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I. Introduction

In this age and time where everything sparks tension, we face
extremes of everything that in one way or another alter our ways of living
which eventually leads to stress. Stress abounds in our day to day living
and it is up to us on how we cope up with this phenomenon. These factors
may make or break our resolution. It is how we deal with it that matters
most, its either we fight or flee and if we lose the battle, we will eventually
succumb to insanity. All this events fall under the field of Psychiatric
Nursing. It is defined as a specialty concerned with the application of
psychiatric principles in caring for the mentally ill. It also includes the
nursing care provided the mentally ill patient. When alcoholism and
psychiatric disorders cooccur, patients are more likely to have difficulty
maintaining abstinence, to attempt or commit suicide, and to utilize mental
health services (Helzer and Przybeck 1988; Kessler et al. 1997). Thus, a
thorough evaluation of psychiatric complaints in alcoholic patients is
important to reduce illness severity in these individuals.

International statistics revealed that mental and behavior changes
due to substance use conditions often co-occur. Over 8.9 million persons
have co-occurring disorders; that is they have both a mental and
substance use disorder. Only 7.4 percent of individuals receive treatment
for both conditions with 55.8 percent receiving no treatment at all.
Prevalence information on co-occurring disorders is available through a
number of sources. (Substance Abuse and Mental Health Services
Administration:http://www.samhsa.gov/cooccurring/topics/data/disorders.a
spx). Nationally, Dr Lourdes Ladrido-Ignacio, a former president of the
Philippine Psychiatric Association, said between 17 to 20 percent of the
countrys adult population have psychiatric disorders and this is mostly
caused by alcoholism, drugs and depression.
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(http://www.gmanetwork.com/news/story/52861/lifestyle/1-in-5-adult-
pinoys-have-psychiatric-disorders)

In line with this, a certain condition of a client caught our attention,
Mr. MPM., a 50 year old male, is diagnosed with Mental and Behavior
Disorder due to alcohol. The very first time we met our client Mr. M., we
thought and expected that he would be like all the other stereotype
patients in such an institution, but through our NPI we get to eradicate that
prejudiced thought that he is not the same as the others for he is as what
we saw a very functional patient and is totally different from the rest. He is
really friendly and hospitable thus we didnt encounter any problem getting
to know him and his life. Through our interviews and friendly chit chats we
get to know more about him and the reason for his admission.
As an implication to the nursing research, this case study aids in
the further research and study for Mental and Behavioral Disorder due to
alcohol. This would allow everyone in the health team to think deeply and
thoroughly and for us students to read more and understand the case. In
the nursing education, this can help everyone who will encounter this case
and have knowledge on what to do and what interventions to be rendered
or health teachings to be given for the how to deal with a client with the
same condition. In the nursing practice, all the knowledge they have
learned from the case study can be applied as practice in the clinical field
and test how far have we learned through application. With this case study
we are hoping to become as competent nursing students in mind, body
and soul.





3


II. Objectives of Purpose
General Objectives:
That within our two weeks exposure at DelaCerna Psychiatric and
Rehabilitation Center, our group, BSN 3-B Group 3, will be able to present a
thorough and comprehensive case study about the selected client.

Specific Objectives:
Specifically, this nursing case study aims to:
a. Establish a good therapeutic relationship with the client;
b. establish a good interpersonal and professional relationship with his family
members;
c. gather pertinent information that is needed to use them as the basis for the
study;
d. create an introduction that is related to the condition being studied, which
includes appropriate research, education, and implication to nursing practice;
e. enumerate specific, measurable, accurate, realistic, and time- bounded
objectives;
f. provide necessary information regarding the personal data and the family
background of our client;
g. gather pertinent information about the client and his family for the anamnesis;
h. provide a diagram of the clients family tree for up to three generations and
determine factors related to genetic disposition that may contribute to his
illness;
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i. present the mental status examination of the client;
j. discuss the psychodynamics;
k. tabulate the psychological examination that the client has undergone and
present significance and nursing interventions;
l. to interpret the result of the psychological exam;
m. identify apparent problems based on the gathered data;
n. present medical management and its implication to the clients present
condition;
o. identify the drugs given, their mechanisms of action, contraindications, side
effects, and nursing interventions in giving the drugs;
p. formulate effective Nursing Care Plans and management based on the
identified problems of the patient;
q. analyze the clients general condition and come up with a prognosis; and
r. provide appropriate health teachings for the client, and for the family that are
essential for the betterment of the clients condition.











