1

CHAPTER I

INTRODUCTION

Mental health is a significant state an individual must conserve in order to function and

live life. According to Videbeck (2020). Mental illness has been long misunderstood, people fear

those who suffer from mental instability and decides to lock them away. Only in this recent times

people are aware and educated about those who are mentally challenged.

Due of this stigma, mental health has been given poor attention by the Philippine

government. Although mental illness has been categorized as the third most common type of

disability in the Philippines. Even after the country passed its very first Mental Health Act and

Universal Health Care Law, only 5% of the healthcare expenditure is directed toward mental

health. There are only 7.76 hospital beds and 0.41 psychiatric physicians per 100.000 Filipinos,

still it could not cater all of the mentally challenged individuals residing in the Philippines.

(Department of Health, 2018).

Mental health nursing, also known as psychiatric nursing, is a specialized field of the

nursing practice in which it directly focuses on the care of individuals with a mental health

disorder to help them recover, bring back their functionality and improve their quality of life.

Mental health nurses have advanced knowledge of the assessment, diagnosis, and treatment of

psychiatric disorders that helps them provide specialized care. They typically work alongside

other health professionals in a medical team with the aim of providing the optimal clinical

outcomes for the patient. (Smith, 2019).

Schizophrenia is a type of mental illness that is illogical to be defined as a single illness

rather it is a syndrome or a disease process in which it comprises of different types of varieties

 2

and symptoms. Schizophrenia as a syndrome, it is a collection of signs and symptoms of

unknown etiology that is predominantly defined by observed signs of psychosis. Schizophrenia

in general form presents with signs and symptoms of paranoia, delusions, and hallucinations in

different forms. These manifestations occur or develop during adolescence or in early adulthood.

(Videbeck, 2019).

Schizophrenia syndrome along with the other type of psychotic illness are characterized

by the abnormalities in one or more following domains; delusions, hallucinations, disorganized

thinking (i.e.. speech), grossly disorganized or abnormal motor behavior (including catatonia),

and negative symptoms. Along with the other abnormalities people who suffers from

schizophrenia often show distractibility, dissacociation, and neural impairments. Several studies

also shows that there are abnormalities in multiple neurotransmitters such as dopaminergic,

serotonergic, and alpha-adrenergic hyperactivity or glutaminergic and GABA hypoactivity. The

development of schizophrenia is considered to be multifactoral and has been linked to gene-

environment interactions. For instance, genes have been found to interact with the use of

cannabis use and occurence of childhood trauma. (Moustafa, 2021).

Schizophrenia occurs all throughout the world, the prevalence of schizophrenia

approaches 1 percent internationally. The incidence rate of schizophrenia is usually diagnosed in

the late adolescent to early adulthood. In men The peak incidence of onset is 15 to 25 years old,

while in females the onset is 25 to 35 years old. The prevalence of schizophrenia approaches 1

percent internationally. (Videbeck, 2020)

Schizophrenia is no longer categorize as a progressive deteriorating illness, however

people with persistent symptomatic remissions are still affected with poor life functioning. The
 3

focus of Schizophrenia has now shifted from psychopathological improvement and

hospitalizations to real-life functioning improvement and identifying its determinants. (Galderisi,

2021).

This case study has been chosen and looks forward to the benefits of the nursing students

and the client. This is an informative study because it assists and helps individuals to aware of

the mental illness Schizophrenia, of what are the factors that leads to developing one and what

are the manifestations to be diagnosed by it.

 4

CHAPTER II

OBJECTIVES

General Objectives:

This case study is for the nursing student, health care professionals, and the general

public to have a thorough understanding of what is Schizophrenia.

Specific Objectives:

To recognize different persons and institutions that aid in the completion of the work.

Specifically, within 4 hours of case presentation, the student nurse should be able to:

1. Give a brief introduction about the case.

2. Define the different terms for a better understanding of the work.

3. Trace patient’s family history.

4. Illustrate the patient's maternal and paternal lineage.

5. Provide patient past psychosocial history.

6. Enumerate abnormalities during early developmental years.

7. Differentiate the different environmental situations that may have

contributed to the present condition.

8. Determine the patient's current mental status.

9. List the laboratory test of the patient.

10. Identify patient diagnosis.

11. Stress the importance of the different examinations that patients

underwent and its relationship to the current health condition.

12. Know patient emotional growth and relate it to his current condition to
 5

determine whether he has been able to satisfy the developmental stages.

13. Present the different precipitating and predisposing factors that may have

been contributory to the current condition.

14. Explain why the physician gave such drugs, its use and rationale.

15. Make a nursing care plan that fits the problem in pursuit for his restoration

of its optimum wellness.

16. Exemplify the prognosis for the patient case.

17. Provide different recommendations and solutions fit for patient problems

and conditions.

18. Contribute new knowledge for further research and development.

 6

CHAPTER III

ANAMNESIS

PATIENT’S DATABASE

Name: “Boning”

Age: 52

Gender: Female

Birth date: March 1, 1970

Height: 156 cm

Weight: 55 kg

Number of Siblings: 8

Ordinal position: 4

Civil status: Single

Number of children: None

Residence: Cateel, Davao Oriental

Nationality: Filipino

Religion: Roman Catholic

Occupation: None

Year of Hospitalization: 2022

Diagnosis: Schizophrenia
 7

INFORMANT:

Name: Emily

Address: Cateel, Davao Oriental

Relationship to patient: Sister

Length of time known to patient:

Apparent understanding of the present illness of the patient: Informant is aware and

understood the present illness of patient Boning. She is supportive of her treatment and is her

primary guardian since the death of their parents.

Other characteristics and attitude of the patient: Informant also stated that she often

goes to the house of boning to give her groceries and other needs. It was at the point when the

place looked like a “balay sa ilaga” due to the amount of accumulated trash and trinkets that

boning hoarded that Ms. Emily decided to have Boning institutionalized

 8

FAMILY TREE

Figure 1. Higala Boning’s G enogram

 9

Maternal and Paternal Grand Lineage

The patient’s grandparents had a history of hypertension. They lived away from her

grandparents but they visited them from time to time as far as the eldest sister of the patient

remembered.

Father

The father of the patient was a farmer. They possessed property where coconut palms

were grown. The production of copra was their primary source of revenue. According to the

eldest daughter, the father was previously engaged in the murder of a specific housebreaker. He

was not imprisoned because he acted in self-defense. His eye was injured as a result of the event.

He was a chain smoker, alcoholic with hypertension. As a result of her father's death from

hypertension in 2021, the patient became sad as she became even more alone and isolated.

Mother

The deceased mother had a sibling whose offspring were similarly affected by mental

illness. When she was alive, she was a housewife who was renowned for her tenderness toward

her children. She was really supportive of the patient's education. She never missed a school

event requiring parental presence. She also taught her girls home duties, which were traditionally

considered a woman's responsibility. She occasionally helped her husband with their copra

business, but because she was asthmatic, she spent much of her time at home performing
 10

household chores, helping at church, and caring for the children. In 2015, she died of asthma at

an advanced age. According to her eldest sister, her mother was a smoker, particularly

throughout her pregnancy with the patient.

Siblings

The patient was the fourth child out of a total of nine. The oldest sibling supported the

patient's requirements through their copra enterprise. The patient was the only one of the nine

admitted to the hospital and diagnosed with schizophrenia. According to her elder sister, she was

the one who cared for her as a youngster while their mother recovered from delivery. When the

patient's conduct began to shift, her elder sister became her primary caretaker.

PERSONALITY HISTORY

Prenatal

During prenatal stage, Boning’s mother, smoke tobacco every single day. She also failed

to go to any prenatal check-up as these practices were not “uso sauna,” according to Boning’s

sister. During the course of her pregnancy, Boning’s mother was under stress due to marital

conflicts between her parents.

Birth

At this period, the patient was able to obtain sufficient care and nourishment, including

adequate rest, breast milk, and other nutritional requirements. During her first month of

existence, however, her mother was unable to provide full-time care since she was instructed to
 11

stay in bed to prevent "bughat." Consequently, her elder sister was responsible for her care.

According to her eldest sibling, she was unable to obtain immunization as a newborn.

Infancy and Childhood Characteristics

Information regarding Boning’s infancy is limited as both the patient and the informant

only provided little information. Boning is the fourth among 9 siblings. Her father works as a

farmer while her mother is a housewife at the time. The was able to receive proper care and

nutrition at this stage such as adequate sleep, breast milk and other nutritional needs. Because her

needs are adequately met at this stage, Boning was able to develop trust, allowing her to feel safe

around the people around her and not be suspicious of her surroundings.

Psychosexual History

At the age of 16 the patient verbalized that she had her menstrual period.

Play Life

The patient verbalized that she was able to play with her neighbors where she stated that she

is the leader of their group. She also preferred to play basketball with her opposite sex friends.

School History

The patient stated that she began attending school at the age of seven. The patient had no

difficulty in school, as she had high marks, was able to engage in all activities, and was an

academic achiever. She also had a strong rapport with her professors. At age 16, she graduated
 12

from high school with excellent grades. After graduating from high school, she stopped attending

classes for two years before enrolling in college. She graduated from the University of Mindanao

with a Bachelor of Science in Accountancy at the age of 21. Her father overlooked her

qualifications; therefore, she was unable to take the board test despite having a BSA degree.

Religious and Social Adaptability

As she grew up in a family where her mother was deeply devoted to Roman Catholicism,

she was a very religious person. She was really active in their church. She was also a member of

the Charismatic and Singles for Christ communities.

Occupational History

The patient worked as a civil servant in their local municipal hall. She did not have

problems with her colleagues and her boss. As she was working, she helped in sustaining her

family’s needs. She was not a regular worker, and she later resigned from her job as she was

already having symptomatic manifestations of her mental illness as verbalized by her eldest

sister.

Marital History

She once had a known lover for a couple of months, and later broke up with him. She was

not married until now, and she did not have any children at all. She remained single throughout

the years. She lived alone in their parents’ house even when her other siblings got wedded and

lived separately.
 13

Onset of Present Illness

Her eldest sister recalled that it was after their mother’s death in 2015 that the patient was

starting to act differently. Her strange behavior worsened after her father died in 2021, the elder

sister would find her talking to herself even when she was alone, she would say “Katingon kamo,

katingon” (Stop you guys, Stop) when there was no one besides her. Her symptoms were slighter

at first. She could in fact buy her own necessities, she could go shopping for groceries, and she

can do household chores, but her condition worsened as time went by.

