SULTANATE OF OMAN

MINISTRY OF HEALTH
DIRECTORATE GENERAL OF EDUCATION & TRAINING
AL-DHAHIRA NURSING INISTITUTE

DONE BY :Omar Juma al abri

Year: II \ Semester: 3
Date of submission: 13\07\2006
Submit to: Mr.Abdullah
Patient Initial: Abdulla -Hospital: Ibri Hospita -
Age: 17years -Sex: Male -Religion: Muslim -
Marital Status: single -Address: Al Murtfi -
Educational level: secondary school -
Occupation: not employed -Unit: Psychiatric OPD -

1.Patient personal and social data:

:Early development
There was no abnormality during pregnancy. He did not
effect from any problem or anything that is lead to cause
.psychiatric problem

:Nervous problems in childhood

He had no problems. He did not report any problem for
example hearing some voice ,or he did not report some
symptom same like it now for example he thought people
can read and know his thoughts

:Schooling and higher education

Mr. Abdullah lived in Al Murtfand. He started with
symptom of hearing voice (Hallucination) in grad 9 in
school. Then he started to thought that people can read
his problem and his thoughts, specially his father and
teacher. Also he left home to sit in their own farm or at
mosque in non prayers time. Now he is 17 old, but he
.starts to recover from some symptom

:Present social situation

He lives with his family which includes his parents and
with tow brothers and one sister. His family is poor. He is
in a grad. He is isolation person and did not want to
.communicate with his community

2.Chief complaint:
He complains hallucinations, also he is fear that he is
seeing him especially father and teacher reading his
thoughts, isolation, little or no interest social activity,
impaired grooming, and hygiene, sexual fantasy, also he
thought the dream come into reality. Also he left home to
sit in their own farm or at mosque in non prayers time. He
thought people’s eyes looking at him reading at him
reading his thought he stop breathing to stop palpitation
.and thought disturbance

:Psychiatric signs/symptoms .3
A) - Physical: poor hygiene and impaired grooming, his
.facial expression is tired
B) - Psychosocial: isolation, Also he left home to sit
in their own farm or at mosque in non prayers time
C) - Psychiatric: hallucination (hearing voice),
delusions (Also he left home to sit in their own farm or at
.(mosque in non prayers time

4. History of present illness:

He started with symptom of hearing voice (Hallucination)
in grad 9 in school. Then he started to think that people
can read his problem and his thoughts, specially his father
and teacher. Also he left home to sit in their own farm or at
mosque in non prayers time. Then he went to the
psychiatric OPD and he was diagnosis as a schizophrenic,
ICD=F20, Now he is 17 old, but he starts to recover from
...some symptom
:Past History .5

Medical: he has throat pain and running nose in

23/3/2010

.Surgical: he does not have any past surgical history

Psychiatry: He was admitted Ibri Hospital at several

times and they described ,in first time 30/1/2010 his
diagnosis is schizotypal disorder (F21), in second time
15/5/2010 his diagnosis is schizophrenia (F20), also in
.(third time 8/6/2010 his diagnosis is schizophrenia (F20

1. Family history in general and in

mental illness in specific:
 General: his father has complains of diabetes
mellitus and the rest of family has normal or good
health.
 Mental illness: no history of mental illness on
his family.

2. Psychiatric Diagnosis:
.Diagnosis is schizophrenia
III. Review of literature of present mental
:illness and the treatment received

:Definition of the disease

A mental disorders characterized by disturbances in

thought process, perception and affective invariably
result in a severe deterioration of social and
occupational functioning that persists for at least 6
.months
Serial According to books In my patient
No
1 BIOLOGIC FACTORS:
Heredity & Genetic -
Defects in structure and function of -
.nervous system
Abnormal neurotransmitters- -
.endocrine interaction
.Too much dopamine -
.Viral exposure in pregnancy -
High arousal level from diseases, -
.trauma and drugs
2 Psychoanalytic and developmental
factors.
Distortion in mother-child-
.relationship
.Ego disorganization-
3
FAMILY FACTORS:
.Repressed unhappiness- My patient
.Double- bind patterns - has family
.Marital problems between parents - factor
Destructive, expressed emotion - problem
.communication pattern (double-bind
4
.(patterns
CULTURAL & ENVIRONMENTAL
FACTORS:
.Low socio- economic status -
.Lessened social support -
5
LEARNING THEORIES:
Irrational problems-solving methods, -
.distorted thinking
Deficient communication pattern -
.learned from parents
Serio According to books In my patient
l .No
.I
:POSITIVE SYMPTOMS
1 HALLUCINATION: The patient has-
 Auditory ( most frequent) auditory and visual
 Visual hallucination. He
 Olfactory .hears some voices
 Gustatory
 Tactile

