DOCTOR’S ORDER

Date Order Rationale Remarks

02/1/19 Please admit to CIU. For close monitoring of the patient Admitted
and proper management of his
2:40pm
condition.

The crisis intervention unit is a

special unit operating on a 24-hour
basis, which serves as a receiving
and action center for walk-in
referred, and rescued individuals
and families in crisis situation.

Secure consent to This is done to ensure that the Secured.

care. client or significant others has
been adequately informed of
significant information concerning
treatment processes and
procedures. When persons, due to
age or mental status, are legally
incapable of giving informed
consent, doctors obtain informed
permission from a legally
authorized person, if such
substitute consent is legally
permissible. To secure the consent
of the client is important for legal
purposes.

DAT with aspiration This is done to give appropriate and Done

precaution. adequate nourishment with the
prevention or minimization of risk
 factors in the patient at risk for
aspiration.

Monitor vsq6 and Vital signs are important for Taken and
record please baseline assessment and to monitor recorded.
02/2/19 patients condition which evaluates

10:11 am the whole treatment course,

especially the medications he
receives that could be a
contributing factor in the variation
results of the vital signs.

Meds: Given
02/14/19
Haloperidol 5mg Haloperidol is an older
1:14 pm
1amp IM now then antipsychotic used in the treatment
q12 of schizophrenia.

Flupentixol is a long acting

injection given two or three weekly
Flupentixol dec 20mg
to people with schizophrenia who
1ampule now then q
have a poor compliance with
monthly
medication and suffer frequent
relapses of illness.

Biperiden is commonly used to

improve parkinsonian signs and
symptoms related to antipsychotic
Biperiden Hcl drug therapy.
2mg/tab 1 tab BID
PRN for EPS

Homicidal and This is ordered so that the patient Done

suicidal tendencies will be monitored closely and to
avoid the harming of patient's life
 escape precaution or others.
please

Restrain patient when Psychiatric facilities often use Done

necessary. medical interventions in the form
of restraints to reduce safety risks
posed by violent patients and to
prevent patients from harming
themselves and others.

Refer accordingly This may create a collaborative Referred

treatment among the client and the
health care providers; thus it also
makes a good coordination on the
treatment of the client.

Hold Haloperidol IM To change to chlorpromazine. Done

Start Chlorpromazine This is given as a substitute for Given

02/19/19 decanoate 200 mg/tab Haloperidol. This is an atypical
½ tab in am, 1 tab at drug and is considered to have less
HS. EPS side effects.
 DRUG STUDY

GENERIC NAME

Haloperidol

BRAND NAME Aloperidin

CLASSIFICATION Typical Antipsychotic

DOSAGE 50mg/ml, IM

MECHANISM OF A butyrophenone that probably exerts antipsychotic effects by

ACTION blocking postsynaptic dopamine receptors in the brain.

INDICATIONS  Psychotic disorders (Adults and children older than

age 12: Dosage varies for each patient. Initially, 0.5

to 5 mg P.O. b.i.d. or t.i.d. Or, 2 to 5 mg I.M. haldol

lactate q 4 to 8 hours, although hourly

 administration may be needed until control is

obtained.)

 Chronic psychosis requiring prolong therapy

(Adults: 50 to 100 mg I.M. haloperidol decanoate q

4 weeks.)

 Tourette Syndrome (Adults: 0.5 to 5 mg P.O. b.i.d.,

t.i.d., or p.r.n.)

CONTRAINDICATION  Use cautiously in elderly and deliberated patients;

in patients with history of seizures or EEG

abnormalities, severe CV disorders, allergies,

glaucoma, or urine retention; and in those and

those taking anticonvulsants anticoagulants,

antiparkinsonians, or lithium.

 In patients hypersensitive to drug and in those

with parkinsonism, coma, CNS depression.

DRUG INTERACTION Drug – Drug

 Anticholinergics: May increase anticholinergic effect and

glaucoma. Azole antifungals, buspirone, macrolides: May

increase haloperidol level. Carbamazepine: May increase

haloperidol level. CNS depressants: May increase CNS

 depression. Lithium: May cause lethargy and confusion after

high doses. Methyldopa: May cause dementia. Rifampin:

May decrease haloperidol level.

Drug – Lifestyle

 Alcohol use: May increase CNS depression.

SIDE EFFECTS  CNS: severe extrapyramidal reactions, tardive

dyskinesia, sedation, drowsiness, lethargy, headache,

insomnia, confusion, vertigo.

 CV: tachycardia, hypotension, hypertension, ECG

changes

 EENT: blurred vision.

 GI: dry mouth, anorexia, constipation, diarrhea, nausea,

vomiting, dyspepsia.

 GU: urine retention, menstrual irregularities, priapism.

 Hematologic: leukocytosis.

 Hepatic: Jaundice.

 Skin: rash, other skin reactions, diaphoresis.

 Other: gynecomastia.

ADVERSE EFFECTS  . CNS: seizures and neuroleptic malignant syndrome.

 CV: torsades de pointes, with I.V. use.

