' "y"los*orine' dia/e*am' le,odo*a' lithium' tetra"y"line% may in"rease a$sor*tion of these dru#s& Monitor *atient for ad,erse effe"ts& Anti"holiner#i"s and o*oiod anal#esi"s% may anta#oni/e -I motility effe"ts of meto"lo*ramide& =se to#ether "autiously& CNS de*ressant% may "ause additi,e CNS de*ression& A,oid use to#ether& +i#o0in% may de"rease a$sor*tion of di#o0in& Monitor di#o0in le,els& Insulin% May influen"e the rate of food a$sor*tion& Ad7ust insulin dosa#e if needed& 1& After PO use' a$sor*tion of "ertain dru#s from the -I tra"t may $e affe"ted& 2& In7e"t slo@ly I1 o,er 1-2 minutes to *re,ent transient feelin#s of an0iety and restlessness& 4& Assess a$domen for $o@el sounds and distention' nausea and ,omitin#& 9& Assess *atient for si#ns of de*ression *eriodi"ally throu#hout the thera*y& ;& A,oid CNS de*ressant& 8& Monitor for tardi,e dys?inesia& :& Monitor neurole*ti" mali#nant syndrome& <& !0tra*yramidal effe"ts should $e re*ortedG may $e treated @ith *arenteral di*henhydramine& 5& +ystoni" rea"tions may o""ur @ithin minutes of I1 infusion and sto* @ithin 29 hours after dis"ontinuation of meto"lo*ramide& 10& Ad,i"e *atient to notify *res"ri$er if in,oluntary mo,ements o""ur&
141

+ru# Intera"tions

Nursin# Res*onsi$ility

+ate Ordered -eneri" Name 3rand Name Classifi"ation Ordered +ose Su##ested +ose

A*ril 4' 200< "a*to*ril Ca*oten Antihy*ertensi,e' AC! Inhi$itor Ca*to*ril 2;m# 1ta$ e,ery 12 hours Mali#nant hy*ertension Adult% PO 2;m# in"reasin# q 2hours until desired res*onseG not to e0"eed 2;0m# Oday )y*ertension Adult% Initial dose% PO 2;m# 3I+ L 6I+G may in"rease to ;0m# 3I+-6I+ at 1-2 @ee? inter,alsG usual ran#e 2;-1;0 m# 3I+6I+G ma0imum of 9;0m# C)F Adult% PO 12&;m# 3I+- 6I+G may in"rease to ;0 m# 3I+- 6I+G after 19 days may in"rease to 1;0 m# 6I+ if needed 1+ after MI Adult% PO ;0m# 6I+' may $e#in treatment 4days after MIG #i,e 8&2; m# as a sin#le dose' then 12&; m# 6I+' in"rease to 2;m# 6I+ for se,eral days' then ;0 m# 6I+ +ia$eti" ne*hro*athy Adult% PO 2;m# 6I+ Renal +ose

A"tion

Adult% PO 8&2;- 12&; m# 3I+- 6I+ Inhi$its an#iotensin- "on,ertin# en/yme resultin# in de"reased
142

*lasma an#iotensin II' @hi"h leads to de"reased ,aso*ressor a"ti,ity Indi"ation Contraindi"ation and de"reased aldosterone se"retion& 6reatment of% hy*ertension' heart failure' dia$eti" ne*hro*athy and left ,entri"ular dysfun"tion after MI& Contraindi"ated in *atients hy*ersensiti,e to the dru# or other AC! inhi$itors =se "autiously in *atients @ith renal im*airment or serious autoimmune disease *arti"ularly S !' and in *atients e0*osed to other dru#s ?no@n to affe"t B3C "ounts or immune Side !ffe"ts res*onse& CNS% fe,er and "hills C1%hy*otension' *ostural hy*otension' ta"hy"ardia' an#ina -I% loss of taste and li,er fun"tion test -=% im*oten"e' dysuria' no"turia' *olyuria' oli#uria' frequen"y )ematolo#i"% anemia Inte#umentary% rash' Mis"ellaneous% hy*er?alemia Ad,erse !ffe"ts Res*iratory% dys*nea and "ou#h -=% *roteinuria' ne*hroti" syndrome' a"ute re,ersi$le renal failure )ematolo#i"% throm$o"yto*enia Mis"ellaneous% an#ioedema +ru# Intera"tions Res*iratory% 3ron"hos*asm Al"ohol% in"reased hy*otension +i#o0in' lithium% in"reased serum le,els' to0i"ity Nursin# Res*onsi$ility Insulin% in"reased hy*o#ly"emia 1& -i,e in the *resen"e of a"id *rodu"ts onlyG do not use al?aline *rodu"ts' *roton *um* inhi$itors' )2 anta#onist or anta"ids @ithin 2hours of dru#& 2& 4& Store in air ti#ht "ontainer at 40 C0 or less& May "rush ta$let and dissol,e in @ater' #i,e @ithin V hour' ma?e sure ta$let is "om*letely dissol,ed& 9& Se,ere hy*otension may o""ur after 1st dose of this
143

neutro*enia'

a#ranulo"ytosis'