5

III. Anamesis
A. PERSONAL DATA
Name: M.P.M
Sex: Male
Age: 48 years old
Birthday: January 6, 1966
Birthplace: Davao City
Address: Topaz street, Diamond vil. Lanang Davao City.
Civil status: Single
Religion: Roman Catholic
Educational Attainment: high school graduate
Occupation: tricycle driver
Father's Name: Gaodencio Mantilla
Educational Attainment: Graduate of vocational course
Occupation: Radio technician
Mother's name: Eulalia Pena Mantilla
Educational Attainment: College Graduate
Occupation: Substitute Teacher
Number of siblings: 7
Date admitted: May 5, 2010
Physician's Diagnosis:
Institution: Dela Cerna Mental Institution and Rehabilitation Center

6

MATERNAL SIDE PATERNAL SIDE

















T
F R C
E
B
B
W
high blood pressure smoker
cardiac arrest
deceased alcoholic

Tumor drug user

11
6 G
R

N

B

T

L

A

M

7

NARRATIVE GENOGRAM:

A Genogram is a pictorial display of a persons family relationships and
medical history. It goes beyond a traditional family tree by allowing the users to
visualized hereditary patterns and genetically acquired disease. It can be used to
identify repetitive pattern of illness and to recognize hereditary tendencies.
The genogram started with grandmother and grandfather of both families
who are already dead. In the maternal side, T. died because of tumor while her
wife F died because of old age. On the other hand, C died because of aging and
her spouse R died for the same reason. T and F were blessed with 4 children.
E was the first child of T and F and she is now 69 years old, she is the
mother of our client. The second child was B with the age of 58 and doesnt have
history of any illnesses, he has the same situation with his younger sister B which
is 42 years old, and they have half-sister W, all of them are alcoholic. On paternal
side C and R are blessed to have 11 children and sad to say the mother of our
client was not able to name all of them because she forgot due to her age but
according to her, her husband is the 6
th
among 11 children, according to Mrs.E
her husband is alcoholic and also uses drugs.
E and G has 7 children. 1
st
is N who is Alcoholic and a smoker, 2
nd
is our
Client which is M who is drug addict, smoker and an alcoholic. B,. T,. L,. A,. and
the youngest R are all alcoholic and a smoker. All of them graduated from
college and professionals except our client.





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a. Informants
Name: Eulalia Penia Mantilla
Address: Topaz St.,Diamond Village Lanang, Davao City
Relationship to patient: Mother
Length of time known to patient: Since birth of MPM
Apparent understanding of present of illness of patient:
Tungud siguro na atung pisu ba, giapil ug lubong sa pamilya sa iya
nabanggaan. Tapos diba para man daw na dili makatulog ang nakasala. Mao
guru tu. Nakonsensya guro siya.
Other characteristics and attitude of the informants:
Mrs. EPM is very accommodating and a very jolly, smiling person. Shes
also a very sociable person and a passive woman. A religious and active leader
of their purok. She cooperates with us and share her feelings without hesitations.
Status: Married
Occupation: Substitute Teacher
Educational Attainment: Bachelor of Science in Elementary Education

D. Family History

A. Maternal and Paternal Lineages

Mrs. EPM was the eldest daughter among the four children in the family.
Her mother died when she was in grade 3 due to tumor. After that, her father had
9

his new family. She chose to live in her aunts place because it is near in the city.
She said that her aunt was not strict and let her do what she wants.
Her father was a farmer; it provides her needs and supports her
educational finances. Her father has hypertension and theres no history of
nervous and mental diseases.
They visit her father often with her children but none of her parents had
taken care of them.
B. Father

Mr.GG died 3 years ago, year 2010, due to cardiac arrest. According to
Mrs. EPM her husband was a good father, a provider and also the bread winner
in the family. He provided enough money for them. He is also a responsible
father to his children but not as a husband. Mrs. EPM claimed that her husband
was a womanizer, alcoholic and also a drug user. Her son, MPM, told her that
her husband was having an affair with other woman. Mr. GGs father had a
second wife and also had 11 children.
He was a graduate of a vocational course as a radio technician and
worked at PLDT as a transmitter after their marriage. He was assigned away
from home and he goes home twice a week. Mr.GG disciplines his children
through talk and not by beating them. He spoils them by giving whatever they
want. Among his children he was close to MM, thats why when he died Mr.MM
changed a lot.
After his death, NM as the eldest son was the one who shouldered the
responsibilities. He was the one who provide money for the expenses of their
family.

