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I. INTRODUCTION
Schizophrenia is a chronic, severe, and disabling mental illness. The termschizophrenia is Greek in origin, and in the Greek meant "split mind." This is not anaccurate medical term. People suffering from schizophrenia may have the followingsymptoms: Delusions which are false personal beliefs held with conviction in spite of
reason or evidence to the contrary, not explained by that person's culturalcontext. Hallucinations which are perceptions (can be sound, sight, touch, smell, ortaste) that occur in the absence of an actual external stimulus. Also, disorganizedthoughts and behaviors, disorganized speech and catatonic behavior, in which theaffected person's body may be rigid and the person may be unresponsive.
II. SUMMARY OF THE CASE
The patient, a 47 year old mother of two, was brought to the mental healthcenter by her sister who expressed concern about recent behavioral changesexhibited by the patient. She stated that the patient was diagnosed withSchizophrenia, undifferentiated type, at age 40 and was placed on Risperdal 1.5 mg
BID. The patient lived with her sister and was able to perform ADLs independently,until recently, when she discontinued taking her medication.
As a result of medication noncompliance, the patient became overlyconcerned about insects and bugs that she believed were in her room. She began towear gloves to protect her hands as she sprayed insect repellant on all thefurniture. She also turned the water on in her bathroom sink, believing the bugscontaminated the sink.
Unfortunately, she neglected to turn the water off and flooded the bathroom.Although she was oriented to TPP, The patients speech had become incoherent attimes. The patient stated that she felt better while taking the medication and,therefore, believed that she was cured of her illness. Consequently, she stoppedtaking the medication. When her sister confronted her about her recent behavioral
changes, the patient was insightful enough to admit needing help and agreed to seethe nurse at the center where she received follow-up care.
III. CLARIFY UNKNOWN TERMINOLOGY
All terminologies are known.
IV. LEARNING ISSUES AND FORMULATE HYPOTHESIS
LEARNINGISSUES
HYPOTHESIS INFERENCES CONCLUSION
1. What is theeffective dosefor Risperdal?
Since thepatient can stillperform ADLswe assume thatthe Risperdal1.5mg BIDordered is justwithin the
In Schizophrenia, Adults withthe medication Risperdalmay be given once or twicedaily.Patients should start with2 mg/day Risperdal. Thedosage may be increased onthe second day to 4 mg/day.
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effectivetherapeuticdosage torelieve signsand symptomsof
Schizophrenia.
From then on, the dosagecan be maintainedunchanged, or furtherindividualized, if needed.Most patients will benefitfrom daily doses of between
4 mg/day and 8 mg/day.Doses above 6 mg/day whenadministered twice dailywere associated with moreextra pyramidal symptomsand other adverse effectsand are not generallyrecommended.
Reference:www.emedicinehealth.com(01/22/12, 1324H)
Dosage for oral Risperdal Schizophrenia, for adults 2mg/day is the starting dose.Dosage may be increased onthe second day to 4 mg. Mostpatients will benefit fromdaily doses of 4-6 mg. But forElderly with renal or liverdisease: starting dose is 0.5mg twice daily and titrates up
to 1-2 mg twice a day inincrements of 0.5 mg/day.
Reference: PPDs NursingDrug Guide 2007, page 421
2. What route
was used in
the order for
the patient of
Risperdal 1.5
mg BID?
Orally, because
in the order it is
given twice a
day not like for
intramuscular
and intravenous
route that singledosing is
commonly used.
Speculative Speculative
3. What route
is available
when taking
Risperdal?
Risperdal can
be given in oral
tablets form,
intramuscular
Risperdal (Risperidone)comes as a tablet, a solution(liquid), and an orallydisintegrating tablet (tabletthat dissolves quickly in the
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injection and
intravenous
injection but
should be taken
with precaution
for the fasterthe absorption
the greater risk
for adverse
effects.
mouth) to take by mouth.
Reference:www.medlineplus.com(01/22/12, 1116H)
Risperdal can be givenby intramuscular injectioninto the buttock by ahealthcare professional onceevery two weeks. Injectionsshould alternate between thetwo buttocks and is not givenby injection into a vein(intravenously). Injectedrisperidone may take up tothree weeks to beginworking. During this time,oral form of this drug oranother medication for yourcondition by mouth should betaken.
Reference:www.medlineplus.com(01/22/12, 1209H)
Health Day Newsabout Risperdal, oral
antipsychotics appear to bemore effective than Risperdal(risperidone) injections. Thisinjection does not appear toimprove outcomes in patientswith Schizophrenia orSchizoaffective disorder, andis mostly associated withmore injection site woundand extra pyramidal adverseeffects.