*an"yto*enia'

medi"ationG de"reasin# hy*otension may $e *re,ented $y redu"in# or dis"ontinuin# diureti" thera*y 4 days $efore $e#innin# Ca*to*ril thera*y& ;& Monitor $lood studies& 8& Monitor 3P' "he"? for orthostati" hy*otension' syn"o*eG if "han#es o""ur' dosa#e "han#e may $e required& :& Assess for aller#i" rea"tions& <& Caution *atient not to dis"ontinue dru# a$ru*tlyG ad,i"e *atient to tell *ersons asso"iated @ith "are& 5& 6ea"h *atient im*ortan"e of "om*lyin# @ith dosa#e s"hedule' e,en if feelin# $etterG to "ontinue @ith medi"al re#imen to de"rease 3P& 10& Caution *atient to re*ort e0"essi,e *ers*iration' dehydration' ,omitin#' diarrheaG may lead to fall in 3P&

+ate Ordered -eneri" Name 3rand Name

+e"em$er 40' 200< flu*enti0ol Fluan0ol

144

Classifi"ation Ordered +ose Su##ested +ose

Anti*sy"hoti" Flu*enti0ol de"oanate 1"" 1month e,ery 40 days For treatment of mild to moderate de*ression @ith or @ithout an0iety#i,en $y mouth 0&; to 1m#% initially 0&;m# t@o times a day' then 0&; to 4 m# daily& Ma0imum% 4m# daily& S"hi/o*hrenia and allied *sy"hosis% 20-90 m# IM e,ery 2-9 @ee?s& S*e"ifi"ally anta#oni/es +1 and +2 do*amine re"e*tors Calso serotoninD& +e*ression in,ol,in# an0iety' asthenia' la"? of initiati,e& Chroni" neurosis @ith an0iety' de*ression and ina"ti,ity& Psy"hosomati" disorders @ith aestheni" rea"tions& An0iety and tension states& S"hi/o*hrenia and allied *sy"hosis es*e"ially @ith sym*toms& !0treme e0"ita$ility' a"ute $ar$iturate al"ohol and o*iate *oisonin#& Patients @ith $one marro@ de*ression and "omatose state& Restlessness andOor insomnia' !PS' sedation' antimus"arini" effe"ts' tardi,e dys?inesia& CNS de*ressants' al"ohol' $ar$iturates' #uanithidine' le,odo*a' adrener#i"s' meto"lo*ramide and *i*era/ine& 1& Administer in the u**er outer quadrant of $utto"?s& 2& +osa#e and inter,al should $e indi,idually ad7usted a""ordin# to thera*euti" res*onse& 4& S"hi/o*hrenia and allied *sy"hosis maintenan"e treatment 20 to 90 m# e,ery 2nd and 9th @ee?& 9& Monitor *atientFs "ondition $efore and after thera*y& ;& Assess *atient if suffered from any diseases Cheart *ro$lems' li,er' ?idney' $reathin# *ro$lem' 7aundi"e' and *ostural hy*otension& 8& Monitor *atient ta?in# any other medi"ine' in"ludin# those O6C and her$al medi"ines& :& Monitor *atient dru# indu"ed ad,erse rea"tions& <& 6a?e missed dose as soon as *ossi$le' if it is time for the ne0t dose' s?i* the missed dose and #o $a"? to re#ular s"hedule& +o not ta?e a dou$le dose to ma?e u* for missed dose& 5& +o not sto* ta?in# medi"ine a$ru*tly&
145

A"tion Indi"ation

Contraindi"ation Ad,erse !ffe"ts +ru# Intera"tions Nursin# Res*onsi$ility

10& Ad,i"e *atient that dru# "an "ause dro@siness' di//iness and $lurred ,ision&

146

147

4IR%?43 C!R. #/!4%

+ateO6ime

Cues

Need

Nursin# Pro$lem

O$7e"ti,es of Care

Nursin# Inter,ention

!,aluation

( A N = A R 2

Su$7e"ti,e% >Oo la#e'

C O N I 6 I 1

Im*aired Sensory Per"e*tion related to auditory hallu"ination

6hat @ithin our 4 1&

3e

a@are

of

all

(anuary 1:' 2005 [ ;%40 PM >-oal Partially MetA

days s*an of "are surroundin#

stimuli'