C. Mother
Mrs. EPM was very accommodating, hospitable to visitors and was quite a
talkative person. She was a carefree, happy go lucky person. She doesnt want
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to stress herself in many problems. Sociable with other people, in fact she is the
leader of their purok and an active member of the chapel. She attends seminars
and programs as a purok leader. As we studied our case we noticed that theres
a conflict between what she confessed and with what we discover from our
study. She was a graduate of Bachelor of Science in elementary education and
worked as a substitute teacher in any school. He leaves her child to her nanny
because she goes to school every morning but she cuddles the baby during her
sleep. As she said, she was not a strict mother. She only reprimands her child.
She taught them how to respect other people. Shes not vocal to her husband
and children. When she knew that her husband was having an affair with other
women she never intended to confront the women instead she said dili ko gusto
ug gubot maam, pasagdaan nalang nako. In case of argumentation, they just
talked about it outside the house or in the place where their children cannot hear
them. When they argue, they dont harm each other physically.

D. Siblings
Name Age Ordinal
Rank
Occupation Educational Status
NM 52 1
st
Marine
engineer
College graduate ( BS in
Marine Engineering)
MM 50 2
nd
NONE Undergraduate (college
level)
BM 49 3
rd
Business man College graduate ( BS in
Economics)
TD 47 4
th
Welder College graduate ( BS in
Mechanical Engineering)
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AM 45 5
th
Marine
Engineer
College graduate (BS in
Marine Engineering )
LM 42 6
th
traffic controller
(airplane)
College graduate ( BS in
Electronics)
RM 39 7
th
seaman Bachelor of Science in
Marine Technology

According to Mrs. EPM, when her children were still young they use to
play with each other. Theres no sibling rivalry that occurred. But when they got
separated due to their works they rarely see each other except for AM because it
lives next to them. She said that after they bought a car, the siblings started to
fight with each other, especially MM and AM. They both short tempered person,
they clashed easily.
She also said that all her children were planned and she never
experienced any miscarriages or tried to abort her baby. Her children were not
vocal but they help each other when someone is in need. Among the siblings, no
history of delinquencies and/or anti-social behaviors was noted and exhibited by
them.

I. Personal History

A. Prenatal
Mrs.EPM married her husband at the age of 18 and had conceived
Mr. MM when she was 20 years old. She continued schooling despite of the fact
that she was pregnant. She said that it really didnt stress her and she never let
pressure get to her. She describes her pregnancy in Mr. MM as stress-free.
She always had her prenatal check-up and also had an adequate obstetrical
supervision because for her it is very important for you to know the situation of
12

the child inside the womb. During her pregnancy she never did any vices or drink
alcohol. She also said that when she was pregnancy with Mr. MM she was
conscious with what she eats. She ate leafy vegetables to have a healthy
pregnancy because according to her after giving birth parents gets fat mostly.
B. Birth
Mr. MM was born on January 6, 1964, he was a full term baby
delivered normally by his mother. There were no difficulties experienced by the
mother in giving birth. No labor/fetal distress. She didnt recognize the
instruments used but she said that daghan man to. Nay gunting, clip ug unsa
pa ba to and also she dont remember how the cord was cut.

C. Infancy
Mr.MM was taken care by her nanny because her mother continued
her schooling but before she left she pumps milk first in her breast but if
sometimes when in a hurry they just bottle feed the baby. During his infancy, her
mother cuddles her every night and make him fall asleep. When we asked her
how her nanny took care of her child, she just replied she didnt know. We also
asked her if needs such as feeding were given instantly, she answered it varied.
Mr.MM was a fully immunized baby boy. Mr. MM got his first teeth
when she was 1 year old and was able to walk and talk during this age. The first
word he pronounced was mama

D. Childhood

Mr.MM was potty trained when she was 2 years old. His mother
was the one who trained him since there nanny had left already. She said that
she will just put the arinola on the side then Mr. MM will sit thereand will urinate
or deficate. She said that she didnt exactly trained him to do it in real toilet, he
just learned it by his self. There were no history of thumb subourscking, night
terror or fall, convulsion and other childhood diseases. At the age of 3, he was
able to run around their house and also he was able to throw whatever he see.
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E. Play life
According to her mother, Mr.MM wants to play tumba-lata, batak-
tsinelas "dampa, holen, dakpanay, taguan and tigso" and also basketball. He
played with his brothers and boy neighbour within his age-range. He usually
loves to play with a group of friends. Sometimes they play far from home but
mostly they will just play near their houses. He loves to play with a group rather
being with his self. He led the group sometimes but mostly he is a follower. When
we asked her if her son ditch the class she answered wala man siguro kay wala
may gareklamo diri na teacher niya

F. School Age
Mr. MM started entering school when he was 6 years old. Her
mother sends him to school with the other teacher. She said that theres no
problem when Mr. MM entered the school. They provide him the finances and all
the supplies he needed. Mrs. EPM said that her son was a smart child since he
doesnt have any failing remarks. She told us that Mr. MM is not fond of reading.
He is not active at theres school. He completed his studies at age of 19. Her
mother didnt know anything about his schooling. She didnt know how the
relationship of Mr. MM to his teachers and other classmates was. She also didnt
know if her son attends the class or not. During highschool she was in the
evening session from 2pm to 9pm. He never spent time for homework or lessons.
He pass every year of every semester. His grades were not that high and not so
low.