Reference:www.mentalhelp.net(01/22/12, 1234H)
4. Why werethere no
reports of thepatients white
blood cell
Risperdal isAtypicalantipsychoticwhichcommonly have
Speculative Speculative
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countreported?
adverse effectofAgranulocytosistherefore thereis theimmediate need
for WBC countmonitoringbefore patientcan get anotherdose. WBCcount required>3500/mm3should bemonthsmonitoredevery 1 weekfor 6.
5. Does whiteblood cell
countmonitoring
alwaysnecessary for
patients takingRisperdal?
Yes, Risperdal isstill a Atypicalantipsychoticwhich has aadverse effectofAgranulocytosis,even thoughlesser thanClozapine andOlanzapine stillit has this effectthat is why it isadvised to betaken atbedtime.
Leukopenia, Neutropenia,and Agranulocytosis havebeen reported as adverseeffects of antipsychotics,including Risperdal. Patientswith history of a clinicallysignificant low white bloodcell count (WBC) or a drug-inducedleukopenia/neutropeniashould have their completeblood cell count (CBC)monitored frequently duringthe first few months oftherapy and discontinuationof Risperdal should beconsidered at the first sign ofa clinically significant declinein WBC in the absence ofother causative factors.Reference:www.dailymed.com(01/22/12, 1344H)
Accepted.
6. Does thepatient gainedweight during
hermedicationregimen?
One side effectof anti
psychotics isweight gain.
Speculative Speculative
7. What areother physical
All generation ofAntipsychotics
Some adverse effects(occurring in 1 to 13 percent
Accepted.
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patientbelieving thatinsects andbugs areinvading herroom and
wearinggloves. Is thisan effect ofthe abruptwithdrawalfrom hermedicationRisperdal?
experiencesdelusions aboutinsects andbugs infecting/invading herroom. And
abruptdiscontinue ofmedicationcauses reboundeffect of muchmore intensesigns andsymptoms.
Schizophrenia signs andsymptoms (hallucinationsand delusions) may bepresent as an effect ofwithdrawal.Reference: www.about.com
(01/23/12, 1359H)
11. Is therereally a needforPsychotherapy plusantipsychotics to effectivelymanage thesymptoms ormedicationsalone woulddo?
The treatmentof choice forSchizophrenia isPsychotherapyplus the antipsychoticmedicationregimen thatshould bescheduled andplanned hand inhand for themaximumbenefit for thepatient.
Speculative Speculative
12. What isthe treatmentof choice forthe patientsdisorder?
The treatmentof Choice forSchizophrenia isthe combinationofPsychotherapyand antipsychoticmedication.
Currently, there is no
method for preventing
schizophrenia and there is no
cure. A comprehensive
treatment program can be
used and this includes:
Antipsychotic medication,
Education & support, for both
ill individuals and families,
Social skills training,
Rehabilitation to improve
activities of daily living,
Vocational and recreationalsupport and Cognitive
therapy.
Reference:
www.nursingcrib.com
(01/23/12, 1543H)
Rejected.
13. DoesSchizophrenia
It is brought bythe non-
Undifferentiatedschizophrenia symptoms may
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disordermanifestspeech
problems orwas thepatients
incoherentspeech wasonly brought
by thewithdrawal?
compliancebecause in themanifestations
ofSchizophrenia itdoes not involve
speechproblems.
include symptoms of morethan one other type of
schizophrenia. Muscle rigidityis common among the signsand symptoms which may
include the face and the jaw.
Reference:www.nursingcrib.com(01/23/12, 1842H)
V. NURSING CARE PLANS
ASSESSMENT
NURSINGDIAGNOSI
S
PLANNING NURSINGINTERVENTION
S
RATIONALE EXPECTEDOUTCOMES
Objective:
Patient hasincoherent
speech
Impairedverbal
communication
related toside
effects ofmedicatio
n asmanifeste
d bypatientsincoherent speech
After 24hours ofnursing
interventions the
patient willexpress atleast two
from theseneeds
a. need forher
medicationb. need ofhelp forbathing
c. need forfood
d. need ofhelp fortoiletinge. needsupport
from familymembers
andcaregiverthrough
congruentverbal and
non verbal
1. Determineability to read/write.
2. Establishrelationshipwith the client,listeningcarefully andattending topatientsverbal/nonverbalexpressions.
3. Maintain eyecontact,preferably atpatients level.
4. Keepcommunicationsimple, usingall modes.
5. Maintain acalm, unhurriedmanner.Providesufficient time
1. Toevaluatemusculoskeletaldexterity.
2. To assistclient inexpressingneeds,wants.
3. Toestablish ameans ofcommunication
4. To helpaccessinformation:visual,auditory,andkinesthetic.
5.Individuals
After 24hours ofnursing
interventions the
patient wasable to
express herneeds as
evidencedby the
following:a. Poin
ting to thetelephoneto call her
sister.b. Writing on theboard thatshe needsto go to
thebathroom.
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communication.
for client torespond.
6. Use andassist patientto learntherapeuticcommunication.
7. Providerealityorientation byrespondingwith simplestraightforward, honeststatements.
8. Validatemeaning ofnonverbalcommunication; do not makeassumptions.Be honest; if itis notunderstood askassistance fromothers.
9. Consider useof alternativemethods ofcommunicationsuch as pictureboard, handsignalsincorporatinginformationabout type ofdisability
withexpressiveaphasiamay talkmore easilywhen they
are restedand relaxedand whenthey aretalking toone personat a time.
6. Improvesgeneralcommunication skills.
7. Tomaintaincontact withreality.
8.Assumptions may bewrong.
9. Cuesnon- verbalor verbalcan be usedto attendpatientsneeds.
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present.
10. Involvefamily in planof care asmuch as
possible.
10.Enhancesparticipation
andcommitment to plan.
ASSESSMENT
NURSINGDIAGNOSI
S
PLANNING NURSINGINTERVENTION
S
RATIONALE EXPECTEDOUTCOMES
Subjective:
Patientsfixed falsebelief of
insects andbugs
invading herroom.
Objective:
Patientspraying
insectrepellants in
her room.
Disturbedthoughtcontent
related topsycholog
icalconflicts
asmanifeste
d bypatientsexperienc
es ofdelusions.
After 24hours ofnursing
interventions the
patient willbe able tointeract on
reality-based
topics byengagingself to atleast 2 of
thefollowingactivities:
a. Mindpuzzles
b. Physical exercisec. Boardgamesd. Arts
andCrafts
making
1. Be sincereand honestwhencommunicatingwith the client.Avoid vague orevasiveremarks.
2. Beconsistent insettingexpectations,enforcing rulesand so forth.
3. Encourage
the client totalk, but do notpry forinformation.
1.Delusionalclient areextremelysensitiveaboutothers andcanrecognizesincerity.Evasivecommentsor hesitationreinforcesmistrust ordelusions.
2. Clear,consistentlimitsprovide asecurestructure forthe client.
3. Probing
increasesthe clientssuspicionandinterfereswith thetherapeuticrelationship.
After 24hours ofnursing
interventions the
patient wasable to
interact onrealitybased
topics byengagingherself to
thefollowing:
a. Patientattendingphysicalexercise
with otherpatients.b. Patientansweringcrossword
puzzlebook.
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4. Destructpatient fromdelusions bygiving physicaland intellectualchallengingactivities suchas board gamesand exercises.
5. Initially, donot argue with
the client or tryto convince theclient that thedelusions arefalse or unreal.
6. Interact withthe client on
the basis ofreal things; donot dwell onthe delusionalmaterials.
7. Do not bejudgmental orbelittle or jokeabout theclients beliefs.
8. Never
4. Engagingpatient tootheractivitiesprovides thepatient toignoredelusionsand focusmore in thereality.
5. Logical
argumentdoes notdispeldelusionalideas andcaninterferewith thedevelopment of trust.
6.
Interactingabout realityis healthyfor theclient.
7. Theclients
delusionsand feelingsare notfunny to himor her. Theclient maynotunderstandor may feel
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convey to theclient that youaccept thedelusional asreality.
rejected byattempts athumor.
8. Indicatingbelief in the
delusionsreinforcesthe clientsillness.
ASSESSMENT
NURSINGDIAGNOSI
S
PLANNING NURSINGINTERVENTION
S
RATIONALE EXPECTEDOUTCOMES
Subjective:
Patientssister
report ofpatient
discontinuing her
medication.
Patientsfixed falsebelief of
insects andbugs
invadingher room.
Objective:
Patientspraying
insectrepellants
in her
room.
Patient hasincoherent
speech.
Non
compliance relatedto alteredthoughtcontent
asmanifeste
d bypatientsmanifestsexacerbat
ion of
symptoms such asincoherent speech
anddelusions.
After 24
hours ofnursing
interventionsthe patient
will verbalizeat least one
from thefollowing
understanding:
a. aboutaccurate
knowledge ofconditionb. about
medication/treatmentregimen.
1. Note length
of illness.
2. Developtherapeuticnurse- clientrelationship.
3. Reviewtreatmentstrategies andidentify whichamonginterventions
aretherapeuticallymet and areleastamenable tocompliance.
4. Give
1. Patients
tend tobecomepassiveanddependentin longterm,debilitatingillnesses.
2.Promotes
trust,providesatmosphere in whichpatient canfreelyexpressconcerns.
3. Setsprioritiesand
encouragesproblemsolvingareas ofconflict.
After 24
hours ofnursing
interventions the
patient wasable to
express herneeds as
evidencedby the
following:c. Poin
ting to thetelephoneto call her
sister.d. Writing on theboard thatshe needsto go to
thebathroom.