*aundan#on na na?o sila' *aundan#on na na?oA' as ,er$ali/ed in a lo@-tone ,oi"e&

our "lient @ill $e in"ludin# sounds from other a$le to im*ro,e rooms Csu"h as tele,ision or sensory *er"e*tion as stereo in ad7a"ent areasD Z Many seemin#ly normal stimuli @ill tri##er or intensify hallu"inations& 6he a&D in attenti,eness the daily of 2& !sta$lish ra**ort and $uild in trust @ith the "lient& Z 6he "lient must trust the nurse $efore tal?in# a$out a&D "lient "an $e o,er@helmed $y stimuli&

Rationale% One sym*tom s"hi/o*hreni" *sy"hosis hallu"ination& in"ludes sensory *er"e*tions& is It false hallmar? of

e,iden"ed $y%

After our 4 days s*an of "are' our "lient @as a$le to im*ro,e sensory *er"e*tion e,iden"ed $y% as his

1;

O$7e"ti,e% - inattenti,e to a"ti,ities

*ro#ram a"ti,itiesG $&D fo"usin#

2005

C*reo""u*ied @ith

It "on,ersations&

in,ol,es the fi,e

attenti,en
156

hallu"inationsD [ - tal?s to self Cli*s mo,es as if 2 PM "on,ersin# unseen @ith P ! R C ! - a**ears to $e listenin# ,oi"es sounds neither to or @hen is P 6 I O N

senses and $odily sensations& 6hey "an $e threatenin# and fri#htenin# for the "lient&

hallu"inationsOother sensory*er"e*tual alterations&

ess daily

in

the

*ro#ram a"ti,ities& 4& Orient the to in a "lient a"tual or non)o@e,er' he @as there not durin# Nurse)e "ontinuously en,ironmental a"ti,ities "hallen#in# @ay&

*resen"eD

e,ents

are instan"es that fo"used the

Z 3rief' frequent orientation our "on,ersations hel*s to *resent reality to the in "lient @ith *er"e*tual distur$an"e& sensory- *atient intera"tions& still tends to tal? $y himself in a 9& A,oid "on,eyin# to the lo@ "lient the $elief hallu"inations are real& +o heard& not reinfor"e the "lientFs $elief in the hallu"inations as reality& tone ,oi"e that that "an $e hardly

*resentG "o"?s head to side as if "on"entratin# on sounds that are inaudi$le to others&

P A 6

157

6 ! R N

Z you must $e honest @ith the "lient' lettin# him or her ?no@ the hallu"inations are not real

;& Call the "lient $y their name& Z usin# "orre"t names of "lient reinfor"es reality and redu"es the im*a"t of hallu"inations&

8& !0*lore the "ontent of the "lients hallu"inations durin# the initial assessment @hat the ?ind "lient to of is determine stimuli re"ei,in#& Z to determine @hether not
158

auditory hallu"inations are >"om*oundA hallu"inations that dire"t the "lient to hurt himself or herself or other& Safety is al@ays a *riority&

:& Communi"ate @ith the "lient A,oid ,er,ally #estures' in dire"t' terms& a$stra"t "on"rete' s*e"ifi"

ideas and innuendos& Z 6he "lientFs a$ility to deal in alterations is diminished& 6he "lient may misinter*ret your #estures or innuendos&

<& A,oid *la"in# the "lient in a situation in @hi"h "hoi"es need to $e made&

159

Z 6he "lientFs a$ility to ma?e de"ision is im*aired& 6he "lient may "hoose to $e done rather than deal @ith reality&

5& if the "lient a**ears to $e hallu"inatin#' attem*t to en#a#e the "lientFs attention' and *ro,ide "on,ersation or a "on"rete a"ti,ity of interest to the "lient& Z @hen the "lient is en#a#ed in real a"ti,ities and intera"tions' it $e"omes more diffi"ult for him or her to res*ond hallu"inations&

10& Maintain sim*le' $asi" to*i"s of "on,ersation to

160

*ro,ide a $ase in reality& Z lon# or "om*li"ated tas?s may $e frustratin# for the "lient& Com*le0 to*i"s may $e diffi"ult&

11& if "lient tolerates it' use tou"h in a non-threatenin# manner to *ro,ide a reality $aseG allo@ to tou"h your forearm& Z Physi"al tou"h is reality and it "an hel* the "lient to re-esta$lish e#o $oundaries&

12& !n"oura#e e0*ressions of any feelin#s of #uilt' remorse and em$arrassment& Z If it may hel* the "lient to
161

e0*ress *arti"ularly

su"h of

feelin#s' you are

su**orti,e a""e*tin# listener&

14& Sho@ a""e*tan"e of the "lientFs $eha,ior and of the "lient as a *erson& Z 6he "lient may need hel* to see that hallu"inations @ere a *art of the illness' not under the "lientFs "ontrol&

19&

Pro,ide

*rote"ti,e

su*er,ision for the "lient' $ut a,oid ho,erin# o,er him or her& Z 6he safety of the "lient and others is a *riority&

162

1;& Remain a@are of "ues indi"atin# that the "lient is hallu"inatin#& Z 6he "lient may a"t on @hat heOshe >hearsA& !arly res*onse to "ues indi"atin# a"ti,e de"reases a"tin# out $eha,ior& the or hallu"inations "han"e of a##ressi,e

163

+ateO6ime

Cues

Need

Nursin# Pro$lem

O$7e"ti,es of Care

Nursin# Inter,ention

!,aluation

( A N = A R 2

Su$7e"ti,e% >3asi# $inuan# ra na sila' du#ay na $aya ?o

R O

Ris? for ,iolen"e 6hat @ithin our 4 1& Note family history of to@ards related to e0*ression others days s*an of "are sui"idalOnon-sui"idal o,ert our "lient @ill $e $eha,ior of a$le demonstrate "ontrol e,iden"ed $y% Rationale% 3e"ause sus*i"ion' of "lient $e"ome a&D *ostureG rela0ed to self as Z to assess "ontri$utin#O "ausati,e fa"tors&

(anuary 29' 2005 [ ;%40 PM >-oal MetA

sus*i"ion&

#a*u#on#'A as ,er$ali/ed $y the "lient -

After 4 days s*an 2& As? dire"tly if the *erson is thin?in# of a"tin# on thou#htsO feelin#s& Z 6o determine of "are' our "lient @as "ontrol ,iolent e,iden"ed $y% a$le to as demonstrate self-

O$7e"ti,e% 22' - mistrust

R !

may to

sui"idal or ,iolent $&D not destroyin# himselfOherself *ro*erty or in7ure or others& Fa"tors othersG and

intent a&D rela0ed

2005

history

of the

li?e mistrust or the *resen"e of history

"&D

,er$ali/e 4& +e,elo* thera*euti" nurse- *ostureG

164

hittin#

feelin#s of an#er' "lient relationshi*& Pro,ide

mother [ 2 PM history of

6 I O N S

of "ontri$ute mistrust

,iolen"e frustration to "an the "onfusion& $e $y

or "onsistent "are#i,er @hen *ossi$le& $&D not destroyin#

dia#nosis& ClientFs o,er@helmed

Z Promotes sense of trust' any *ro*ertiesG allo@in# "lient to dis"uss feelin#s o*enly& "&D of ,er$ali/ation feelin#s of

thro@in# o$7e"ts

sus*i"ion to *eo*le&

- resistant to others do"torD Cstaff nurses and the

) I *

3i$lio#ra*hy% Anti-Oton#' +e$orah& >Psy"hiatri" Nursin# 3iolo#i"al

9& Maintain strai#htfor@ard an#er' frustration "ommuni"ation& Z to a,oid reinfor"in# >-i*an#utana naman na?o and ;& A""e*t "lientFs rea"tin# an#er on do"tor ra Pan#utanon 3asi# #i$inuan#an lan# ?o&A 8& )el* "lient identify more
165

or "onfusion%

mani*ulati,e fa"tor

P A 6 6 ! R

and !dition&

3eha,ioral B3

*ero man&

Chan#es&ASe"ond Saunders Com*any& Philidel*hia& K2002& *a#es 294299&

@ithout

*a$un#ul-$un#ol

emotional $asis&

Z Promoted a""e*tan"e and nalan# na?o usa$& sense of safety&

a**ro*riate solutionsO$eha,iors& Z 6o lessen sense of an0iety and asso"iated *hysi"al manifestations&

:& 3e truthful @hen #i,in# information to "lients& Z to $uild trust' enhan"in# thera*euti" relationshi*&

<& Maintain distan"e and do not tou"h "lient @hen does not tolerate "loseness& Z Patients "an $e

un*redi"ta$le& 6hey "an $e une0*e"tedly harmful

166

5&

Remain "alm and state in an a**ro*riate

limits

$eha,ior Z 6o assist "lient in

"ontrollin# $eha,ior&

10&

Pro,ide of

stru"tured of

en,ironment @ith s"heduled routines +aily A"ti,ities li,in#& !0*lain

une0*e"ted "han#es& Z a"? of stru"ture and

une0*lained "han#es usually @ill in"rease a#itation and an0iety& Stru"ture enhan"es se"urity&

11&

#i,e for

*ositi,e "lientFs
167

reinfor"ement

efforts& Z !n"oura#es "ontinuation of desired $eha,iors&

12& Pro,ide safety' quiet en,ironment items from and the remo,e "lientFs

en,ironment that "ould $e used to infli"t harm for selfOothers Z to *romote safety in e,ents of ,iolent $eha,iors

