Case Study Psy 2

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CASE STUDY

DIPLOMA IN NURSING

MENTAL HEALTH NURSING

TOPIC : SCHIZOPRENIA

Student Name: A

Metric number: 9

NRIC: 9

Telephone number: 012-

E-mail address: a

Tutor’s name: SHAMSIAH BINTI SETAPA

Learning Centre: KOLEJ KEJURURAWATAN KUBANG KERIAN,

KELANTAN

PENGAMBILAN : JANUARY 2009 SEMESTER : V



CASE STUDY

CONTENTS PAGE

1. Identification data

2. Chief complaint

3. History of presenting complaint

4. Past history

5. Family history

6. Personal history

7. Pre-morbid personality

8. Physical examination

9. Mental state examination

10. Investigations

11. Summary

12. Provisional diagnosis

13. Differential diagnoses

14. Final diagnosis

15. Formulation

16. Management

17. Progress

18. Prognosis

19. Discussion

20. References

4

4

5

10

12

13

15

16

18

20

21

22

24

25

26

27

30

31

31

36



I. DATA COLLECTION

1.1. BIO DATA PATIENT

Name of patient JAMRUS BIN SHAARI Sex Male

Age 50 years Date of Birth 15 December 1959 Dr Incharge Dr Choy

Religious Islam Race Malay Registration No PEL 061661 (1977)

Identity card number 591215-08-5329 Marital status Divorced

Marital data Married , and was divorced

Language ininterviewed

Bahasa Malaysia

Address No 16 Felda Lasah, Sungai Siput, Perak

1.2. REASON FOR ADMISSION

Date andtimeadmission

23 Disember 2009 @ 11. 55 pm

Unitadmission

Male Admission Ward Class III Discipline Psychiatric

Form use Peninsular Malaysian Mental Disorder Ordinance 1952 :-

1. Form 3

Sign by Dr Leaw Shiw Shin Shee No 465618, Pegawai Perubatan UD 41 fromJabatan Kecemasan Hospital Sungai Siput

2. Form 4

Sign by Police Superintendan from Balai Polis Lintang



Reasonadmissionin referral’sletter

Potential self / other persons abuse or material destructive cause by :-

1. Defaulted treatment 2/52

2. Aggressive toward family members

3. Throwing chair toward family member

4. Insomnia (Poor sleep)

5. Talkative and Hyperactive behaviour

Chief Complaint

Patient relapse psychiatric illness, defaulted treatment uncompliant to medicationorally, and claims he didn’t sick

• Patient defaulted treatment and uncomplient to medication, developed multi

symptoms such as Insomnia, restlessness, irritability, distractibility, poor appetite, poor concentration and potential aggressive

• Patient admission to ward with an Incident of aggressive behaviour, he tried

to throw out chair toward family members

1.3 . HISTORY OF PRESENT ILLNESS

Chief Complainfrom Patient

Complain from patient

• Feeling uneasy (un finish business)

• Headache

• Unable to eat

• Uncontrolled emotion

Real Problemface bypatient

• Patient relapse psychiatric disorder, post admission to ward 7 times

since 17 years old with episode of aggressive related to non

compliant to medication.

• Patient defaulted follow up as schedule, drug depot anti psychotic IM

Fluanxol had not given since 2/52

Relapse symptom occur 1/52 after defaulted treatment

• Hallucination – Complain of hearing stranger voice ask him to brake

down the television set



1st time AdmissionOnset Acute

CRONOLOGICAL INCIDENT CRISIS

Acute Onset

1973 (13 yrs) 1974 (14 yrs) 1975 ( 15 yrs) (16 yrs) 3 February 1977 (17 yrs)

Grandma died Fail exam SRP Fail repeat SRP Symptoms Occur 1st Admission

examination Poor sleep, irritability

Onset Acute

• 1973 (13 years) – History of grandma pass away (father’s mother)

• 1974 (14 years) - Fail examination SRP

• 1975 (15 years) - Fail repeat SRP examination (Gred C)

Incident crisis

Patient suffer quit severe mentally stress continuously start after grandma passaway then, he had fail examinations.

Critical Financial problem

Patient and his family live in critically financial problem, patient had to work veryhard, and he must self study and also collecting rubber milk from estate everyday,beside manage his father’s rubber estate. Stress continuously occurs after patienthad plenty of responsibility then, he fall in sick after he had failed his cooping



mechanism.

Poor cooping mechanism

Patient had to settle down his problem himself, He had to work very hard self study, collected rubber milk and manage his father’s rubber estate everyday.Claims his ambition to be a Lecture in university, then he feels frustrated andneglected.

