1

A Case Analysis on
SCHIZOPHRENIA

In Partial Fulfillment of the

Requirements in NCM 217 - RLE
MALADAPTIVE NURSING ROTATION

Submitted to:

Mrs. Portia P. Ituhat, RN, MN

Clinical Instructor

Submitted by:

Casilac, Rodney John A., St. N.

Leonor, Stefanie P., St. N.
Monsalud, Janielle Christine T., St. N.
Mucsan, Rohaina M., St. N.
Ng, Katherine A., St. N.

BSN - 3H Group 3 - Subgroup 2

March 12, 2021

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Criteria

Rationale/Personal Profile---------------------------------------------------------------------__/5%

Course in the Hospital

● MSE------------------------------------------------------------------------------------------/10%

Psychodynamics

● Risk Factors-----------------------------------------------------------------------------
__/15%
● Symptomatology--------------------------------------------------------------------------/15%
● Differential Diagnosis-----------------------------------------------------------------__/10%
● Medical Management/Drug Studies/Therapies--------------------------------__/10%
● NCP---------------------------------------------------------------------------------------__/20%
● Prognosis/Recommendation --------------------------------------------------------__/5%
● Bibliography------------------------------------------------------------------------------__/5%
● Mechanics/Promptness/Format-----------------------------------------------------__/5%
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Table of Contents

Introduction ………………………………………………………………….........(page 4)
Goals and Objectives……………………………………………....................... (page 6)
Biographical/Clinical Data & Brief History ………………………………………(page 7)

Course in the Hospital

● MSE…………………………………………………..................................(page 9)

Psychodynamics (page 22)

● Risk Factors …………………………………………………….......................
(page 22)
● Signs and Symptoms ………………………………………………........(page 25)

Laboratory Exams ……………………………………………............................(page 28)

● Differential Diagnosis……………………………………………........ (page 30)

Medical Management (page 39)

● Therapies ……………………………………………….......................... (page 39)
● Drug Studies (Possible) …………………………………………….......(page 45)
● Nursing Theories ………………………………………………...............(page 43)

NCP …………………………………………………………………....................(page 65)

Recommendation ………………………………………………………………...(page 79)
Prognosis …………………………………………………………………............(page 89)
References ……………………………………………………………….............(page 93)
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I. Introduction

Schizophrenia is characterized by skewed and bizarre beliefs, feelings,

gestures, and behaviour. Schizophrenia is not a particular illness; rather, it is
regarded as a condition or a disease process with a wide range of signs and
manifestations, similar to cancer. Many people assumed that people with
schizophrenia should be institutionalized and hidden away from society. Only
recently has the mental health community learned and educated the general public
that schizophrenia has a wide range of symptoms and presentations and is a
treatable disorder.

Positive or hard symptoms/signs, which include delusions, hallucinations, and

grossly disorganized thought, expression, and actions, and negative or soft
symptoms/signs, which include flat affect, lack of volition, and social isolation or
distress, are the two main types of schizophrenia symptoms.

Schizophrenia is most often detected in late adolescence or early adulthood. It rarely

shows up in childhood. Childhood-onset schizophrenia affects around one out of
every 40,000 children. It affects people of all races and backgrounds in the same
way. For men, the peak age of onset is 15 to 25 years old, and for women, it is 25 to
35 years old. Males (1.4:1) and people growing up in cities are more likely to be
diagnosed with it (Haddad et al., 2015). Males are more likely than females to
develop the disease between the ages of 15 and 25, and it is associated with
impaired functioning and more anatomical abnormality in the brain.

The prevalence of schizophrenia is estimated to be about 1% of the population. This

amounts to almost 3 million people in the United States who are, have been, or may
be affected by the disease. Around the world, the incidence and lifespan prevalence
are nearly the same (Jablensky, 2017).

According to data gathered from 10 government hospitals and four private hospitals
for Johnson & Johnson's Philippine Health Information System on Mental Health
Conditions (PHIS-MH), schizophrenia is the most common brain illness in the
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Philippines, affecting at least 42 percent of patients seeking psychiatric help. It is

said that one in five adult Filipinos suffer from mental or psychiatric disorders. This
represents an average of 88 reported cases of mental illness for every 100,000
Filipinos.

The implications of this case in nursing education are that it will improve the
groundwork and broaden the expertise of student nurses in relation to the illness
being highlighted, which will serve as a weapon and tool in caring for clients with
similar conditions. It can serve as a guide and a foundation in nursing practice when
providing services, management, or treatments to clients diagnosed with
schizophrenia, especially therapeutic communication, in order to achieve successful
delivery of optimum health care to them. Finally, in nursing research, it can be a
method for conducting additional studies that will assist potential researchers in
developing new theories and hypotheses that will benefit and enhance the nursing
profession, especially in the field of psychiatric nursing.
 6

II. Goals and Objectives

At the end of this psychiatric nursing rotation, the BSN 3H, Group 3, Subgroup 2 will
acquire and enhance the knowledge, skills and attitudes related to the maladaptive
patterns of behavior concept. The group will be able to better recognize and
comprehend the factors that affect a client's health and overall well-being, especially
in the case of schizophrenia, as well as develop skills relevant to the delivery of
interventions and management of the condition by applying the concepts and
theories developed in delivering high-quality care, and thereby develop compassion
and empathy in dealing with psychiatric patients.

Specifically, the group aims to:

a. introduce the case study by defining what schizophrenia is and by showing

the statistics globally, nationally, and locally;
b. identify how this case study applies to the nursing education, practice, and
research;
c. formulate specific, measurable, attainable, realistic and time bound objectives;
d. present the patient’s biological/clinical data & brief history
e. discuss the Mental Status Exam (MSE);
f. determine the risk factors of the client;
g. identify the symptomatology of the client’s disorder;
h. report the diagnostics/laboratory confirmatory tests;
i. discuss the differential diagnosis of the disorder;
j. elaborate the different managements and therapies applicable to the client, as
well as the drug studies;
k. relate the case study to nursing theories;
l. create two nursing care plans applicable to the client;
m. formulate recommendations for the client;
n. rationalize the prognosis of the case; and
o. cite the references using APA format.
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III. Biographical/Clinical Data/Brief History

Personal Data

Name: Patient X
Nickname: X
Age: 33
Sex: Male
Ordinal rank: 5th
Birthdate: May 17, 1987
Birthplace: Baybay Malalag Davao Del Sur
Civil Status: Single
Address: Baybay Malalag, Davao Del Sur
Current Address: Punta Biao, Digos City
Religion: Islam
Educational Attainment: Elementary level
Occupation: None
Date of Admission: 2011
Physician: Davie Janine S. Padillo, MD

History of Present Illness

In the initial interview, it was mentioned that the symptom/s started

when he worked at the Mango Juice Factory in Toril. He fell in love with a girl,
but he could not tell his feelings to her so he kept it until it reached the point
his way of thinking has been affected by it. His guardian reported, he once
walked from Digos to Toril instead of commuting as his attempt to confront the
girl.

Past Medical and Psychiatric History

In 2011, patient X was first checked-up at Benedictine Clinic in Digos

City. The doctor said that he has a serious mental illness and prescribed
 8

sedative drugs for him. In 2013, he was taken to Southern Philippines Medical
Center as his condition worsened. This includes inflicting violence over his
family members. In 2015, along with his father they went back to Southern
Philippine Medical Center, Institute of Psychiatry & Behavioral Medicine for a
medical check-up conducted by Davie Janine S. Padillo, MD. He was
prescribed with Olanzapine 10 mg to be taken once a day and Amlodipine 10
mg taken once a day.

Family History

He is currently living with his mother and his siblings. When he was 22
years old he could not accept the fact that his parents separated. As time
passed by, he managed to adapt with his current situation. He established a
good relationship with his father and his current partner.

Personal History

Childhood History

During his childhood years, many would describe him as unsociable.

He rarely opens up about his personal life like his performance in school and
his other interactions. He limits establishing friendships and prefers to work on
his own.

a. School History

Patient X is an elementary graduate.

b. Religious Background

Prior to his condition, patient X was a religious person. He goes to

church and prays five times a day.

c. Occupation
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Patient X was once a factory worker at Mango Juice Toril.

d. Drugs, Alcohol and Tobacco History

Patient X has no history of using the said substances.

IV. Course in the Hospital

Mental Status Exam

I. PRE EXAMINATION Mark Description/Verbatim

Quotes

A. General Appearance
The client was properly dressed,
/ moderately groomed, he appears to
1. Grooming and be wearing baggy clothes; shirt and
dressing pants.

2. Hygiene

a. Note evidence of
body or breath odor
b. Condition of /
The patient’s skin is dry. His
skin, fingernails
fingernails and toenails are
c. Disheveled
untrimmed.
d. Untidy

3. Height and Weight

a. Perform
 10

accurate
measurements

4. Level of Eye Contact

a. Intermittent
/
b. Occasional and He rarely maintains eye contact.
fleeting
c. Sustained and intense
d. No eye contact

5. Hair and Color Texture

a. Is hair clean The hair color of the client is black,

/
and healthy it is clean, well-trimmed, and is
looking? healthy looking.
b. Greasy,
matted, tangled

6. Evidence of scars, No evidence of scars, tattoos, or

X
tattoos or other other distinguishing skin marks.
distinguishing skin marks
a. Note any evidence
of swelling or
bruises
b. Birthmarks
c. Rashes

7. Evaluation of client’s The patient’s appearance is

/
appearance compared with appropriate to his chronological
chronological age, age, because the patient is well
deterioration of guided by his parents/guardians.
appearance, client needs to
be reminded
 11

B. General Mobility

1. Posture The patient’s posture is hunchback.

/
a. Posture If standing, he appears to be
b. Note if standing slumped over.
upright, rigid,
slumped over
Note for:
● Catatonia
● Catatonic
● Stupor
● Catatonic
Rigidity
● Catatonic
posturing
● Waxy
flexibility
● Catalepsy
● Cataplexy

2. Gait patterns

a. Any evidence The patient has no evidence of

X
of limping limping.
b. Limitation of
range of motion
c. Ataxia
d. Shuffling

C. Motor Activity The patient is normoactive and plays

Note for: by himself (raising his hands, walking

around and pointing his hands
● Normoactivity /
elsewhere).
● Hyperactivity
● Psychomotor
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retardation
● Agitation
● Tremors (hands, legs,
continuous, at specific
time
● Tics
● Jerky or spastic The patient’s stereotypical
movements movements are raising his hands
● Stereotypical often, pointing up and talking by
Movements / himself.
● Mannerisms and He always rubs his fingers.
Gestures
/
● Aggressiveness
● Echopraxia
● Bradykinesia
● Pacing and Rocking
● Somnambulism
● Anchoring
● Anergia
● Anhedonia
● Regression
● Compulsions

D. Behavior/ Nurse
patient Interaction

a. Cooperative The patient is cooperative.