2 DELUSIONS:
 Persecution he thought people-
 Grandeur
can read or know his
 Reference
.thought
 Control or influence
Somatic

3 DISORGANIZED There was poor eye-

THINKING: contact during the
 Resulting in speech .interview
 Loose association
 Incoherence
 Clang association The patient prefers to-
 Word salad isolate himself to
 Neologism prevent him from
 Concrete thinking people who can read
 Echolalia .or know his thought
4
DISORGANIZED
BEHAVIOUR:
 Disheveled appearance
 Inappropriate sexual
.II behavior
 Restless, agitated
5  Waxy flexibility.
 :NEGATIVE SYMPTOMS

:AFFECTIVE SYMPTOMS
 Unchanging facial
6 expression
 Poor eye contact
 Reduced body
language
 Inappropriate affect
7  Diminished emotional
expression

ALOGIA ( poverty of -he want every time to

(speech
pray and sit in home
 Brief empty responses and mosque.
 Decreased fluency
and content of speech
8
( AVOLITION ( Apathy
 Inability to initiate
goal- direct activity The patient has -
 Little or no interest in diminished sexual
work or social activities .interest
 Impaired grooming,
hygiene

ANHEDONIA
 Absence of pleasure
in social activities
 Diminished intimacy\
sexual interest
 Social isolation
:Treatment

How is schizophrenia treated?

Because the causes of schizophrenia are still unknown,

treatments focus on eliminating the symptoms of the
disease. Treatments include antipsychotic medications
and various psychosocial treatments.

Antipsychotic medications
Antipsychotic medications have been available since the
mid-1950's. The older types are called conventional or
"typical" antipsychotics. Some of the more commonly used
typical medications include:

• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Perphenazine (Etrafon, Trilafon)
• Fluphenazine (Prolixin).

In the 1990's, new antipsychotic medications were

developed. These new medications are called second
generation, or "atypical" antipsychotics.

One of these medications, clozapine (Clozaril) is an

effective medication that treats psychotic symptoms,
hallucinations, and breaks with reality. But clozapine can
sometimes cause a serious problem called
agranulocytosis, which is a loss of the white blood cells
that help a person fight infection. People who take
clozapine must get their white blood cell counts checked
every week or two. This problem and the cost of blood
tests make treatment with clozapine difficult for many
people. But clozapine is potentially helpful for people who
do not respond to other antipsychotic medications.

Other atypical antipsychotics were also developed. None

cause agranulocytosis. Examples include:

• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega).

When a doctor says it is okay to stop taking a medication,

it should be gradually tapered off, never stopped
suddenly.

What are the side effects?

Some people have side effects when they start taking
these medications. Most side effects go away after a few
days and often can be managed successfully. People who
are taking antipsychotics should not drive until they adjust
to their new medication. Side effects of many
antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.

Atypical antipsychotic medications can cause major

weight gain and changes in a person's metabolism. This
may increase a person's risk of getting diabetes and high
cholesterol. A person's weight, glucose levels, and lipid
levels should be monitored regularly by a doctor while
taking an atypical antipsychotic medication.

Typical antipsychotic medications can cause side effects

related to physical movement, such as:

• Rigidity
• Persistent muscle spasms
• Tremors
• Restlessness.

Long-term use of typical antipsychotic medications may

lead to a condition called tardive dyskinesia (TD). TD
causes muscle movements a person can't control. The
movements commonly happen around the mouth. TD can
range from mild to severe, and in some people the
problem cannot be cured. Sometimes people with TD
recover partially or fully after they stop taking the
medication.