G. Psychosexual history

According to the client's mother, Mr. MM was aware that he's girl when he
was four years old. She can differentiate between male and female. The mother
14

noticed that the client was fondling her genitals at the age of six. The parent
didn't know particularly if the client masturbates.
His voiced lowered in pitch at the age of 10 yrs. old. He was circumcised
at the age of 2 years old.

H. Religious Social Adaptability
When he was in high school and college he used to hang up with
many people in his age level, more on boys. They drink and smoke a lot of times.
Sometimes they do it at their house. He was a shy-type person according to her
mother and also moody and irritable when he cant get what he wants. He once
played a guitar in their chapel. He was not religious but he knows how to pray.

I. Occupational History

His present occupation before he was put to rehabilitation center
was a tricycle driver. He used to rent a tricycle from his friend. He had been a
tricycle driver for 3 months to support his partner. His income was only enough
for their foods. His income ranges 100-200 pesos per day.

J. Marital history
Sir MPM had two partners in her life. His first partner broke
up with him due to issues of money. Mr. MPM cant provide financial
matters anymore they have lasted for 3 months. He also had his second
partner they lived in the house of Mrs. EMP but they broke up due to money
issues again. He never had a child with his two partner.

K. Onset of illness
According our interview, it is caused by a major depression due to the
accident and also due to the death of his father. His mother observed that Mr MPM
15

gets irritated easily. He kills cat and chicken. He gets angry when you cant give
him the money that he wants. Her mother was afraid that maybe if this will get long
he can hurt people next time. After the death of his father, he acted differently, he
even talked to his father even though it is already dead, and he said asa naman
ang kwarta. After the burial of his father they immediately admitted him at the
SPMC mental rehabilitation but then the said establishment wont allow her mother
to leave the client, so they have decided to transfer Mr MPM to dela cerna.
















16

IV. Course in the Hospital

A. MENAL STATUS EXAMINATION
PRE-EXAMINATION
(December 7, 2013)

A. General Appearance
Our resident is Mr. MPM; he is 50 yrs. old, male and is a Filipino. He is
neat and clean with brown complexion uniform all throughout his body and bears
no unpleasant body odor upon assessment. He has a black short hair. He
dresses appropriately at the time he was endorsed to us; he was wearing a
Green shirt, black shorts and a pair of black slippers. He has an endomorphic
body built and has a height of 5 feet and 6 inches. His eyes were brown in color.
He also maintains eye to eye contact every conversation. His fingernails were
trimmed well upon the initial assessment. He is noted to have barrel chest and
also has difficulty in walking maybe due to his posture. He smiled and was
accommodating when we introduced ourselves to him which implies that the
client acknowledge our presence.
B. General Mobility
Sometimes his posture is slightly slouched when standing and sitting. His
gait is not steady though client can still walk, sit, stand and move around without
support or assistance from others. It was also observed that he sits properly and
comfortably on the chair. He has this mannerism of rubbing both his arms in his
laps, and shakes his one feet when sitting. He wears a smile everytime we greet
him and his facial expression is congruent to the statement he utters. He is able
to perform activities of daily living independently.

B1. Activity
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(/) normoactive ( ) psychomotor retardation
( ) hyperactive ( ) agilated

We categorized our resident as normoactive in which he participates well
on the activities prepared for them by the student nurses. He always takes part
on our games. He remains in this kind of approach all throughout the day. He
follows instructions given by the facilitators. He stands up when it is required and
silently goes back to his seat after. He claps his hands or cheer when he wants
to in appropriate times.
B2. Facial Expression
The client seems to smile most of the time. Whenever the student nurses
smiles and greets him, he apparently shows his big smile and responds positively
to the student nurses. He laughs accordingly if theres something funny and
humorous. His facial expressions appear to be congruent on what he says or
sees. He usually shows that he is happy with the programs prepared for them
and with this; the client shows that he is fun to be with; he is friendly and most of
the time approachable.

C. Behavior
(/) friendly ( ) impulsive ( ) angry
( ) embarrassed ( ) negativistic ( ) evasive
( ) seductive ( ) indifferent ( ) withdrawn


The client is friendly and approachable when we first met. He was very
cooperative whenever questions were thrown to him. He seems to interact well
with the other residents. As observed, sportsmanship was evident in him
18

whenever we have activities and during the course of our interaction, the client
smiles most of time and he can easily be acquainted with the other student
nurses.

D. Nurse-Patient Interaction
(/) cooperative ( ) uncooperative
( ) initially ( ) all throughout
Quality: (/) warm ( ) distant ( ) dependent
( ) hostile ( ) suspicious ( ) talkative

The patient was consistently very cooperative and responds well to the
questions. Hes warm to talk with. However before he answers our questions he
pauses for a while he was sort of thinking. The resident doesnt seem to avoid
having conversations, in fact, he seems to like talking but granted that we initiate
the convo.

II. STREAM OF TALK

A. Character
(/) spontaneous ( ) deliberate
( ) pressured ( ) blocking

The client talks spontaneously all throughout the course of our interaction.
It was a typical kind of conversation in which we initiate the conversation and the
client answers congruently and goal directed. Sometimes when we asked
questions, he at first pauses for a while then answers. He was not fond of talking
or opening up a topic first.

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B. Organization of Talk
(/) relevant ( ) loose association ( )
tangentially
( ) irrelevant ( ) flight of ideas ( ) neologism
( ) incorrect ( ) circumstantiality ( ) others_____

The client answers all of our questions relevantly and congruently. It was
all in accordance to all of the questions we asked him.

C. Accessibility
( ) good ( ) self-absorbed ( ) defensive
(/) fair ( ) mute ( ) inaccessible

The clients accessibility was fair, since he was able to respond to the
questions asked to him but before he answers our questions he sometimes
pause for a while. He also has no difficulty in answering back all the questions
that weve asked for. Sometimes he shares his ideas, thoughts and feelings at
times which were good signs that he can already establish relevant issues
concerning his life experiences. It was fair enough even if his answers were brief.
III. EMOTIONAL STATE AND REACTIONS

A. Mood
(/) euthymic ( ) depression ( ) euphoria

The clients mood was euthymic since he usually smiles to things that
amuse him. His facial expressions were congruent to what he says or feels like
when he smiles or laughs to hilarious things during our activities. For example,
20

when he talks about happy experiences, he wears his smile and talks in a jolly
manner.

B. Affect -
(/) appropriate ( ) inappropriate
Quality:
( ) flat (/) elated ( ) histrionic
( ) blunted ( ) labile ( ) angry
( ) hostile ( ) anxious ( ) others______

It was properly observed that the clients affect is appropriate to his mood.
The quality was slightly elated since he never exaggerates his laugh on simple
funny events or he was never in a shrink of mood. Whenever the client joins our
activities he would be overjoyed and smiles most of the time.
C. Depersonalization and Derealization
( ) present (/) absent
Upon our initial assessment, depersonalization and derealizations were
absent since the client did not even show any manifestations of sense of feeling
unreal, strange, unfamiliar, numbness and loss of sense of reality towards his
environment.

D. Suicidal Potential
( ) present (/) absent
There were no signs or manifestations of any suicidal ideation, intent nor
threat observed. There were also no records of observations of him from his
chart about suicidal and homicidal attempts.
21


IV. THOUGHT CONTROL

A. Perception
( ) present (/) absent
The clients perception about reality is intact and normal upon initial
assessment; there were no manifestations of the client having hallucinations,
misperceptions and misinterpretations of the real external stimuli or simply
illusions.
B. Delusions
( ) present (/) absent
Among all the types of delusions, the resident never manifested even one
during the course of our assessment nor verbalized by the resident.
C. Ideas of Reference

( ) present (/) absent
No manifestation of ideas of reference noted or any verbalization of the
resident.

D. Preoccupations and Ruminations
( ) present (/) absent
Preoccupations and ruminations were not evident during the
interation. The resident was spontaneous and does not attend to any repetitive
22

thought. Even his gestures would not display any cues that would indicate that he
is bothered or occupied about something.
E. Dj vu and Jamais Vu
( ) present (/) absent
Dj vu and Jamais Vu were not noted to our resident. He did not
experience any illusion of visual recognition to a particular situation or strange
feeling towards situations that are actually familiar to him upon observation.

V. NEUROVEGETATIVE DYSFUNCTION

A. Sleep
() normal ( ) MNA ( ) DFA
( ) hypersomnia ( ) EMA (/ ) interrupted sleep
He usually sleeps early at night prior to the institutions rules and
regulation and then he wakes up early in the morning. He frequently wakes up
during his sleep. He verbalized that he sleeps at around 8 oclock in the evening
and wakes up at around 5:30- 6:00 in the morning. He is experiencing dreams
but not nightmares and doesnt see or hear things in his mind during his sleep
however he has interrupted sleep.

B. Appetite
( ) Increased (/) Good ( ) Poor
( ) Decreased ( ) Fair
He has a good appetite. He is able to consume the food that was given to
him during our snack time.
23

.
C. Diurnal Variation

The resident was able to work out on his activities of daily living
independently. An example of which is the residents capacity to take a bath,
brush his teeth, shampoo his hair, activities of the like with ease and doesnt
have any mood swings.

D. Weight
His weight is 54.1 just right for his age and size.

E. Libido
The residents level of energy is moderate. He indulges himself on all of
our activities enthusiastically. He shows great desire and interest on the things
he usually does. If he is interested in our program he participates and cooperates
well but when he is not interested it directly shows on his physical appearance
and mood. But most of the time he participates. There were no signs of the
resident being sexually preoccupied all throughout the program and the time we
spent at the facility. According to the resident, he experienced getting into a
relationship or even tried to court a girl way back when he was outside the facility
and when he was younger. He actually had experience having live-in partners
but for only a short period of time.

GENERAL SENSORIUM AND INTELLECTUAL STATUS

24

A. ORIENTATION

The resident is oriented to the place where he is, the time, person
and every situation and he is able to verbalize it. His answer is correct
when he answered Karon kay Sabado, December 7, 2012.

B. MEMORY

He was able to recall some of his memories. He shared a remote
memory; he remembers his birthday. Another memory was a recent
one which was the death of his father 3 years ago due to cardiac arrest
which was also validated by his mother upon our interview. With
regards to immediate memories, it is also unimpaired he could
remember the food he had eaten this morning.

C. ATTENTION SPAN

Resident's attention span is fair. He can stay focused for long period of
time but there is a tendency that he pauses before answering the our
questions. He can also easily understand instructions of the games during
the activity and he actively participates during the program.

D. GENERAL INFORMATION

Resident MPM was able to distinguish general informations. He was
able to identify that Rodrigo Duterte is the current mayor of Davao City;
Noynoy Aquino is the current president of the Philippines and that he is in
25

Dela Cerna Hospital. He also knew about the Yolanda incident that
happened in Tacloban.

E. ABSTRACT THINKING ABILITY

He was able to correlate certain topics to his experiences. He gives
opinions to a certain abstract topic. He concretized it based on his past
experiences.

F. JUDGMENT AND REASONING

He was able to reason out things like when Sir Allan another resident
asks Naga-atche lagi ko ron? then our resident answered Basig tungod
sa abog or kay bugnaw ang panahon, as verbalized by the resident.

G. INSIGHT

The resident knows why he was admitted in the hospital. Kabalo
man ko naa ko problema maong naa o diri. Thus this would imply that the
residents insight is not impaired.

H. SUMMARY OF MENTAL STATUS EXAMINATION

Mr. MPM has problems with his appearance and gait however
despite it he is still able to do daily activities of living. His behavior does
not cause harm to others. He is an active resident and is participative
26

during every program. He has congruent facial reactions during
conversations. He is oriented and does not manifest any kind of threat to
self and others. He is also well-informed about his situation and the
environment.

B. DIAGNOSIS CATEGORY

He belongs to non-psychotic diagnosis category. He is still functional,
in fact, he can do his activities of daily living without the assistance of
other persons.

C. DSM IV TR DIAGNOSIS

AXIS I - Substance-related disorder
AXIS II - None
AXIS III - None
AXIS IV - None
GAF 75

We diagnose him under axis I which is substance-related disorder
with a GAF score of 75. Symptoms were present however resident can
still function in most of his ADL. He however is affected with stressors in
the environment but fortunately he has his coping ways.

27

B. PROGRESS NOTES
December 7, 2013 (1
st
day)
It was 2:30 pm and it was our first meeting with the resident. As the
resident approached the group, it was observed that he was well groomed,
wearing green shirt, black shorts and a pair of black slippers. At the time of the
examination, the client is 50 years old and looks appropriate for his age and sex.
He has an endomorphic body but is noted to have a barrel chest. He has also
poor posture and gait. He can walk, sit, stand and move even without assistance.
During our interaction, we ask him about how was his feeling today and he
answered he was okay. We asked him why he was in this institution and he just
smile then answered because he is sick. After that he didnt respond to us and he
was just stared at us sort of waiting for a conversation. Our resident is
participative during our program. He remained normoactive all the time and
always has a ready smile for us.
December 12, 2013 (2
nd
day)
He was wearing a blue sando and black shorts. He was well groomed and
smelled okay. During the demonstration of Paper Bag, we have observed that
he can follow easily the instructions without any help. He was very happy when
he saw the result of his own Paper Bag. When we asked him a question about
his realization in making the Paper Bag, he answer that he felt happy because he
was able to make something of his own. During NPI, he smiles at us when we
approached him and when we asked him a question he answers it congruently.