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informationabout illness,treatment andmedications inmanageableamounts,
using verbal orwritten, atlevel ofpatientsability.
5. Havepatientparaphraseinstructions/informationheard.
6. Acceptpatientschoice of pointand avoidconfrontation.
7. Contractwith thepatient forparticipation incare.
8. Encouragepatient tomaintain self care in and outof hospitalcare andacceptpatientsevaluation ofown strengthandweaknesses.
9. Provideinformationand helppatient to
4.Facilitateslearning.
5. Helpsvalidatepatientsunderstand
ing andrevealsmisconceptions.
6. Tomaintainopencommunication.
7.Enhancescommitment to followthrough.
8. Toimprovepatientsabilities.
9.Promotesindependence andencourages
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know whereand how tofind it on own.
10. Stress
importance ofthe patientsknowledgeandunderstandingof the need fortreatment/medication.
11. Develop asystem for selfmonitoring.
informeddecisionmaking.
10.Enhances
participation andcommitment to plan.
11. Toprovidepatientwith self
control andassist withmakingchoices.
VI. DRUG STUDY
GENERIC
(Brand)
DOSAGE INDICATION ADVERSE
EFFECT
NURSING
CONSIDERATIONRisperidone
(Risperdal)
1.5 mg BID
Oral:
Schizophrenia Adult:
start with 2
mg. dosage
may
increased
2nd day to 4
mg. Most
patient will
benefit from
daily dosesof 4-6 mg.
Reference:
PPDs
Nursing Drug
Guide 2007,
page 421
Acute and
chronic
psychoses
include firstepisode
psychoses and
other psychotic
conditions in
which positive
and/ or negative
symptoms are
prominent. Also
alleviates
symptomsassociated with
schizophrenia.
Treatment of
behavioral
disturbances in
patient with
dementia whom
-Insomnia,
agitation,
anxiety, head
ache, fatigue,dizziness,
impaired
concentration,
constipation,
nausea, and
vomiting,
blurred vision.
1. Assess
potential for
interactions with
otherprescriptions,
OTC
medications, or
herbal products
patient may be
taking.
2. Monitor vital
signs; fasting
lipid profile andfasting blood
glucose/Hgb Alc
(prior to
treatment, at 3
months, then
annually); body
mass index BMI,
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symptoms e.g.,
aggressiveness,
activity
disturbances or
psychotic
symptoms areprominent.
personal /family
history of
obesity, waist
circumference.
3. Weight shouldassess prior to
treatment.
4. Be alert to
the potential
orthostatic
hypotension.
Reference: PPDs Nursing Drug Guide 2007, page 421
VII. POSSIBLE OUTCOMES
Outcome A (Best Case Scenario)
The patient following the following management gain insight and control of
signs and symptoms from her Undifferentiated Schizophrenia condition:
Patients should be educated about the following:
o Social skills training
o Medication compliance
o Reducing expressed emotions
o Cognitive rehabilitation
o Family therapy
Family education should involve reduction of expressed emotions, criticism,hostility, or overprotection of the patient; such reduction may lead to decreases inrelapse rates.
Reference: www.nursingcrib.com (01/23/12, 1956H)
Outcome B (Worst Case Scenario)
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The patient noncompliant with her medication regimen experiences
worsening of signs and symptoms.
Patient ignoring about the following:
o Social skills training = poor relationship, loss of ego boundaries, which
poses difficulties for themselves and others in their environment andcommunity.
o Medication compliance = abrupt discontinuation of medication causes
abrupt and intense signs of symptoms of delusions, hallucinations,agitation.
o Cognitive rehabilitation = Patients experiencing delusions and
hallucinations are at greater risk of imposing harm to others. Thepatient needs to be institutionalized.
Reference: www.nursingcrib.com (01/23/12, 1956H)
VIII. CONCEPT MAP
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Diagram 1. Concept Map for the patients Undifferentiated Schizophrenia
case
REFERENCES
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Published References
Kasper et al. 2005 Harrisons Principle of Internal Medicine Manual of MedicineInternational Edition 16th Edition
PPDs Nursing Drug Guide 2007, page 421
Videbeck S. L 2008 Psychiatric Mental Health Nursing Fourth EditionChina, Lippincott Williams and Wilkins Chapter 14 pages 267 290
Online References
RisperdalOnline article retrieved from www.emedicine.medscape.com (01/22/2012, 2034H)
Risperdal
Online article retrieved from www.medlineplus.com (01/22/2012, 2209H)
SchizophreniaOnline article retrieved from www.emedicine.medscape.com (01/22/2012, 1817H)
SchizophreniaOnline article retrieved from www.medicinenet.com (01/30/2012, 1515H)
Undifferentiated schizophreniaOnline article retrieved from www. Freemedical-dictionary.com (01/30/2012, 1442H)
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