She would also collect things and store them in her house. She collected play moneys,

and whenever she got real money, she would photocopy them, to claim that she had a sack of

money in her house and that she was very rich. She would often tear some of those photocopied

moneys and put hole at the center of many coins. She would use them as “designs” in her house,

and she would record what she had done on a logbook, like writing her daily journal.

When the patient was assessed for hallucinations, she described that she would see her

workmate in her window. They would talk random things and would keep the patient company at

night even when she was already confined to the facility.

She was admitted at Castillones last February 12, 2022, by her eldest sister who brought

her all the way from Cateel, Davao Oriental to Davao City. She felt bad and sorry for bringing

her sister to the facility, and it was not an easy choice for them. But she was already at the stage

where she was capable of hurting people as she was already randomly throwing rocks at them.
 14

She could have been treated earlier, but because of the pandemic and financial matters, it got

further delayed.

The eldest sister verbalized that they would miss her sister and somehow, she was

hopeful that her sister’s illness will be managed well during her stay in the facility so they can

bring her home soon.

 15

CHAPTER IV
COURSE OF HOSPITALIZATION

1. Vital Signs

DATE & SHIFT BP T PR RR

Out In Out In Out In Out In

June 14, 2022 120/80 120/80 36.4 36.4 75 70 20 20

June 15, 2022 120/90 110/90 36.9 36.6 75 70 18 20

June 16, 2022 120/90 120/90 36.8 36.8 72 71 20 20

June 17, 2022 120/80 120/80 36.3 36.3 78 74 20 20

June 20, 2022 120/80 120/80 36.5 36.5 76 73 21 20

June 22, 2022 120/80 110/70 36.1 36.8 76 80 20 20

June 23, 2022 120/80 110/80 36.7 37.4 75 81 20 20

June 24, 2022 120/80 100/70 36.5 36.8 74 76 19 20

June 27, 2022 120/80 110/70 36.4 36.7 79 75 18 20

2. Mental Status Examination

CRITERIA DAYS
1 2 3 4 5 6 7 8 9
I. GENERAL DESCRIPTION
A. Appearance / / / / / / / / /
B. Behavioral & Psychomotor Activity
Normal / / / / / / / / /
Inappropriate
Restlessness
Psychomotor Retardation
Agitation
Rigidity
Others
 16

II. MOOD AND AFFECT

A. Mood
Depressed
Anxious
Angry
Euphoric
Frightened
Labile
Others Narcissistic
B. Affect
Appropriate
Inappropriate
Flat
Blunted / / / / / / / / /
Constricted

III. NEURONEGATIVE FUNCTION

A. Sleep
Normal / / / / / / / / /
Hypersomnia
Early Insomnia
Late Insomnia
Mixed Insomnia
B. Appetite
Normal / / / / / / / / /
Increased
Decreased
C. Weight 55 kg
D. Diurnal variation
E. Libido
F. Attention
Good / / / / / / / / /
Fair
Poor

IV. SPEECH
Spontaneous / / / / / / / / /
Pressured
Whispered
Deliberated
Loud
Hesitant
Talkative
Mumbled
Slurred
 17

Others

V. PERCEPTION
A. Type Visual &
auditory
hallucinatio
n
B. Description She said,
she would
see her
workmate at
the window
talking
random
things and
said her
coworkers
would talk
to her
outside the
room.
Her sister
also she
found
Boning
talking to
herself
“katingin
kamo,
katingin”.

VI. THOUGHT
A. Thought Process
Loose association
Tangentiality / / / / / / / / /
Neologism
Flight of Ideas
Circumstantiality
Thought blocking
Others
B. Thought Content
Type of delusion Grandiose
delusion
Preoccupation
Suicidal ideation
Homicidal ideation
 18

Ideas of reference
Others

VII. SENSORIUM AND COGNITON

A. Orientation
Time / / / / / / / / /
Place / / / / / / / / /
Person / / / / / / / / /
B. Memory
Remote
Impaired / / / / / / / / /
Unimpaired
Recent past
Impaired
Unimpaired / / / / / / / / /
Recent
Impaired
Unimpaired / / / / / / / / /
Immediate
Impaired
Unimpaired / / / / / / / / /
C. Concentration & Attention
Serial subtraction
Spelling
Abstract thought
Information & Intelligence

VIII. JUDGMENT AND INSIGHT

A. Judgment
Impaired
Unimpaired /
B. Insight (Specify Level)

IX. SUMMARY OF M S E
A. Disturbances in:
General description /
Perception /
Thought /
Sensorium & Cognition /
Judgment and Insight /
B. Diagnostic Category
Psychotic /
Non-psychotic
Functional
Organic
 19

Both functional and organic

Within 9 days in contact with the patient, Higala Boning’s vital signs are all within

normal. Her general appearance is rated GOOD as what it is observed that the patient is well

groomed, well dressed, fixed hair, and no foul odor noted.

During the interaction, the patient does not maintain eye contact, does head twitching

when responding to the question. She has a narcissistic mood because she shows no emotion, flat

and numb. She has blunted affect because she shows a little facial expression, sometimes she

smiles or when she told to. She sleeps and eats normally with a weight of 55kg. Her attention

towards us was rated good.

She has visual and auditory hallucinations, as stated she would see her coworkers at the

window and someone was talking to her outside the room and her sister also found Boning

talking to herself “katingon kamo, katingon” (stop you guys, stop). She has grandiose delusion

and always says she is a “CPA” and wants the title after her name. Her thought process is

tangentiality because she’s wandering off the topic “comes from within, not from without”. She

has an impaired remote memory, where she can’t remember her past and made things up about

her past. She has unimpaired judgment and insight.

 20

CHAPTER V

PSYCHODYNAMICS

Patients Name: Boning Student’s Name: Charise Gaile Lomugot

Age: 52 years old Rayyan Morib
Sex: Female
Diagnosis: Schizophrenia

SUGGESTED SCHEMATIC PRESENTATION OF PSYCHODYNAMICS

BIOLOGICAL PSYCHOLOGICAL ENVIRONMENTAL

PRE SCHOOL YOUNG

PRENATAL INFANCY TODDLER ADOLESCENCE INTERNAL EXTERNAL
SCHOOL AGE ADULTHOOD

The patient’s During prenatal Information As observed, Pre-school At this stage, Boning had a very When the patient Patient Boning’s
maternal lineage stage, Boning’s regarding the patient is years is the Boning feels eventful adolescent was 18 years old. Boning is parents lived
had history of mother, smoke Boning’s well-groomed time where a happy as she stage. She She experienced self-driven in a small
unspecified mental tobacco every infancy is and always child interacts enjoys going graduated with being a victim of and barrio in
illness. single day. She limited as neatly socially with to school. honors during burglary with her competitive. Lower Abijod,
also failed to both the dressed. others, where She would elementary and parents. At the She is also Cateel, Davao
When she was in go to any patient and Considering they can always have immediately time, her father had ambitious as Oriental. The
high school, the prenatal check- the informant the develop self good grades proceeded to high just had a fresh seen by her neighborhood
patient became a up as these only characteristic confidence and is an school, wherein harvest of dried insistence of is generally
victim of drug use. practices were provided manifested by and a sense of achiever she graduated with coconut kernels being a CPA. peaceful with
 21

Marijuana was not “uso little the patient, purpose. throughout honors as well. while her mother During ample
placed in her food, sauna,” information. we can infer her academic financed lotto activities, distance
which may have according to Boning is the that the Whether life. She also She also started outlets. When the she is very between the
caused changes in Boning’s sister. fourth among patient has Boning went enjoyed admiring people of event happened, participative neighbors’
brain function. During the 9 siblings. developed to pre-school playing the opposite Boning witnessed and would houses.
course of her Her father autonomy at or not was basketball gender at this her father shoot 2 always to be
pregnancy, works as a this stage. not stated by with her stage. The patient of the 4 robbers recognized
Boning’s farmer while the friends at verbalized that she who invaded their or
mother was her mother is informant. school. She had 2 boyfriends home. acknowledge
under stress a housewife said that her and the d.
due to marital at the time. friend group relationships lasted
When asked about
conflicts consisted of for 9 months and any behavioral
between her The was able both boys the other, 1 year.changes after the
parents. to receive and girl but event, the patient
proper care she prefers to When she was in said that she was
and nutrition play with her high school, the still able to function
at this stage male friends. patient became a normally. However,
such as victim of substance she admitted that
adequate Through use as one of her for about a month
sleep, breast these friends put after the event
milk and experiences, marijuana in her happened, she kept
other Boning has food. on thinking about
nutritional developed what had
needs. competence transpired.
and
Because her confidence in When the patient
needs are her skills and was 19 years old,
adequately abilities. she proceeded to
met at this college at
stage, Boning University of
was able to Mindanao, taking
develop trust, BS Accountancy.
allowing her
to feel safe After finishing her
 22

around the degree, Boning

people passed the civil
around her service exam which
and not be allowed her to get a
suspicious of job order
her employment from
surroundings. the local municipal
hall. After the
termination of her
contract, she was
unable to find other
jobs. During this
time, Boning
wanted to take the
CPA board exams
but failed to do so
due to financial
constraints.

Family studies have According to The first Autonomy vs. According to According to The fifth stage of Popovic, et al According to Situational
shown that child and Stathopoulou stage of Erik Shame and Erikson, the Erik Erikson, Erik Erikson’s (2019) suggest that McLeod factors or
adolescent onset and Berratis Erikson’s doubt is the third stage of The fourth theory of trauma, especially (2021), type external
schizophrenia (2013), theory of second stage psychosexual psychosocial psychosocial severe childhood A factors are
carries a greater prenatal psychosocial of Erik development stage takes development is trauma can increase personality influences that
familial risk than exposure to development Erikson’s is the place during Identity vs. Role the likelihood of show people do not occur
adult onset and 20% cigarette smoke is Trust vs. psychosocial Initiative vs. the early Confusion stage. It someone response to from within
of child and causes chronic Mistrust. development. Guilt. In this school years occurs during developing stress. Type the individual
adolescent onset fetal hypoxia, During this During this stage, from adolescence, from schizophrenia or A but from
schizophrenia had at disregulation of stage, stage, children approximatel about 12 to 18 expressing similar personality is elsewhere like
least one primary endocrine children children begin to take y ages 5 to years. During this symptoms later in characterized the
relative with equilibrium, learn to become more more control 11. Through stage, adolescence life. by a constant environment
schizophrenia and and disruption either trust or mobile. They over their social develop a personal feeling of and others
50% had a first- of fetal mistrust their develop self environment. interactions, identity and a In Erik Erikson’s working around a
 23

degree relative with neurodevelopm caregivers. sufficiency They begin to children sense of self. Teen theory of against the person such as
psychosis (Nuhu, ent associated The care that by controlling interact with begin to explore different psychosocial clock and a work,
Eseigbe, Issa & with brain adults activities other children develop a roles, attitudes, and development, strong sense community
Gomina, 2016). malfunction, provide such as and develop sense of identities as they Intimacy vs. of and other
all of which determines eating, toilet interpersonal pride in their develop a sense of Isolation is competitiven people.
Regarding cannabis, potentially whether training and skills. Those accomplishm self. developed. Young ess.
a recent meta- could induce children talking. who are ents and adults need to form Individuals According to
analysis reaffirmed vulnerability to develop this Children who successful at abilities. With proper intimate, loving with a Type Adams
its potential role: schizophrenia. sense of trust are supported this stage Children encouragement, relationships with A (2016),
higher rates of in the world at this stage develop a need to cope children will other people. personality companionshi
cannabis use were Freedman, around them. become more sense of with new emerge from this Success leads to generally p and
associated with an Hunter and Children who confident and purpose while social and stage with a strong strong experience a emotional
increased risk of Hoffman do receive independent. those who academic sense of self and relationships, while higher stress support has a
psychosis in a dose- (2018), also adequate and struggle are demands. what they want to failure results in level, hate great impact
dependent fashion, stated that folic dependable In Sigmund left with Success leads accomplish. Those loneliness and failure and on someone
where heavy users acid and care may Freud’s feelings of to a sense of who struggle will isolation. find it coping with a
had a 4-fold risk and phosphatidylch develop a second stage guilt. competence, remain confused difficult to mental health
moderate users had oline sense of trust of while failure about who they are stop problem.
a 2-fold risk of supplements to others and psychosexual The third results in and their place in working, Someone who
developing have shown the world. development, stage of feelings of society. even when suffers from
psychosis (Marconi evidence for the anal Sigmund inferiority. they have mental illness
et al., 2016). While improving stage, Freud’s Adolescence achieved may require
this does not development children gain psychosexual played a critical their goals. intense
necessarily indicate associated with a sense of development role in both environmental
causality, premorbid later mental mastery and is known as Freud’s and support.
cannabis use is illness. competence the phallic Erikson’s theories
associated with an by controlling stage. In this of development. In
earlier age of onset bladder and stage, the both theories, teens
of psychotic bowel libido’s begin to forge their
symptoms movements. energy is own sense of
(Donoghue et al., Children who focused on identity. In this
2014; Stefanis et al., succeed at the genitals period, the goal is
2013), and the this stage (Videbeck, to integrate tasks
relationship between develop a 2020). mastered in the
 24

age of onset of sense of previous stages

cannabis use and capability and into a secure sense
age of onset of productivity. of self. Identity is
psychosis seems to achieved when
be linear-- with one adolescents are
study showing a 7–8 allowed to
year gap between experience
cannabis use and the independence by
initiation of making decisions
psychotic symptoms that influence their
(Stefanis et al., lives (Videbeck,
2013) 2020).

Vulnerability to Intrapsychic
Trust Autonomy Guilt Industry Role Confusion Isolation Confusion and Frustration
develop illness trauma

Irritable, easily-angered, delusional

Weakened Ego State of Disequilibrium
 25

Balancing Factor

Perception of Events: When the crisis occurred, the patient’s consciousness and perception of her surroundings shifted. She is irritable and easily-angered most of
the time. She is having grandiose delusions of being a CPA even though she failed to take the board exams. Aside from that, the patient seem to believe that
someone is after her as verbalized through the statement, ïng-ana gayud basta CPA, daghan gusto mag strike sa imo. All of these perceptions are manifectations of
his health crisis.

Situational Support: The patient is single with no kids. After the death of their parents, she continued to live alone. Her eldest sister became her guardian and
provided her with groceries and other needs. Her sibling visits her once or twice a month.

Coping Mechanism: DENIAL - denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them.
After failing to take the board exams for CPAs, patient Boning started to manifest denial as she refused to accept that she is ill by declining to take prescribed
medications. Another coping mechanism that patient Boning manifested is suppression. According to Videbeck (2020), it is the conscious exclusion of
unacceptable thoughts and feelings from conscious awareness. She refused to express her feelings about her past trauma.
PROJECTION
The patient manifested projection through blaming his father about her inability to take the board exam. She conjured ill memories about her father physically
abusing her, which was denied by the informant.
 26

Tabular Presentation of Predisposing and Precipitating Factors

Factors Present Rationale

Predisposing Factors
1. Gender Female According to Giordano, Bucci,
Mucci, Pezella and Galderisi
(2021), literature addressing
gender differences in people
with schizophrenia shows that
males, as compared to
females, have an earlier age of
illness onset—limited to early-
and middle-onset
schizophrenia—a worse
premorbid functioning, a
greater severity of negative
symptoms, a lower severity of
affective symptoms and a
higher rate of comorbid
alcohol/substance abuse.
Despite the overall finding of
a more severe clinical picture
in males, this does not seem to
2. Genetics The patient’s uncle on his translate into a worse
mother’s side had unspecified outcome.
mental illness.
Most genetics studies have
focused on immediate families
to examine whether
Schizophrenia is genetically
transmitted or inherited or
inherited. Studies have shown
that children with one
biological parent with
Schizophrenia have 15% risk,
and 35% risk if both
biological parents. Studies
have indicated a genetic risk
or tendency for schizophrenia
(Kendal, Kirov & Owen,
2017).
3. Age Age of onset was around 26
years old

4. Insufficient prenatal care
Precipitating Factors
1. Dysfunctional family Isolated from other siblings
relationships
Mother had no prenatal check-
up during pregnancy with
patient
Mother was also under a lot of women, onset peaks at 25 to
stress because of marital
conflicts
Mother consumed tobacco Myles,
every day even during Nielssen, Shiers, and Large,
pregnancy
27
Videbeck (2020) stated that
schizophrenia usually is
diagnosed in late adolescence
or early adulthood. It rarely
manifest in childhood. For
35 years of age.
Newall, Curtis,
(2012) stated that tobacco
smoking plays a role in the
development of schizophrenia.
This is in line with the high
prevalence of smoking in
patients with first-onset
psychosis at 58%.
Furthermore, it has been
shown that nicotine modulates
the release of nearly all
neurotransmitters, including
dopamine and serotonin,
which are the primary
neurotransmitters involved in
schizophrenia.
The family environment can
either play a detrimental or a
protective role in symptom
severity for people with
schizophrenia. The current
study examined both patient
and caregiver perspectives of
the family environment in an
ethnically diverse group of
patients with schizophrenia.
Schizophrenia is a severe and
chronic mental illness that
affects the entire family, with
family members often
becoming life-long caregivers
for patients. Due to strong
familial involvement in the
care of the diagnosed
 28

individual, the family

When patient Boning was in
2. Substance use
high school, she became a
victim of substance use as one
of her friends put marijuana in
her food.
environment has been studied
extensively as an influential
psychosocial factor that relates
to prognosis (Gurak, K &
Mamani, A. 2016).
Marijuana has an effect on the
endocannabinoid system,
which is the portion of the
brain that governs most of the
processes we utilize on a daily
basis, such as cognition, sleep,
emotion and reward
processing (The Recovery
Village Drug and Alcohol
Rehab, 2021).

People suffering from

schizophrenia are also more
prone to drug misuse.
According to one major
research, 47 percent of people
have drug or alcohol issues,
compared to 16 percent of
those who do not have the
disease. According to another
3. Traumatic life events Became a victim of burglary; recent study, this group is
patient witnessed her father three times as likely to use
shot 2 men dead. alcohol. In fact, it is the
second most commonly used
psychoactive drug among
persons suffering from
schizophrenia (Key, 2020).

According to NHS, (2019),

The main psychological
triggers of schizophrenia are
stressful life events, such as:
bereavement, losing your job
or home, divorce, the end of a
relationship, physical, sexual
or emotional abuse. These
kinds of experiences, although
stressful, do not cause
schizophrenia. However, they
can trigger its development in
29

someone already vulnerable to

it.
 30

CRISIS INTERVENTION

PREDISPOSING FACTORS PRECIPITATING FACTORS

 Gender (Female)
 Genetic (family history of mental illness  Dysfunctional family relationships
on mother’s side)  Substance use (cannabis)
 Age of onset (26)  Traumatic life event (burglary; witnessed
 Insufficient prenatal care father shoot two men dead; failure to take
 No prenatal check-ups board exams; death of parents: mother -
 Stress during pregnancy because of 2015, father - 2021)
marital conflicts
 Substance abuse (tobacco)

State of Disequilibrium
Behavioral changes when patient Boning failed to take the CPA board exams that resulted in being
irritable, easily-angered, auditory and visual hallucinations

Balancing Factor
Perception of Events Situational Support Coping Mechanism

When the crisis occurred, the
patient’s consciousness and
perception of her surroundings
shifted. She is irritable and easily-
angered most of the time. She is
having grandiose delusions of
being a CPA even though she
failed to take the board exams.
Aside from that, the patient seem
to believe that someone is after
her as verbalized through the
statement, ïng-ana gayud basta
CPA, daghan gusto mag strike sa
imo. All of these perceptions are
manifectations of his health crisis.
On top of that, she also began to
have auditory hallucinations of
her co-workers which later on led
to visual hallucinations
The patient is single DENIAL - denial is an attempt to screen
with no kids. After or ignore unacceptable realities by
the death of their refusing to acknowledge them.
parents, she After failing to take the board exams for
continued to live CPAs, patient Boning started to manifest
alone. Her eldest denial as she refused to accept that she is
sister became her ill by declining to take prescribed
guardian and medications. Another coping mechanism
provided her with that patient Boning manifested is
groceries and other suppression. According to Videbeck
needs. Her sibling (2020), it is the conscious exclusion of
visits her once or unacceptable thoughts and feelings from
twice a month. conscious awareness. She refused to
express her feelings about her past
trauma.
PROJECTION
The patient manifested projection
through blaming his father about her
inability to take the board exam. She
conjured ill memories about her father
physically abusing her, which was denied
by the informant.
 31

CRISIS

The point of crisis for patient Boning was when she started to have grandiose delusions of being a CPA,
tangential thinking, being irritable, and having blunted affect, auditory and visual hallucinations.

All of these manifestations led to the diagnosis of schizophrenia.

CRISIS INTERVENTION (Ideal) CRISIS INTERVENTION (Actual)

 Psychopharmacology
 Neuroleptics
 Psychosocial Treatment
 Individual group therapy
 Family therapy
 Family education
 Social skills training
 Promote safety of client and others.
 Approach the client in nonthreatening
manner
 Give client ample personal space
 Observe for signs of building
agitation or escalating behavior
 Move client to a quiet, less
stimulating environment
 Establish a therapeutic relationship
 Establish trust to allay client’s fears.
 Provide explanations that are clear,
direct, and easy to understand.
 Use therapeutic communication
techniques.
 Implement interventions for delusional
thoughts
 Avoid openly confronting the
delusion or arguing about it
 Avoid reinforcing the delusional
belief by “playing along” with what
the client says.
 Present and maintain orientation to
reality
 Psychopharmacological treatment of:
 Fluphenazine decanoate 1 amp @ IM
now & monthly
 Clozapine 100 mg 1 tab PM HS
 Clozapine 100 mg 1/2 tab AM
 Develop trusting relationships by giving
patient ample personal space during nurse-
patient interaction and using therapeutic
communication techniques.
 Provide instructions that are clear, direct and
easily understood.
 Provide structured program for therapy such
as art therapy for expressing thoughts and
feelings, music therapy, play therapy and
occupational therapy.
 Ensure client safety
 Encourage participation during structured
activities and acknowledge accomplishments.
 32

CHAPTER VI

LABORATORY EXAMINATIONS AND RESULTS OF PSYCHOLOGICAL TESTING

This chapter presents the ideal and actual laboratory tests that can be performed to the

client. This chapter discusses the possible tests and its results.

A. Neuropsychological Test

Positive and Negative Syndrome Scale (PANSS)

They'll assign you a score on the PANSS scale based on your responses and your doctor's

observations of your conduct. Each item is ranked from 1 (not present) to 7 (severe), resulting in

a score ranging from 30 to 210.

Scale for the Assessment of Negative Symptoms (SANS test)

- It measures 25 negative symptoms of schizophrenia, including: lack of facial expressions,

social inattentiveness, lack of interests and relationships.

Scale for the Assessment of Positive Symptoms (SAPS test)

- It checks 34 positive symptoms, including: hallucinations, delusions. In both scales, each

symptom is scored from 1 (none) to 5 (severe).

Brief Psychiatric Rating Scale (BPRS)

- It's one of the most common tests used by psychiatrists to determine the severity of someone's

schizophrenia. The test checks for 18 different symptoms or behaviors, including irritability,

disorientation, and hallucination. On a scale of 1 (not present) to 7, it assigns a score to each

(extremely severe). The results are based on a 20- to 30-minute chat between you, your family

members, or other caregivers and your doctor.

 33

Clinical Global Impression-Schizophrenia (CGI-SCH)

- The CGI-SCH measures two things: How severe your schizophrenia is and how much

the symptoms have changed since your last checkup. Each result is measured on a scale of 1 to 7,

with 7 being the more severe form of schizophrenia or the greatest increase in schizophrenia

symptoms. The appointment includes questions about your symptoms over the previous 7 days.

Calgary Depression Scale for Schizophrenia

- Doctors use this test to check you for symptoms of depression that could affect your

daily life or might even lead you to have thoughts of suicide.

B. Laboratory Tests

Although there are no laboratory tests to specifically diagnose schizophrenia, the doctor

might use various diagnostic tests such as MRI or CT scans or blood tests to rule out physical

illness as the cause of your symptoms.

Type of Test Indication Ideal Values Rationale Nursing

Responsibility
Hematology Hematology 120-155 g/L For baseline Monitor vital
CBC+PLT tests are done 34.9-44.5% signs to note
data
-HgB to check for 3.8-5.8x1012/L presence of
-Hct blood diseases 4,500 to 11,000 infection
-RBC and disorders, cells/mm³ -Explain test
-WBC infections in procedure
55-73%
the blood,
Differential - Observe for
oxygen levels 20-40%
Count redness and
in the blood, 2-8%
-Neutrophils pain at the
liver disease 1-4%
-Lymphocytes affected site
and a host of 0.5-1%
-Monocytes -Monitor the
ailments. 150,000-400,0
-Eosinophils puncture site
00/mL
-Basophils for
-Platelet Count oozing or
hematoma
 34

formation.
Magnetic In In patients with MRI allows Explain that the
Resonance schizophrenia, schizophrenia, MRI for test takes 30 to
Imaging MRI is shows a smaller total high-quality 90 minutes.
indicated in brain volume and imaging of the - Explain to the
the enlarged brain with patient
same ventricles. Specific good anatomic that he’ll hear
circumstances subcortical regions are detail. MRI the scanner
as CT. MRI affected, and an scans are used clicking and
can be useful increase in the volume to measure thumping
in evaluation of the brain activity sounds.
of globus pallidus. In the and how they - Reassure the
ischemia, cortex can be seen can be used to patient that
vascular changes in folding compare he’ll be able to
anomalies, patterns and a differences in communicate
hemorrhage, reduction in mental states. with the
infection, cortical volume and technician at all
headaches, and thickness, most times.
cranial pronounced in the -Instruct the
neuropathies. frontal patient to
and temporal lobes. remove all
metallic
objects,
including
jewelry,
hairpins, or
watches.
- Ask whether
the patient has
any surgically
implanted
joints, pins,
clips, valves,
pumps, or
pacemakers
containing
metal that could
be attracted to
strong MRI
magnet.
- Monitor vital
signs.
-Monitor the
patient for
orthostatic
hypotension.
 35

Computed Computerized Ventricular size has Neuroimaging Obtain an

tomography tomography been in schizophrenia informed
scan (CT) is reported to increase can provide consent
frequently with several hints for properly
used progression of the the diagnosis. signed.
routinely in disease. Computed - Instruct the
schizophrenia. Temporal lobe volumes tomography is a patient to not to
It is indicated in useful and eat or drink for
to identify patients with accurate a
intracranial schizophrenia are cross-sectional period amount
abnormalities smaller imaging test of time.
and lesions compared to control ideally suited - During the
and patients. This includes for investigating examination,
determine a possible tell
focal reduction in the size of pathology in the patient to
neurological the body cavities. remain still and
abnormalities amygdala- to report
hippocampus symptoms of
complex, which is itching,
responsible for difficulty,
memory breathing or
formation and swallowing.
emotional - Remove any
reactions. The corpus metal objects,
callosum is also thicker such as a belt or
in jewelry, which
patients with might interfere
schizophrenia. with image
results.
 36

CHAPTER VII

DIAGNOSIS

This chapter discusses the five axes included in the DSM IV TR. A multiaxial system

involves the evaluation of several axes, each of which relates to a distinct category of

information that may benefit the physician in treatment planning and result prediction.

Axis Clinical Syndrome

I
DIAGNOSTIC CODE DSM - V NAME
295.90 (F20.9) Schizophrenia
Prior to admission and treatment, the patient experienced behavioral changes
when patient failed to take the CPA board exams that resulted in being irritable,
easily-angered and delusions.

Axis Personality Disorder, Mental Retardation and Defense Mechanism

II
DIAGNOSTIC CODE DSM -V NAME
301.81 (F60.81) Narcissistic Personality Disorder
297.1 (F22) Delusional Disorder
Denial
Suppression
Projection

Due to traumatic emotional life events, patient developed grandeur and

persecutory delusions. As the patient was having mental changes, she also
developed narcissistic and delusional personality disorder where she exhibited
emotional flat, numb emotions and sharp stair; odd beliefs such as believing
that she is a certified public accountant, and that she is employed freelance; odd
thinking and speech like having irrelevant phrases constantly inserted into her
responses “its comes from within, not from without.”

Patient’s coping mechanisms are denial as the patient denies the reality of her
situation causing her to delay medical treatment. Moreover, she also has
delusional personality disorder as she often refers to herself as a CPA even
when she is not. She also believes that as a part of being a CPA, people are after
her most of the time.

Another coping mechanism of the patient is suppression since she excludes her
personal feeling from her trauma and projection the patient manifested
 37

projection through blaming his father about her father inability to take the board
exam. Patient conjured ill memories about her father physically abusing her,
which was denied by the informant.
Axis General Medical Condition
III
No medical condition has been diagnosed to the patient.

DIAGNOSTIC CODE DSM - V NAME

None None

None

Axis Global Assessment of Functioning

V Score 40-31 Time frame: 26 years
GAF Scale Code 40: Patient displays some impairment in reality testing or
communication with obscure or illogical perception of events. Patient has major
impairment in several areas such as work, thinking, such as tangentiality and
her blunted affect.
Diagnosis: Schizophrenia
 38

CHAPTER VIII

MEDICAL MANAGEMENT

This chapter presents the ideal medical interventions applicable to the client’s current

condition. This includes different forms of therapies and pharmacological management suitable

for alleviating illness.

IDEAL MANAGEMENT

The primary treatment for schizophrenia is psychopharmacology.

Psychopharmacology

Antipsychotic medications

Antipsychotic medications are prescribed primarily for clients with schizophrenia. It is used

to treat the symptoms of psychosis, such as delusions and hallucinations seen in schizophrenia.

Antipsychotic drugs work by blocking receptors of the neurotransmitter dopamine. These drugs

do not cure schizophrenia, rather, they are used to manage symptoms of the disease.

When compared to other antipsychotic drugs, clozapine stands out as a distinct member of

the so-called "third class" of antipsychotics. It is the only antipsychotic drug with established

efficacy in treating schizophrenia that is resistant to treatment (TRS). Although the exact

mechanism underlying clozapine's superior efficacy in TRS has not been determined,

approximately 50–60% of schizophrenia patients who are resistant to other antipsychotics will

respond to clozapine.

Psychosocial Treatment
 39

In addition to pharmacologic treatment. Many other modes of treatment can help a person

with schizophrenia. Individual and group therapy sessions are often supportive in nature, giving

the client an opportunity for social contact and meaningful relationships with other people.

Clients with schizophrenia can improve their social competence with social skill training,

which translates into more effective functioning in the community. Basic social skills training

involves breaking complex social behavior into simpler steps, practicing through role-playing,

and applying concepts in the community or real-world setting.

Cognitive Behavioral Therapy

The cognitive behavior therapy used to treat schizophrenia differs from the cognitive

behavior therapy used to treat depression or anxiety disorders. Instead, the methods are changed

to address some of the unique restrictions brought on by the illness (such as cognitive

dysfunction) or its side effects (e.g., stigma and loss). Creating a therapeutic alliance based on

the patient's viewpoint, coming up with alternate explanations for schizophrenia symptoms,

minimizing the impact of both positive and negative symptoms, and providing alternatives to the

medical model as a means of addressing medication adherence are a few of the key stages of

cognitive behavior therapy. (Douglas Turkington, 2006)

For patients who are referred because of persistent symptoms following an initial course of

pharmacotherapy and supportive treatment, cognitive behavior therapy for schizophrenia should

ideally consist of at least 10 planned sessions over a period of six months with specially trained

therapists.

IDEAL NURSING MANAGENMENT

Assessment
 40

History

 Assess the age and onset of schizophrenia, knowing that poorer outcomes are associated

with an earlier age at onset.

 Assess the client for previous suicide attempts

 Elicit information about any history of violence or aggression because a history of

aggressive behavior is a strong predictor of future aggression.

 Assess whether the client has been using current support systems by asking the client or

significant others the following questions:

o Has the client kept in contact with family or friends?

o Has the client been to scheduled groups or therapy appointments?

o Does the client seem to run out of money between paychecks?

o Have the client’s living arrangements changed recently?

 Assess the client’s perception of his or her current situation ---- that is , ehat the client

believes to be significant present events or stressors.

General Appearance, Motor Behavior, and Speech

 Assess for patient appearance, which ay vary widely among different clients with

schizophrenia. Note strange or unusual postures or gestures.

 Examine the client's motor behavior to see if it seems unusual overall. The client might

be restless and unable to sit still, show agitation and pacing, or seem immobile

(catatonia). He or she may also make odd facial expressions, such as grimacing, and

gestures that appear to have no purpose (stereotypical behavior).

 Assess if client exhibits psychomotor retardation (a general slowing of movements).

 Assess for unusual speech patterns, note rate and volume of speech.
 41

Mood and Affect

 Observe client’s mood and affect;

o Flat affect (no facial expression)

o Blunted affect (few observable facial expressions)

 Note facial expression, client may exhibit inappropriate expression or emotions

incongruent with the context of the situation.

 Assess if client reports feeling depressed and having no pleasure or joy in life

(anhedonia). Conversely, he or she may report feeling all-knowing, all-powerful and not

at all concerned with the circumstance or situation.

Thought Process and Content

 Assess thought process by inferring from what the client says.

 Assess thought content by evaluating what the client actually says, for example the client

may suddenly stop talking in the middle of a sentence and remain silent for several

seconds to 1 minute (thought blocking). Clients may also state that others can hear or

trying to take away their thoughts.

Delusions

 Note if client has delusions, common characteristic of schizophrenic delusions I the

direct, immediate, and total certainty with which the client holds these beliefs.

 Note if the client is suspicious, mistrustful, and guarded about disclosing personal

information; he or she may examine the room periodically or speak in hushed, secretive

tones.
 42

 Assess the content and depth of the delusion to know what behaviors to expect and to try

to establish reality for the client.

 When eliciting information about the client’s delusional beliefs, the nurse must be careful

not to support or challenge them. For example, the nurse might ask the client to explain

what he or she believes by saying. “Please explain that to me” or “Tell me what you’re

thinking about that.”

Sensorium and intellectual process

 Because the client's thought process is impaired, the nurse shouldn't assume that the

client has a limited intellectual capacity. It's possible that the client lacks the necessary

focus, concentration, or attention span to accurately demonstrate their intellectual

abilities.

 Obtain accurate assessment of the client’s intellectual abilities when the client’s thought

process is clearer.

 Clients may respond in a literal way to other people and the environment. For example,

when asked to interpret the proverb, “A stitch in time saves nine,” the client may explain

it by saying, “I need to sew my clothes.” The client may not understand what is being

said and can easily misinterpret instructions. This can pose serious problems during

medication administration. The client may misinterpret the nurse’s statement and take the

entire supply of medication at one time.

Judgment and insight

 Assessing the client's capacity for accurate environmental interpretation, it follows that a

client with disorganized thought patterns and inaccurate environmental interpretations

will struggle greatly with judgment.

 43

 Ensure safety. Sometimes the lack of judgment is so severe that clients must put

themselves in danger to meet their needs for safety and protection.

Self-concept

 Note any difficulties that are the source of many bizarre behaviors such as public

undressing or masturbating, speaking about oneself in third person, or physically clinging

to objects in the environment.

 Assess if client recognizes body parts as their own, or may fail to know that they are male

or female.

Roles and Relationships

 Note clients with problems with trust and intimacy, which interfere with the ability to

establish satisfactory relationships.

 Note that clients may experience great frustration in attempting to fulfill roles in the

family and community.

Physiologic and self-care considerations

 To assist the client with community living, the nurse assesses daily living skills and

functional abilities.

Drug Study
Drug # 1
Brand name Not indicated
Generic name Clozapine
Classification Antipsychotics
Indication/s
 Indicated for reducing the risk
of recurrent suicidal behavior in
patients with schizophrenia
or schizoaffective disorder in
patients who are judged to be at
chronic risk to re-experience
suicidal behavior
 44

Contraindication/s Clozapine is contraindicated in patients

with serious hypersensitivity reactions to
clozapine or any component of the
formulation.

 Neutropenia (due to the risk of

agranulocytosis)
 Orthostatic hypotension.
 Seizures.
 Myocarditis.
 Dementia (risk of a cardiovascular
event)
Dosage  50 mg/tab AM
 100 mg/tab PM HS
Mechanism of Action Clozapine is a dibenzodiazepine
derivative. It has a weak dopamine
receptor-blocking activity at D1, D2, D3
and D5 but has high affinity to D4. It also
possesses α-adrenergic blocking,
antimuscarinic, antihistaminic,
antiserotonergic and sedative properties.
Side Effects Side effects of clozapine include:

 Low blood pressure (hypotension)

 Fast heart rate
 Fever, sedation, seizures (with
high doses)
 Appetite increased
 Constipation
 Heartburn
 Nausea
 Increased hunger
 Excess salivation/drooling
(especially at night)
 Vomiting
 Weight gain
 Sleep problems
 Increased sweating
 Dry mouth
 Blurred vision
 Drowsiness
 Spinning sensation
 Headache
Nursing Responsibilities  Differential blood counts must be
normal on commencement and
 45

monitored regularly.

 Due to potential for myocarditis and

cardiomyopathy, patients should
have:

 Full physical examination and

medical history;

 Specialist examination if there are

any cardiac problems;

 Investigations for myocarditis or

cardiomyopathy in the presence of
tachycardia.

 Stop taking if cardiomyopathy or

myocarditis is suspected.

 Use with caution in conjunction with

drugs causing constipation.

 Withdraw drug over 14 days to

prevent rebound psychosis.

Rationale of Giving the Drug
Patient teaching
 Patients must immediately report
symptoms of infection, especially flu-
like symptoms.
 Avoid hot baths or showers as
hypotension can occur.
 Oral hygiene is important to avoid
oral candidiasis.
 Avoid overexposure to the sun as
heatstroke can occur.
 Nurses should refer to manufacturer’s
summary of product characteristics
and to appropriate local guidelines
Clozapine is a medication that works in
the brain to treat schizophrenia. It is also
known as a second generation
antipsychotic (SGA) or atypical
antipsychotic. Clozapine rebalances
dopamine and serotonin to improve
thinking, mood, and behavior.

Drug #2
Brand name Not indicated
 46

Generic name Flupentixol decanoate

Classification antipsychotics
Indication/s  Maintenance treatment of
schizophrenia in patients whose
symptomatology does not include
excitement, agitation, or hyperactivity.
Contraindication/s  Circulatory collapse, depressed level of
consciousness due to any cause (e.g.
alcohol intoxication, opiates,
barbiturates), coma;
 severe depression requiring
electroconvulsive therapy or
hospitalisation, and states of
excitement or overactivity, including
mania (for 0.5 or 1 mg tab used in
depression).
 Not recommended for use in excitable
or agitated patients.
Dosage 1 amp 20mg/mL left deltoid
Mechanism of Action inhibits the postsynaptic dopamine
receptors in the CNS which results in the
blockage of dopamine-mediated effects.
Side Effects  changes in menstrual periods
 constipation
 decreased interest in sexual activity
 decreased sexual ability
 dizziness
 dry mouth
 fatigue
 increased production of saliva
 increased sensitivity of the skin to
sunlight
 increased sweating
 swelling of breasts (in men and
women)
 unusual secretion of milk
 weight changes
 blurred vision or other eye problems
 circular eye movement
 decreased blood pressure (fainting,
dizziness, lightheadedness)
 difficult urination
 fast, pounding, or irregular heartbeat
 mask-like face
 muscle spasms, especially of the neck
and back
 47

 new or worsening constipation

 severe restlessness or need to keep
moving
 shuffling walk
 signs of liver damage (e.g., yellowing
of skin or whites of eyes, abdominal
pain, loss of appetite, dark urine, light-
coloured stools, tiredness, or
weakness)
 skin rash
 stiffness of arms and legs
 symptoms of a blood clot in the arm or
leg (tenderness, pain, swelling,
warmth, or redness in the arm or leg)
or lungs (difficulty breathing, sharp
chest pain that is worse when breathing
in, coughing, coughing up blood,
sweating, or passing out)
 symptoms of high blood sugar (e.g.,
frequent urination, increased thirst,
excessive eating, unexplained weight
loss, poor wound healing, infections,
fruity breath odour)
 trembling and shaking of fingers and
hands
 uncontrolled body movements (e.g.,
twisting movements, chewing
movements, puffing cheeks, lip
smacking or puckering)
 long-lasting (more than 4 hours) and
painful erection
 seizures
 signs of a heart attack (e.g., chest pain
or pressure, pain extending through
shoulder and arm, nausea and
vomiting, sweating)
 signs of neuroleptic malignant
syndrome (e.g., high fever, muscle
stiffness, confusion or loss of
consciousness, sweating, racing or
irregular heartbeat, or fainting)
 signs of a serious allergic reaction
(e.g., abdominal cramps, difficulty
breathing, nausea and vomiting, or
swelling of the face and throat)
 signs of a stroke (e.g., headache, loss
 48

of coordination, slurred speech,

weakness, numbness, or unexplained
pain in the arm or leg)
Nursing Responsibilities Assessment
 Assess mental status (orientation,
mood, behavior) before and
periodically during therapy.
 Monitor BP (sitting, standing, lying),
ECG, pulse, and respiratory rate before
and frequently during the period of
dose adjustment. May cause Q-T
prolongation.
 Observe carefully when administering
oral medication to ensure that
medication is actually taken and not
hoarded.
 Assess weight and BMI initially and
throughout therapy.
 Assess fluid intake and bowel function.
Increased bulk and fluids in the diet
help minimize constipation.
 Monitor 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, mask-like face, shuffling
gait, rigidity, tremors 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. Reduction in dose
or discontinuation of medication may
be necessary. Benztropine or
diphenhydramine may be used to
control these symptoms.
 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).
Report immediately; may be
irreversible.
 Monitor for development of
 49

neuroleptic malignant syndrome

(fever, respiratory distress,
tachycardia, seizures, diaphoresis,
arrhythmias, hypertension or
hypotension, pallor, tiredness, severe
muscle stiffness, loss of bladder
control). Report immediately.
 Monitor for symptoms related to
hyperprolactinemia (menstrual
abnormalities, galactorrhea, sexual
dysfunction).
Patient teaching:
 Instruct patient to take as directed. If a
dose is missed, omit and take next dose
as scheduled. Discontinuation should
be gradual; abrupt discontinuation may
cause withdrawal symptoms (nausea,
vomiting, anorexia, diarrhea,
rhinorrhea, sweating, myalgias,
paraesthesias, insomnia, restlessness,
anxiety, agitation, vertigo, feelings of
warmth and coldness, tremor).
Symptoms begin within 1 to 4 days of
withdrawal and abate within 7 to 14
days. Advise patient to read Patient
Information leaflet prior to starting
therapy and with each Rx refill in case
of changes.
 Inform patient of possibility of
extrapyramidal symptoms and tardive
dyskinesia. Caution patient to report
these symptoms immediately to health
care professional.
 Advise patient to change positions
slowly to minimize orthostatic
hypotension.
 Medication may cause drowsiness.
Caution patient to avoid driving or
other activities requiring alertness until
response to medication is known.
 Advise patient to notify health care
 50

professional of all Rx or OTC

Rationale of Giving the Drug
medications, vitamins, or herbal
products being taken and to consult
with health care professional before
taking other medications.
 Caution patient to avoid concurrent use
of alcohol and other CNS depressants.
 Instruct patient to notify health care
professional promptly if sore throat,
fever, unusual bleeding or bruising,
rash, weakness, tremors, visual
disturbances, dark-colored urine, or
clay-colored stools occur.
 Instruct patient to avoid sun exposure
and to wear protective clothing and
sunscreen when outdoors.
 Advise patient to notify health care
professional of medication regimen
before treatment or surgery.
 Advise female patients to notify health
care professional if pregnancy is
planned or suspected or if breast
feeding.
Long‐acting depot injections of drugs such
as flupenthixol decanoate are extensively
used as a means of long‐term maintenance
treatment for schizophrenia.

Actual Medical Management

Establishing and growing therapeutic nurse-patient relationships, milieu management, and
psychopharmacology are the core objectives of nursing management of schizophrenia. To rid
individuals with schizophrenia of their hallucinations is the main therapeutic objective.
Nurse-Patient Relationship
 Orientation patient to time, place, and person. Rationale: So the patient may be aware about
the environment and the time.
 Don’t touch patient without warning him/her. Rationale: he or she might perceive that as a
threat and he/she will retaliate.
 Focus on real people and events. Rationale: This helps patient stay in touch with reality.
 51

 Be diligent in attempting to understand patients. Rationale: it is therapeutic to help patients

communicate what they want to say; however, use good judgment. Pushing too hard can be
frustrating to the patient.
 Encourage identification of strengths and accomplishments. Rationale: To help thepatient
have the feeling and sense of accomplishment.
 Allow and encourage verbalization of feelings. Rationale: Patients are helped if the patient
can express their thoughts without the nurses becoming defensive

Pharmacology
 Clozapine 50 mg/tab AM
 Clozapine 100mg/tab PM HS
 Flupentixol decanoate 1 amp 20 mg/mL left deltoid @ 4:00pm

Milieu Management
 Provide distracting activities. Rationale: to decrease environmental stimuli in order to
prevent agitation.
 Provide a safe and calm environment. Rationale: modifying the environment may help
minimize objects that can be used as weapons and prevent harm.
 Discouraged situation in which patient may be anxious. Rationale: to encourage patient to
cooperate and alleviate anxiety
 52

CHAPTER IX

NURSING CARE PLAN

Nursing Care Plan of Disturbed Thought Process

Health Nursing Desired Evaluation

Assessment Intervention Rationale Evaluation
Pattern Diagnosis Outcome Modification
Subjective Cognitive Note: Use P-E-S General Independent Goal >Continued
Cues: Health format Objectives: Intervention: Partially met. evaluation is
Perceptua After 2 necessary.
“Ako diay si Disturbed thought After 2 > Present the >To be able to
l weeks of
Boning, process related to weeks of reality to the re-align the >Reiteration
nursing
CPA” as alteration in nursing patient. patient’s and
intervention
verbalized by mental status as intervention, orientation of reinforcement
patient was
the patient. evidenced by patient will reality. of the
able to:
grandiose be able to: interventions.
“Nakagraduat > >To easily
delusions,respons Maintain
e man sya sa >Maintain Communicate build the trust >Schizophreni
e, and short usual
college, pero usual to the patient in from the a requires
attention span. orientation to
wala sya naka orientation to the most client and to
reality with long- term
take ug board Background reality with therapeutic have a therapy and
assistance,
exam kay Knowledge: the assistance way successful
Although the evaluation and
wala mi of student nurse-patient usually takes
delusions are
kwarta A delusion is a nurses. interaction. time to control
still present,
pambayad.” false belief held the student the
by a person. It Specific >Patients may
As verbalized > Maintain a nurses manifestations
contradicts reality Objectives: respond with
by the pleasant and correct it in of the
or what is anxious or
informant. quiet accordance condition.
commonly >Verbalize aggressive
environment with reality.
Objective considered true. concrete behaviors if
and approach
Cues: The strength of a environmenta patients in a startled or
Patient
delusion is based l happenings slow and calm overstimulate
verbalizes
Patient on how much the without d
 53

responds person believes it. talking about manner in a concrete

inaccurately Specifically, a delusions in a specified time environmenta
to the delusion of specified l happenings
>Recognize the >Recognizing
questions grandeur is a time without
client’s the client’s
person’s belief talking about
>Patient will delusion and perception
that they are delusions in a
be able to do perception of can help
someone other specified
assigned the understand
than who they are, time but
tasks given environment. the feelings he
such as a there are still
by student is
supernatural times that the
nurses. experiencing.
figure or a patient
celebrity. A >Provide >When experiences
delusion of >Maintain grandiose
attention and structured thinking is
grandeur may also activities for focused on delusions
be a belief that concentration related to her
to complete the patient by reality-based
they have special engaging him activities, the occupation
abilities, activities. and career;
in reality-based client is free
possessions, or activities such of delusional Patient was
powers. as: thinking able to do
(Chaunie Brusie, - simple arts during that assigned
2017) and crafts time. Helps tasks given
project focus by the
attention student nurse
externally. such as
>Initially do simple arts
not argue with >Arguing will and crafts
the client’s only increase project like
beliefs or try to defensive drawing and
convince the position, coloring
client that the thereby activities.
delusions are reinforcing
false and false beliefs.
unreal. This will
 54

result in the
client feeling
even more
isolated and
misunderstoo
>Encourage d.
healthy habits
to optimize >All are vital
functioning: to help keep
- Maintain the client in
medication remission
regimen
- Maintain
regular sleep
pattern

>Show
empathy
regarding the
client’s
feelings;
reassure the
client of your
presence and
acceptance

>Refrain from
forcing
activities and
communication
s
 55

>Helps
Dependent patients learn
Intervention: to recognize
and change
>Discuss the thought
use of patterns and
Cognitive- behaviors that
behavioral lead to
therapy (CBT) troublesome
feelings.

>This
medication
eases
>Administer symptoms
prescribed such as
medication delusions and
such as hallucinations
Olanzapine . These drugs
decanoate, work on
clozapine chemicals in
the brain such
as dopamine
and serotonin

Collaborative >FT helps

 56

Intervention: families deal

more
>Collaborate effectively
with a family with a loved
and cognitive one who is
behavioral delusional,
therapist enabling them
to contribute
to a better
outcome for
the patient.

> CBT help

people with
schizophrenia
improve their
social and
problem-
solving skills,
lessen the
severity of
their
symptoms,
and reduce the
chance of
relapse

Nursing Care Plan of Impaired Verbal Communication

 57

Assessmen Health Nursing Desired Evaluation

Intervention Rationale Evaluation
t Pattern Diagnosis Outcome Modification
Subjective Role Note: Use P- General Independent -Continuity of
Cues: relationshi E-S format Objectives: Intervention: Goal partially care and
p pattern met. After 2 evaluation are
“The Impaired >After 2 >Maintain a >This weeks of necessary to
activity Verbal weeks of calm, promotes time nursing
identify
was Communicatio nursing unhurried for the patient intervention,
improvements.
presented it n on related to intervention, manner. to comprehend the patient was
comes altered mental the patient will Provide or understand able to: - Impaired
from status as be able to: sufficient time the verbal
within not evidenced by for the patient information he Participate in communicatio
from inappropriate >Express to respond. received. therapeutic n due to
without.” verbalization feelings and communication schizophrenic
thoughts in >Maintaining . There are
as conditions
Background reasonable and >Maintain communicatio times when the
verbalized require long
knowledge: logical, goal- established n with the patient can
by the therapy and
directed communication patient will express
patient. Disorganized evaluation.
manner. with the patient improve their thoughts and
speech is a This means
Objective daily. expression of feelings
symptom that the
Cues: Specific feelings and coherently in a
common in intervention
Objectives: thoughts and logical, goal-
schizophrenia provided
Patient has at the same directed
. should be
difficulty >Actively time will manner but is continuously
expressing participate in allow them to still
Schizophrenia rendered in
his thought therapeutic preserve inconsistent At
patients have a order to
and communicatio communicatio Times, the
variety of maintain and
constantly n n skills patient can also
cognitive improve the
mentioning abnormalities, >Use clear, communicate communicatio
phrase that >Communicat >To provide
including simple words, in a clear and n capability of
isn’t e in a clear better
slower speak slowly, comprehensive the patient
related to and understanding
processing keep your manner with within limits
the comprehensiv as the client
speed and poor voice low, and the help of of the
questions. e manner, with might have
 58

cognitive the help of keep difficulty medication and condition.

control. Poor medication instructions processing student nurses
cognitive and attentive simple as well. even simple as well.
control task listening from sentences.
performance the nurse and Loud or high-
has been linked family pitched voices
to disorganized may trigger
speech anxiety,
symptoms, agitation, or
such as confusion in
communication patients with
difficulties schizophrenia.
(Merril, >Maintain eye
Karcher, contact with >Patient need
Cicero, Becker, patients when to see the
Docherty, speaking. stand nurse's face or
Kerns, 2017). close within lips to enhance
the patient line their
In patient’s of vision understanding
case, when (generally of what is
asked what can midline). being
she say about communicated
the activity, she >Use .
answered “It therapeutic
comes from communication >Encourage
within not from : the patient to
without” that is - Silence: verbalize,
obviously not Absence of provided that
related to the verbal it is interesting
question. communication and expectant.
, which Give time to
provides time recognize
for the client to thoughts,
direct the topic
 59

put thoughts or of interaction,

feelings into or focus on
words, regain issues that are
composure most
important.
>Presenting
reality- >When a
Offering for patient is
consideration misinterpretin
on that which g reality, the
is real. nurse can
indicate what
is real. The
nurse does this
by calmly and
quietly
expressing the
nurse’s
perception or
the facts not
by way of
arguing with
> Offering self the patient or
belittling his
experience.

Offering time
and presence
>Translating initiates
into feelings interest and
understanding
to the patient.

>Seeks to
 60

>Voicing verbalize the

doubt patient’s
feelings that
he expresses.

>This permits
the patient to
become aware
Dependent that others do
Intervention: not necessarily
perceive
>Administer events in the
prescribed same way or
medication draw the same
such as conclusion.
Olanzapine
decanoate, >This
clozapine medication
eases
symptoms
such as
delusions and
hallucinations.
These drugs
work on
>Discuss the chemicals in
use of the brain such
Cognitive- as dopamine
behavioral and serotonin.
therapy (CBT)
>Helps
patients learn
to recognize
Collaborative and change
 61

Intervention: thought
patterns and
>Collaborate to behaviors that
a speech and lead to
language troublesome
therapist feelings.

>To address
the patient’s
symptoms
with regards to
expressing his
thoughts

Nursing Care Plan of Impaired Social Interaction

Health Nursing Desired Evaluation

Assessment Intervention Rationale Evaluation
Pattern Diagnosis Outcome Modification
Subjective Role Note: Use P- General Independent After 2 weeks -Continuity of
Cues: relationship E-S format Objectives: Intervention: of nursing care and
pattern intervention, assessment
“Nakakulong Impaired After 2 weeks >Keep the >Patient might
the patient are necessary
ra man gud social of nursing patient in an respond to
was able to: in order to
na sya sa interaction intervention, environment as noises and
evaluate the
among balay related to the patient free of stimuli crowding with >Able to course of
ma’am kay altered will be able (loud noises, agitation, attend condition.
gapanglabay thought to: crowding) as anxiety, and structured
sya ug bato if process as possible. increased activities in -
naa sya sa evidenced by >State that she inability to social Schizophrenia
gawas.” as inappropriate is comfortable concentrate on situations is a long-term
verbalized by emotional in at least outside events. settings with condition
informant response, three the help and which
>Give >Recognition
structured
 62

Objective spends time activities that acknowledgmen and of student requires

Cues: alone by self, are goal t and appreciation nurses that consistent
Unable to directed. recognition for go a long way encourages reinforcement
Observed maintain eye positive steps to sustaining her to do so and support
discomfort contact Specific the client takes and increasing >The patient from the
during the Objectives: in increasing a specific was able to health care
course of Background social skills and behavior state that she provider and
assessment; knowledge: >Able to use appropriate was the family.
Unable to appropriate interactions comfortable Patients with
initiate social Behavior and social skills in with others. and happy a progressive
interaction; functional interaction s. >Social skills
with the form of the
inability to deficiencies >Provide training helps
structured disease are
maintain eye seen in > attend one opportunities the patient
activities that increasingly
contact; schizophrenic structured for the client to adapt and
are goal socially
Blunted patients, one group activity learn adaptive function at a
oriented. isolated.
affect; Sits of within 6-11 social skills in a higher level in
alone during the signs and days. non-threatening society, and >She was
activities. symptoms are environment. increases the able to attend
negative > use client’s quality
Initial social on the
symptoms appropriate of life.
skills training structured
(Kibe, social skills in
could include activities for
2021). interactions.
basic social 11 days.
> maintain behaviors such
as starting a >Used
interaction
conversation appropriate
with another
and exchanging social skills
client while
of nonverbal in
doing an
signals like interactions.
activity (e.g.,
simple frowns, or >Encourages
smiles continuation of >Maintains
drawing) interaction
desired
>Provide behaviors and with another
positive efforts for client while
reinforcement doing the
 63

for change activity.

improvement in
social behaviors others but
and interactions >Group there are
therapy/interac times that the
>Involve patient t ions helps patient would
in group individuals feel
interaction or as develop uncomfortabl
the situation communicatio e and
allows. n skills and annoyed
socialization because of
skills, and this he cannot
allows clients be forced to
to learn how to interact with
express their others as it
issues or may cause
problems. him to get
angry and
>Well- combative.
>Assist client to developed
develop positive social
social skills interaction
through practice skills are
of skills in real critical for
social situations developing
such as: positive self-
- Listening to esteem, and
others; building
- staying calm relationships.
with others; Social skills
getting along training helps
with others and the client
by following the adapt and
steps and rules function at a
 64

accompanied by higher level in

a support society.
person.

>Encourage the >These

client’s interventions
engagement and measures are
participation in to help the
Physical and patient in
Social overcoming
Activities the sense of
isolation in
impaired
social
interaction
Dependent with
Intervention: individuals of
various age
>Administer groups
prescribed
medication such >This
as Olanzapine medication
decanoate, eases
clozapine symptoms
such as
delusions and
hallucinations.
These drugs
work on
chemicals in
the brain such
>Conduct as dopamine
Social and serotonin.
interaction
 65

therapy, as >Social skills

ordered training (SST)
is a type of
behavioral
therapy used
to improve
Collaborative social skills in
Intervention: people with
mental
>Refer to disorders or
psychiatric developmental
mental health disabilities.
nurse
practitioners for >A PMHNP
additional assesses,
assistance when diagnoses and
indicated. treats patients.
By
incorporating
their scientific,
clinical and
theoretical
knowledge,
PMHNPs help
patients who
are coping
with and
managing
physical and
mental health
concerns.

Nursing Diagnosis
Disturbed thought process
related to alteration in mental
status as evidenced by grandiose
delusion
Impaired Verbal
Communication on related to
altered mental status as
evidenced by inappropriate
verbalization
Impaired social interaction
related to altered thought
process as evidenced by
inappropriate emotional
response, spends time alone by
self, unable to maintain eye
contact.
66
Prioritizati Rationale
on on
High 1 Disturbed thought process is considered
high 1 priority because the patient
presents disturbed thinking and
distorted reality orientation, the patient
experiences delusion, this mental
process may lead to inaccurate
interpretation of the situation and may
result in an inability to evaluate reality
accurately. Delusional disorder may
progress to develop life-long illness,
common complications of delusional
disorder include depression, violence
and legal problems, and isolation.
High 2 Impaired verbal communication is
considered high 2 priority. The patient
exhibits poor communication function.
Patient present sudden stops in thought
process, respond inaccurately and do not
maintain eye contact, inability to
communicate enhances a patient's sense
of isolation and may promote a sense of
helplessness.
High 3 Impaired social interaction is
considered a high 3 priority nursing
diagnosis.
Patient isolates himself and doesn't
want to interact with others that may
lead to poor physical, emotional, and
cognitive function. Perceive social
isolation with adverse health
consequences including depression,
poor sleep quality and poor physical
health.
 67

CHAPTER X
PROGNOSIS AND RECOMMENDATION

ACTUAL PROGNOSIS

Criteria Poor Fair Good Justification

Duration of Illness ✓ This is rated as poor, as of the

present observation, the patient

is now in the long-term phase of

her disease.

Onset of Illness ✓ This is rated as poor as the

patient was still considered to

have schizophrenia at 52 years

old & she can’t recall the reason

why she was admitted. The

patient was only treated from her

home as the patient is mentally

ill since high school

Precipitating Factors ✓ This is rated as fair, all the

precipitating factors were

considered influential to her

condition. This factor

contributed to her condition

 68

based on genetics &

environmental factors acquired

by the patient.

This is rated as good, in terms of

Willingness to Take ✓

Medications
her attitude and willingness, the

patient was able to seek

medication and treatment

without hesitation.

Age ✓ This is rated as poor because the

patient is already 52 years old.

Considering that the patient is

now in her long-term phase,

complications can emerge.

Studies have found that people

with long-term schizophrenia

have higher levels of oxidative

stress that makes your body

slowly loses its ability to repair

cell damage. Also, people with

schizophrenia also tend to have a

lowered ability to think as they

age.
 69

Environment ✓ The patient is now admitted to

the health care facility for 3

months. As observed the

environment is safe for the

patient, considering that health

care facility ensures the safety of

their clients. The facility

provides day-to-day activities

and staffs-patient interaction

which can be beneficial for the

development of the patient

Family Support ✓ The patient’s siblings visited her

twice or once month especially

when there is such an occasion

like her birthday. Her family is

supportive also to her.

Total Criteria: Poor - 1, Fair - 3, Good – 5

Computations

Formula: Σ(Frequency X Score)/7

Average Score =

POOR (1X3) = 3

FAIR (3x2) = 6
 70

GOOD (5x2) = 10

Total: 3+6+10 = 19/7

SCALE FOR INTERPRETATION

Poor = 0 - 1.6

Fair = 1.7 - 3.3

Good = 3.4 - 5

Implication Prognosis: This suggests that the

presenting condition is likely to

partially resolve with proper planning

of care to be given and provision of

sufficient support both emotional and

financial, but the patient’s condition

has the potential to worsen with non-

compliance to the treatment regimen.

CRITERIA PATIENT’S RESULT

The onset of Present Illness, Her eldest sister

Onset of Illness
recalled that it was after their mother’s death

in 2015 that the patient was starting to act

differently. Her strange behavior worsened

after her father died in 2021; the elder sister

would find her talking to herself even when

she was alone, and she would say, “Katingon

kamo, katingon” (Stop you guys, Stop) when

 71

there was no one besides her. Her symptoms

were slighter at first. She could in fact buy her

necessities, she could go shopping for

groceries, and she can do household chores,

but her condition worsened as time went by.

She would also collect things and store them

in her house. She collected play money, and

whenever she got real money, she would

photocopy them, to claim that she had a sack

of money in her house and that she was

wealthy. She would often tear some of those

photocopied money and put holes at the

center of many coins. She would use them as

“designs” in her house and record what she

had done on a logbook, like writing her daily

journal. When the patient was assessed for

hallucinations, she described that she would

see her workmate in her window. They would

talk random things and keep the patient

company at night even when she was already

confined to the facility. She was admitted at

Castillones last February 12, 2022, by her

eldest sister who brought her all the way from

 72

Cateel, Davao Oriental to Davao City. She

felt terrible and sorry for bringing her sister to

the facility, which was not an easy choice for

them. But she was already at the stage where

she was capable of hurting people as she was

already randomly throwing rocks at them. She

could have been treated earlier, but it got

further delayed because of the pandemic and

financial matters. The eldest sister verbalized

that they would miss her sister, and somehow,

she was hopeful that her sister’s illness would

be managed well during her stay in the

facility so they could bring her home soon.

Duration of Illness - Boning's mental illness

Duration of Illness
started to manifest in 1996. In that same year,

she was diagnosed with schizophrenia. In

2022, Boning was at a psychiatric facility

until now (June 2022), and the patient is still

mentally unstable.

Dysfunctional Family Relationship Traumatic

Precipitating Factor
life experiences: -Blurgary -Witnessed father

shoot two men dead. -Failure to take the

 73

board exam. -Death of parents

Boning appeared attentive to their assigned

Mood and Affect
student nurse. On the first day of interaction,

Boning could not maintain eye contact with

the patient displaying head twitching. Though

the patient has a narcissistic personality as she

expresses flat emotions, she still manages to

exhibit episodes of feeling motivated. During

the whole duration of nursing exposure,

Boning's affect is, blunted affect; the patient

expresses little or no facial expressions. As

observed, the patient verbalized that she is

happy and feeling motivated, but her facial

expressions do not express her feelings.

Boning has taken medications after consulting

Attitude & Willingness to Take
with a psychiatrist and is now admitted to a
Medication & Treatment
psychiatric facility. The patient accepted that

she needed help up to this day, and she

expressed willingness to participate in any

structural activities given by her health care

provider.
 74

During the interaction, bunning showed no

Any Depressive Features
signs and symptoms of severe mood changes,

suicidal thoughts, attempts, or auditory

hallucinations. However, the patient is

experiencing grandiose delusions as

manifested by thinking that she is a certified

public accountant even though she is not.

Besides that, boning did not express any

concerns or worries during deaths of a loved

one because she understood the reasons and

the cause of death.

The patient's siblings show support by

Family Support
accompanying her to check-ups and putting

her in a psychiatric institution. In terms of

emotional support, the patient gets it from her

family. Her eldest sister is the one who pushes

her to fight and continue her treatment.

Schizophrenia is usually treated with an

PROGNOSIS
individually tailored combination of talking
 75

therapy and medicine. The goal is to provide

day-to-day support and treatment while

ensuring you have as much independence as

possible. People who have severe psychotic

symptoms as the result of an acute

schizophrenic episode may require a more

intensive level of care; these episodes are

usually dealt with by antipsychotic

medication and special care. Psychological

treatment can help people with schizophrenia

cope with hallucinations or delusions better to

help treat some of the negative symptoms of

schizophrenia, such as apathy or a lack of

enjoyment and interest in things you used to

enjoy. Psychological treatments for

schizophrenia work best when they're

combined with antipsychotic medication.

Antipsychotics are usually recommended as

the initial treatment for the symptoms of an

acute to chronic schizophrenic episode

(United Kingdom National Health Service,

2019). Based on the data gathered and the

case studied, there is a fair prognosis.

76
 77

Recommendations: (Specify to individual, family or community health

agencies).

INDIVIDUAL:

 Seek for more information and educate yourself about the disorder. The more you know

about schizophrenia, its process and treatments, the higher the chance you will be better.

For instance, understanding the symptoms of hallucinations, delusions and psychosis can

help you react appropriately during onset of disorder .

 Being patient. Don’t expect an immediate and total cure. Have patience with the

treatment process. It can take time to find the right program/ treatment that works for

each person.

 Communicate with a treatment provider/doctor. The treatment program will change over

time, so keep in close contact with your doctor or therapist. Talk to your provider if your

condition or needs change and be honest about your symptoms and any medication side

effects.

 Take your medication as instructed. If you’re taking medication, follow all instructions

and take it faithfully. Don’t skip or change your dose without first talking with your

doctor.

 Getting therapy. While medication may be able to manage some of the symptoms of

schizophrenia, therapy teaches you skills you can use in all areas of your life. Therapy

can help you learn how to deal with your disorder, cope with problems, regulate your

mood, change the way you think, and improve your relationships.

 Monitor your symptoms and moods. In order to stay well, it’s important to be closely

attuned to the way you feel. By the time obvious symptoms and psychosis appear, it is
 78

important to keep a close watch for subtle changes in your mood, sleeping patterns,

energy level, and thoughts. If you catch the problem early and act swiftly, you may be

able to prevent the symptoms and initial episode of psychosis from turning into a full

diagnosis of schizophrenia.

 Develop a wellness toolbox. If you spot any warning signs of decline level of

functioning, withdrawal from friends, families, and hobbies and interests or exhibit

peculiar behavior, it’s important to act swiftly. A wellness toolbox consists of coping

skills and activities you can do to maintain a stable mood or to get better when you’re

feeling “off”. Take time for yourself to relax and unwind, increase your exposure to light,

exercise, talk to a supportive person, attend a support group, call your doctor or therapist,

write in your journal, and ask for extra help from loved ones.

 Encourage vigorous exercise as this may improve a person's cognitive ability, enhance

emotional intelligence and improve quality of life.. Keep it simple at first, such as

walking with a friend. Gradually, work up to working out for at least 30 minutes a day on

most days of the week.

 Limit or avoid caffeine as this can exacerbate positive symptoms, such as delusions and

hallucinations. Don’t drink a lot of soda, coffee, or tea. And take it easy on chocolate,

too, because it has caffeine.

 Reach out for face-to-face connection. Having a strong support system is essential to

staying happy and healthy. Often, simply having someone to talk to face-to-face can be

an enormous help in relieving schizophrenia and boosting your outlook and motivation.

 Encouraging to have adequate sleep. Being sleep-deprived can sometimes trigger

delusions, hallucinations, and paranoia. It can also be a sign of a flare-up of symptoms.

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For instance, just a few nights of less sleep may mean that a manic episode could be

coming on.

FAMILY:

 Family need to understand that long-term treatment is necessary.

 Each family member should be educated with the prognosis of the disorder to ensure that

they understand the do’s and don'ts.

 Be an inspiration and a guide to the patient.

 Teach them to recognize early signs and symptoms of schizophrenia and onset od

psychosis and how to prevent them.

 Be a champion. Patients with schizophrenia, it can sometimes feel like the whole world is

against them . Assuring the person that you’re on their side can help them feel more

stable. You don’t have to agree with the person’s behaviors and actions, but telling them

that you’ll always have their back can be very beneficial.

 Listen, offering your acceptance and understanding. You don’t always need to provide

answers or advice to be helpful. As a family member with schizophrenia, simply being a

good listener is one of the best things you can do for them, especially when they want to

talk to you about the challenges they’re facing and helping them feel more comfortable

with their condition.

 Attend family therapy or family coping.

COMMUNITY:

 Teach about de-stigmatization and non-discrimination and promote positive mental

health environment.
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 Promote mental health awareness and define roles of community members in the

recovery of patients with mental illness.

 Educate the importance of social inclusion in decreasing the risk of mental health crises.

 Educate the community regarding their influence in a person’s sense of belongingness,

support system, purpose and roles which can help improve their mental health.
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CHAPTER XI

BIBLIOGRAPHY

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorder (DSM-

5), Fifth Edition

Chao, D & Brian, D,. (2013). Frontiers in Neuro Cellular Science (Mapping the pathophysiology of

schizophrenia: interactions between multiple cellular pathways)

Department of Health (2018). Mental Health Program. https://doh.gov.ph/national-mental-health-

program (accessed May 5, 2021).

Davis, F.A,. Company Wolters, K. (2016), Nursing drug Handbook, 36th Edition

Marilyn, D,. Moorhouse, M, F, & Murr, A, C,. (2016) , Nurse’s Pocket Guide ( Diagnoses, Prioritized

Interventions and Rationales),

Moustafa, A,. (2021). Cognitive and Behavioral Dysfunction in

Schizophrenia.https://books.google.com.ph/books?

id=dnINEAAAQBAJ&printsec=copyright&source=gbs_pub_info_r#v=onepage&q&f=false

Schizophrenia in a 4-Year Follow-up Study of the Italian Network for Research on Psychoses.

doi:10.1001/jamapsychiatry.2020.4614

NHS. (n.d.). NHS choices. Retrieved June 29, 2022, from

https://www.nhs.uk/mental-health/conditions/schizophrenia/overview/
Silvana, G, MD,  Dino, G, PhD, Armida, M., MD, (February 10, 2021). Factors Associated With

Real-Life Functioning in Persons With Schizophrenia in a 4-Year Follow-up Study of the Italian

Network for Research on Psychoses. doi:10.1001/jamapsychiatry.2020.4614

Smith, Y,. (2019). Mental Health Nursing. Retrieved February 27, 2019 from https://www.news-

medical.net/health/Mental-Health-Nursing.aspx
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Videbeck, S,. (2020). Psychiatric-Mental Health Nursing Eight Edition. Wolters Kluwer Health, Inc.