December 13, 2013 (3
rd
day)
When we went downstairs and we saw him wearing a dirty white t-shirt and a
black short. His appearance was fine and he looked well. The theme for the day
is Dela CernaLympics. We prepared games like Basketball and Volleyball in
which all the client enjoyed the event and had a chance to show their skills in ball
28

games. Mr. MPM was very good in volleyball because he can pass the ball to his
opponent without delay or even touching the net spontaneously. As we have
observed, he was so silent but he was enjoying the game. When one of his group
mates failed to pass the ball he did not get mad nor did he blamed his groupmate
but he just smiled and laugh you could really sense he enjoy the game. At the
end of the game their group was won. During NPI, he shared to us that he really
enjoy the todays activity and how he misses playing those kinds of games. He
verbalized that Nalingaw jud ko sa karon na activity. Ganahan pako na usabon
ni.

December 14, 2013 (4
th
day)
Mr. MPM was wearing a maroon shirt and a black short. He looks like he
just got up from his bed. He looks neat with no noted unpleasant odors. As we
told him to go upstairs, he told us that he would like to drink water first. Our
todays theme was celebrating Christmas Party. As he went upstairs, he saw
the designs of our backdrop, the snowman and the Christmas tree made of
Styrofoam and we saw that he smiled and he verbalized that Wow, mag
Christmas party diay ta karon. During the activity, he was so enjoyed; he was
very happy. When they present their song to us, Mr. MPM just stands in the back
among with his other co-residents but aleast still he participated even though he
wasnt familiar with the song. Before the start of our conversation, he told us first
Thank you jud kaayo sa mga gipanghatag ninyo. During the conversation, we
asked him to showcase to us his talent in return a reward will be given however
he refused to do so for he told us he was shy.

January 9, 2014 (5
th
day)
Resident was wearing his blue jersey, a black short and the pair of slippers
that we gave to them as a Christmas gift. Again he looks like he just got up from
29

his bed. As we greeted him, he smiled and said hello in a low soft voice. Our
todays theme was Tara na, Luto na, Mangaon Ta. The agenda for this was to
teach our client how to cook a shawarma. During the activity we observed that
Mr. MPM was the one who saut the ingredients and he enjoy it so much. He
also communicates to his groupmates and he told them what to do next. After
cooking all the ingredients, it is time for the assigned student nurse to tell what
are the expenses in making shawarma he actively listens to the student nurse as
if he was very interested. During NPI, we asked him what he did during the
cooking of shawarma and he verbalized that Kanang ako man ang nag halo sa
mga ingredients og nag gisa. We also found out that just the other day was his
birthday and so we greeted him and he smiled warmly to us. We asked him if
there was any relative who visited him and he verbalized Nagbisita ang akong
mama dire ug gihandaan ko niya ug biko ug cake. As he said that, we noticed
that he was teary.

July 10, 2009 (6
th
day)
He was wearing his yellow t-shirt, a red short and white slippers. He looked
neat and there were no unpleasant odors noted. Our theme for the day was
Perya-Perya. So we had the NPI first we asked him about how he was feeling
for the day and he said that he was alright and that he is very excited. We asked
also if there was a game that he cant do and he verbalized that Kato oh.
(referring to the game SHOOT THE BALL) Lisod man jud kaayo ishoot ang ball
sa gamay na buslot. After we heard that, we encouraged him to try the game
and he told us Okey, sige i-try ko na. All throughtout the activity we noticed that
he was enjoying it alot. He spent the money he earned for food like hotdog with
bun and checherias. Then after getting his food he just sits in the corner
concentrating well on his food.