 Hematologic: Leukopenia
NURSING  Although drug is least sedating of the antipsychotics,

RESPONSIBILITY warn patient to avoid activities that require alertness and

good coordination until effects of the drugs are known.

 Educate patient that drowsiness and dizziness usually

subside after a few weeks.

 Inform patient to avoid alcohol while taking this drug.

 Tell patient to relieve dry mouth with sugarless gum or

hard candy.

 Always remember, don’t give deconate form IV.

 Monitor the client for signs of tardive dyskinesia which

may occur after prolonged use. It may not appear until

months or years later and may disappear spontaneously

or persist for life, despite ending drug.

 Watch out for signs and symptoms of neuroleptic

malignant syndrome, which is rare but fatal.

 Inform patient to do not withdraw the drug abruptly

unless required by severe adverse reactions.

 Remind patient to always protect the drug from light.

Slight yellowing injection or concentrate is common and

doesn’t affect potency. Discard the drug if there is a

markedly discolorations in the solutions.

 Stop taking haloperidol and check the patient with their

doctor right away if they have any of the following

symptoms while using haloperidol: convulsions

(seizures); difficulty with breathing; a fast heartbeat; a

high fever; high or low blood pressure; increased

sweating; loss of bladder control; severe muscle stiffness;

unusually pale skin; or tiredness. These could be

symptoms of a serious condition called neuroleptic

malignant syndrome (NMS).

GENERIC NAME

Flupentixol

BRAND NAME Fluanxol

CLASSIFICATION Typical Antipsychotics

DOSAGE Flupentixol decanoate 20 mg 1 amp now then q monthly

MECHANISM OF Flupenthixol is a type of thioxanthene drug and acts by antagonism

ACTION of D1 and D2 dopamine receptors (as well as serotonin). Side

effects are similar to many other typical antipsychotics, namely

extrapyramidal symptoms of akathisia, parkinsonian tremor and

rigidity. However, anticholinergic adverse effects are low.

INDICATIONS  Schizophrenia and other psychoses

 Depression

CONTRAINDICATION  If patient is allergic to flupentixol or any other

medicine of this class.

 If patient is allergic to any other medicine including

preservative and dyes.

  Elderly people should be prescribed flupentixol with

caution.

 If patient has history of kidney problem, liver

problem or epilepsy.

 If patient has a problem of heart disease, high blood

pressure or diabetes.

DRUG INTERACTION  Prescription and nonprescription medications,

especially those that may cause drowsiness such as:

sedatives, narcotic pain relievers (e.g., codeine), anti-

anxiety agents (e.g., diazepam), antidepressants or

other psychiatric medicine, dopamine-type drugs

(e.g., cabergoline, pergolide, bromocriptine,

pramipexole), muscle relaxants (e.g.,

cyclobenzaprine), drowsiness-causing antihistamines

(e.g., diphenhydramine), atropine-like drugs, anti-

seizure drugs.

 Many cough-and-cold products contain ingredients

that may add a drowsiness effect.

SIDE EFFECTS  Nausea, drowsiness, dizziness, diarrhea, constipation,

blurred vision, insomnia, urine problem, tremor,

 weakness, vomiting, and difficulty in breathing, slow

heart rate, irregular blood pressure and convulsions.

 Less common side effects of flupentixol include skin

rashes, muscle problem, dizziness while rising from

bed, sore throat, dark urine, increased sweating.

ADVERSE EFFECTS  . Yellowness of skin and eyes, decreased sex drive and

painful erection, chest pain and muscle spasms.

NURSING  Educate patient that Flupentixol can cause

drowsiness, dizziness and blurred vision.
RESPONSIBILITY  Remind client that alcohol will increase feelings of
drowsiness.
 Remind patient that before having any surgery,
including dental or emergency treatment, tell the
surgeon, doctor or dentist that you are taking
flupentixol.
 Inform client that Flupentixol can occasionally
cause a dry mouth. If patient experiences this, try
chewing sugar-free gum, sucking sugar-free sweets
or pieces of ice.
 Flupentixol can cause some people's skin to become
more sensitive to sunlight than it usually is. Avoid
strong sunlight and sunbeds until you know how
your skin reacts and use a suncream higher than
factor 15.
 If client experience 'flu like' symptoms such as
stiffness, high temperature, abnormal paleness,
leaking bladder and a racing heartbeat contact their
doctor or go to the accident and emergency
department of your local hospital immediately.
 Educate the patient that the symptoms of overdose
may include seizers, muscle spasms, weakness, fast
 heartbeat, fever, difficult breathing, severe
dizziness, drowsiness, convulsions, irregular
heartbeat, disturbed concentration, constipation and
coma.
 Inform patient to take the medicine with a full glass
of water.
 Remind the patient that the medicine can be taken
with or without food.
GENERIC NAME

Chlorpromazine

Hydrochloride

BRAND NAME Chlorpromanyl

CLASSIFICATION Typical Antipsychotic

DOSAGE 30 mg/ml PO

MECHANISM OF A piperidine phenothiazine that probably blocks postsynaptic

ACTION dopamine receptors in the brain.