Poor emotional support

Patient claim that nobody involved with him together settled his problem due to hisrelatives are all busy working and fighting for life, and there are such of challengesfor everybody, everyone had to fight for their own family. He also claims that hislovely alder brother had pass away in an accident (2nd sibling)

•

Personality disorder

Patient suffering from personality disorder, claims he get his genetically from hisfather’s, such as rigid personality and temper tantrum personality, that led him tobrooked thing off on the floor for several times. The worth condition is when patientIn half way building the cast from wood, he had shown temper and brake it off suddenly. After that he claims to be setting alone, angry to himself, frustrated and

feeling unworthiness, followed by breaking thing off again and again. He alsoclaims that he feel his coping mechanism become worse, he always disagreetoward the result of his own work. Claims several time he had punished by hisfather especially after failed in examinations, father fell disappointed toward himafter his examination result

Stressor

Father is one of stressor to him, his father always punished him because he hadfailed in examinations. Father also always didn’t agree with result of his work and

started scolding him for a few reasons. His father with rigid personality makes hima few challenges, which were the reasons why incident crisis burst out especiallyafter fail in examinations.

Withdrawal episode

Symptoms occur after Incident crisis :



• Isolated himself in his room

• Poor concentration

• Signs of distractabilities and irritating

• Poor personal hygiene

• Temper tantrum

• Anger

• Stress

Present Admissiononset Gradual

CRONOLOGICAL INCIDENT CRISISOnset gradual

5 May 2008 November 2009 20 December 2009 23 December 2009

Discaj from Wad Hyperactive Insomnia Admission

Symptoms not really recognised

Discaj 5 May 2009, symptoms occurred slowly between 7 months

Effect on workand socialfunction

Job

After the 1st admission to psychiatric ward, patient manage to get job at armydepartment than as a policeman, Patient was excused his job at army department(civilian man), then also excused his job as a policeman.

With a few admissions to psychiatric ward, only mild deterioration detected, patientable to do his basic activity daily leaving such as bathing and personal hygiene, but

his personality disorder become worse, his rigid, temper tantrum, and irritabilitybehaviour worse, he didn’t focusing on his task, poor concentration, and easy todistractibility, and with irritable mood he was lost all his jobs.

Social function

Patient is friendly friends he likes social activities, patient involved in a fewnegative social behaviours and activities with his friends such as e.g.: cigarette



smoking, alcoholic, drugs and substance abuse. He also involved in gangstersactivities, at time they fighting toward the other gang Patient also claims at presenthe didn’t have financial problem, he can easily get money from his father palmestate Patient claimed that he still couldn’t controlled both of his bad habits and hisdisturbances behaviour

Effect to sleeppatterns andbehaviours

Poor sleep, abnormal pattern

Patient insomnia due to hyperactive and bizza behaviour

Poor appetite

Patient refused food due to hallucination, grandiosity and hyperactive

Behaviours

Hyperactive due to Hypo mania

Bizza behaviour due to hallucination, rigid, distractive, irritative, grandiosity andhyperactive behaviours

Symptomssuggest

Hypo mania / Hyperactive

Patient hyperactive, not enough time to manage basic needs



Grandiosity

Claims of he has power to damage the television set,

Irritability

Restlessness like un finish business and show (irritability),

Distractibility

No concentration, show interrupted during interview

Hallucination

Auditory hallucination – Claims herring fear male voice ask to brake of thetelevision set (1st person voices).

Visual hallucination - Claims saw black ghost

History of Sexual

P

History of Trauma

P

History of Infection

P.

History of Alcoholic,cigarettesmoker,Cocaine andusingSubstance

Abuse

P

TreatmentWhatever Source (refer from above)

Patient denied any medical and surgical treatment before illness

TypeTreatmentreceive

Patient denied any special treatment received from physician before illness



I.4. HISTORY OF PRESENT ADDMISSION

1st time Admission

1st Admission

1st Admission 3.2.1977 ages 17 years and 1 month.

Incident crisis

Starting problem after grandma pass away, continuously with he failed hisexaminations in SRP. He said that his ambition to be a lecturer at university will notfulfill.

Critical Financial problem

In severe financial situation, patient was forced to work hard studying, collectingtaper milk and manage his father’s estate. The stress become more severe andpatient cooping mechanism was burn out, then symptom started occurred

Poor cooping mechanism

Patient had to cope with his problem himself, he had to study for examination,picking up taper milk and had to manage his father’s estate every day, he fell sochallenges due to his ambition to be a university lecturer.