+ateO6ime

Cues

Need

Nursin# Pro$lem

O$7e"ti,es of Care

Nursin# Inter,ention

!,aluation

168

O$7e"ti,e% ( A N = A R 2 - demonstrates ina$ility to "on"entrate in "on,ersations 1;' - *refers to $e 2005 alone than [ other "lients rather to P ! - @ith $lunt affe"t *oor eye C O N I 6 I 1 ! Rationale% Auditory hallu"ination is the most "ommon ty*e of hallu"ination& It in,ol,es hearin# sounds' most often ,oi"es' tal?in# to the may "lient& $e 6here one or or $&D e0*ression of *leasure from ,oi"es' a&D ,er$ali/in# and So"ial Isolation 6hat @ithin our 4 1& Monitor the e0tent of the self-im*osed (anuary 1:' 2005 [ ;%40 PM >-oal MetA

"onta"t

related to altered days s*an of "are "lientFs auditory hallu"inations a$le demonstrate enhan"ed intera"tion e,iden"ed $y% so"ial as

sensory *er"e*tion% our "lient @ill $e isolation' and its effe"ts on to the "lient' in an on#oin# manner& Z Continuous monitorin# of the "lientFs isolati,e $eha,iors hel*s the nurse *lan strate#ies to $rea? the *attern of @ithdra@al @ith intera"tions and a"ti,ities and to maintain "lient safety&

After 4 days s*an of "are' our "lient @as a$le to so"ial as demonstrate enhan"ed intera"tion e,iden"ed $y%

thou#hts

insi#hts a$out the a"ti,ities done in more than one senten"eG

2& Assist the "lient to meet $asi" needs Ce&#&' nutrition' *ersonal hy#ieneD durin# times of so"ial @ithdra@al&

a&D"lientFs ,er$ali/ation% > O? man an# dula& Nalin#a@ ?o man ?ay $i$o ?ayo
169

so"iali/e @ith

multi*le familiar

unfamiliar *ersonFs

deri,ed ZMeetin# $asi" need hel*s so"ial to *romote the "lientFs

2 PM

does

not or @ith

R C ! P

,oi"e s*ea?in#& ,oi"es and

may may tends

$e "on,ersations and *hysi"al health and @ell6his a"ti,ities @ith $ein#' @hi"h may *ositi,ely nursesG health& $e other "lients and affe"t the "lientFs mental

tanan&A

share e0*ress feelin#s others and tal?in# turns

*er"ei,ed as real student to and them' entertain attention' so"ially them&

$&D >Maayo man& -anahan ?o ?ay na#-#itara

his starts in

head to side

6 I O N

#ettin# the "lientFs isolatin# so"ial

4& S*end lon# inter,als @ith a"ti,ities in meanin#ful' non-

si (eho,en&A' as ,er$ali/ed the $y the "lient after sho@"ase of talent of his "o-residentG

thus' "&D en#a#in# in the "lient ea"h day' en#a#in# @ith others in the "hallen#in# intera"tions& milieu li?e "rafts' #ames' meals' and e0er"ises& Z ease on# intera"tions hel* to "lient into the

@his*ers as if he is tal?in# to someone&

en,ironment $y de,elo*in# trust' ra**ort' and res*e"t& "&D en#a#ed in

P - late res*onse to questions as?ed A 6 6 ! R

so"ial a"ti,ities 9& +is"uss @ith the "lient anythin# of interest to the "lient&Ce&#&' items in room' fa,orite a"ti,ities' ho$$iesD Z +is"ussin# the "lientFs
170

@ith others in the milieu li?e "rafts' meals' e0er"ises& #ames' and

interests en"oura#es so"ial s?ills and de"reases so"ial isolation&

;& and

Identify

the

"lientFs them to for *hone

si#nifi"ant su**ort *ersons' en"oura#e the "onta"t "lient

intera"tions' ,isits& Z A stron# so"ial so"ial

"on,ersations' a"ti,ities' and

su**orti,e the s?ills' *ositi,e "onta"t'

net@or? "lientFs enhan"es fa"ilitates

in"reases

*romotes self-esteem' and relationshi*s&

8& )el* the "lient "om*are

171

the differen"e $et@een so"ial isolation and a desire for solitude or *ri,a"y& Z 6he "lient may

o""asionally "hoose to $e alone at a**ro*riate times and should $e #i,en the o**ortunity&

:& A"t as a role model for so"ial $eha,iors in one-toone and #rou* intera"tions& Z !ffe"ti,e role modelin# $y staff hel*s the "lient identify a**ro*riate so"ial s?ills for a#e and status&

<& )el* the "lient see? out other "lients to so"iali/e @ith
172

@ho ha,e similar interests& Z Shared or *romote is li?ely to "ommon more $e

interests en7oya$le @hi"h re*eated&

so"iali/ation'

5Pro,ide and

the other

"lient

@ith milieu

stimulation from re"reational mana#ement& Z 6hese a"ti,ities e0*ose the "lient to so"ial situations and in"rease *ra"ti"e o**ortunities so"iali/ation to and

im*ro,e so"ial s?ills&

10& Inter,ene @ith the "lient demonstratin# "om*ulsi,e

173

a"ts'

hallu"inations'

delusions' or im*aired ,er$al "ommuni"ation& Z Carin#' em*atheti"

$eha,iors demonstrate the nurseFs understandin# of the "lientFs limitations' hel* to fill the "lientFs so"ial ,oid durin# ,ulnera$le times' and hel* safety& to maintain "lient

11& !n#a#e the "lient in so"ial a"ti,ities and that are @ithin the "lientFs *hysi"al "a*a$ilities le,el& Z A"ti,ities *ro,ide the "lient @ith su""essful so"ial e0*erien"es li?ely to $e
174

toleran"e

re*eated

and

demonstrate and

understandin#

"onsideration of the "lient&

12& !n"oura#e e0*ressions of any feelin#s of #uilt' remorse and em$arrassment& Z If it may hel* the "lient to e0*ress *arti"ularly su"h of feelin#s' you are

su**orti,e a""e*tin# listener&

14& Sho@ a""e*tan"e of the "lientFs $eha,ior and of the "lient as a *erson& Z 6he "lient may need hel* to see that hallu"inations @ere a *art of the illness' not under the "lientFs "ontrol&
175

19&

Pro,ide

*rote"ti,e

su*er,ision for the "lient' $ut a,oid ho,erin# o,er him or her& Z 6he safety of the "lient and others is a *riority&

1;& Remain a@are of "ues indi"atin# that the "lient is hallu"inatin#& Z 6he "lient may a"t on @hat heOshe >hearsA& !arly res*onse to "ues indi"atin# a"ti,e de"reases a"tin# out $eha,ior& the or hallu"inations "han"e of a##ressi,e

176

+ateO6ime

Cues O$7e"ti,e%

Need

Nursin# +ia#nosis Im*aired ,er$al

O$7e"ti,e of Care 6hat @ithin our 4 @ee?s s*an of "are the "lient @ill $e a$le to esta$lish methods of "ommuni"ation as e,iden"ed $y%

Nursin# Inter,entions 1&D Prote"t the "lient and others in the en,ironment from harm or in7ury that may result from the "lientFs misinter*retation of e,ents and ina$ility to ,er$ally e0*ress thou#hts and feelin#s&

!,aluation

( A N = A R 2

- stutterin# - +iffi"ulty in e0*ressin# thou#hts ,er$ally as e,iden"ed $y late res*onses - $lunted affe"t - *oor eye "onta"t durin# intera"tions - auditory hallu"inations

C O N I 6 I 1 ! P ! R C ! P 6 =

"ommuni"ation related to *hysiolo#i"al $arriers% *sy"hosis se"ondary to s"hi/o*hrenia' *aranoid ty*e&

(anuary 24' 2005 [ 11 *m -oal metJ

At the end of our 4@ee? s*an of "are' the "lient @ill $e a$le to esta$lish methods of "ommuni"ation as e,iden"ed $y%

a&D *arti"i*ate in ZClients @ith s"hi/o*hrenia in #eneral' may e0hi$it an unusual s*ee"h *attern& 6@o ty*i"al *attern are @ord salad and e"holalia& S*ee"h may $e slo@ed or a""elerated in rate and ,olume& 6he "lient may s*ea? in @his*ers or hushed toes or may tal? loudly or yell& aten"y or hesitation may last 40-9; se"onds and thera*euti" "ommuni"ation su"h as statin#' refle"tin#' a"ti,e listenin#O a""e*tan"eG $&D demonstrate "on#ruent ,er$al and non-,er$al "ommuni"ationsG and "&D a$le to e0*ress thou#hts and feelin#s&

Z 6he nurseFs first *riority is to maintain the safety of the "lient' others' and the en,ironment throu#h a**ro*riate thera*euti" inter,entions a""ordin# to fa"ility *oli"ies&

2 0 0 5

a& *arti"i*ate in 2D Identify the e0tent to @hi"h im*aired ,er$al "ommuni"ation interferes @ith the "lientFs a$ility to "on,ey to others the meanin# $ehind the "lientFs ,er$al messa#e& Z Identifi"ation of the "lientFs "ommuni"ati,e a$ility ser,es as a #uideline $& demonstrate "on#ruent ,er$al and non-,er$al "ommuni"ation su"h as e0hi$itin# a smile fa"e @hen he is ha**y&
177

Coften times turns his head to other side

thera*euti" "ommuni"ation&

2PM

and starts tal?in# to himself in a hushed tone as if someone is tal?in# to himD

178

+ateO6ime

Cues Su$7e"ti,e%

Need

Nursin# +ia#nosis Ineffe"ti,e denial

O$7e"ti,e of Care 6hat @ithin our 4 the *atient @ill $e a$le to a"?no@led#e reality of situation

Nursin# Inter,entions 1&D Prote"t the "lient and others in the en,ironment from harm or in7ury that may result from the "lientFs misinter*retation of e,ents and ina$ility to ,er$ally e0*ress thou#hts and feelin#s&

!,aluation

( A N = A R 2

> Ana sila *ata$alan da@ ?o& Asa *ud an# *atam$alanTJ O? man ?o&A

C O P I N -

related to failure to day s*an of "are admit reality of situation&

(anuary 292005 [ ;%00 *m

Z +efense me"hanism are "o#niti,e distortions that a

as e,iden"e $y%

At the end of our 4+ay s*an of "are to a"?no@led#e reality of situation as e,iden"ed $y%

22 2 0 0 5

O$7e"ti,e% -refuses to ta?e the medi"ations -does not *er"ei,e *ersonal rele,an"e of sym*toms& -ma?es "omments

a& See?in# a**ro*riate assistan"e from staff nurses for *resentin# *ro$lemG

Z 6he nurseFs first *riority our "lient @as a$le is to maintain the safety of the "lient' others' and the en,ironment throu#h a**ro*riate thera*euti" inter,entions a""ordin# to fa"ility *oli"ies& A& +is*layed a**ro*riate affe"t 2D Identify the e0tent to @hi"h the *atientFs denial interferes @ith the "lientFs a$ility to "on,ey to others the meanin# $ehind the "lientFs ,er$al messa#e& Z Identifi"ation of the "lientFs "ommuni"ati,e a$ility ser,es as a #uideline for hel*in# the 3& !0*ressed reality "on"ern thoru#h ,er$ali/ation >o si#e ' a# in#on lan# ?o ?un# na#a sa?it a?on# li-o#&A CSho@in# his "ondition
179

S 6 R ! S S

*erson uses un "ons"iously to maintain sense of $ein# in "ontrol of the situation to lessen dis"omfort' and to deal @ith stress& 3e"ause

$& +is*lay a**ro*riate affe"t%

6 O ! R A N C !

defense me"hanism arise from the un"ons"ious' the *erson is una@are of usin# them & Some *eo*le o,er use defense me"hanism @hi"h sto*s them from

"& !0*ression of realisti"-"on"ern a$out sym*toms throu#h ,er$ali/ation&

2PM

@hen s*ea?in# of distressin# e,ents su"h as his admission

?no@led#e a$out

180

N=RSIN- MANA-!M!N6

)!A 6) 6!AC)IN-S
181

Medi"ation !n"oura#e the "lient to ta?e the full "ourse of medi"ation as *res"ri$ed $y the *hysi"ian& Z Non"om*lian"e is the ,ery reason @hy rela*se o""ur and leads to readmission& Com*letion of thera*y is a must to a"hie,e ma0imum le,el of @ellness on the *art of the *atient& !du"ate family to a,oid a$ru*t @ithdra@al of medi"ation& Z A$ru*t dis"ontinuin# of dru# may "ause e0tra*yramidal sym*toms to o""ur& !0er"ise !n"oura#e "lient to so"iali/e and *arti"i*ate in *ur*oseful a"ti,ities& Z 6o in"rease the *atients self-esteem throu#h so"iali/ation !n"oura#e the "lient to #i,e am*le time for e0er"ise& Z Physi"al e0er"ise hel*s *romote #ood $ody "ondition and it *re,ents *hysiolo#i" deterioration& Reinfor"e and re"o#ni/e "lient for the #ood a"tions he had done Z It sho@s su**ort in the "lientFs a$ility and stren#th& It also $oosts self-esteem& 6hera*y In"lude effe"ti,e thera*ies in the milieu su"h as art thera*y' musi" thera*y' +an"e thera*y' *lay thera*y and others& Z !ffe"ti,e thera*ies enhan"e *atientFs a$ility to "o*e emotionally' emotionally' and *hysiolo#i"ally !n"oura#e "lient to *arti"i*ate in a"ti,ities offered $y the institution or the a"ti,ities *re*ared $y the student nurses in their *ro#rams& ZA"ti,ities hel* in de,elo*in# so"ial s?ills and $uild u* self-esteem& !n"oura#e "lient to e0*ress feelin#s and emotions su"h as an#er' ha**iness' desires' sadness' et"& Z!0*ression of feelin#s and emotions hel*s *atient to relie,e an0iety and stress& )y#iene
182