/
b. Cooperative (initially,
/ During the interview he initially
all throughout)
interacted and showed cooperation
c. Uninterested/Apathe
that he is willing to be interviewed.
tic
d. Friendly
e. Embarrassed
f. Seductive
 13

g. Impulsive
h. Negativistic
i. Indifferent
j. Angry/hostile
k. Evasive
l. Withdrawn He seemed warm during the interview
/
m. Warm because he easily answered the
n. Distant questions that were given to him.
o. Guarded/Suspiciou
p. Dependent
q. Distracted

II. STREAM OF TALK Mark Description/Verbatim Quotes

a. Character

Note for:

● Slowness or rapidity
● Intonation
● Volume
● Stuttering, hoarseness,
slurring
● Spontaneous
● Blocking The patient easily answered the
/
● Deliberate questions, but when I repeat a question
● Pressured he blocks out and cannot answer the
● Aphasia question.

B. Organization of Talk/Form

a. Relevant / The patient’s answers were relevant,

b. Irrelevant but he always answered the

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c. Incorrect
questions in one word.
d. Flight of Ideas
e. Loose association
f. Circumstantiality
g. Tangentiality
h. Neologism
i. Concrete Thinking
j. Clang Association
k. Word Salad
l. Perseveration
m. Echolalia
n. Mutism
o. Bradylalia
p. Poverty of Speech
q. Glossolalia /
r. Coprolalia
s. Verbigeration
t. Condensation

III. EMOTIONAL
STATE AND Mark Description/Verbatim Quotes
REACTIONS

A. Mood

a. Euthymic
The patient lacked energy during the
b. Depression/despairing
/ interview which indicates anergia. He
c. Euphoria
also has a depressive face, but when
d. Elation
I start asking he suddenly shifts his
e. Fearful
mood and laughs.
f. Irritable
g. Anxious
h. Guilty
i. Labile
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B. Affect

a. Congruence with mood

b. Constricted/ Blunted
c. Flat / There are delays with his response

d. Appropriate as well, therefore blunted when it

e. Inappropriate / comes to affect. However, he always

answers the question appropriately.

IV. THOUGHT
Mark Description/Verbatim Quotes
CONTROL/ PROCESS

Content of Thought The patient’s mother said that her son

always talks about a girl that he madly
A. Delusions
fell in love with where they think she is
a. Persecutory
the reason behind the patient’s
b. Grandiose
condition. Therefore, the patient has
c. Reference/ideas of
an erotomanic delusion.
reference
d. Control/Influence
(Thought
Broadcasting, Thought
Withdrawal, Thought
Insertion)
e. Somatic
f. Nihilistic /
g. Erotomanic
h. Jealous
i. Religious

B. Suicidal Thought/ideation

a. Attempt The patient has no history of suicidal

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b. Threat attempts, and denied suicidal and

X
c. Gestures homicidal ideation.

C. Obsessions The patient is obsessed with a girl he

/
fell in love with. If someone asks him
who his girlfriend is, he will answer the
name of the girl and he would also say
that they have two children.

D. Magical Thinking The patient does not manifest any

X
belief or superstition or that he has
magical powers in his words or
actions.

E. Phobia The patient does not have any phobia.

X

F. Poverty of Content
Perceptual
Disturbances:
The patient said, “I see things,” but it
Hallucination is unclear at this point whether what
the patient is referring to. However,
a. Hypnagogic
there was obvious evidence of the
b. Hypnopompic
/ patient seeing people or objects. His
c. Visual
parents observed that their son has
d. Auditory
been talking with someone that they
e. Tactile
cannot see, and sometimes he would
f. Olfactory
talk to his shadow. Therefore, it could
g. Gustatory
indicate visual hallucination.
h. Trailing Phenomenon
i. Micropsia (Lilliputian)
j. Marcopsia
 17

Illusions:

a. Visual
b. Auditory
c. Tactile
d. Olfactory
e. Gustatory

Depersonalization
a. Derealization

Preoccupation

a. Ruminations

Déjà vu

a. Jamais vu

Impulse Control

a. Ability to
control
The patient is still affectionate toward
impulses
his previous person of interest.
b. Aggression
Sometimes the patient would bring up
c. Hostility
sexual intention such as sexual
d. Fear
assault and thought of killing.
e. Guilt
f. Affection /

g. Sexual feelings /

V.
Mark Description/Verbatim Quotes
NEUROVEGETATIV
E DYSFUNCTIONS
 18

A. Sleep

a. Normal Patient’s sleep pattern is irregular; he

b. Hypersomnia may be experiencing MNA, he would
c. MNA / wake up usually around midnight. His
d. EMA mother reported of him murmuring and
e. DFA stating his sexual urges like commiting
f. Interrupted rape.

B. Appetite So far, patient X has no eating

/
problems.
a. Poor/fair/good
b. Polyphagia
c. Voracious
d. Pica
e. Binge eating
f. Coprophagia

C. Diurnal Variation The patient’s mood of pattern is

/
subjective to the person he is
talking to.

D. Weight

E. Libido The patient’s libido increases

since he always mentioning
about committing rape.

VI. GENERAL
Mark Description/Verbatim Quotes
SENSORIUM AND
INTELLECTUAL
 19

STATUS

Describe
impaired or
unimpaired

The patient is only oriented to

A. Orientation (place,
person and place but unaware
time, person, situation) /
of the current date and time.

B. Memory

a. Recent The patient cannot remember about his

/
b. Remote personal details such as his birthday
c. Immediate and age.
d. Confabulation
e. Agnosia
f. Apraxia
g. Amnesia

C. Attention Span

D. General Information In general, the patient apparently has

disturbances in posture and gait,
mood and affect and is aware of his
mental condition. He was observed
to have a slouched posture and gait
with his mood swings occurring too
often.

E. Abstract Thinking
Ability
 20

F. Judgment /Reasoning The patient cannot solve or make

1. Ability to solve his own decisions and plans, since I

/
problems and make asked him if he would be given a

decisions, make plans for chance to have a vacation during

the future this pandemic where he would want

to go,and he said “wala koy
maingon”.

VII. INSIGHT
Mark Description/Verbatim Quotes

Describe impaired At this point the patient has fair

or unimpaired insight. He knows his condition but
Knowledge about he cannot explain it in complete
Self, limitations detail.

1. Awareness of illness

Ask: Do you think you

have a problem?

Do you think you need

treatment?

Adaptive/Maladaptive
use of coping
mechanism

VIII. SUMMARY OF MSE

A. Disturbances in:
( ) Presentation
( ) Stream of Talk
( ) Emotional State and
 21

Reactions
( ) Thought Processes
( ) Neurovegetative
Dysfunctions
( ) Sensorium and
Intellectual Status
( ) Insight
B. Diagnostic Category
(DSM IV : Diagnostic and
Statistical Manual of Mental
Disorders

V. Psychodynamics

a. Risk Factors

Factors Present Justification Rationale

Genetic Factors X There is no one in the Schizophrenia runs in

family with families, but no one
schizophrenia or any gene is believed to be
mental disorders. to blame. It's more
likely that different
genetic combinations
make people more
susceptible to the
disease. Getting these
genes, however, does
not guarantee that one
will develop
schizophrenia.
 22

Stress / In the past, when he Stress plays an

was working in Toril, he important part in the
liked someone, he management of the
however found it hard to disease. Schizophrenia
confess, letting his makes people very
feelings bottled up. He vulnerable to stress and
came home to Digos transition. An episode
because he quit his job. can be triggered simply
Because he liked that by psychological stress.
girl so much, he walked One of the most critical
from Digos to Toril to aspects of preventing
see her. relapse is developing
and sustaining a
routine.

Life Changing / When he was young, his In the period leading up

Events parents separated, to a first psychotic
leading the client to be episode, people's lives
depressed. are often filled with loss.
However, early-onset
symptoms such as
skepticism, memory
disruption, withdrawal,
and lack of motivation
are often the cause of
those losses (such as
relationships,
employment, education,
injuries, and so on). In
other words, previously
undiagnosed
schizophrenia can be
the catalyst for a variety
of life-altering incidents,
 23

rather than the other

way around.

Drug Abuse X The client did not Drugs do not directly

mention drugs or vices. cause schizophrenia,
but studies have shown
drug misuse increases
the risk of developing
schizophrenia or a
similar illness.

Certain drugs,
particularly cannabis,
cocaine, LSD or
amphetamines, may
trigger symptoms of
schizophrenia in people
who are susceptible.
Using amphetamines or
cocaine can lead to
psychosis, and can
cause a relapse in
people recovering from
an earlier episode.

Environmental / The client lives in the Scientists think that

Factors squatter’s area. They interactions between
are living in a noisy genetic risk and
environment as there aspects of an
are many kids in their individual’s environment
house. may play a role in the
development of
schizophrenia.
Environmental factors
that may be involved
 24

include living in poverty,

stressful surroundings,
and exposure to viruses
or nutritional problems
before birth.

b. Signs and Symptoms

Symptoms Present Justification Rationale

Delusions / The client has Delusions are

delusions. He has an extremely common in
erotomanic delusion. schizophrenia,
If asked if he has a occurring in more than
girlfriend, he would 90% of those who
say the name of the have the disorder.
girl and say they have Often, these delusions
two kids. involve illogical or
bizarre ideas or
fantasies.

Hallucinations / He has hallucination Seeing or hearing

as sometimes he something that
would talk to himself doesn't happen is a
saying, “Should we common occurrence.
rape them and also kill The individual with
them?” then he would schizophrenia, on the
laugh afterwards. other hand, is
subjected to the full
force and effect of a
normal experience.
Hearing voices is the
most common
 25

hallucination, but
hallucinations can
occur in any
context.Command
hallucinations are
voices demanding
that the
client take action,
often to harm the self
or others, and are
considered
dangerous.

Disorganized X During the interview, Disorganized

Thinking when asked about expression may be
various questions like used to infer
who is the president, disorganized thought.
or what is COVID he Communication may
answered the right be hampered, and
answers to the right responses to
questions. questions can be
partly or entirely
unrelated. Rarely,
speech can involve
the use of
meaningless terms
that are difficult to
understand, a practice
known as word salad.

Extremely / In the interview, when This can manifest

disorganized or answering questions, itself in a variety of
abnormal motor he would smile and ways, ranging from
behavior then frown while childish silliness to
looking down, as he erratic agitation. It's
 26

keeps on touching his difficult to complete

hands. He would also tasks when behavior
play as if he is a child. isn't based on a
target. Resistance to
orders, improper or
bizarre posture, a total
lack of response, or
unnecessary and
repetitive movement
are all examples of
behavior.

Negative / When the interview This is a term that

Symptoms was conducted, he describes a
would avoid eye diminished or absent
contact and speak in a capacity to act
monotonous, low normally. The
voice. He has a blunt individual may, for
affect. example, neglect
personal hygiene or
appear emotionless
(i.e., does not make
eye contact, does not
alter facial
expressions, or
speaks in a
monotone). In
addition, the individual
can lose interest in
daily activities,
withdraw socially, or
be unable to enjoy
pleasure.
 27

VI. Laboratory Exams

● Physical Examination

The family's medical and psychological background, as well as information about

pregnancy and early childhood, travel history, and a history of drugs and drug abuse,
are all crucial. Other causes of psychotic symptoms can be ruled out with this
information. A general physical examination normally yields noncontributory results.
This test is needed to rule out any other illnesses. Since antipsychotic medications
may trigger certain neurological symptoms, a neurologic test can be useful as a
guide before starting them. Before receiving antipsychotic medication, some people
with schizophrenia experience motor disturbances. Left and mixed handedness, mild
physical abnormalities, and soft neurologic symptoms have also been linked to
schizophrenia.

● Psychological Functions

The doctor or therapist then determines whether the person's symptoms point to a
specific disorder as defined by the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), which is the standard reference book for recognized mental
illnesses and is published by the American Psychiatric Association. An individual is
diagnosed with schizophrenia if they have two or more core symptoms for at least
one month, one of which must be hallucinations, delusions, or disorganized speech,
according to the DSM-5.

● Medical Diagnostics

Schizophrenia is not associated with any characteristic laboratory results. The

following should be performed on all patients, both at the beginning of the illness and
periodically afterward, to rule out other or concomitant illnesses:

● Complete blood cell (CBC) count

● Liver, thyroid, and renal function tests
 28

● Electrolyte, glucose, vitamin B-12, serum methylmalonic acid, folate, and

calcium levels
● Pregnancy testing (if the patient is a woman of childbearing age)
● Urine testing for drugs of abuse, such as alcohol, cocaine, opioids, cannabis
● Urine for culture and sensitivity (to look for urinary tract infection)
● Brain imaging to rule out subdural hematomas, vasculitis, cerebral abscesses,
and tumors
● Tests that scan and make pictures of the body and brain, like magnetic
resonance imaging (MRI) or computed tomography (CT scan), might also help
rule out other problems, like a brain tumor.

a. Differential Diagnosis (3)

Schizophrenia

Criteria Mark Justification

 29

A. Two (or more) of the following, 1. The patient is saying that

each present for a significant he has 2 children from the
portion of time during a 1-month woman that he believes to
period (or less if successfully be in love with him ; it is
treated). At least one of these must according to the relative of
be (1), (2), or (3): the patient.
/ 2. The patient is experiencing
1. Delusions.
hallucinations, according to
/
2. Hallucinations. the patient’s relative he is
X talking and laughing to
3. Disorganized speech (e.g., someone even if there is no
frequent derailment or one with him.
incoherence). 3. During the interview the
X
patient's speech and words
4. Grossly disorganized or catatonic
are well organized.
behavior.
4. When interviewing the
/
5. Negative symptoms (i.e., client his behavior is
diminished emotional expression or normal except when he is
avolition). having hallucination.
5. The patient is manifesting
some negative symptoms
like depression; the client
developed his disorder
because of heartbreak and
that cause him to become
depressed, blunted affect;
when asking questions to
the patient his emotion and
tone is flat and lastly the
flat affect; which is the
facial expression of the
patient is flat when the
 30

student nurse is asking

questions except when he
is experiencing
hallucination.

B. For a significant portion of the / - The patient’s relative stated

time since the onset of the that they are assisting the
disturbance, level of functioning in client in his activities of
one or more major areas, such as daily living and the patient
work, interpersonal relations, or does not have a job.
self-care, is markedly below the
level achieved prior to the onset (or
when the onset is in childhood or
adolescence, there is failure to
achieve expected level of
interpersonal, academic, or
occupational functioning).

C. Continuous signs of the / - The patient has manifested

disturbance persist for at least 6 hallucination for more than
months. This 6-month period must 10 years according to the
include at least 1 month of patient’s relative.
symptoms (or less if successfully
treated) that meet Criterion A (i.e.,
active-phase symptoms) and may
include periods of prodromal or
residual symptoms. During these
prodromal or residual periods, the
signs of the disturbance may be
manifested by only negative
symptoms or by two or more
symptoms listed in Criterion A
present in an attenuated form (e.g.,
 31

odd beliefs, unusual perceptual

experiences).

D. Schizoaffective disorder and / - The patient has no major

depressive or bipolar disorder with
psychotic features have been ruled
out because either
1) no major depressive or manic
episodes have
concurrently with the active-phase
symptoms, or
depressive or manic
episodes that occurred
currently, according to the
patient’s relative the patient
became manic last 2016.
occurred

2) if mood episodes have occurred

during active-phase symptoms,
they have been present for a
minority of the total duration of the
active and residual periods of the
illness.

E. The disturbance is not X - The patient has not used

attributable to the physiological any drugs or taken any
effects of a substance (e.g., a drug medication.
of abuse, a medication) or another
medical condition.

F. If there is a history of autism X - According to the patient's

spectrum disorder or a relative and also in medical
communication disorder of history the client has no
childhood onset, the additional history of autism spectrum
diagnosis of schizophrenia is made disorder.
only if prominent delusions or
hallucinations, in addition to the
other required symptoms of
 32

schizophrenia, are also present for

at least 1 month (or less if
successfully treated).

MAJOR DEPRESSIVE DISORDER

CRITERIA MARK JUSTIFICATION

A. Five (or more) of the

following symptoms have been
present during the same 2-
week period and represent a
change from previous
functioning; at least one of the
symptoms is either (1)
depressed mood or (2) loss of
interest or pleasure.

Note: Do not include

symptoms that are clearly
attributable to another medical
condition.

1. Depressed mood most of the / - The client is always alone,

day, nearly every day, as quiet and sad. According to the

indicated by either subjective patient’s relative he became

report (e.g., feels sad, empty, depressed when he

hopeless) or observation made experienced heartbreak and

by others (e.g., because of his poor coping

appears tearful). (Note: In mechanism he became

children and adolescents, it can depressed.

be an irritable mood.)

2. Markedly diminished interest
or pleasure in all, or almost all,
activities most of the
day, nearly every day (as
indicated by either subjective
account or observation).
3. Significant weight loss when
not dieting or weight gain (e.g.,
a change of more than
5% of body weight in a month),
or decrease or increase in
appetite nearly every day.
(Note: In children, consider
failure to make expected
weight gain.)
4. Insomnia or hypersomnia
nearly every day.
5. Psychomotor agitation or
retardation nearly every day
(observable by others, not
merely subjective feelings of
restlessness or being slowed
down).
33
X
- The patient did not lose any
interest because he can still do
some activities every day
according to the patient’s
relative.
X
- The patient’s appetite is good
and according to the patient's
relative he did not experience
abrupt weight loss.
/
- The patient’s relative stated
that the patient is having
difficulty in sleeping at night
because of his hallucination
because the patient will say
“dong patuloga sa ko dong.”
even if he has no one beside
him.
X
- There is no psychomotor
agitation or retardation every
day because sometimes the
patient is still active.

6. Fatigue or loss of energy
nearly every day.
7. Feelings of worthlessness or
excessive or inappropriate guilt
(which may be delusional)
nearly every day (not merely
self-reproach or guilt about
being sick).
8. Diminished ability to think or
concentrate, or indecisiveness,
nearly every day (either
by subjective account or as
observed by others).
9. Recurrent thoughts of death
(not just fear of dying),
recurrent suicidal ideation
without
a specific plan, or a suicide
attempt or a specific plan for
committing suicide.
B. The symptoms cause
clinically significant distress or
impairment in social,
occupational,
or other important areas of
functioning.
34
X
- The patient does not
experience fatigue or loss of
energy because he is not
X hyperactive all day.
- According to the patient’s
relative the patient did not
show any feelings of
worthlessness or excessive
guilt.
X
- The client can still answer the
questions appropriately but
when his hallucination will start
he gets distracted.
X - According to patient’s relative
he never said to them that he
will harm himself and he also
does not show any signs of
suicide.
/ - Due to the patient’s condition
he has no job, he is always by
himself. He can communicate
with other people but only in a
short time and some people on
their barangay are afraid of
him.
 35

X - The patient has not used any

C. The episode is not
drugs or taken any medication,
attributable to the physiological
according to the patient’s
effects of a substance or to
relative.
another medical condition.
Note: Criteria A–C represent a
major depressive episode.
Note: Responses to a
significant loss (e.g.,
bereavement, financial ruin,
losses from a natural disaster,
a serious medical illness or
disability) may include the
feelings of intense sadness,
rumination about the loss,
insomnia, poor appetite, and
weight loss noted in Criterion
A, which may resemble a
depressive episode. Although
such symptoms may be
understandable or considered
appropriate to the loss, the
presence of a major depressive
episode in addition to the
normal response to a
significant loss should also be
carefully considered. This
decision inevitably requires the
exercise of clinical judgment
based on the individual’s
history and the cultural norms
for the expression of distress in
the context of loss.
 36

X - The occurrence of the major

D. The occurrence of the major
depressive episode is better
depressive episode is not
explained by schizophrenia
better explained by
because the required criteria to
schizoaffective disorder,
diagnose the patient are met.
schizophrenia,
schizophreniform disorder,
delusional disorder, or other
specified and unspecified
schizophrenia spectrum and
other psychotic disorders.

/ - According to the patient’s

E. There has never been a
family the last manic episode
manic episode or a hypomanic
of the client was seen last
episode. Note: This exclusion
2015
does not apply if all of the
manic-like or hypomanic-like
episodes are substance-
induced or are attributable to
the physiological effects of
another medical condition.

DELUSIONAL DISORDER

CRITERIA MARK JUSTIFICATION

A. The presence of one (or / - The patient is reported to have

more) delusions with a duration erotomanic delusion because
of 1 month or longer. he said that he had 2 children
with his lover even though he
does not have one.

B. Criterion A for schizophrenia X - The criterion A of

has never been met. Schizophrenia are met.
 37

Note: Hallucinations, if present,

are not prominent and are
related to the delusional
theme (e.g., the sensation of
being infested with insects
associated with delusions of
infestation).

C. Apart from the impact of the / - Delusions affect the behavior

delusion(s) or its ramifications,
functioning is not markedly
impaired, and behavior is not
obviously bizarre or odd.
of the patient, it’s level of
functioning especially in social,
occupational and the
educational attainment of the
patient.

D. If manic or major depressive X - The last manic episode was

episodes have occurred, these seen last 2015 and it has no
have been brief relative connection to the delusion
to the duration of the delusional because the patient does not
periods. have delusions.

E. The disturbance is not X - The patient has not used

attributable to the physiological drugs in the past or taken any
effects of a substance or medications.
another
medical condition and is not
better explained by another
mental disorder, such
as body dysmorphic disorder or
obsessive-compulsive disorder.

VII. Medical Management

A. THERAPIES
PSYCHOSOCIAL THERAPY
 38

a. Social Skills Training

This focuses on enhancing communication and social experiences, as well as

improving everyday activities participation. The aim of this form of training is to
improve communication and social interactions.

b. Family Therapy

Family counseling is a method of assisting the client and the family in dealing with
the illness. It entails a series of informal meetings over a six-month span.
Meetings may include:

● discussing information about schizophrenia

● exploring ways of supporting somebody with schizophrenia
● deciding how to solve practical problems that can be caused by the symptoms
of schizophrenia

c. Self-Help Groups

To continue focusing the client’s social skills start by enrolling them in community
care and outreach programs. For example, the National Alliance on Mental Illness
(NAMI) is a support group that provides a free peer-to-peer service. It consists of ten
workshops for adults with mental illness who wish to learn more about their illness
from those who have been through it or who have gone through it with a loved one.

d. Rehabilitation

Schizophrenia most often manifests during the years that we are establishing our
careers. As a result, work therapy, problem-solving assistance, and money
management instruction can all be part of the recovery process.

e. Coordinated Specialty Care (CSC)

 39

This is for those who are having their first psychotic episode. It's a multidisciplinary
approach that incorporates medicine and psychotherapy. It provides social and job
programs, and it makes every effort to include the family. The aim is to change the
course of the disease and its prognosis by identifying it early on.

f. Assertive Community Treatment (ACT)

This program provides highly specialized resources to assist individuals with

schizophrenia in dealing with day-to-day problems such as taking medications. ACT
experts also assist them in anticipating challenges and working to avoid
emergencies.

g. Social Recovery Therapy

This therapy focuses on assisting the individual in setting and achieving goals as
well as cultivating hope and positive values about themselves and others.

h. Art Therapy

Arts therapies are meant to encourage people to express themselves creatively.

Working with an arts therapist in a small group or one-on-one will help you express
your schizophrenia symptoms.

Some people feel that using the arts to express themselves in a nonverbal way will
give them a new perspective on schizophrenia and help them develop new ways of
relating to others. In certain people, arts therapies have been shown to help with the
negative effects of schizophrenia.

PSYCHOTHERAPY

a. Cognitive Behavioral Therapy (CBT)

 40

CBT helps to assist in identifying the thinking habits that are causing to experience
unpleasant emotions and behaviors, as well as learning to replace these thoughts
with more rational and beneficial ones.

One may be taught to recognize examples of delusional thought, for example. One
will then be offered assistance and guidance on how to avoid acting on one’s
feelings. The majority of people need a series of CBT sessions spread out over
many months. CBT sessions are normally an hour long.

b. Individual Psychotherapy

A therapist or counselor may teach the individual how to manage their emotions and
behaviors during sessions. They'll gain a better understanding of their condition and
its consequences, as well as how to say what's true and what's not. It can also assist
them in managing their daily lives.

c. Cognitive enhancement therapy (CET)

Cognitive remediation is another name for this form of therapy. It teaches people
how to enhance their concentration, memory, and ability to coordinate their thoughts
by teaching them how to identify social cues, or triggers. It integrates group sessions
with computer-based brain training.

B. NURSING THEORIES
 41

Dorothea Orem’s Self-Care Deficit Theory

Self-Care Deficit Nursing Theory is the correct terminology for Orem's general
nursing theory (SCDNT). The Self-Care Deficit Nursing Theory is made up of three
minor interconnected theories: self-care, self-care deficit, and nursing systems
theory. To begin, self-care is described as the act of initiating and carrying out
activities on one's own behalf in order to preserve one's life, health, and well-being.
Orem's self-care deficiency theory helps nurses in assessing which aspects of
patient care they should concentrate on in a given situation, thus emphasizing the
importance of patients retaining control over their own self-care processes. Patients
are more able to heal when they have some control of their own self-care, according
to Orem's self-care deficiency theory.

Orem’s self-care theory can be beneficial for a schizophrenic patient who has
difficulties maintaining self-care. Patients who are unable to care for themselves
should be given nursing care, according to the guidelines. This theory can be
applicable to people who, as a result of their illnesses, overlook self-care needs such
as protection, hygiene, relaxation, and nutrition. This theory can be related to our
patient, he is able to do his activities of daily living (ADL) however he is unable to do
this by himself therefore, needing assistance. So as nurses, it is our duty to help the
client to help them attain self-care independently.
 42

Rosemarie Rizzo Parse’s Human Becoming Theory

The Human Becoming Theory of Nursing is a model that focuses on the

quality of life of the patient and sees the patient not as different aspects of a whole,
but as a person. Meaning, rhythmicity, and transcendence are the three primary
themes. By focusing on these three the nurses can give patients greater respect,
autonomy, and empowerment.

Since the nurse is not focused on "fixing" issues, but rather on seeing the
patient as a whole individual living experiences in his or her environment, the idea
helps nurses to build a better nurse-patient relationship. Parse’s nursing theory of
human becoming is used in psychiatric nursing practices. According to this theory,
the nurse’s role is to guide individuals to explain the meaning of their own
experiences, and this theory recommends that individuals’ experiences, not their
problems, should be the focus in community mental health nursing. As nurses, it is
our duty to see our patients not in different aspects but to understand and look at
them as a whole and by accepting them; only then we are able to create a good
patient-nurse relationship and we will also be able to help them.
 43

Hildegard Peplau’s Theory of Interpersonal Relations

Hildegard Peplau’s Interpersonal Relations Theory emphasized the nurse-

client relationship as the foundation of nursing practice. It emphasized the give-and-
take of nurse-client relationships that was seen by many as revolutionary. Peplau
went on to form an interpersonal model emphasizing the need for a partnership
between nurse and client as opposed to the client passively receiving treatment and
the nurse passively acting out doctor’s orders.

Application of Peplau's theory helps a schizophrenic patient deal with drug

noncompliance. It was found that the main reasons for noncompliance were poor
insight and lack of illness and drug-related knowledge. Based on Peplau's theory of
establishing a therapeutic relationship, giving guidance in medication and monitoring
the effects of medication in order to improve drug compliance, the most important
role of the nurse is as an assessor and educator. Nurse and patient were able to
learn to achieve the common goal of drug compliance through the interactive human
relationship.

C. DRUG STUDY

A. Antipsychotics

FIRST GENERATION ANTIPSYCHOTICS

 44

Generic Name Haloperidol

Brand Name Haldol, Haldol Decanoate

Drug Classification Therapeutic: Antipsychotics

Pharmacologic: Butyrophenones

Mode of Action Alters the effects of dopamine in the CNS.

Also has anticholinergic and alpha-
adrenergic blocking activity.

Therapeutic Effects: Diminished signs

and symptoms of psychoses. Improved
behavior in children with Tourette’s
syndrome or other behavioral problems.

Suggested Dose PO (Adults): 0.5–5 mg 2–3 times daily.

Patients with severe symptoms may
 45

require up to 100 mg/day.

PO (Geriatric Patients or Debilitated

Patients): 0.5–2 mg twice daily initially;
may be gradually ↑ as needed.

PO (Children 3–12 yr or 15–40 kg):

0.25–0.5 mg/day given in 2–3 divided
doses; increase by 0.25–0.5 mg every 5–7
days; maximum dose: 0.15 mg/kg/
day (up to 0.75 mg/kg/day for Tourette’s
syndrome or 0.15 mg/kg/day for
psychoses).

IM (Adults): 2–5 mg q 1–8 hr (not to

exceed 100 mg/day).

IM (Children 6–12 yr): 1–3 mg/dose

every 4–8 hours to a maximum of 0.15
mg/kg/day.

IV (Adults): 0.5–5 mg, may be repeated q

30 min (unlabeled).

Haloperidol Decanoate

IM (Adults): 10–15 times the previous

daily PO dose but not to exceed 100 mg
initially, given monthly (not to exceed 300
mg/mo).

Availability (generic available)

 46

Tablets: 0.5 mg, 1 mg, 2 mg, 5 mg, 10

mg, 20 mg.

Oral concentrate: 2 mg/mL.

Haloperidol lactate injection: 5 mg/mL.

Haloperidol decanoate injection: 50

mg/mL, 100 mg/mL.

Indications Acute and chronic psychotic disorders

including: schizophrenia, manic states,
drug-induced psychoses. Patients with
schizophrenia who require long-term
parenteral (IM) antipsychotic therapy. Also
useful in managing aggressive or agitated
patients. Tourette’s syndrome.
Severe behavioral problems in children
which may be accompanied by:
unprovoked, combative, explosive
hyperexcitability, hyperactivity
accompanied by conduct disorders (short-
term use when other modalities
have failed). Considered second-line
treatment after failure with atypical
antipsychotic.

Unlabeled Use: Nausea and vomiting

from surgery or chemotherapy.

Contraindications Contraindicated in: Hypersensitivity;

Angle-closure glaucoma; Bone marrow
depression; CNS depression;
Parkinsonism; Severe liver or
cardiovascular disease (QT interval
 47

prolonging conditions); Some products

contain tartrazine, sesame oil, or benzyl
alcohol and should be avoided in patients
with known intolerance or hypersensitivity.

Use Cautiously in: Debilitated patients

(dose ↓ required); Cardiac disease (risk of QT
prolongation with high doses); Diabetes;
Respiratory insufficiency; Prostatic
hyperplasia; CNS tumors; Intestinal
obstruction; Seizures; Patients at risk for falls;

OB: Neonates at ↑ risk for extrapyramidal

symptoms and withdrawal after delivery when
exposed during the 3rd trimester; use only if
benefit outweighs risk to fetus;

Lactation: Discontinue drug or bottle-

feed;

Geri: Dose ↓ required due to ↑ sensitivity; ↑

risk of mortality in elderly patients treated for
dementia-related psychosis.

Adverse Reaction/Side Effects CNS: SEIZURES, extrapyramidal

reactions, confusion, drowsiness,
restlessness, tardive dyskinesia.

EENT: blurred vision, dry eyes. Resp:

respiratory depression.

CV: hypotension, tachycardia, ECG

changes (QT prolongation, torsade de
pointes), ventricular arrhythmias.
 48

GI: constipation, dry mouth, anorexia,

drug-induced hepatitis, ileus, weight gain.

GU: impotence, urinary retention.

Derm: diaphoresis, photosensitivity,

rashes.

Endo: amenorrhea, galactorrhea,

gynecomastia.

Hemat: AGRANULOCYTOSIS, anemia,

leukopenia, neutropenia.

Metab: hyperpyrexia.

Misc: NEUROLEPTIC MALIGNANT

SYNDROME, hypersensitivity reactions.

Drug Interactions Drug-Drug: May enhance the QTc-

prolonging effect of QTc-prolonging
agents. ↑ hypotension with
antihypertensives, nitrates, or acute
ingestion of alcohol. ↑ anticholinergic
effects with drugs having anticholinergic
properties, including antihistamines,
antidepressants, atropine, phenothiazines,
quinidine, and disopyramide. ↑ CNS
depression with other CNS depressants,
including alcohol, antihistamines, opioid
analgesics, and sedative/hypnotics.
Concurrent use with epinephrine may
result in severe hypotension and
 49

tachycardia. May ↓ therapeutic effects of

levodopa. Acute encephalopathic
syndrome may occur when used with
lithium. Dementia may occur with
methyldopa.

Drug-Natural Products: Kava-kava,

valerian, or chamomile can ↑ CNS
depression.

Nursing Responsibilities 1. Assess mental status (orientation,

mood, behavior) prior to and
periodically during therapy.

2. Assess positive (hallucination,

delusions) and negative (social
isolation) symptoms of
schizophrenia.

3. Assess weight and BMI initially and

throughout therapy. Refer as
appropriate for nutritional/weight
and medical management.

4. Monitor BP (sitting, standing, lying)

and pulse prior to and frequently
during the period of dose
adjustment. May cause QT interval
changes on ECG.

5. Observe the patient carefully when

administering medication, to ensure
that medication is actually taken
and not hoarded.
 50

6. Monitor intake and output ratios

and daily weight. Assess the
patient for signs and symptoms of
dehydration (decreased thirst,
lethargy, hemoconcentration),
especially in geriatric patients.

7. Assess fluid intake and bowel

function. Increased bulk and fluids
in the diet help minimize
constipating effects.

8. Monitor for tardive dyskinesia

(uncontrolled rhythmic movement
of mouth, face, and extremities; lip
smacking or puckering; puffing of
cheeks; uncontrolled chewing;
rapid or worm-like movements of
tongue, excessive eye blinking).
Report immediately; may be
irreversible.

9. Monitor for symptoms related to

hyperprolactinemia (menstrual
abnormalities, galactorrhea, sexual
dysfunction).

10. Lab Test Considerations: Monitor

CBC with differential and liver
function tests periodically during
therapy.
 51

CALCIUM CHANNEL BLOCKERS

Generic Name Amlodipine

Brand Name Norvasc

Drug Classification Pharmacotherapeutic: Calcium

Channel Blockers

Clinical: Antihypertensive, antianginal.

Mode of Action Inhibits the transport of calcium into

myocardial and vascular smooth muscle
cells, resulting in inhibition of
excitation-contraction coupling and
subsequent contraction.

Therapeutic Effects: Systemic

vasodilation resulting in decreased BP.
Coronary vasodilation resulting in
decreased frequency and severity of
attacks of angina.

Suggested Dose PO (Adults): 5–10 mg once daily;

antihypertensive in fragile or small patients
or patients already receiving other
antihypertensives—initiate at 2.5 mg/ day,
 52

↑ as required/tolerated (up to 10 mg/day) as

an antihypertensive therapy with 2.5 mg/day
in patients with hepatic insufficiency.

PO (Geriatric Patients):
Antihypertensive—Initiate therapy at 2.5
mg/day, ↑ as required/tolerated (up to
10 mg/day); antianginal—initiate therapy at
5 mg/ day, ↑ as required/tolerated (up to 10
mg/day).

PO (Children 6–17 yr): 2.5–5 mg once

daily.

Indications Alone or with other agents in the

management of hypertension,
angina pectoris, and vasospastic
(Prinzmetal’s) angina.

Contraindications Contraindicated in: Hypersensitivity;

Systolic BP 90 mm Hg.

Use Cautiously in: Severe hepatic

impairment (dose reduction
recommended); Aortic stenosis; History
of HF; OB, Lactation,

Pedi: Children 6 yr (safety not

established);

Geri: Dose reduction recommended; ↑ risk

of hypotension.

Adverse Reaction/Side Effects CNS: dizziness, fatigue.

 53

CV: peripheral edema, angina,

bradycardia, hypotension, palpitations.

GI: gingival hyperplasia, nausea.

Derm: flushing

Drug Interactions Drug-Drug: Strong CYP3A4 inhibitors,

including ketoconazole, itraconazole,
clarithromycin, and ritonavir may ↑
levels. Additive hypotension may occur
when used concurrently with fentanyl, other
antihypertensives, nitrates, acute ingestion
of alcohol, or quinidine. Antihypertensive
effects may be ↓ by
concurrent use of nonsteroidal anti-
inflammatory agents. May ↑ risk of
neurotoxicity with lithium. ↑ risk of
myopathy with simvastatin (do not exceed
20 mg/day of simvastatin). May ↑
cyclosporine and tacrolimus levels.

Herbal: St. John’s wort may decrease

concentration. Ephedra, yohimbe
may worsen hypertension. Garlic may
increase antihypertensive effects.

Food: Grapefruit products may increase

concentration, hypotensive effects.

Lab Values: May increase hepatic

enzyme levels.

Nursing Responsibilities 1. Monitor BP and pulse before

therapy, during dose titration, and
 54

periodically during therapy.

Monitor ECG periodically during
prolonged therapy.

2. Monitor intake and output ratios

and daily weight. Assess for
signs of HF (peripheral edema,
rales/ crackles, dyspnea, weight
gain, jugular venous distention).

3. Monitor frequency of prescription

refills to determine adherence.

4. Do not abruptly discontinue

medication.

5. Avoid tasks that require

alertness, motor skills until
response to drugs is established.

6. Do not ingest grapefruit products.

SECOND GENERATION ANTIPSYCHOTICS

 55

Generic Name Olanzapine

Brand Name Zyprexa, Zyprexa Intramuscular,

Zyprexa Relprevv, Zyprexa Zydis

Drug Classification Therapeutic: Antipsychotics, mood

stabilizers

Pharmacologic:
Thienobenzodiazepines

Mode of Action Antagonizes dopamine and serotonin

type 2 in the CNS. Also has
anticholinergic, antihistaminic, and anti–
alpha1-adrenergic effects.

Therapeutic Effects: Decreased

manifestations of psychoses.
 56

Suggested Dose PO (Adults—Most Patients): 5–10

mg/day initially; may ↑ at weekly intervals
by 5 mg/day (target dose 10 mg/day; not to
exceed 20 mg/day).

PO (Adults—Debilitated or
Nonsmoking Female > Patients 65
yr): Initiate therapy at 5 mg/day.

PO (Children 13–17 yr): 2.5–5 mg/day

initially; may ↑ at weekly intervals by 2.5–5
mg/day (target dose 10 mg/day; not to
exceed 20 mg/day).

IM (Adults): Oral olanzapine dose 10

mg/day—210 mg every 2 wk or 410 mg
every 4 wk for the first 8 wk, then 150
mg every 2 wk or 300 mg every 4 wk as
maintenance therapy; Oral olanzapine
dose 15 mg/day—300 mg every 2 wk for
the first 8 wk, then 210 mg every 2 wk or
405 mg every 4 wk as maintenance
therapy; Oral olanzapine dose 20
mg/day—300 mg every 2 wk for the first
8 wk, then 300 mg every 2
wk as maintenance therapy.

IM (Adults—Debilitated or
Nonsmoking Female Patients > 65
yr): Initiate therapy at 150 mg every 4
wk.

Indications Schizophrenia. Acute therapy of manic

or mixed episodes associated with
 57

bipolar I disorder (as monotherapy

[adults and adolescents] or with lithium
or valproate [adults only]). Maintenance
therapy of bipolar I disorder. Acute
agitation due to schizophrenia or bipolar
I mania (IM). Depressive episodes
associated with bipolar I disorder (when
used with fluoxetine). Treatment-
resistant depression (when used with
fluoxetine).

Unlabeled Use: Management of

anorexia nervosa. Treatment of nausea
and vomiting related to highly
emetogenic chemotherapy.

Contraindications Contraindicated in: Hypersensitivity;

Lactation: Discontinue drug or bottle

feed; Phenylketonuria (orally
disintegrating tablets contain
aspartame).

Use Cautiously in: Patients with

hepatic impairment; Patients at risk for
aspiration or falls; Cardiovascular
or cerebrovascular disease; History of
seizures; History of attempted suicide;
Diabetes or risk factors for diabetes
(may worsen glucose control); Prostatic
hyperplasia; Angle-closure glaucoma;
History of paralytic ileus; Dysphagia and
aspiration have been associated with
 58

antipsychotic drug use; use with caution

in patients at risk for aspiration;

OB: Neonates at ↑ risk for extrapyramidal

symptoms and withdrawal after delivery
when exposed during the 3rd trimester; use
only if maternal benefit outweighs risk to
fetus;

Pedi: Children <13 yr (safety not

established); adolescents at ↑ risk for weight
gain and hyperlipidemia;

Geri: May require ↓ doses; ↑ risk of

mortality in elderly patients treated for
dementia-related psychosis.

Adverse Reaction/Side Effects CNS: NEUROLEPTIC MALIGNANT

SYNDROME, SEIZURES, SUICIDAL
THOUGHTS, agitation, delirium,
dizziness, headache, restlessness,
sedation, weakness, dystonia, insomnia,
mood changes, personality disorder,
speech impairment, tardive dyskinesia.

EENT: amblyopia, rhinitis, increased

salivation, pharyngitis.

Resp: cough, dyspnea.

CV: orthostatic hypotension,

bradycardia, chest pain,
 59

tachycardia.

GI: constipation, dry mouth, ↑ liver

enzymes, weight loss or gain, abdominal
pain, appetite, nausea, ↑ thirst.

GU: impotence, ↓ libido, urinary

incontinence.

Hemat: AGRANULOCYTOSIS,
leukopenia, neutropenia.

Derm: DRUG REACTION WITH

EOSINOPHILIA AND SYSTEMIC
SYMPTOMS (DRESS), photosensitivity.
Endo: amenorrhea, galactorrhea, goiter,
gynecomastia, hyperglycemia.

Metab: dyslipidemia.

MS: hypertonia, joint pain.

Neuro: tremor.

Misc: fever, flu-like syndrome.

Drug Interactions Drug-Drug: Effects may be ↓ by

concurrent carbamazepine,
omeprazole, or rifampin. ↑ hypotension
may occur with antihypertensives. ↑ CNS
depression may occur with concurrent use of
alcohol or other
CNS depressants; concurrent use of IM
 60

olanzapine and parenteral

benzodiazepines should be avoided.
May antagonize the effects of levodopa
or other dopamine agonists.
Fluvoxamine may ↑ levels. Nicotine can ↓
olanzapine levels.

Nursing Responsibilities 1. Assess mental status

(orientation, mood, behavior)
before and periodically during
therapy. Monitor closely for
notable changes in behavior that
could indicate the emergence or
worsening of suicidal thoughts or
behavior or depression.

2. Monitor BP (sitting, standing,

lying), ECG, pulse, and
respiratory rate before and
frequently during dose
adjustment.

3. Assess weight and BMI initially

and throughout therapy.

4. Observe the patient carefully

when administering medication to
ensure that medication is taken
and not hoarded or cheeked.

5. Assess fluid intake and bowel

function. Increased bulk and
fluids in the diet may help
 61

minimize constipation.

6. Assess for falls risk. Drowsiness,

orthostatic hypotension, and
motor and sensory instability
increase risk. Institute prevention
if indicated.

7. Monitor patient for onset of

akathisia (restlessness or desire
to keep moving) and
extrapyramidal side effects
(parkinsonian—difficulty speaking
or swallowing, loss of balance
control, pill rolling of hands,
mask-like face, shuffling gait,
rigidity, tremors; and dystonic—
muscle spasms, twisting motions,
twitching, inability to move eyes,
weakness of arms or legs) every
2 mo during therapy and 8–12 wk
after therapy has been
discontinued. Report these
symptoms if they occur, as
reduction in dose or
discontinuation of medication
may be necessary.
Trihexyphenidyl r benztropine
may be used to control
symptoms.

8. Monitor for tardive dyskinesia

(uncontrolled rhythmic movement
 62

of mouth, face, and extremities;

lip smacking or puckering; puffing
of cheeks; uncontrolled chewing;
rapid or worm-like movements of
tongue, excessive blinking of
eyes). Report immediately; may
be irreversible.

9. Monitor for symptoms related to

hyperprolactinemia (menstrual
abnormalities, galactorrhea,
sexual dysfunction).

10. Monitor blood glucose prior to

and periodically during therapy.
 63

VIII. Nursing Care Plan

Name of Patient: X Age/Sex: 33/M Room#:

Chief Complaint: Physician:

Diagnosis: Schizophrenia

Cues N Nursing Diagnosis Patient Outcome Planning/Intervention Implementation

e
e
d

Subjective: P Disturbed thought processes By the end of our 1. Be sincere and honest when 2
related to neurological psychiatric nursing communicating with the client.
The patient’s E
dysfunction as evidenced by rotation the client will Avoid vague or evasive
relative
R visual hallucinations be able to; remarks.
verbalized that
“naa syay C a. establish contact RATIONALE:
kadula permi with reality;
niya gina E Rationale: Delusional clients are extremely
b. will express sensitive about others and can
estorya” Disturbed Thought Processes
 64

P describes an individual with thoughts and feelings recognize insincerity. Evasive

altered perception and cognition in a safe and socially comments or hesitation
Objective: T
that interferes with daily living. acceptable manner; reinforces mistrust or delusions.
- auditory and I Causes are biochemical or
c. will participate in
visual psychological disturbances like
O depression and personality prescribed
hallucination 2. Assess attention
therapeutic
disorders. Schizophrenia is a span/distractibility and ability to
N interventions. 1
-inappropriate
mental disorder that results in make decisions or problem
non-reality- / disturbed thought processes, solve.
based thinking
associative looseness,
C RATIONALE:
- erotomanic hallucinations, delusions, and

delusion O limited socialization (asociality). This determines the ability of the

patient to participate in
- decreased G
planning/executing care.
concentration
N Reference:

- short
I
attention span 3. Have the patient write his/her
T Wayne G., (2017). Disturbed name periodically; keep this
Thought Processes Nursing record for comparison and
I Care Plan. Retrieve March 10, 3
report differences.
 65

O 2020 from, RATIONALE:

https://nurseslabs.com/disturbed
N These are important measures
-thought-processes/
to prevent further deterioration
and maximize level of function.

4. Schedule structured activity

and rest periods.

RATIONALE: 4

This provides stimulation while

reducing fatigue.

5. Present reality concisely and

briefly and do not challenge
illogical thinking. Avoid vague or
6
evasive remarks.

RATIONALE:
 66

Delusional patients are

extremely sensitive about others
and can recognize insincerity.
Evasive comments or hesitation
reinforces mistrust or delusions.

6. Be consistent in setting
expectations, enforcing rules,
and so forth.
7

RATIONALE:

Clear, consistent limits provide a

secure structure for the patient.

7. Reduce provocative stimuli,

negative criticism, arguments,
and confrontations.
8
RATIONALE:
 67

This is to avoid triggering

fight/flight responses.

8. Refrain from forcing activities

and communications.

RATIONALE:

9
The patient may feel threatened
and may withdraw or rebel.

9. Engage the patient in one-to-

one activities at first, then
activities in small groups, and
gradually activities in larger
groups.
5
RATIONALE:

A distrustful patient can best

 68

deal with one person initially.