TD happens to fewer people who take the atypical

antipsychotics, but some people may still get TD. People
who think that they might have TD should check with their
doctor before stopping their medication.

How are antipsychotics taken and how do

people respond to them?
Antipsychotics are usually in pill or liquid form. Some anti-
psychotics are shots that are given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and

having hallucinations, usually go away within days.
Symptoms like delusions usually go away within a few
weeks. After about six weeks, many people will see a lot
of improvement.

However, people respond in different ways to

antipsychotic medications, and no one can tell beforehand
how a person will respond. Sometimes a person needs to
try several medications before finding the right one.
Doctors and patients can work together to find the best
medication or medication combination, as well as the right
dose.

Some people may have a relapse -- their symptoms come

back or get worse. Usually, relapses happen when people
stop taking their medication, or when they only take it
sometimes. Some people stop taking the medication
because they feel better or they may feel they don't need it
anymore. But no one should stop taking an antipsychotic
medication without talking to his or her doctor. When a
doctor says it is okay to stop taking a medication, it should
be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other

medications?
Antipsychotics can produce unpleasant or dangerous side
effects when taken with certain medications. For this
reason, all doctors treating a patient need to be aware of
all the medications that person is taking. Doctors need to
know about prescription and over-the-counter medicine,
vitamins, minerals, and herbal supplements. People also
need to discuss any alcohol or other drug use with their
doctor.

To find out more about how antipsychotics work, the

National Institute of Mental Health (NIMH) funded a study
called CATIE (Clinical Antipsychotic Trials of Intervention
Effectiveness). This study compared the effectiveness and
side effects of five antipsychotics used to treat people with
schizophrenia. In general, the study found that the older
typical antipsychotic perphenazine (Trilafon) worked as
well as the newer, atypical medications. But because
people respond differently to different medications, it is
important that treatments be designed carefully for each
person.

Psychosocial treatments
Psychosocial treatments can help people with
schizophrenia who are already stabilized on antipsychotic
medication. Psychosocial treatments help these patients
deal with the everyday challenges of the illness, such as
difficulty with communication, self-care, work, and forming
and keeping relationships. Learning and using coping
mechanisms to address these problems allow people with
schizophrenia to socialize and attend school and work.

Patients who receive regular psychosocial treatment also

are more likely to keep taking their medication, and they
are less likely to have relapses or be hospitalized. A
therapist can help patients better understand and adjust to
living with schizophrenia. The therapist can provide
education about the disorder, common symptoms or
problems patients may experience, and the importance of
staying on medications.

Illness management skills. People with schizophrenia

can take an active role in managing their own illness.
Once patients learn basic facts about schizophrenia and
its treatment, they can make informed decisions about
their care. If they know how to watch for the early warning
signs of relapse and make a plan to respond, patients can
learn to prevent relapses. Patients can also use coping
skills to deal with persistent symptoms.

Integrated treatment for co-occurring substance

abuse. Substance abuse is the most common co-
occurring disorder in people with schizophrenia. But
ordinary substance abuse treatment programs usually do
not address this population's special needs. When
schizophrenia treatment programs and drug treatment
programs are used together, patients get better results.

Rehabilitation. Rehabilitation emphasizes social and

vocational training to help people with schizophrenia
function better in their communities. Because
schizophrenia usually develops in people during the
critical career-forming years of life (ages 18 to 35), and
because the disease makes normal thinking and
functioning difficult, most patients do not receive training in
the skills needed for a job.

Rehabilitation programs can include job counseling and

training, money management counseling, help in learning
to use public transportation, and opportunities to practice
communication skills. Rehabilitation programs work well
when they include both job training and specific therapy
designed to improve cognitive or thinking skills. Programs
like this help patients hold jobs, remember important
details, and improve their functioning.

Family education. People with schizophrenia are often

discharged from the hospital into the care of their families.
So it is important that family members know as much as
possible about the disease. With the help of a therapist,
family members can learn coping strategies and problem-
solving skills. In this way the family can help make sure
their loved one sticks with treatment and stays on his or
her medication. Families should learn where to find
outpatient and family services.