INDICATIONS  Psychosis, mania (Adults: for hospitalized

patients with acute disease, 25 mg I.M.)
 Nausea and vomiting (Adults: 10 to 25 mg
PO q 4 to 6 hours, p.r.n. Or, 25 mg IM
initially.)
 Acute intermittent porphyria, intractable
hiccups (Adults: 25 to 50 mg PO t.i.d. or
q.i.d.)
 Tetanus (Adults: 25 to 50 mg IV or IM t.i.d.
or q.i.d.)
CONTRAINDICATION  In patients hypersensitive to drug; in those

with CNS depression, bone marrow

suppression, or subcortical damage, and in

those in coma.

 Use cautiously in elderly and deliberated

patients and in patients with hepatic or renal

disease, severe CV disease, respiratory

disorders, hypocalcemia, glaucoma, pr

prostatic hyperplasia.

 Use cautiously in acutely ill or dehydrated

children.

DRUG INTERACTION  Antacids: May inhibit absorption of oral

phenothiazines. Anticholinergics such as tricyclic

antidepressants, antiparkinsonians: May increase

anticholinergic activity, aggravated parkinsonian

symptoms. Anticonvulsants: May lower seizure

threshold. Barbiturates, lithium: May decrease

phenothiazine effect. Centrally acting

anthypertensives: May decrease antihypertensive

effect. CSN depressants: May increase CNS

depression. Electroconvulsive therapy, insulin: may

cause severe reactions. Lithium: May increase

 neurologic effects. Meperidine: May cause excessive

sedation and hypotension. Propanolol: May increase

levels of both propanolol and chlorpromazine.

Warfarin: May decrease effect of oral anticoagulants.

Drug – Lifestyle

 Alcohol use: May increase CNS depression, particularly

psychomotor skills

SIDE EFFECTS  CNS: extra pyramidal reactions, sedation, tardive

dyskinesia, pseudoparkinsonism.

 CV: orthostatic hypotension

 GI: dry mouth, constipation

 GU: urine retention

 Skin: mild photosensitivity reactions, pain at IM

injection site

ADVERSE EFFECTS  CNS: Seizures and neuroleptic malignant syndrome.

 Hematologic: Leukopenia, agranulocytosis, aplastic

anemia, thrombocytopenia

NURSING  Obtain baseline blood pressure measurements before

starting therapy, and monitor regularly. Watch client for
RESPONSIBILITY orthostatic hypotension.
 Monitor client for tardive dyskinesia, which may occur
after prolonged use.
 Warn patient to avoid activities that require alertness or
good coordination until effects of drug are known.
 Remind client that drowsiness and dizziness usually
subside after a few weeks.
 Advise patient not to crush, chew, or break extended
release capsule form before swallowing.
 Educate patient to avoid alcohol while taking the drug.
 Have the patient to report signs of urine retention or
constipation.
 Remind patient to use sunblock and to wear protective
clothing to avoid oversensitivity to the sun.
 Advise client to relieve dry mouth with sugarless gum
or hard candy.
 Withhold dose and notify prescriber if jaundice,
symptoms of blood dyscrasia, or persistent
extrapyramidal reactions develop.
 PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the ☻ Patient first experiences the signs and symptoms of

illness schizophrenia when he 16 years old and now he is
23 years old. The first signs that patient showed
was when he started to have bad behavior
influenced among his peers and since then people
who are close to him noticed that he has illogical
speech and flight of ideas. The onset of illness was
poor since the family waited that the situation of
patient worsened and did not immediately seek
medical advice immediately when there was
changes in his behavior like when he showed
illogical speech and flight of ideas.
 Duration of ☻ The client has been years ago. The patient went to
illness the Davao Medical Hospital for his third admission
last January 19, 2010 and was diagnosed with
schizophrenia undifferentiated. As we can see, the
duration of illness has been very long since it was
years ago since he was mentally sick thus rating him
with poor prognosis.

Precipitating ☻ Intake of drugs, substances or chemicals which

factors increase levels of dopamine and developmental
factors are the present precipitating factors seen in
the patient. The proponents rated this area as poor
since the patient is abusing substances like alcohol,
and “katchobong” . In his development, the patient
developed mistrust, shame and doubt, guilt,
inferiority, role confusion, and isolation which rated
him poor.

Mood and Affect ☻ During the interview, the patient has appropriate
mood and affect therefore rating him with good
prognosis.

Family Support ☻ The patient is not really receiving appropriate

family support since his mother and father
abandoned him during his early life. The patient was
deprived of consistent support thus we rate this area
as poor.
 Willingness to ☻ The patient was forced to brought to the hospital
take medications for check-up because his grandparents noticed and
and treatment were alarmed with his behavior like Started
laughing for no reason and listening to loud
undesirable music. During the interview with his
close neighborhood, the patient was willing to take
medications but his grandparents cannot sustain or
provide his meds due to financial instability

Depressive ☻ During the interview, the patient does not show any
features depressive features.

Computation:

 Poor: (4*1)/7 = 4/7

 Fair: (1*2)/7 = 2/7
 Good: (2*3)/7 = 6/7
Total: 1.68
Total 2 1 4
General Prognosis:

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD