Republic of the Philippines

Mariano Marcos State University

College of Health Sciences
Department of Nursing
Batac City, 2906

Case Analysis in Patient with

Undifferentiated Schizophrenia

Presented by:

Corpuz, Allysa Dulce Marie A.

Gano, Nina Rona G.
Montano, John Herald P.
Pumaras, Angel Anne P.
Reynon, Angelique Joy T.
Somera, Beatrice Audra C.
Teano, Beverly Clair A.
Valdez, Arizza Jane R.
Ventura, Kathleen Louise D.
Villa, Mikhaela Joyce R.
Vizcarra. Anjela Clare F.

III-C GROUP 11
I. PERSONAL DATA

NAME : Josan Mary Antonio Capili

HOSPITAL NUMBER : 086400

ADDRESS : Brgy. Batasan Hills, Quezon City

AGE : 31 years old

SEX : Female

DATE OF BIRTH : September 15, 1986

CIVIL STATUS : Married

RELIGION : Roman Catholic

OCCUPATION : None

EDUCATIONAL ATTAINMENT : College Graduate

ADDMISSION DATE : April 13, 2018 @ 3:47 PM

ADMITTING DIAGNOSIS : Undifferentiated Schizophrenia

ADMITTING PHYSICIAN : Jong T. Mazo, M.D.

CHIEF COMPLAINT : gustong magpakamatay

mang-aagaw ng baril

maraming bulong
 III. PSYCHOPATHOLOGY

Schizophrenia is a severe psychotic illness that affects the mood, regulation of emotion,

thought process, behavior, and total personality integrity. Although this is called a psychotic

illness, the person is not continuously psychotic. It is commonly thought of today as more than

one illness, as one label covering a heterogenous group of syndromes.

The term schizophrenia was first used by E. Bleuler in 1911 to emphasize the schism or

splitting off of the mind between the functions of feeling and thinking. Many people falsely think

of schizophrenia as the splitting of the personality into two parts; the term actually was meant to

describe the disorganization of the thinking and emotional processes. (Psychiatric/ Mental Health

Nursing Giving Emotional Care Third Edition, Murray & Huelskoetter, 1991)

Incidence

Schizophrenia affects around 0.3–0.7% of people at some point in their life, or 24 million

people worldwide as of 2011 (about one of every 285).

Despite the received wisdom that schizophrenia occurs at similar rates worldwide, its

prevalence varies across the world, within countries, and at the local and neighborhood level. It

causes approximately 1% of worldwide disability-adjusted life years (DALYs). The rate of

schizophrenia varies up to threefold depending on how it is defined.

According to World Health Organization, schizophrenia is one of the top 10 cause of

disabilities in developed countries. A disability survey made by the National Statistics Office

(NSO) showed it is among the third most common form of disabilities with prevalence rate of 88

cases per 100,000 population. The NSO revealed that the region with the highest prevalence rate
is southern Tagalog at 132.9 cases per 100,000 population, followed by NCR at 130.8 per

100,000 population and Central Luzon at 88.2 per 100,000 population.

2 Major Categories of the Symptoms of Schizophrenia

1. Positive or hard symptoms/signs

These include delusions, hallucinations, and grossly disorganized thinking, speech, and

behavior.

2. Negative or soft symptoms/signs

These include flat affect, lack of volition, and social withdrawal or discomfort.

Medication can control the positive symptoms, but frequently the negative symptoms

persist after positive symptoms have abated. The persistence of these negative symptoms over

time presents a major barrier to recovery and improved functioning in the client’s daily life.

Types of Schizophrenia According to the DSM-IV-TR

1. Schizophrenia, paranoid type: characterized by persecutory (feeling victimized or spied

on) or grandiose delusions, hallucinations, and, occasionally, excessive religiosity

(delusional religious focus) or hostile and aggressive behavior

2. Schizophrenia, disorganized type: characterized by grossly inappropriate or flat affect,

incoherence, loose associations, and extremely disorganized behavior

3. Schizophrenia, catatonic type: characterized by marked psychomotor disturbance,

either motionless or excessive motor activity. Motor immobility may be manifested by

catalepsy (waxy flexibility) or stupor. Excessive motor activity is apparently purposeless

and is not influenced by external stimuli. Other features may include extreme negativism,

mutism, peculiarities of voluntary movement, echolalia, and echopraxia.

 4. Schizophrenia, undifferentiated type: characterized by mixed schizophrenic symptoms

(of other types) along with disturbances of thought affect, and behavior.

5. Schizophrenia, residual type: characterized by at least one previous, though not a

current, episode; social withdrawal; flat affect; and looseness of associations.

Undifferentiated Schizophrenia

Undifferentiated Schizophrenia is a severe and chronic mental disorder that is caused by

a physical breakdown of mental processes that results in a loss of normal emotional responses.

Symptoms include auditory hallucinations (hearing voices), bizarre or paranoid delusions

(strange and compelling beliefs), and disorganized thought or speech.

Undifferentiated Schizophrenia is different from Paranoid Schizophrenia in that

undifferentiated lacks the paranoid symptoms (sense of persecution) that is part of paranoid

schizophrenia. The onset of this disease process usually starts in young adulthood (late teens or

early twenties). The specific causes are not clearly understood although there is evidence that

genetics, early environment, neurobiology and psychological factors may all be contributing

factors to this condition.

Risk factors

A. Non- Modifiable

1. Genetics

Risk of schizophrenia is elevated in biologic relatives of persons with schizophrenia but

not in adopted relatives. The risk of schizophrenia in first-degree relatives of persons with

schizophrenia is 10%. If both parents have schizophrenia, the risk of schizophrenia in their child

is 40%. Concordance for schizophrenia is about 10% for dizygotic twins and 40-50% for
monozygotic twins. Children adopted at birth into a family with no history of schizophrenia still

reflect the genetic risk or tendency for schizophrenia, but genetics cannot be the only factor;

identical twins have only a 50% risk even though their genes are 100% identical.

Two genetically determined processes were of particular importance to schizophrenia, the

"calcium channel pathway" and the "micro-RNA 137" pathway. The calcium channel pathway

includes the genes CACNA1C and CACNB2. The proteins determined by these genes play an

important part in nerve cell processes. CACNA1C and CACNB2 — both of which are involved

in the balance of calcium in brain cells, are implicated in several of these disorders, and could

provide a potential target for new treatments. The micro-RNA 137 pathway includes the gene

MIR137, a known "regulator of neuronal development," and many other genes are regulated by

it.

Current evidence suggests that there are a multitude of genetic abnormalities involved in

schizophrenia, possibly originating from one or two changes in genetic expression. Scientists are

beginning to discover the ways in which specific genes affect particular brain functions and

cause specific symptoms. Genes that have been studied include the neuregulin-1 gene, the

OLIG2 gene, and the COMT gene.

Catechol-O-methyl transferase (COMT) is a catabolic enzyme involved in the

degradation of a number of bioactive molecules; of principal interest to psychiatry, these include

dopamine. The enzyme is encoded by the COMT gene. COMT is located (along with 47 other

genes) in a fragment of chromosome 22q11 which when deleted results in a complex syndrome,

the psychiatric manifestations of which include schizophrenia and other psychoses. These 2

observations have placed COMT near the top of a rather long list of plausible candidate genes for

schizophrenia.
 Neuregulin 1 (NRG1) is a plausible susceptibility gene because of its involvement in

neurodevelopment, regulation of glutamate, proper transmission of messages within the central

nervous system (CNS) and other neurotransmitter receptor expression, and synaptic plasticity.

Earlier research suggests that schizophrenia is associated with changes in myelin, the

fatty substance or white matter in the brain that coats nerve fibers and is critical for the brain to

function properly. Myelin is formed by a group of central nervous cells called oligodendrocytes,

which are regulated by the gene oligodendrocyte lineage transcription factor 2 (OLIG2). Patients

with schizophrenia are known to have insufficient levels of oligodendrocytes, however the

source of this deficiency has not been identified.

2. Neuroanatomic Factors

Abnormal brain structure is found consistently in people with schizophrenia. This

includes enlarged ventricles and asymmetrical hemispheres. Computer Tomography Scan and

Magnetic Resonance Imaging found decrease blood flow to the frontal lobes of people with

schizophrenia. These types of brain abnormalities forecast certain symptoms, like loss of

attention, difficulty with abstract thinking, and the inability to solve problems.

Findings have demonstrated that people with schizophrenia have relatively less brain

tissue and cerebrospinal fluid than other people who do not have schizophrenia; this could

represent a failure in development or a subsequent loss of tissue. CT scans have shown enlarged

ventricles in the brain and cortical atrophy. PET studies suggest that glucose metabolism and

oxygen are diminished in the frontal cortical structures of the brain. The research consistently

shows decreased brain volume and abnormal brain function in the frontal and temporal areas of

persons with schizophrenia. This pathology correlates with the positive signs of schizophrenia

(temporal lobe) such as psychosis and the negative signs (frontal lobe) such as lack of volition or
motivation and anhedomia. It is unknown if these changes in the frontal and temporal lobes are

the result of failure of these areas to develop properly or if a virus, trauma, or immune response

has damaged them. Intrauterine influences such as poor nutrition, tobacco, alcohol, and other

drugs, and stress also are being studied as possible causes of the brain pathology found in people

with schizophrenia.

The most prominent and consistent finding in schizophrenia is an enlarged ventricular

system with a subsequent decreased brain volume, with reduced regional hippocampus, thalamus

and frontal lobes. Someone with the diagnosis of schizophrenia has a structural change within

the limbic system that often creates impulsivity, aggression, and sexually inappropriate behavior.

B. Partially Modifiable

1. Neurochemical factors

The neuronal networks that transmit information by electrical signals from a nerve cell

through its axon and across the synapse require a complex series of biochemical events; studies

have implicated the actions of dopamine, serotonin, norephinephrine, acetylcholine, glutamate,

and several neuromodulary peptides.

Currently the most prominent neurochemical theories involve dopamine and serotonin.

One prominent theory suggests excess dopamine as a cause. This theory was developed based on

two observations. First, drugs that increase activity in the dopaminergic system, such as

amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to

schizophrenia. Second, drugs blocking postsynaptic dopamine receptors reduce psychotic

symptoms; in fact, the greater the ability of the drug to block dopamine receptors, the more

effective it is in decreasing symptoms of schizophrenia.

 Serotonin has been included among the leading neurochemical factors affecting

schizophrenia. The theory modulates and helps control excess dopamine. Some believe that

excess serotonin itself contributes to the development of schizophrenia. Newer atypical

antipsychotics such as clozapine (Clozaril) are both dopamine and serotonin antagonists. Drug

studies have shown that clozapine can dramatically reduce psychotic symptoms and ameliorate

the negative signs of schizophrenia.

Researchers also are exploring the possibility that schizophrenia may have three separate

symptom complexes or syndromes: hallucinations/delusions; disorganization of thought and

behavior; and negative symptoms. Investigations show that three syndromes relate to

neurobiologic differences in the brain. It is postulated that schizophrenia has subgroups, which

may be homogenous relative to course, pathophysiology, and therefore, treatment.

Positive symptoms of schizophrenia are related to the function of a combination of

neurotransmitters, primarily the overproduction of dopamine or inhibition of dopamine reuptake.

Dopamine monitors energy levels and controls metabolism and as evident by the manic-like

characteristics of positive symptoms, dopamine can also produce physiological effects similar to

those induced by amphetamines.

Dopamine also plays a role in cognition, mood, attention, and learning, which accounts

for symptoms like thought disorders (disorganized thinking and thought blocking), movement

disorders (catatonic stupor or catatonic excitement), delusions (persecutory, erotomanic,

grandiose, somatic, or broadcasting), hallucinations, and in paranoid schizophrenia.

Hallucinatory and delusional symptoms can be attributed to abnormalities in

acetylcholine pathways as well. Acetylcholine is the regulatory neurotransmitter responsible for

processing sensory input and accessing stored information. Abnormalities at this level can result

in misreading sensory information and memory problems.

Although negative symptoms can also be related to dopamine, other neurotransmitters

such as gamma-aminobutyric acid (GABA), serotonin, and acetylcholine can also account for the

depression-like symptoms experienced on the other extreme of the schizophrenic symptom

spectrum.

GABA is the primary inhibitory neurotransmitter of the nervous system and is

responsible for producing endorphins. Under peak functionality, GABA promotes relaxation,

however abnormalities in its production or distribution can have opposing effects which result in

negative symptoms. Negative symptoms consist primarily of emotional and physical apathy.

Glutamate is the key excitatory neurotransmitter in the brain and plays a primary role in

prefontral cortical function and vital behavioral activities, including memory and learning.

Mounting evidence implicates dysregulation glutamate neurotransmission in the pathogenesis of

schizophrenia and prefrontal cortical functioning.

2. Immunovirologic factor

Theories have emerged that exposure to a virus or the body’s immune response to a virus

could alter the brain physiology of people with schizophrenia. Although scientists continue to

study these possibilities, few findings have validated them.

Cytokines are chemical messengers between immune cells, mediating inflammatory and

immune responses. Specific cytokines also play a role in signaling the brain to produce

behavioral and neurochemical changes needed in the face of physical or psychological stress to

maintain homeostasis. It is believed that cytokines may have a role in the development of major

psychiatric disorders such as schizophrenia.

 C. Modifiable

1. Life Experiences

The chance of developing schizophrenia has been found to increase with the number of

adverse social factors (e.g. indicators of socioeconomic disadvantage or social exclusion) present

in childhood. Stressful life events generally precede the onset of schizophrenia. A personal or

recent family history of migration is a considerable risk factor for schizophrenia, which has been

linked to psychosocial adversity, social defeat from being an outsider, racial discrimination,

family dysfunction, unemployment and poor housing conditions. Childhood experiences of abuse

or trauma are risk factors for a diagnosis of schizophrenia later in life. Recent large-scale general

population studies indicate the relationship is a causal one, with an increasing risk with

additional experiences of maltreatment, although a critical review suggests conceptual and

methodological issues require further research. There is some evidence that adversities may lead

to cognitive biases and/or altered dopamine neurotransmission, a process that has been termed

"sensitization". Specific social experiences have been linked to specific psychological

mechanisms and psychotic experiences in schizophrenia. In addition, structural neuroimaging

studies of victims of sexual abuse and other traumas have sometimes reported findings similar to

those sometimes found in psychotic patients, such as thinning of the corpus callosum, loss of

volume in the anterior cingulate cortex, and reduced hippocampal volume.

2. Family Relationship

Evidence is consistent that negative attitudes from others increase the risk of

schizophrenia relapse, in particular critical comments, hostility, authoritarian, and intrusive or

controlling attitudes (termed 'high expressed emotion' by researchers). Although family members

and significant others are not held responsible for schizophrenia - the attitudes, behaviors and
interactions of all parties are addressed - unsupportive dysfunctional relationships may also

contribute to an increased risk of developing schizophrenia.

3. Alcohol

Gamma-aminobutyric acid (GABA) is the brains most abundant inhibitory, or “calming”

neurotransmitter. While GABA is known primarily for its ability to put you in a relaxed state, it

actually plays a crucial role in regulating many aspects of mood, attention, cognition, and sleep.

GABA deficiency symptoms may involve any of these functions and include depression, anxiety,

and insomnia.

While alcohol doesn’t increase GABA, it does increase the amount pf serotonin and

dopamine released in the brain. Even drinking a little bit of alcohol of serotonin and dopamine in

your brain and stimulate certain reward centers. This is why people feel pleasurable effects when

they drink.

4. Smoking

Excess dopamine is the best biological explanation we have for psychotic

illnesses such as schizophrenia. It is possible that nicotine exposure, by increasing the

release of dopamine, causes psychosis to develop.

MANIFESTATIONS

DSM 5 Criteria

The DSM 5 outlines the following criterion to make a diagnosis of schizophrenia:

1. Two or more of the following for at least a one-month (or longer) period of time, and

at least one of them must be 1, 2, or 3:

 Delusions

 Hallucinations

 Disorganized speech

 Grossly disorganized or catatonic behavior

 Negative symptoms, such as diminished emotional expression

1. Impairment in one of the major areas of functioning for a significant period of time

since the onset of the disturbance: Work, interpersonal relations, or self-care.

2. Some signs of the disorder must last for a continuous period of at least 6 months. This

six-month period must include at least one month of symptoms (or less if treated) that

meet criterion A (active phase symptoms) and may include periods of residual symptoms.

During residual periods, only negative symptoms may be present.

3. Schizoaffective disorder and bipolar or depressive disorder with psychotic features

have been ruled out:

 No major depressive or manic episodes occurred concurrently with active phase

symptoms

 If mood episodes (depressive or manic) have occurred during active phase symptoms,

they have been present for a minority of the total duration of the active and residual

phases of the illness.

Others:

General Appearance, Motor Behavior and Speech

 Appearance may vary widely among different clients with schizophrenia.

 Some may appear normal in terms of being dressed while some may wear strange or

inappropriate clothing.

 Odd or bizarre behavior

 Overall motor behavior may appear odd

 Restless and unable to sit still

 Agitation and pacing

 Appear unmoving (catatonia)

 Demonstrate seemingly purposeless gestures (stereotypic behavior)

 Odd facial expressions such as grimacing

 Echopraxia – imitate the movements and gestures of someone whom the patient is

observing

 Psychomotor retardation – general slowing of all movements

 Sometimes immobile and curled into a ball (fetal position)

  Waxy flexibility – maintain any position in which they are placed, even if the position is

awkward or uncomfortable (for catatonic type of schizophrenia)

 Unusual speech patterns

o Word salad – jumbled words and phrases that are disconnected or incoherent and

make no sense to the listener

o Clang association – ideas that are related to one another based on sound or

rhyming rather than meaning

o Neologisms – words invented by patient

o Verbigeration – stereotyped repetition of words or phrases that may or may not

have meaning to the listener

o Stilted language – use of words or phrases that are flowery, excessive and

pompous

o Perseveration – persistent adherence to a single idea or topic and verbal repetition

of sentence, phrase, word, even when another person change the topic

o Word salad – combination of jumbled words and phrases that are disconnected

and incoherent and make no sense to the listener.

 Echolalia – repetition or imitation of what someone else says

 Slowed or accelerated speech in rate and volume; may speak in whispers or hushed tones

or may talk loudly or yell

 Latency of response – hesitation before the client responds to questions which may last

30 or 45 seconds and usually indicates the client’s difficulty with cognition or thought

processes

Mood and Affect

  Flat affect or blunted affect

 Silly characterized by giddy laughter for no reason

 Inappropriate expression or emotions incongruent with the context of the situation

 Anhedonia – feeling depressed and having no pleasure or joy in life

 exaggerated feelings during episodes of psychotic or delusional thinking

 lack of energy during chronic or long-term phase of illness

Thought Process and Content

 distorted thought processes

 disrupted continuity of thoughts and information processing

 thought blocking

 thought withdrawal – believe that others are taking their thoughts

 thought insertion

 poverty of content (alogia) – lack of any real meaning or substance in what the client says

Delusions

 experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase

of Illness

Sensorium and Intellectual Processes

 Hallucinations – hallmark symptom of schizophrenic psychosis

o Auditory hallucination – most common type of hallucination experienced

 Depersonalization

 Disoriented to time, place, person

  Poor intellectual functioning related to disordered thoughts

 Difficulty with abstract thinking

Judgment and Insight

 Impaired judgment

 Impaired insight

Self-concept

 Deterioration of self-concept

 Loss/lack of ego boundaries

 Body image distortion

 Low self-esteem

Roles and Relationships

 Social isolation

 Problems with trust and intimacy

 Inability to establish satisfactory relationships

 Cannot fulfill roles in the family and community

Physiologic and Self-care Considerations

 Self-care deficits

 Malnourishment and constipation – secondary to failure to recognize hunger or thirst

 Sleep problems – insomnia

Prognosis
 Individuals with schizophrenia have more than twice the rate of death than those without

the disorder. Almost half of people with schizophrenia will suffer from a substance-use disorder

(for example, alcohol, marijuana, or other substance) during their lifetime. Research shows that

Cognitive remediation continues to be an experimental treatment that addresses the cognitive

problems that are associated with schizophrenia (for example, memory problems, and learning

problems). Studies using this intervention in combination with vocational rehabilitation to

improve work functioning have shown some promise, but more research is needed, particularly

that which focuses on improving how well the person with schizophrenia functions in real-world

situations as a result of this treatment.

Peer-to-peer treatment is a promising possible intervention since it promotes active

constructive involvement from people who have schizophrenia, provides role models for

individuals whose functioning is less stable, and may be accessible in individual and group

settings, in person as well as by telephone or through the Internet. However, further research is

necessary to demonstrate its effectiveness in decreasing symptoms or otherwise clearly

improving functioning for people with schizophrenia.

In terms of weight management, more research is needed to explore how to best help

people with schizophrenia retain the weight loss they achieve and even to prevent weight gain in

the first place.

People with schizophrenia or schizoaffective disorder have a better quality of life if their

family members tend to be more supportive and less critical of them.

VI. MENTAL HEALTH STATUS

A. GENERAL DESCRIPTION
 Josan Marie Capili is 31 years old. She is mesomorph, appears clean and neat wearing their

uniform. Her apparent age is congruent with her actual age. She was comfortably sitting

during the interview and maintains good eye contact. Her gait is normal and her back is

slouched when sitting. Her rate of speech is normal, fluent and clear with good articulation

and she displays blunted affect. She responds to questions without any delay.

B. EMOTIONAL STATUS

Her facial expression is not congruent on the way she answers the question, because most

of the time she displays blunted affect, she has a difficulty portraying the correct emotions

relating to the situation. For example, after the movement therapy, when asked how she

felt, the patient answered “masigla at nabuhayan po” but displays a poker face. When the

student nurse asked about her past experiences, blunted affect was noted and when she

asked about her current mood or feelings, the patient claimed that she feels okay and

contented. She smiles at times, but when she is not talking, it seems like she is thinking

about something deeply.

C. THOUGHT CONTENT, PROCESSES AND EXPERIENCES

The patient stated that she is not experiencing any dreams at all. Problems in thought

content and process are not evident to the client during the examination.

D. SENSORIUM AND COGNITION

Level of Orientation

The client is oriented with time, place and the person herself. When the student nurse asked

about where she was at the moment, she stated that she is at National Center for Mental
Health, and she was also asked about the date that time and she stated it correctly which she

said that it was “July 4, 2018 araw ng miyerkules”.

As for the memory, the client was asked for his immediate, recent, and remote memory.

For the immediate memory, she was asked what therapy was done earlier that day. She said

Occupation therapy which is correct. For the recent memory, she was asked what she ate

this morning. She answered “kumain kami ng pandesal at uminom ng isang basong tubig”.

For the remote memory, she was asked what is reason why her grandmother and grandfather

died. She answered, “Yung grandmother ko namatay dahil sa cancer at yung grandfather ko

naman ay namatay dahil sa sakit na hypertension at diabetic, she also stated the date of their

marriage which is on October 28, 2010.

The digit span test which the client repeat are the following numbers 3, 8, 6, 5, 1, 7, 4,

2,3,8, and after 2 trials she was able to repeat 3, 8, 6, 5, 3, 8 and the rest she wasn’t able to

repeat them because she was not able to recall them. She was also asked to repeat it

backwards and she was able to say the numbers, 8, 3, 2, 6, 8, 3, she was only state 4 digits

correctly. The client is an average level because she stated 6 digits correctly forward and 6

digits backward.

The Serial 7’s test was performed and the client answered immediately and answered it all

correctly which is considered normal. The client was also asked different questions such as:

1. How many days are there in a week?

Answer: “7 days sir”

2. How many months are there in a year?

Answer: “12 months sir”

3. What should you do to make water boil?

 Answer: “papakuluan sir”

4. What is celebrated every December 25? February 14?

Answer: “Christmas sir; valentine’s sir”

For the vocabulary, she was asked to interpret different words.

1. Love

Answer: “pag-ibig, pagmamahal,”

2. Smile

Answer; “happy, nakangiti”

3. Happiness

Answer: “kaligayahan”

4. Angry

Answer: “nagagalit”

5. Crying

Answer: “lumuluha, umiiyak”

6. Sad

Answer: “nalulungkot”

ABSTRACTION

The client was asked to explain the proverb “Nasa Diyos ang awa, nasa tao ang gawa” and

the client’s response is “kahit sobrang dami nating kasalanan sa isat isa, mapapatawad parin

tayo ng Diyos” at “Ang diyos ang nagpapatawad sa mga taong makasalanan”

JUDGMENT AND COMPREHENSION

 In another scenario, we asked this question “Kung may nakita kang wallet na may laman na

pera at may ID ng taong nakaiwan, ano ang gagawin mo?” The client said “kukunin ko at

isasauli ko sa may ari”.

PERCEPTION AND COORDINATION

She was able to write her full name when she was asked to write on a sheet of blank paper, and

able to draw a simple circle, cross and square.

IV. PSYCHOTHERAPIES

1. Music and Art therapy

Music therapy is the clinical and evidence-based use of music interventions to

accomplish individualized goals within a therapeutic relationship by a credentialed professional

who has completed an approved music therapy program. Music therapy is one of the expressive

therapies, consisting of a process in which a music therapist uses music and all of its facets—

physical, emotional, mental, social, aesthetic, and spiritual—to help clients improve their

physical and mental health. It is a type of expressive arts therapy that uses music to improve and

maintain the physical, psychological and social wellbeing of individuals involves a broad range

of activities such as listening to music, singing and playing a musical instrument. Music is used

to improve the quality of a patient’s life. Music therapy helps the patient with both motor and

communication skills. It is also a reduction of pain, loneliness, and stress as well as improved

feelings of self- esteem.

 Art therapy -involves the use of creative techniques such as drawing, painting, collage,

coloring, or sculpting to help people express themselves artistically and examine the

psychological and emotional undertones in their art. The patient creates using paints, pens,

pencils and many other types of materials to convey emotions that may be difficult painful for

them to put into words. This approach is often used

to help treat trauma, addictions, grief, anxiety and

stress s. The benefits of this therapy are

improvement in mood, resolved conflicts, and a

sense of personal fulfillment and improved self-

observation skills and to reduced stress.

The facilitators played a slow music entitled

“Kanlungan” by Noel Cabangon. During the slow

music therapy, the patient drew a house and a tree.

The student nurse asked her and she claimed that she drew their house and the tree beside their

house because she misses their home and she wants to stay in their home already.

Analysis

Listening to music enhanced the patient’s cognitive functions such as memory,

concentration and reasoning skills. This therapy helped her express her feelings because her

drawing was very specific and she briefly explained that her drawing is all about how she

misses home and how she really wanted to stay on their home already. With regards to the

drawing, it was presented through a simple drawing which signifies that the client is selfish.

Moreover, the client also uses light stroke which means inadequacy. The client also uses green

color for the house which indicates that the client has more controlled behavior which is
 evident and observed upon the client throughout the whole encounter. Overall, the client has

still feelings of longingness but it is more controlled as to this moment.

2. Occupational Therapy

Occupational therapy is the only profession that helps people across the lifespan to do

the things they want and need to do through the therapeutic use of daily activities (occupations).

Occupational therapy practitioners enable people of all ages to live life to its fullest by helping

them promote health, and prevent—or live better with—injury, illness, or disability. A form of

therapy for those recuperating from physical or mental illness that encourages rehabilitation

through the performance of activities required in daily life.

Occupational therapy practitioners have a holistic

perspective, in which the focus is on adapting the

environment and/or task to fit the person, and the person

is an integral part of the therapy team. It is an evidence-

based practice deeply rooted in science.

In the Occupational Therapy the patient was able to make a design in the cupcake nicely and

neat. She was able to follow instructions and she performed the activity well and organized. She

designed her cupcake with a girl wearing a smiley face using the different colors.

Analysis

The patient was able to successfully perform the activity. She uses mixed colors in the

designing of her cupcake which signifies that the client has higher level of intellectual

functioning. When asked to present her output, she told them that she designed her cupcake with

smiley face which means that the she is happy and she drew a girl on the cupcake symbolizing
her child. Overall, the design of the cupcake showed that she misses her child and she wants to

be with her child now.

3. Bibliotherapy

Bibliotherapy is an expressive therapy that involves storytelling or the reading of

specific texts with the purpose of healing. It uses an individual's relationship to the content of

books and poetry and other written words as therapy.

In the bibliotherapy the patient is able to verbalize his feelings and thoughts in the short

story/fable read out loud by the student nurses.

The goal of bibliotherapy is to broaden and deepen the client’s understanding of the

particular problem that requires treatment. 

Analysis

Bibliotherapy provides the opportunity for the participants/patients to recognize and

understand themselves. It may reduce feelings of isolation that may be felt by people with

problems. After the short story (si langgam at si tipaklong), questions were asked such as:

a. Ano po ang aral na mapupulot ninyo sa istorya? (Dapat magsumikap sa buhay. Never

give up, kahit anong mangyari tuloy lang ang buhay)

b. Kung kayo po ay pipili, ano po gugustuin ninyo? Maging katulad ni langgam o si

tipaklong? (Si langgam kasi masipag)

Based from her interpretation and analysis of the story, the patient was able to

appropriately reflect and relate life with the storyline hence, the patient has clear understanding

of the story that was read.

4. Remotivation Therapy

Remotivation therapy is defined by the National Remotivation Therapy Org. Inc.

(N.R.T.O.) as “Remotivation is a small group therapeutic modality in nature, designed to help

clients by promoting self-esteem, awareness and socialization.” Those who facilitate these

groups are referred to as Remotivation therapists.  A Remotivation therapy session is designed to

create fun and it consists of five structured steps. Remotivation differs from other therapies

because it focuses on the patient’s abilities rather than on their disabilities.  The major endeavor

is to discuss and develop the patient’s healthy aspect no matter how repressed they maybe.

In the Remotivation therapy the patient will able to cooperate and listen to the pictures

and poems conducted by the student nurses.

5. Movement Therapy

Movement Therapy is defined as the psychotherapeutic use of movement and dance to

support intellectual, emotional, and motor functions of the body. As a form of expressive

therapy, movement therapy looks at the correlation between movement and emotion. The

benefits include stress reduction and mood management. 

Movement is the primary way therapists observe, evaluate, and implement therapeutic

intervention. In the case of our patient, during the movement therapy, she seems to be lacking

energy and drive to join the activity – all throughout the therapy, even with the effort of the

student nurse to encourage her, she still lacks energy and presents with blunt affect.

Also, when asked how she felt after the therapy, there is incongruence of her facial

expression to her verbal answer because the patient was emotionless while saying that she felt

happy and energized after the exercise was done.

 V. DRUG STUDY

1. OLANZAPINE

A. Generic Name : Olanzapine

A. Brand Name : Zyprexa

B. Classification : Atypical Anti-psychotic

C. Dosage, Route, Frequency : 5-10 mg PO BID

D. Mechanism of Action : This drug produces antipsychotic effect by

interfering with the binding of dopamine at D1, D2, D3 and D5 receptors, and has a high affinity

for the D4 receptor in the limbic region of the brain. It also acts as an antagonist at α-adrenergic,

histamine H1, cholinergic and other dopaminergic and serotonergic (5-HT2A) receptors. It

produces fewer extrapyramidal reactions and less tardive dyskinesia than standard anti

psychotics. It is believed that many psychotic illnesses are caused by abnormal communication

among nerves in the brain and that by altering communication through neurotransmitters, thus

can alter the psychotic state.

E. Desired Effect : To maintain her controlled behavior, promote

emotional quieting and decrease hallucinations (auditory) from recurring.

F. Nursing Responsibilities

Nursing Interventions Rationale

1. Check and verify the doctor’s order. To prevent errors in administering the

medication to the patient.

2. Observe the 10 rights in medication To ensure safety and prevent committing
 administration. mistakes.
3. Obtain the patient’s history about To determine if it’s contraindicated to the

allergies and if she experienced a medication.

severe infection.
4. Explain the action of the drug in a To gain cooperation and compliance in

simple manner based on the ability of taking the drug.

the patient to comprehend.

5. Provide diversional activities such as To divert the client’s attention and to

engaging the client to different potentiate the action of the drug.

therapies.
6. Monitor for the adverse and side

effects of the drug as to:

 increase body temperature A transient increase above 100.4° F (38 °C)

may occur, most often within the first 3 weeks

of therapy.

 tachycardia Tachycardia may also be a side effect of the

drug.

 weight gain To check for a sudden increase in body weight.

To prevent injury and falls

 dizziness
7. Document the procedure done. For legal purposes and to provide information

that the procedure has been rendered to the

patient.

2. RISPERIDONE

A. Generic Name : Risperidone

 B. Classification : Atypical Anti-psychotic; Mood stabilizers

C. Dosage, Route, Frequency : 2 mg PO OD HS

D. Mechanism of Action : It blocks the dopamine and 5HT2 receptors in the

brain. Specifically, it inhibits dopaminergic dopamine receptors and serotonergic receptors in

the brain. It may also block histamine receptors, and other neural receptors to improve

schizophrenia

E. Desired Effect : This drug was given to decrease or reduce

symptoms of auditory hallucination. It promotes emotional quieting, produces calmness and

improves alteration in thought to maintain the stability of the client. It also suppresses psychotic

behavior and to decrease it symptoms.

F. Nursing Responsibilities

Nursing Interventions Rationale

Check and verify the doctor’s order. To make sure thus, avoiding mistakes on giving

medication to the patient.

Observe the 10 rights in medication To ensure safety and prevent committing

administration. mistakes.
Observe patient when administering medication. To ensure that the medication is swallowed and

not hoarded or cheeked.

Assist patient to change positions slowly or get To minimize orthostatic hypotension

up from sitting/laying position to standing

position
Monitor patient’s mental status (orientation, For notable changes in behavior that could

mood, and behavior) and mood before and indicate the emergence or worsening of suicidal

periodically during the therapy. thoughts or behavior or depression, especially

 during the therapy.
Monitor and observe the possible side effects of To be able to address the side effects

the drug such as drowsiness, dizziness, light- immediately and prevent worsening of the

headedness, drooling, nausea, weight gain, condition.

tiredness, or hypotension
Monitor patient for onset of extrapyramidal side To be able to refer to the physician immediately

effects (akathisia-restlessness; dystonia-muscle thus action required like reduction of dose or

spasms and twisting motions; pseudo discontinuation may be necessary as ordered and

parkinsonism-mask-like face, rigidity, tremors, to prevent further complications.

drooling, shuffling gait, dysphagia; or

Neuroleptic Malignant Syndrome- fever,

respiratory distress, tachycardia, seizures,

diaphoresis, hypertension).
Document the procedure done. For legal purposes and to provide information

that the procedure has been rendered to the

patient.
Diazepam is a benzodiazepine that exerts anxiolytic, sedative, muscle-relaxant, anticonvulsant
and amnestic effects. Most of these effects are thought to result from a facilitation of the action
of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter in the central nervous
system.