Gradual introduction of others
when the patient can tolerate is
less threatening.

10. Encourage patients to

participate in resocialization
activities/groups when available.

RATIONALE:

This is to maximize level of

function.
10
 69

2.

Name of Patient: X Age/Sex: 33/M Room#:

Chief Complaint: Physician:

Diagnosis: Schizophrenia

Cues N Nursing Diagnosis Patient Outcome Planning/Intervention Implementation

e
e
d

Subjective: S Risk for other-directed By the end of our 1. Use a calm and firm approach. 1
violence related to psychiatric nursing rotation
The patient’s A RATIONALE:
psychotic disorder as the client will be able to:
relative
F evidenced by verbal Provides structure and control for a
verbalized a. verbalized control of
threats against others client who is out of control.
that the E feelings;
patient is
T b. will refrain from
sometimes
Rationale: provoking others to 2. Frequently assess client’s behavior
saying “
Y physical harm, with the aid for signs of increased agitation and 2
“unsa man, Violent behavior was
 70

pang rapepon / defined by suicide of nursing interventions; hyperactivity.

nato ni sila attempts; recurrent
P c. will be safe and free RATIONALE:
tapos suicidal behavior;
from injury.
pamatyon. R gestures, threats, or self- Early detection and intervention of
hahahaha” mutilating behavior (self- escalating mania will prevent the
O directed); and multiple
possibility of harm to self or others,
items of violence toward and decrease the need for
T
Objective: others (other-directed) in seclusions.
E four categories: none,
- visual
self-directed only, other-
hallucination C
directed only, and 3. Use short, simple and brief
- auditory T combined self-/other- explanations or statements. 5

hallucination directed.
I RATIONALE:
- threatening
O Short attention span limits
verbalization Reference:
understanding to small pieces of
N
-poor Harford T., Chen C., information.
frustration Kerridge B., Grant B.
tolerance (2019). Self- and Other-
directed Forms of 4. Decrease environmental stimuli
- frowning
 71

- glaring Violence and Their (e.g., by providing a calming 3

Relationship with Lifetime environment or assigning a private
DSM-5 Psychiatric room)
Disorders: Results from
RATIONALE:
the National
Epidemiologic Survey on Helps decrease escalation of anxiety
Alcohol Related and manic symptoms.
Conditions–III
(NESARC–III). Retrieve
March 10, 2021 from, 5. Remove any objects that could
https://www.ncbi.nlm.nih. harm the environment around the
gov/pmc/articles/PMC584 patient. 4
9477/
RATIONALE:

If the patient is in a state of agitated,

confused, patients will not use these
objects to harm themselves or others.

6. Redirect agitation and potentially

 72

violent behaviors with physical outlets

in an area of low stimulation (e.g.,
7
punching bag).

RATIONALE:

Can help to relieve pent-up hostility

and relieve muscle tension.

7. Maintain a consistent approach,

employ consistent expectations, and
provide a structured environment. 6

RATIONALE:

Clear and consistent limits and

expectations minimize potential for
client’s manipulation of staff.

8. Remain neutral as possible; Do not

 73

argue with the client.

RATIONALE: 8

Clients can use inconsistencies and

value judgments as justification for
arguing and escalating mania.

9. Have enough physically strong

staff that can help secure the patient
if needed.
9
RATIONALE:

It is necessary to control the situation

and also provide physical security to
the staff.

10. Provide appropriate tranquilizer

drugs therapeutic treatment program.
 74

Monitor the effectiveness of drugs

and their side effects.
10
RATIONALE:

How to achieve the alternative

minimum limits should be selected
when planning interventions to
psychiatry.
 75

IX. Recommendation

a. For the individual, family and community

For the individual, they have an option to live independently, so they must undergo
psychiatric rehabilitation because this helps them manage their lives, make effective
treatment decisions, and improve their quality of life. Because mental health
promotion helps to give the client the ability to bounce back and manage obstacles in
life.

For the family and community, since patients with schizophrenia are no longer
hospitalized, then it is recommended that once they return to the community and
their families, they they can either live with them, or be in a residential program,
enroll in a family or group therapies, be aware of community support programs, and
case management services.

b. METHOD

METHOD DISCHARGE PLAN

- Take medications as prescribed.

MEDICATIONS Call the health care provider if
there are any problems due to
the medication/s.

- Take prescribed antipsychotics.

These help decrease psychotic
symptoms and severe agitation.
Antiparkinson medicines may
also be taken in order to control
muscle stiffness, twitches, and
restlessness caused by
 76

antipsychotic medicines.

- Contact the health care provider

for medications that cause side
effects or those that do not help
improve the condition.

- Inform the health care provider

for any allergies to medications.

- Keep a list of medications,

vitamins, and herbs. Include the
amount, when, and why is it
taken. Bring the list or pill bottles
to follow-up check-ups.

- Always carry the list of

medications in case of an
emergency.

- Never stop and skip medications

even when feeling better. Take
as scheduled.

- Stool softeners are permissible,

but laxatives should be avoided.

- If there is a missed dose, then

take it if it is only 3 to 4 hours
late. If the next dose is 4 hours
late or the next dose is due, then
forgo the missed dose.
 77

- For those who have difficulty in

remembering medications, use a
pillbox labeled with dosage times
and/or days of the week, chart,
and record doses whenever they
are taken.

- First, consult with the health care

EXERCISE provider before starting any
exercise routine because this
helps the patient find the right
routine to complement the
therapies for a better quality of
life.

- Aerobic exercises. Such as the

usage of treadmills and exercise
bikes. Other options are: running,
walking, swimming, weightlifting,
and biking. For slowed paced
exercises the patient can also do
tai chi and yoga. This improves
sleep, mood, stress and
relaxation.

- Household chores can also be

classified as exercise.
Vacuuming and cutting the grass
are some examples.

- It is recommended that the

exercise program must last for
about 150 minutes a week,
meaning it is 30 minutes a day, 5
 78

times a week.

- If possible, exercise with

someone or a friend.

- Make time for it, do not try to fit it

in on working or busy days.

- Be realistic. Pace yourself, do not

rush and overachieve.

- Start with a modest level and

gradually build up as the exercise
tolerance increases.

- Try exercising outdoors.

Treatment Settings/Options
TREATMENT
- Crisis Residential Program. A
program wherein the patient is
relocated to a home-care facility.
Helpful for relapse cases.

- Day Treatment Program. A

program where it gives a chance
to learn, practice skills, and
provide long-term support for a
better quality of life.

- Outpatient Program. A program

that requires frequent meetings
with the therapist. The
arrangement is one-on-one or
 79

group therapy.

- Partial Care Program. Also

known as Day Hospitalization or
Partial Hospitalization. This lasts
4 to 6 hours a day, 3 to 5 days a
week. This either helps to avoid
going back to the hospital or
hasten the discharge process. It
may also help the symptoms get
under control and avoid relapse.

- Assertive Community Treatment.

This includes a team of health
care providers and support
groups in the community that
help people undergoing therapy.

- Cognitive Behavior Therapy. This

helps change certain behaviors,
handle symptoms such as
hallucinations and delusions.

- Illness Management Skills. This

teaches skills that can help
manage the disease.

- Family Psychoeducation. This

helps families to be a part of the
therapy.

- Social Skills Training. This helps

patients learn social skills and get
 80

along with people.

- Supported Employment. This is a

form of therapy that helps
patients place them in a job that
fits their skillset. This facilitates
independence and self-
confidence.

- Relearning good hygiene can be

HYGIENE achieved by making the patient
attend to social-skills groups or
cognitive behavioral therapy.
- Make a checklist of daily tasks,
like brushing one’s teeth and
getting dressed. Ask help for
checking off each task once
completed. This helps establish a
routine and build confidence.

- Ensure regular dental check-ups.

- Encourage drinking a lot of water

and use sugar-free candy or
gum. This helps combat dry
mouth and improve dental
hygiene.

- Kegel exercises, biofeedback,

scheduled voiding, positive
reinforcement, and some
additional medications may help
reduce incontinence.
 81

- Use sunscreen to prevent

sunburn. Avoid long periods of
time in the sun, and wear
protective clothing.
Photosensitivity can cause
burning easily.

- No usage of alcohol and illegal

OUT-PATIENT drugs. Because this interacts with
the medications used to treat
schizophrenia.

- Always go to counselling
sessions. Never stop attending.
Discuss with the counsellor for
any concerns.

- Keep the number for a suicide

crisis center (National Mental
Health Crisis Hotline) on hand.
Always get help whenever
necessary.

- Check for rash, swelling, or

difficulty of breathing after taking
medications.

- Sleeping problems such as not

able to sleep well or sleeping
more than usual.

- Watch out for increased or

decreased appetite.
 82

- Call the health care provider for

any concerns regarding the
condition.

- Get 6 to 8 hours of sleep. Monitor

and report to the health care
provider if experiencing sleep
problems such as not being able
to sleep or oversleeping. Avoid
driving or doing potential
dangerous activities.

- Rising slowly from a lying or

sitting position prevents falls from
orthostatic hypotension or
dizziness due to a drop in blood
pressure. Wait until any dizziness
has subsided before walking.

- Eat a healthy diet. Discuss with a

DIET dietician on what type of diet
works best.

- No calorie-laden beverages and

candy because they promote
dental caries, contribute to weight
gain, and do little to relieve dry
mouth.

- Constipation can be avoided or

relieved by increasing intake of
 83

water and bulk-forming food (e.g.

apples and citrus fruits) in the diet
and by exercising.

- Eat fruits such as pears and

apples. Because these are some
of the best sources of fiber, have
vitamins, and it helps lower bad
cholesterol, aids in digestion, and
also lowers the risk of having
other schizophrenia related
problems like heart disease,
diabetes, and obesity.