Poor emotional support

Patient claims that he didn’t have someone to share or as a guide him or getemotional support. He claims he had to counter his problem himself. His stressbecome critical due to he didn’t had someone from his family member support him.Most of his siblings also accounted financial problem and fighting for life. Theylived separately with their own family. According to patient, his significant sibling ishis alder brother (2nd sibling) whom was pass away in 2006

Personality disorder Patient inherits his father’s personality, temper tantrum led to broken things off.Patient admit that he always disqualified his own hard work due to his rigidpersonality, he claims that he broken off the cast what he had builder up fromwood because his feeling unsatisfied, then isolated himself, frustration towardhimself. He disagrees toward enquired of provocation from others then he turn toaggressive behavior. The worse part is after he had punished by his father after to



fail in his examinations.

Stressor

His father is a stressor to him. His father didn’t agree with his behaviors. Hisfather’s personality also the same as him, his examinations result are the mostfactor as an incident crisis among them.

No insight

Patient with no sight and claims that he is not ill and refused to take medication

Incompliant to medication

Patient with no insight, refused to take medication and not being force by anyone.

Patient defaulted to see doctor and defaulted treatment. Patient also refuse totake medicine orally

Relapse

Nobody in his family had really taken care for the patient, patient’s enjoy himself with his own attitude and was uncontrolled, not any medication patient had takenpertaining to his illness until symptoms relapse occur after 2/52.

Number of subsequentrelapse

History of patient relapse and admission at HBUK 7 time

A d m i s s i o n H i s t o r y Date Days No. Medical

RecordCertificate

No. KodDiagnosis

Reason for addmission

1 3.2.1977 – 12.2.1977 10 196 Fired, claims to burn out his

house

2 25.12.1984 -12.1.1985 16 111 295 Not funct ion well in work at

army station

3 3.4.1993 – 21.4.1994 18 274 295.6 Not funct ion well in police

constable

4 1.8.1995 – 10.8.1995 9 115 295.6 Fighting with brother

5 12.5.1995 – 27.5.1995 15 233 F 33.2 Tried to hang himself

6 14.3.05 – 9.4.1908 26 69 F 31.9 Threatened to scolded some

one after scolded that guy’s

sister

7 4.4.1908 – 5.5.1908 30 6 F 30.9 Push father until fell down



8 23.12.1909 Throwing chair toward family

member

Psychiatrichelp :

Narativehealer

Patient treated by traditional bomoh for several times due to his personality andbehavior disturbance such as ;

• Temper tantrum reaction

• Distractibility

Bomoh treated patient with holy water

1.5. HISTORY OF PRESENT MEDICAL/SURGICAL ILLNESS

Date and timeadmission

1969

Unit of admission Patient admitted to orthopaedic ward after fall from coconut tree.

? cerebral concultion

History of accident,

allergic reaction,drug tolerances,recent medicationfor medical disorders

Denied any history of accident, allergic reaction or side effect of drug

1.6. FAMILY HISTORY

GENEOLOGICAL FAMILY CHART

71 75



59 54

56 52 50 48 43

39

Accident

Male

Female

Family Tree Patient is the 5 th from 8 siblings.

5 male and 3 female

Father’s name Haji Shaari bin Abdul Rahman Age 71 years

No Telefon 05 – 5911404 Bekarja sebagai Rubber tapper at Felda Lasah

Now no mo work

Mother’s name Ramlah binti Omar Age 75 years

Work as House Wife

List of (Sibling) 1. Faizah bt Shaari (Female) 59 years – alive health

House wife married with a Captain with 3 children, lives in their own house inKuala Lumpur

At present : widow, lives with their parents

2. Jamal Sudin bin Shaari (Male)– died in an accident (2006)

A Surveyor, work at Kuala Lumpur, married with 3 children, salaryRM700.00,live at Kuala Lumpur

3. Mohamad Helme (Male) 54 years - alive health

A Supervisor at Nasional Mosque Kuala Lumpur salary RM600.00, married with7 children, live at Kajang

4. Faridah binti Shaari (Female) 52 years - alive health

A house wife, married with Policeman salary RM 600.00, 6 children, live atgovernment’s quarters

5. Patient (Male) 50 years widows with 3 children. His children live with their mother

6. Fazimah binti Shaari (Female) 48 years - alive health

A house wife, married with Supervisor at Felda Sungkai salary RM700.00 with 6



children

7. Mohamad Fadzil bin Shaari (Male) 43 years - alive health

Work at Kuala Lumpur and lives alone

8. Mohamad Hairul Annuar bin Shaari (Male) 39 years - alive health

Work and lives at Kuala Lumpur

Dicition making infamily

Father is the head of family, all dicition make up by father. His father’s personalityis a rigid, fear and temper tantrum

Family EconomicStatus

Logistic in Felda Lasah quite poor at that particular time, They live in small tinyhouses made up by wood in a programme Felda estate, most of them are rubber taper, their in income are small, low economic status and most of them are fightingfor live. Most of their family are unilevel with more then 2 children live in the limitedbasic of need.

Family Socialstanding

Social interaction between family and community are very close and intimate, theyalways do work together, play together and socialised as a big family member, butthey are most lack of knowledge toward care to build up attitude and aptitude intheir family and society because of very hard work struggle gaining more and moremoney.

Family Socialstanding : Interaction

All father, mother and siblings live together, interaction are harmony, but patientgather genetically personality disorder from his father such as rigid, fighting andtemper tantrum change their live and turn to disharmony after he failed his

examinations. It begin when father disagree with patient personality disorder andfighter him after failed in his examinations.

History of mentalillness in family

Father’s brother (uncle) also known as mentally illness, lives alone until died

1.7. PATIENT PERSONEL HISTORY

Date and Area of Born 5 December 1959 born at No 16 Felda Lasah, Sungai Siput, Perak

Infancy andChildhooddevelopment

Born via Spontaneous Vagina Delivery, Full Term, Home delivery with nocomplication

Development andEarly Milestones

Early milestone not delayed, teething, sitting, walking according to stage of age

No neurotic trait



No bed wetting

Tamper-tantrum since milestone

No nail betting

Sleep pattern good

Premobid personality good, able to settle problems by himself

Walking pattern good

Poor stress Management, Poor Management Crisis and Poor in CoopingMechanism Patient will turn to Aggressive when Provocation

Personality disorder such as temper tantrum was build up and untreated frommilestone will led to disruptive behaviour and patient miss obedient to anyone, poomanagement crisis and poor cooping mechanism led to provokes and aggressivebehaviour.

History of Education Schooling event

• Primary school at Sekolah Rendah Meyrsodist English School Sungai Siput

1966 – 1971 Standard I to VI

• Secondary school at Sekolah Menengah Meyrsodist English School Sungai

Siput 1972 – 1974 Form I to III. (fail SRP)

1975 Self study, they fail repeat SRP with result Grade C

Patient also had to manage parent’s rubber estate and collect rubber milk

•Patient denied any truancy when he was schooling

Co Curriculum dan activity

• Good relationship with friends and teachers

• Active in sport and collect plenty awards in games such as foot ball, valley

ball act.

• Denied any truancy in co curriculum activity

Responsible to Peer group

• When fighting (involved in his gang)

• Denied in truancy/ccigarettes smoking/alcoholic/substance group



Ambition A University Lecturer

History of previousJobs

Work as civilian man at army department at Sungai Besi Kuala Lumpur salary RM350.00 monthly 1977 for 2 ½ years then excluded.

Work as a policemen for a few month and excluded

Assisted parent in their estate management (kelapa sawit) supervisor their maids

Patient changes position and jobs every time because of poor cooping mechanismtamper tantrum, poor crisis management and easily aggressive when provocation.

History of Menarcheand effect

Patient claims menarche at 13 years old via sexual dreaming. Nothing abnormalhappened and until now he claims his sexual organ normal.

Sexual History Denied any problem in sexual organ or sexual activity

Denied any family planning or contraception used

Claims sexual interaction between him and his wife good until divorced after hiswife agreed with his brother gaining toward him

Denied heterosexual / homosexual experience. Father claims probably done withhis girlfriend

Denied using current sexual practice with prostitute

Denied history of sexual transmitted disease

Marital History Widow, his 3 children live separately

1.8. MARITALL HISTORY

Spause Patient berkahwin 8 years dan bercerai dengan 3 orang childrens

Setelah bercerai, childrens di jaga oleh isterinya dan jarang berjumpa

Bekas isteri adalah sepupu di sebelah father’s, sekarang tidak lagi berhubung

Children All 3 children live at Kuala Lumpur

• 1st Child 29 years (female) married, with 3 children

• 2nd Child 27 years (male) unmarried, work at Kuala Lumpur

• 3rd Child 24 years (female) unmarried, assisted her brother in low do



business

Good interaction among patient and his children and his son in low, they at timevisited him

1.9. PAST SOCIAL CULTURAL BACK GROUND

Housing Married with 3 children, 1st son and 2nd son and 3rd girl, divorced in 1997

1.10. PRESENT SOCIAL CULTURAL BACK GROUND

Housing After divorce patient lives with parents and care by his alders widow sister.

Social interaction less harmony but at present they become rich family. They live ina bungalow 4 rooms and no problem in financial.

Composition of household

His parent and his sister live together in their house Household and estate workdone by maids from Indonesia

Social contract andsupport

Social interaction between family and neibour very good

Finances Financial are loaded they get from parent’s estate, (2 – 3 tan weight for a sale, 2time a week)

1.11. BAD HABITS / DISORGANISED BEHAVIORS

Tobacco Cigarettes smoking since 1980, 2 boxes per day, present he reduced smoking attime

Alcohol and drugs Started take alcohol, taken ampitamin and ganja since 1980, normally 3 - 5 dosesa week, denied taken any type of injection

Sexual involvement Father’s said that patient probably done sexual intercourse with girlfriends, but

patient denied.

1.12.. PREMOBID PERSONALITY

Lifelong personality Personality



trait Patient agree his rigid, cyclothymic, irritability and temper tantrum personality

Lifelong coopingresources

Poor Stress Management, Poor Crisis Management and Poor CoopingMechanism, and easily aggressive when provocation

Claims of poor cooping mechanism, self seclusion, easily aggressive and temper tantrum. Patient claims he sleep al the time when stress and broken thing whenprovocation.

2. FIZIKAL EXAMINATION

Vital Sign BP 133/85 Pulse 65/min Temperature 370 C Respiration 20/min

Pupils 3 mm both pupils are equal and reactive to lightGlasgow Coma Scale: Normal response, normal reaction and stable condition

Abdomen : Soft, non tender, Bowel sound positive

Chest : Normal sound, Lung clear no murmur

Cardiovascular : Normal size, normal sound, DRNM (no murmur)

Post X-ray result : No fracture

High: 171 cm

Weight : 76 kg

Healthy looking, normal body size, poor hygiene and with long nail

Multiple skin Bruises over his body :

• Lt head 1 x 2 mm

• Rt Cheek 2 x 2 mm

• Swelling over Lt Eye 2 x 3 mm

• Swelling at Rt mandible region 2 x 3 mm

• Swelling over Lt Ear. Auto scope done, eardrum intact

• Multiple bruises over Lt chest 1 x 1 to 2 x 3 mm

• Multiple bruises over Lt Leg 3 x 2 mm and 2 x 2 mm



1.13. HOBIES AND INTEREST

Hobies Hobbies is group sport, and intention to win at all the time

1.14. AMBITION

Ambition Lecturer at University

Restrain

Patient in restrain 24 hours, able to tolerate with others and obey simple commandafter off restrain

Laboratory test Routein

Investigation Result Note

Hb % 13 mg % Normal range :

TWDC WBC : 13.7 mmol/l

RBC : 6.25 mmol/l

Hb : 19.0 mmol/l

Platelet : 299,000

Differential Count :

Neutrophils : 59.1 %

Lymphocytes : 29.3 %Monocytes : 8.9 %

Eosinophils : 2.2 %

Basophils : 0.5 %

(150,000 – 400,000 mm)

(40% - 75 %)

(20% - 45 %)(2% - 10 %)

(1% - 6 %)

(less 1 %)

BU 7.9 mmol/l (2.6 – 8.2 mmol/l)



SE Sod : 126 mmol/l

Potassium : 2.6 mmol/l

Chloride : 99 mmol/l

(135 – 152 mmol/l)

(3.6 – 5.2 mmol/l)

(96 – 108 mmol/l)

Urine FEME Albumin : negativeSugar : Blue

Pus cell : nil

Red blood cell : nil

Epithelial cell : 2-4 / h.p.f cast

cell

Chest X-Ray Cardiac normal size

Lung Clear

RBC 6.25

Investigation Result Note

Scull X-Ray no sceletal fracture

Lt Leg X-Ray No fracture Normal

Urine for drugs Negative cannabis /morfin / empeyrsamine

Body posture,involve in activityand gesture

Walking with normal gaitSitting with open postureSign of presence when interviewInvolvement in ward activity such as games and interaction

Able to maintain eye contact

Eye contact Maintain nature eye contactNot any staring, gaze intently, frightened of uneasy to other person

Appropriate bodymotion

Indicate natural readiness and ease in listening to what being saidNo use any bad gesture activity

Using Environmentin Ward

ComfortableNot distracting to other people



3. MENTAL STATUS EXAMINATION

General appearance Physical appearance

Level of consciousness

General behaviour Force comingCooperativeNo distractibilityMild concentrationNo attention seeking

Thought Sequence flow of ideas, pressure of speechFlight of ideasNo looseness of associationDenial any passivity feeling

Denial any delusion except Grandiosity delusionDenial any paranoid ideationDenial any thought insertionThought obsessionalDenial any Thought broadcasting

Affect Appropriate face presentatione.g. : When talk about hobbies patient shows euthimic but look sad when toldabout he always lost his job, Sometime slightly stereotype appearance

Perception Hallucination

Visual Hallucination: “Aku nampak lembaga hitam’

When asked when did you saw the goose, he said that when going to the toilet

Auditory Hallucination, he said that he here (1 st person voice): “Orang lelalki mintaaku rosakan television’

Suicidal Ideation Denial any suicidal idea, Admission on 12 May 2005 with suicidal ideation andpatient trying to hang himself

Speech High rate in voice and high tone of speechCoherence, relevance and rationalPressure of speech, some tangentially sentence given such as asking telefonnumbers and irritation behaviour

Non verbalcommunicating

Irritating behaviour accompanied in his communication with female guyNormal eye contact, sometime gaze as sign of he likes to be friendsShow mild inner body restlessness when interview, show imitative behaviour in



simple provocation

Consciousness Orientation to time, place and person goodNo disturbance of perception and attitude shown

Show mild focusing to activity, easily destructive behaviour e.g.: games

Mood EuyrsymicNo anxiety looking

Personality disorder Temper tantrumIrritabilityDistractibilityCyclothymicRigidUnable cooping mechanism with provocation

Unable to manage simple stress

Motor activity No disturbance behaviour No psychomotor retardationNo mannerism

Memory Good memory for resent evente.g. : good memory about menu this morning and yesterday

Fair memory about past event (remote event)e/g/ : lost of memory about date married and date of birth all the children (sign of

traumatic amnesia)

No memory disturbance (no amnesia, no dementia and no confabulation)

Attention Goode.g.: Good concentration when interviewPatient able to answer “mathematic counting 7 series”100 – 7 = 93, 93 – 7 = 86 -> 9 – 7 = 2

Fair Memory and concentration test 5 barangJam, cincin, duit, pen, kunci, name tag, kertas, jam

1 minit 1st question about 5 things with good memory5 minit 2 nd question with 3 things in his memory20 minit 3 rd question with 3 things in his memory



Abstract thinking Goode.g.: Mulut murai – orang yang bercakap banyak

Kaki bangku – orang tidak pandai bermain bola

Judgment Goode.g.: rumah terbakar – panggil bombajumpa beg duit – ambiljumpa surat berstem – poskanmana satukah lebih berat 1 kg kapas berbanding 1kg paku – sama

General knowledge Goode.g.: Perdana Menteri – Datuk Najib

Insight Poor Patient said he need to take medication contineuosly to soft medical problem

Traumatic Amnesia When come to things as incident crisis he show that he had lost memory and startturning his face to the other side

GrandiositySymptom

Some answers are debating because he answer the question spontaneously andshowed that he is always perfect

4. FORMULATION DIAGNOSIS ACCORDING TO DSM IV :-

AXIS 1

Pg. 182

Clinical disorder : 296.4x

Bipolar I Disorder – Most Recent Episode Manic

A Clinical Disorder

Currently manic episode (pg 169)

a. No distinct period of abnormally and persistently elevate

Irritable mood at lease 1 week – Irritable mood 10 days

B Previously 1 episode Depression – Admission on 12 May 2005

Mood disorder with :

• Grandiosity

e.g.: said “I have power to brake television”

• Insomnia

e.g.: Talkative, hyperactive and bizza behaviour



• Distractibility

e.g.: cannot concentrate to what he doing or watching television

• Flight of ideas

e.g.: talkative non stop• Excessive involvement in pleasure activities

e.g.: Keinginan sex dengan melayan female yang lalu

C Nil

D Disturbances of mood (observe by family/friends)

E Not clear impairment in social and occupational functioning

F Nil

AXIS II Temper tantrum

Irritability

Cycloyrsymic

AXIS III Nil

AXIS IV

AXIS V

5. ETIOLOGY



Predisposing factors 1. Mild genetic factor

e.g.: Uncle lives alone until died

2. Mild Personality disorder

e.g.: Cycloyrsymic personality

3. Mild clinical disorder

e.g.: Temper tantrum personality

3. Poor in personnel bring up

e.g.: father’s temper tantrum type, he olso temper tantrum type without anyonecontrol

4. Poor environment

e.g.: parent are rubber tapers, not enough time to controlled and maintainingattitude of children

poor family aim for money, they didn’t care about attitude

5. Trauma

e.g.: Potential cerebral conclusion due trauma after fall from tree at 10 years old

6. Infection

e.g.: Potential infection due to fever concurrently when childhood

Precipitating factors 1. Poor family awareness

e.g.: Father’s resist patient, not support him

2. Poor family supporte.g.: patient has to settle his problem himself, not anyone care for hismedication

3. Lack of knowledge about mental illness among family member

e.g.: family not treated him well

4. Hallucination and suicidal ideation (nobody observed)

e.g.: Admission 12 May 2005 due to patient was going to hang himself after Auditory hallucination (1ST voice) asked him to hang himself

5. Patient always have argument between family members

e.g.: Patient claim that he divorce after argument with second brother and hiswife was support his brother and a gaining him

6. Lack or positive social practice/habit among peer group

e.g.: Patient smoked and drink alcohol, take stimulant occasionally

7. Social Taboo said to see bomoh first



e.g.: Well known Family will get psychiatric patient to bomoh first before hospitatreatment

8. Social norms said Illness come from Allah, we have to doa

Community member normally pray and doa to get thing go right they redho to

Allah

Perpetuating factors Negative

Lack of knowledge about illness

1. Repetitive defaulted treatment

2. Non compliant to medication

3. Single man

Positive

1. Active community care

2. Mental healyrs association involve

3. Home care

6. TYPE OF TREATMENT

Anti Psychotic drugs IM depot Fluanxol 20 mg 2/52

Tab Haloperidol 10 mg BD and PRN

Mood stabilizer/AntiEpileptic symptoms

Titrate dose

Mood Stabiliser : Start Tab Epilim 400 mg BD, Loading dose 20 mg/kg b/wt(maxima 1600 mg/day)

Glasgow Coma Scale Charting, to inform if GCS drop

(no changes in neurological test)

Anti cholinergic / Antiparkinsonism

Tab Benxezole (Artane) 2 mg PRN

Sedation Tab Lorazepam 1 mg ON/PRN



7. REHABILITATION

PsychologicalTreatment

Individual Therapy

1. Relaxation Therapy

e.g.: Meredakan perasaan patient di saat-saat genting patient menghadapimasalah dengan divert ional kepada aktiviti Audio-visual seperti muzik, bacaan

Al quran, nasyid dll

2. Anger Management supaya patient dapat mengurus anger dengan

berkesan

e.g.: Dalam keadaan yang marah, segera mengambil air sembahyang,sembahyang dan doa untuk Allah segerakan selesai masalah tersebut, jikamasih tidak berupaya, redhalah itu perancangan dan kehendak Ilahi, pasti adahikmahNya

3. Crisis Management supaya patient dapat menangani masalah yangdihadapinya dengan divertion kepada perkara-perkara yang positif terhadapdirinya

e.g.: putus cinta dianggap memang itu bukan jodohnya yang terbaik, syukurlahtalah putus sekarang dan bukannya setalah dia berkahwin dan mempunyaichildrens

4. M

Group Therapy

1. Cigarette smoking

2. Substance abuse



3. Job seeking

4. Self awareness

5. Parenting skill

Social InteractionTherapy

Reactianal Therapy

Audio-visual :

1. Radio

2. Television

3. Karaoke

4. story from CD player

Untuk menerima interaksi dan mengalih tumpuan patient dari dunianya sendiri

Environment :

1. Morning / Evening walk

2. Gardening

3. Games

4. Fun Fair

Untuk berinteraksi kepada persekitaran dan mencegah pemikiran patient daridunianya sendiri

Anger Management :

1. Interaction programm

2. Games

Untuk mengelak provokasi dan agresive readtion

Job replacement

1. Vocational training

2. Simple industrial skill training

3. Sub industrial business

Rebuilding up emej:



1. Shooping

2. Dormicilary work

3. Do small and easy business

Untuk membina semula imej patient setelah tidak berupaya melakukanya

Socio Interactive Therapy

1. Socio party

2. Karaoke

Untuk menggalakan patient berinteraksi dengan orang lain dalam komuniti

8. NURSING DIAGNOSIS / MANAGEMENT

Nursing diagnosis Actual problem

1. Rawatan dengan restrain and seclusion

2. Insomnia : Hypo manic

3. Poor insight : deteriorisation of illness

4. Poor nutrition : Hypo mania

5. Anger crisis : temper tantrum

6. Ineffective cooping mechanism : stress / Provocation / crisis



7. Lack of knowledge : Bipolar disorder

? Potential problem

8. Non compliant to medication : Poor Insight

9. Potential Aggressive : irritable personality

10.

1 Patient with Restrain and seclution on admission : Unstable rapport

Bukti: Patient datang dengan strep jacket dan tangan bergariGoal Short Term Goal:

Patient dapat bergaul bebas dengan staf dan patient lain tanpa agressivebehaviour dengan pengawasan staf dalam masa 2 hari.

Long Term Goal:Patient dirawat seperti semua patient lain yang bebas berinteraksi

IntervensiKejururawatan

:

1. Wujudkan raport.Staf meluangkan masa bersama-sama patient untuk membantu patientuntuk memenuhi keperluan asas seperti suasana wad yang terapeutik,mandi, pakaian yang bersih, makanan dan jagaan kebersihan patientuntuk meyakinkan patient untuk beri kerjasama

2. Lakukan pemerhatian pada lokasi restrain setiap 5 minit dan catitdalam restrain and seclution chart. Lakukan pemerhatian terperinci(close observation) routein patient yang dirawat dengan restrainsupaya patient sentiasa dalam keadaan stabil

3. Beri ubatan untuk menenangkan keadaan patient seperti arahanpriskripsi:-

• Anti psychotic

• Mood stabilizer

• Anti parkinsonism

4. Beri masa patient mengenali staf dan dapat bekerjasama

menjalankan aktiviti di wad dengan komunikasi yang efektif 5. Galakan explore masalah dan kenalpasti punca masalah patient, di

kongsi bersama untuk mengurangkan stress yang ditanggung olehpatient

6. Dengar aduan patient untuk memahami masalah sebenar patient7. Beri panduan dan bimbingan kepada patient untuk belajar sendiri

menangani masalahnya8. Pemantauan dibuat keatas pengambilan makanan dengan



menggunakan intake & output chart setiap shif dan pengambilanberat badan setiap minggu bagi mengawal taraf kealive healyrsanpatient

NURSING INTERVENSI

3 Potensi kecederaan anggota b/d Loss of memory Tarikh

&

Catitan

Bukti: Pesakit mungkin jatuh kerana hilang ingatan

Goal Jangka Pendek:Pesakit tidak terjatuh dan tidak tercedera dengan pengawasan rapi

jururawat dalam masa 2 hari selepas kemasukan.

Jangka Panjang:

Pesakit dapat melakukan aktiviti dengan baik tanpa terjatuh dan

tercedera dengan pengawasan rapi jururawat setiap masa

IntervensiKejururawatan

:

1. Wujudkan persekitaran yang selamatSimpan barang berbahaya seperti pisau tajam, lantai terturap

baik atau tidak licin, supaya pesakit tidak tercedera

Pencahayaan yang cukup supaya pesakit dapat mellihat dengan jelas semasa berjalan dan melakukan aktiviti, mengelak pesakit

terjatuh.

Pagar wad sentiasa berkunci supaya pesakit tidak terkeluar dantersesat semasa berjalan-jalan dan bersiar-siar

Lantai yang rata dan tidak licin, dengan susun atur yang jelas

dan tanda-tanda untuk pesakit mengecam dengan mudah bilik

mandi, ruang tamu dan tandas

2. Gunakan signash secara bergambar seperti tandas, bilik tidur,

ruang dapur

3. Susun atur perabut dengan baik 4. Wujudkan raport untuk dapat hubuangan mesra dengan pesakit

dan dapat memberi kepercayaan pesakit5. Penyediaan makanan dengan lembut, ikan dan ayam di

asingkan isi untuk memudahkan makan

6. Libatkan pesakit dalam aktiviti yang tidak mencederakan

7. Beri ubatan anti dementia dan vitamin untk menin gkatkankecergasan



8. Pemantauan dengan rapi keselamatan pesakit

9. Ajar pesakit laluan dan aktiviti routin untuk kemudahan harian pesakit

Evaluasi : 1. Pesakit tidak dapat mengawal dirinya dan perlu bantuan jururawat sentiasa .

2. Pesakit menjalankan aktiviti dayly living dengan bantuan

jururawat sentiasa

REFERENCES:

Gammon, J. & Morgan-Samuel, H. (2005). A study to ascertain the effect of structured

student tutorial support on student stress, self esteem and coping. Nurse Education inPractice 5, 161–171.

Evans, W. & Kelly, B. (2004). Pre-registration diploma student nurse stress and coping

measures. Nursing Education. Today 24, 219–228.

Lambert, V.A., Lambert, C.E. & Ito, M. (2004). Workplace stressors, ways of coping and

demographic characteristics as predictors of physical and mental health of JapaneseHospital nurses. Int. J. Nursing. Stud. (41), 85–97.

Ramathibodi School of Nursing. (1992). A Master's Program in Nursing Science. (Thefirst revision) Faculty of Graduate Studies, Mahkiot University.

Lazarus RS & Folkman S. (1984). Stress, appraisal and coping. New York: Springer.

CASE STUDY

SISTEM MARKING : TOTAL MARK = 100

(A) Presentation - 10 Marks

- Facts/Contents, gambarajah, overall - 7- Booklet - 3

(B) Introduction of Condition, Psychiatric management - 10 Marks

( Including Library Research )



(C) Assessment - 20 Marks- Data Collection.

(D) Nursing Process Format - 55 Marks

( As in format below. Must have 5 Nursing Problems )

1. Nursing Care Plan

Bil. IdentifyProblems

( 5 )

NursingDiagnosi

s( 10 )

Goal ( 5 ) Nursing Care Plan( 25 )

Evaluation (10 )

1.2.

3.4.5.

Or

2. Critical Nursing Pathway

Bil IdentifyProblems

(5)

CriticalNursing

Pathway(10)

Goal (5) Critical NursingPathway Plan

(25)

Evaluation(10)

1.2.3.4.5.

( E ) Summary and Referrences - 5 Marks.

Case Study Psy 2

Documents

Transcript of Case Study Psy 2