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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.

Rejected.

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http://www.emedicinehealth.com/script/main/art.asp?articlekey=11106http://www.emedicinehealth.com/script/main/art.asp?articlekey=11106


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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

Rejected.

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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


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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.


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.


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

Rejected.

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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


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


S


Subjective:

Patientsfixed falsebelief of

insects andbugs

invading herroom.

Objective:

Patientspraying

insectrepellants in

her room.

Disturbedthoughtcontent

related topsycholog

icalconflicts

asmanifeste

d bypatientsexperienc

es ofdelusions.


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.


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


S


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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