- Eat vegetables such as kidney

beans and sweet potatoes.
Because these are low in fat and
calories, rich in fiber, have
important vitamins, potassium for
keeping blood sugar under
control, and does not have heart-
heavy cholesterol.

- Eat fish such as tuna, salmon,

and mackerel. Because these are
rich in Omega-3 fatty acids which
can prevent and ease
schizophrenia symptoms and
slow down the disease progress.

- Eat spinach and beef liver

because this is high in folate
which can help ease symptoms
 84

of schizophrenia.

- Do not eat bread because wheat

sensitivity can be a factor in
schizophrenia. A study suggests
that switching to a gluten-free diet
helps improve their condition.

- Eat oysters, crab, lobster, beef,

and fortified cereals because
there may be a relationship
between low levels of zinc and
schizophrenia. Supplements can
also be taken, but with the health
care provider's approval.

- No refined sugar because this

can increase the risk for diabetes.
Sweetened beverages, candy,
and cake are some examples.

- Eat more clams, liver, and breads

because these are rich in vitamin
B12. Low levels of vitamin B12
has shown in those with
psychosis (where schizophrenia
is a part of). Vitamin B12 can
ease symptoms. Supplements
can also be taken, but with the
health care provider's approval.

- Other food sources to consume

are the following: Cod Liver Oil
 85

(Vitamin D source), and Dairy-

Free yogurt.

X. Prognosis

50% of people with schizophrenia are either recovered or improved to the

point that they can work and live on their own. 25% are better but need help from a
strong support network to get by. 15% are not better. Most of these are in the
hospital. Long-term numbers for 30 years after diagnosis are similar to those at the
decade mark, except that more people get better and can live on their own. The
lifetime risk of suicide for people with schizophrenia is about 5%, but getting
treatment and taking medication seems to lower that risk. Women seem to be better
than men at staying in recovery long term.

Onset of Illness
While the onset can be sudden or
subtle, most clients experience signs
and symptoms over time, such as social
isolation, erratic activity, lack of interest
in school or at work, and poor grooming.
When a person starts to exhibit more
actively optimistic signs of delusions,
hallucinations, and disordered thought,
they are diagnosed with disordered
thinking (psychosis). The implications
for most clients and their families are
significant and long-lasting, regardless
of where and how the disorder occurs or
the form of schizophrenia. Where and
how the disease manifests seems to
have an effect on the result. The client's
age at the time of onset tends to be a
significant factor in how well he or she
 86

does.

Those who experience the disease

sooner have a worse prognosis than
those who develop it later. Clients who
are younger have a worse premorbid
transition, more pronounced negative
symptoms, and more cognitive
dysfunction than those who are older.
Those who develop the disease
gradually (about half of the time) have a
worse immediate and long-term
prognosis than those who develop it
suddenly.

Duration of Illness The time it takes from the onset of

symptoms to the diagnosis and
treatment of the condition. The earlier
one receives treatment for
schizophrenia once symptoms appear,
the better chances of improving and
recovering. However, prodrome, or the
period of time between the onset of
symptoms and the onset of complete
psychosis, can last days, weeks, or
even years. The average time between
the onset of psychosis and the initiation
of therapy is 6 to 7 years.

Within a year of an acute episode, one-

third to one-half of clients with
schizophrenia relapse. Nonadherence to
medication, continued drug use,
 87

caregiver criticism, and a hostile attitude

toward treatment are all linked to higher
relapse rates (Wade, Tai, Awenot, &
Haddock, 2017).

Factors Researchers believe that a variety of

genetic and environmental factors play a
role in causation, and that life stressors
can influence the onset and progression
of symptoms. Since several causes may
be involved, scientists are unable to
pinpoint the exact cause of each case
(American Psychiatric Association,
2021).

Mood and Affect Schizophrenia patients report and

display a wide range of mood and affect.
They are often characterized as having
a flat or blunted affect (no facial
expression) (few observable facial
expressions). The standard facial
expression is often compared to that of
a mask. The client may express feelings
of depression and a lack of enjoyment in
life (anhedonia).

Attitude & willingness to take Patient X, who was prescribed

medication Olanzapine, was willing to take his/her
medication before, however now that
his/her signs and symptoms subsided,
he/she refuses to take the medication,
even throwing it away.

Any depressive features Depressive symptoms are a common

clinical feature in schizophrenia patients.
When contrasted to patients with
 88

schizophrenia who do not have

depression, patients with depression
have a worse prognosis and results.
When interviewed, he speaks in a low
tone, making it hard to hear. When a
family member is asked about his
condition, he has “mental depression.”

Family Support The family supports the client, when the

disease first appeared, he was taken for
check-ups. The medications prescribed
were also bought for the client to take.

Patient X, who has schizophrenia, has been going through check ups a
couple of times to various psychiatric institutions. Correlating his condition, Patient X
may have a bad prognosis since he has not been taking his medicine Olanzapine,
and is not undergoing any therapies to help his condition.However, he also had a
group of people who acted as a social support for her condition. Patient X could have
a good prognosis if he continually takes his medicine as well as undergo therapies
for the disease, thus it is recommended to continuously attend treatment modalities.

XI. References

American Psychiatric Association. (2021). What is schizophrenia? Retrieved

March 10, 2021, from https://www.psychiatry.org/patients-
families/schizophrenia/what-is-schizophrenia#:~:text=Symptoms%20of
%20schizophrenia%20usually%20first,their%2020s%20and%20early%2030s.

Beasley, E. (2020, November 29). How exercise can ease schizophrenia

symptoms. Retrieved March 10, 2021, from
https://www.healthgrades.com/right-care/schizophrenia/how-exercise-can-
ease-schizophrenia-symptoms
 89

Bhandari, S., MD. (2019, April 09). What to eat when you have schizophrenia.
Retrieved March 11, 2021, from
https://www.webmd.com/schizophrenia/ss/slideshow-best-nutrition-for-
schizophrenia

Bhandari, S., MD. (2020, January 21). Schizophrenia treatment: Types of

Therapy and Medications for Treating Schizophrenia. Retrieved March 8, 2021,
from https://www.webmd.com/schizophrenia/schizophrenia-therapy

Casarella, J. (2021). Schizophrenia diagnosis & tests: How doctors know if

someone has it. Retrieved March 10, 2021, from
https://www.webmd.com/schizophrenia/schizophrenia-tests

Clarke, J. (2021). Causes and risk factors of schizophrenia. Retrieved March

10, 2021, from https://www.verywellmind.com/what-causes-schizophrenia-
2953136

Cleveland Clinic. (2018). Schizophrenia: Symptoms, causes, treatments.

Retrieved March 10, 2021, from
https://my.clevelandclinic.org/health/diseases/4568-
schizophrenia#:~:text=Although%20there%20are%20no%20laboratory,the
%20cause%20of%20your%20symptoms.

Diagnostic and statistical manual of mental disorders: DSM-5. (2017). Arlington,

VA: American Psychiatric Association.

Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5;

American Psychiatric Association, 2013).

Exercise and schizophrenia. (2018, August 17). Retrieved March 10, 2021,
from https://livingwithschizophreniauk.org/information-sheets/exercise-
schizophrenia/

Exercise can tackle symptoms of schizophrenia. (2016, August 12). Retrieved

March 10, 2021, from
 90

https://www.sciencedaily.com/releases/2016/08/160812073654.htm#:~:text=Su
mmary%3A,according%20to%20a%20new%20study.

Frankenburg, F. (2020, December 06). Schizophrenia workup: Approach

considerations. Retrieved March 10, 2021, from Gonzalo A., (2021). Hildegard

Peplau: Interpersonal Relations Theory. Retrieved March 11, 2021 from,

https://nurseslabs.com/hildegard-peplaus-interpersonal-relations-
theory/#:~:text=Peplau's%20theory%20defined%20Nursing%20as,involving
%20an%20interaction%20between
%20twohttps://emedicine.medscape.com/article/288259-workup

Garippo, G. (2020, July 29). Schizophrenia and Hygiene. Retrieved March 8,

2021, from https://www.healthgrades.com/right-
care/schizophrenia/schizophrenia-and-hygiene#:~:text=Apathy%20and
%20Disorganization,motivation—symptoms%20of%20the%20illness.

Halter, Margaret J., (2018) Varcarolis’ foundations of psychiatric mental health

nursing : a clinical approach (8th). | St. Louis, Missouri : Elsevier, [2018.

Mayo Clinic. (2020, January 07). Schizophrenia. Retrieved March 10, 2021,
from https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-
causes/syc-20354443

NHS. (2019). Causes - Schizophrenia. Retrieved March 10, 2021, from

https://www.nhs.uk/mental-
health/conditions/schizophrenia/causes/#:~:text=Schizophrenia%20tends%20to
%20run%20in,mean%20you'll%20develop%20schizophrenia.

Nursing Theory. (2019, September 18). Parse's human Becoming Theory.

Retrieved March 11, 2021, from https://nursing-theory.org/theories-and-
models/parse-human-becoming-theory.php

R. K. J., & Hodgson, K. (2018). Saunders Nursing Drug Handbook 2019 (1st
ed.). Saunders
 91

Schizophrenia: Care instructions. (2020, January 31). Retrieved March 8, 2021,

from
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?
hwid=tw12395

Schizophrenia (discharge care) - what you need to know. (2021, March 4).
Retrieved March 8, 2021, from https://www.drugs.com/cg/schizophrenia-
discharge-care.html

Siris, S., & Braga, R. (2020). Depression in Schizophrenia. Retrieved March 10,
2021, from https://www.uptodate.com/contents/depression-in-schizophrenia

Vallerand, A., & Sanoski, C. A. (2018). Davis's Drug Guide for Nurses
(Sixteenth ed.). F.A. Davis Company.

Videbeck, S. L. (2019). Psychiatric-Mental Health Nursing (Eighth ed.). LWW.