Cognitive behavioral therapy. Cognitive behavioral

therapy (CBT) is a type of psychotherapy that focuses on
thinking and behavior. CBT helps patients with symptoms
that do not go away even when they take medication. The
therapist teaches people with schizophrenia how to test
the reality of their thoughts and perceptions, how to "not
listen" to their voices, and how to manage their symptoms
overall. CBT can help reduce the severity of symptoms
and reduce the risk of relapse.

Self-help groups. Self-help groups for people with

schizophrenia and their families are becoming more
common. Professional therapists usually are not involved,
but group members support and comfort each other.
People in self-help groups know that others are facing the
same problems, which can help everyone feel less
isolated. The networking that takes place in self-help
groups can also prompt families to work together to
advocate for research and more hospital and community
treatment programs. Also, groups may be able to draw
public attention to the discrimination many people with
mental illnesses face.

Once patients learn basic facts about schizophrenia and

its treatment, they can make informed decisions about
their care.

How can you help a person with schizophrenia?

People with schizophrenia can get help from professional
case managers and caregivers at residential or day
programs. However, family members usually are a
patient's primary caregivers.

People with schizophrenia often resist treatment. They

may not think they need help because they believe their
delusions or hallucinations are real. In these cases, family
and friends may need to take action to keep their loved
one safe. Laws vary from state to state, and it can be
difficult to force a person with a mental disorder into
treatment or hospitalization. But when a person becomes
dangerous to himself or herself, or to others, family
members or friends may have to call the police to take
their loved one to the hospital.
Treatment at the hospital. In the emergency room, a
mental health professional will assess the patient and
determine whether a voluntary or involuntary admission is
needed. For a person to be admitted involuntarily, the law
states that the professional must witness psychotic
behavior and hear the person voice delusional thoughts.
Family and friends can provide needed information to help
a mental health professional make a decision.

After a loved one leaves the hospital. Family and

friends can help their loved ones get treatment and take
their medication once they go home. If patients stop taking
their medication or stop going to follow-up appointments,
their symptoms likely will return. Sometimes symptoms
become severe for people who stop their medication and
treatment. This is dangerous, since they may become
unable to care for themselves. Some people end up on
the street or in jail, where they rarely receive the kind of
help they need.

Family and friends can also help patients set realistic

goals and learn to function in the world. Each step toward
these goals should be small and taken one at a time. The
patient will need support during this time. When people
with a mental illness are pressured and criticized, they
usually do not get well. Often, their symptoms may get
worse. Telling them when they are doing something right
is the best way to help them move forward.

It can be difficult to know how to respond to someone with

schizophrenia who makes strange or clearly false
statements. Remember that these beliefs or hallucinations
seem very real to the person. It is not helpful to say they
are wrong or imaginary. But going along with the
delusions is not helpful, either. Instead, calmly say that
you see things differently. Tell them that you acknowledge
that everyone has the right to see things his or her own
way. In addition, it is important to understand that
schizophrenia is a biological illness. Being respectful,
supportive, and kind without tolerating dangerous or
inappropriate behavior is the best way to approach people
with this disorder.

People with schizophrenia can get help from professional

case managers and caregivers at residential or day
programs.

:VI. HEALTH EDUCATION

-: According to my patient the health education is

• Patient:

1. Encourage the patient to share with the social

activity, such as, to make for hisself such friends to
promote his behavior/skills & to reduce his isolated.

2. Encourage his to expresses his feeling to his

favorite/nearest family member or follow various way
to express his feeling outwards such as physical
activities. to reduce his anxiety or fear.

3. Encourage his to practice his habits/hobbies

(this patient his hobby is reading), by always tell
him that he can do something for his society and he
is an important individual in it even with his hobbies.

4. Explain to the patient the need to continue

therapy and avoid abrupt withdrawal of therapy the
patient had past experiences
 5. Encourage the patient gradually increase the
amount of time that he spends with others and family
members and avoid isolate himself in a room for
along time.

6. Encourage him to follow up his treatments and

the hospital appointments, { on Sunday, 2 July
2006}.

• Family:

1. It is important that family members learn about

schizophrenia and understand the difficulties and
problems associated with the illness.

2. It is also helpful for family members to learn

ways to minimize the patient's chance of relapse – for
example, by using different treatment adherence
strategies, and to be aware of the various kinds of
outpatient and family services available.

3. Family "psychoeducation," which includes teaching

various coping strategies and problem-solving skills,
is a cognitive-behavioural treatment approach to
family therapy. This approach can help families deal
more effectively with their ill relative and may
contribute to an improved outcome for the patient.

4. Encourage them to do not keep the patient

alone in his room.

5. Encourage them to follow up his treatments

and the hospital appointments, {2 July 2006}.
6. Encourage them to accept him as he is.

7. Encourage them to keep any medications/sharp

materials far away from him.
:VII. CONCLUSION

:Prognosis

I spent 15 minutes with my patient in Psychiatric OPD and

I observed that he felt quite trust and comfortable on
spooking with us. Also, he said that the he is OK as long as
he takes his medications and his health status is
improving daily and it's much better than before.
according to the book there are several factors
:associated with a more positive prognosis. They include
Good premorbid adjustment
Later age at onset
Being female
Abrupt onset of symptoms precipitated by stressful
event
Associated mood disturbance
Brief duration of active phase symptoms
Minimal residual symptoms
Absence of structural brain abnormalities, normal
neurological functioning
A family history of mood disorders and no family history
.of schizophrenia

:Self Evaluation

I get many benefits from this case study. I learned what is

the schizophrenia, its sings & symptoms, causes &
treatments. Also, I learn how I can care of the
schizophrenics’ patients and what certain health
education I should gave them/their family. Also, my fear to
give care to these types of psychiatric patients is reduced,
because while I interviewed my patient I understand that
they are as any medical/surgical patients if we treat them
.in humanity and on the right way
:Nursing Diagnosis

Anxiety, related to lack of impulse control over self

.manifested by facial expression of patient

Self-esteem disturbance, related to, Low socio- economic

status manifested by withdrawal into social isolation &
.lack of eyes contact

Social isolation, r/t poor interpersonal relationships and

Hallucination manifested by patient reports that he prefers isolation
rather than harm others by bad comments
Sleep pattern disturbance, related visual and auditory
hallucination manifested by patient reports that he is
unable to sleep at night because he sees pictures of
.frightens animals and faces

Potential for disrupted homeostasis related to effects of

medications.
 Name Of Classification Dose Indication Action Possible Side Nurse's responsibilities
Drug Effects
mg 5 management-
Procyclidine Antipsychotic OD of Anticholinergic • Give with meals if
(kemadrin) Antianxiety oral manifestation action in CNS, Blurred vision, dry GI upset occur.
agent s of psychotic which helps to mouth, constipation,
.disorders normalize the urinary retention, • May be taken
imbalance of drowsiness, before food if dry
Treatment of cholinergic/dopam confusion, nausea, mouth is troublesome.
nonpsychotic ine-rgic vomiting, rash. With
anxiety neurotransmission high doses mental • Advise the patient
confusion and to consult the physician
.excitement immediately if any
rashes develop.

• Advise the patient

that the drug therapy is
best withdrawn
gradually to reduce risk
of inducing
Parkinsonian Crisis.
 Name Of Classification Dose Indication Action Possible Side Nurse's responsibilities
Drug Effects
mg 5 management of- Mechanism of action CNS: Headache, Avoid prolonged exposure
Trifuloperazine Antipsychotic OD manifestations not fully understood: insomnia, drowsiness, to sunlight or sunlamps; use a
hydrochloride Antianxiety agent oral of psychotic antipsychotic drugs vertigo, weakness, sunscreen or protective
.disorders block postsynaptic .tremor .garments
(Stelazine ) dopamine receptors
Treatment of in the brain, but this RESP: bronchospasm, Antacids should be given
nonpsychotic may not be necessary .laryngospasm, dyspnea one hour before or two hour
anxiety and sufficient for after antipsychotics.
antipsychotic CV: hypotension,
activity; depresses the orthostatic hypotension Handel injectable
RAS, including the hypertension, , preparations using gloves to
parts of the brain .tachycardia avoid contact dermatitis.
involved with
wakefulness and EENT: glaucoma, Do not crush the tablets/skin
emesis, blurred vision, contact with crushed tablets
Anticholinergic, .photophobia, miosis may lead to dermatitis.
antihistaminic H1 and
adrenergic blocking AUTONOMIC: dry Give IM injections slowly
activity also may mouth, salivation, and deeply to avoid irritation
contribute to some of nausea, vomiting, and to subcutaneous tissues.
its therapeutic .anorexia
.actions Rotate injection sites.
ENDOCRINE:
hyperglycemia or Observe carefully to
.hypoglycemia differentiate between return of
psychotic behavior and the
.ones of EPS
 Nursing Diagnosis Objectives/Goals Nursing intervention Rationale Outcome Criteria
Self-esteem :The Client Will Encourage the Positive The Patient:
disturbance, related patient to participate in feedback from
to, Low socio- short term group activities. group members Initiates own self-
economic status :goal will increase self- care according to
manifested by voluntarily Offer support & esteem. written schedule and
withdrawal into spend time empathy when patient willing accept as
social isolation & with peers in expresses Lift self- assistance as
.lack of eyes contact dayroom embarrassment at esteem. needed.
activities inability to remember
within 1 week. people, event, places. Interact with others
in group activities.
long term Encourage patient to The ability to
:goal be as independent as perform Look for job to
exhibit possible by looking independently secure his family
increase after a simple job to preserves self- financially
feeling of self- earn money. Eg. Work esteem. Also, to
worth. as a farmer have good
income.
 Nursing Diagnosis Objectives/Goals Nursing intervention Rationale Outcome Criteria
Social isolation, related :The Client Will Provide attention in a Flattery can be The Patient:
to poor interpersonal sincere, interested interpreted as
relationships and short term manner. belittling by the Patient demonstrates
Hallucination :goal client. willingness and desire
manifested by patient Increased to socialize with others.
reports that he prefers feelings of self- Support any successes Sincere &
isolation rather than worth. or responsibilities fulfilled,genuine praise that Patient voluntarily
harm others by bad projects, interactions with the client has attends group activities.
comments staff members and others. earned can improve
long term self-esteem. Patient approaches
:goal others on appropriate
Engage in social Avoid trying to convince Demonstrate a manner for one-to-one
interaction. the client verbally of her or positive behavior interaction.
her own worth. before the nurse
can genuinely
recognize it. Experience
decreased frequency
Teach the client social Provides a of hallucinations
skills. Describe & concrete example
demonstrate specific skills, of the desired skills.
such as eye contact,
attentive listening, nodding
and so forth.
If the client appear to Help the
hallucinating, attempt patient to
to engage the client's contact with
attention and provide reality
conversation.
 Nursing Diagnosis Objectives/Goals Nursing intervention Rationale Outcome Criteria
Sleep pattern :The Client Will The Patient:
disturbance, related Be aware of all Interrupt the
visual and auditory short term surrounding stimuli, client's pattern of Able to fall a sleep
hallucination :goal including sounds from hallucinations within 30 minutes for
manifested by experience other rooms, e.g. TV retiring and sleep for
patient reports that decreased sounds. 6-7 hours without a
he is unable to sleep hallucinations wakening
at night because he If the client appear to Help the
sees pictures of long term hallucinating, attempt patient to Avoid all drinks
frightens animals :goal to engage the client's contact with that can cause CNS
.and faces be able to attention and provide reality stimulant
achieve 6 to 7 conversation.
hours of Experience
undisturbed Avoid conveying to decreased frequency
sleep per the client the belief Interrupt the of hallucinations
night. that hallucinations are client's pattern of
real. Do not converse hallucinations
with voices or
otherwise reinforce the
client's belief in the
hallucination as reality

Set with patient until

he falls in a sleep Presence of a
trusted individual
provides a
feeling of
Establish routine security.
hours of sleep and
discourage deviation The body
from this schedule. responds and
adjusts to a
routine cycle of
Ensure that foods and rest and activity.
drinks that contain
caffeine are omitted Caffeine is a
from patient's diet central nervous
system stimulant
that can interfere
with sleep