 dirt&

!m*hasi/e to the *atient the im*ortan"e of ?ee*in# the $ody "lean and free from Z Mi"roor#anisms "an s*read and in,ade the $ody and tem*orarily defeat the $odyFs defenses "ausin# diseases& !n"oura#e *atient to do *ersonal "are ha$its su"h as ta?in# a $ath e,eryday and $rushin# of teeth& Z+urin# *sy"hoti" e*isodes' s*e"ial attention should $e #i,en to hy#iene or #roomin# needs& 6he *atient fails to *erform $asi" a"ti,ities of daily li,in# for he $e"omes *reo""u*ied @ith hallu"inations& !du"ate the family mem$ers to remind the "lient al@ays a$out *ersonal hy#iene and #roomin#& Z Family mem$ers are the "losest indi,iduals to the "lient @hen he @ould $e out of the ,i"inity of the reha$ilitation "enter& 6heir reminders @ould im*ro,e the "lient and hel* him stay in "onta"t @ith reality& !m*hasi/e im*ortan"e of o$ser,in# #ood oral hy#iene& Z For hy#ieni" *ur*oses' es*e"ially *atientFs ta?in# medi"ines& 6his may "ause the mouth to dry& !n"oura#e the *atient to stay neat and *resenta$le& Z 6o enhan"e self-esteem and self-"onfiden"e&

Out Patient Instru"t family and si#nifi"ant others to assist the "lient in daily a"ti,ities& Z Patient may ha,e diffi"ulties in "o*in# u* in a ne@ en,ironment outside the institutionG family su**ort is an essential fa"tor to hel* *atient "o*e& Instru"t family to *ro,ide safety for the *atient& Pro,ide o**ortunities for the "lient to do thin#s $y himself if *ossi$le& Z Safety is one of the im*ortant need of *atients @ith mental illness& Z 6o *romote inde*enden"e& +iet
183

!n"oura#e *atient to eat nutritious food' es*e"ially hi#h "alori" or hi#h *rotein

foods su"h as meat& Z 6o meet the *atientFs in"reased ener#y e0*enditure and *ro,ide nourishment to the $ody& Instru"t "lient not to s?i* meals& Instru"t *atient to in"rease oral fluid inta?e and hi#h $ul?-formin# foods Instru"t *atient not drin? al"ohol Instru"t *atient not drin? "affeine-"ontainin# $e,era#es or any other stimulants Z 6o re*lenish lost ener#y& Z 6o *re,ent and relie,e "onsti*ation& Z It @ill "ause CNS de*ression Z may "ountera"t the s*e"ifi" a"tions of le,ome*roma/ine&

184

R!COMM!N+A6ION

Be formulated the follo@in# re"ommendation for the "ontinuity and ,alidity of the study% further o$ser,ation on the "lientFs $eha,ior and mental statusG "ontinuous assessment on the "lient "ondition and needsG
185

further "lient and family tea"hin#G follo@-u* "he"?-u*s and "ounselin# on the "lientFs *art as @ell as the family mem$ers&

186

187

PRO-NOSIS

Criteria Onset of Illness +uration of Illness

Poor Fair -ood ]

(ustifi"ation Sin"e he is admitted at the institution for almost 9 years still there are *resent of si#n and sym*toms of *sy"hosis' su"h as hallu"ination& Be rate the duration of illness as *oor $e"ause e,en he is

in the institution for almost 9 yearsG he is not fully re"o,ered from the illness& 3rief *sy"hosis is "ommon on a#es 22-40& Sin"e his si#n

A#e Pre"i*itatin# Fa"tor Mood and Affe"t Attitude and Billin#ness to ta?e Medi"ation Family Su**ort

] ]

and sym*tom of *sy"hosis started at the a#e of 24' so itFs 7ustified as *oor& 6here are some fa"tors that are hi#hly ,aria$le to the "lient that tri##er the o""urren"e of his "ondition& Be rate his mood and affe"t as fair for he sometimes "anFt ] e0*ress his feelin# due to his hallu"ination& +urin# the assessment and inter,ie@ @e ?no@n that Mr& Ara*o" donFt ta?e any of medi"ation and thus refused to tell us if @hen he sto*& ] )is family ,isited him e,ery 1;th day of the day $ut de*end if he is ad,isa$le to see his family&

-eneral Pro#nosis Res*e"ti,e numeri"al ,alues are as follo@s% Poor 10;\ ; Fair 202 \9
188

-ood 400 \0 5O:\ 1&25 ^POOR C1- 2D Inter*retation -enerally' @e rated Sir eonardo @ith a *oor *ro#nosis "onsiderin# the fa"tors su"h as onset and duration of illness' a#e' the *re"i*itatin# fa"tors' and his attitude and @illin#ness to ta?e his medi"ations&

189

BIBLIOGRAPHY

3I3 IO-RAP)2

A& 3oo?s 3er$er' 3ar$ara& a$oratory 6ests and +ia#nosti" Pro"edures& 9th !dition& Philadel*hia% !lse ,ier In"'& K2009&
190

3oyd' Mary Ann& Psy"hiatri" Nursin# Contem*orary +ia#nosis& 9th Pennsyl,ania& BB&K 200<&

edition& Philadel*hia'

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