30

January 11, 2014
Our client was wearing a blue jersey, a black short and a pair of white
slippers. He looked neat and well. Our theme for the day was Sinulog. It was
obvious that he was happy. The agenda for the afternoon was to make a
headdress. As the student nurses demonstrated it Mr. MPM easily followed the
instructions with no assistance. Sometimes he would ask for our ideas where to
best put the feathers and the designs but we would just tell him and encourage
him that he should design it on his own. And fortunately he did. After the
headdress making we asks them to dance and we noticed that he cant follow
some of the steps but he had so much fun. He was all smiles during the dance
therapy. During NPI, he told us that he like the Bibingka and Sapin-sapin a lot
and he asked for more but we told him that the food was counted; gladly he didnt
force on getting another set of our prepared snacks. He verbalized again Lami
man jud bah. Dugay najud ko wala katilaw na ani. We asked if his sleeping
pattern and duration changed due to its cold weather and he answered Same
lang man gihapon makamata ko ug 6pm then makatulog ko ug 8pm.

V. Psychodynamics

A. Tabular Presentation
31

Predisposing Factors

Factors

Present

Rationale

1. Gender


Gender is a critical determinant of mental health
and mental illness. The morbidity associated with
mental illness has received substantially more
attention than the gender specific determinants
and mechanisms that promote and protect mental
health and foster resilience to stress and
adversity.
Gender determines the differential power and
control men and women have over the
socioeconomic determinants of their mental
health and lives, their social position, status and
treatment in society and their susceptibility and
exposure to specific mental health risks.
Overall rates of psychiatric disorder are almost
identical for men and women but striking gender
differences are found in the patterns of mental
illness.

2. Age



The disorder usually begins in late adolescence
or early adulthood, often between the ages of 16
and 30. The disorder is usually life-long, although
the symptoms tend to improve gradually over the
persons life. (Stuart)
32


3.Environmental
stressors


Certain stressors -- such as a death or divorce, a
dysfunctional family life, changing jobs or schools,
and substance abuse -- can trigger a disorder in a
person who may be at risk for developing a
mental illness.

4. Psychological
Trauma


Some mental illnesses may be triggered by
psychological trauma suffered as a child, such as
severe emotional, physical, or sexual abuse; a
significant early loss, such as the loss of a parent;
and neglect.
5. Biology Some mental illnesses have been linked to an
abnormal balance of special chemicals in the
brain called neurotransmitters. Neurotransmitters
help nerve cells in the brain communicate with
each other. If these chemicals are out of balance
or are not working properly, messages may not
make it through the brain correctly, leading to
symptoms of mental illness. In addition, defects in
or injury to certain areas of the brain also have
been linked to some mental conditions

Precipitating Factors

Factors

Present

Rationale
33


1. Prenatal



It is thought that processes in early
neurodevelopment are important, particularly
during pregnancy. There is now significant
evidence that pre-natal exposure to stressful
events experienced by the mother increases the
risk for developing psychotic disorder later in life,
providing additional evidence for a link between
developmental pathology and risk of developing
the condition. (Stuart)

2. Loss of
Attachment

.

Loss in adult life can precipitate depression. The
loss may be real or imagined and may include
the loss of love, a person, physical functioning,
status, or self- esteem. (Townsend)

3. Life events




Adverse life events are a potent factor in
precipitating depression. Such events include
loss of self-esteem, interpersonal discord,
socially undesirable occurrences, and major
disruptions of life patterns. Events perceived as
undesirable are most often the precipitants of
depression. (Townsend)
34


4. Psychosocial
and
Environmental



Depression is more common in people who have
a history of trauma, sexual abuse, physical
disability, bereavement at a young age,
alcoholism, and insufficient family structure. In
adults, loss of a spouse is the most common
cause of a depressive episode. Women are at
increased risk for depression during and within
the first few months after pregnancy. (Sadock)


B. Schematic Presentaion

35























FATHERS CHARACERISTICS
Mr. G.G.M, deceased last 2010 at the age of
75 due to cardiac arrest

Roman Catholic
Educational Attainment: Graduate of
Vocational Course
Radio Technician
Work History: He became a radio
technician when he was still single, then
a PLDT transmitter after his marriage
with Ms. Eulalia

Mr. G.G.M was described by Mrs. E.P.M as a
good man and a responsible breadwinner. She
recalled that it was Mr. G.G.M who provided
for their kids. However, she rarely sees him
since he is always assigned away from home.
He wasnt always present in the lives of his
kids since he goes home only twice a week.
He wasnt health conscious like his wife but
instead, an alcoholic and a drug addict. He
was also a womanizer as claimed by his wife.
He isnt strict in implementing rules. He doesnt
spank his kids, he just talks to them. He spoils
them especially their 2
nd
child, Mr. M.P. M.
Mrs. E.P.M related that both of them were very
close that after his death, everything went
downhill for Mr. M.P.M.


MOTHERS CHARACTERISTICS
Mrs. E.P.M currently 69 years old, healthy and
well-abled

Roman Catholic
Educational Attainment: College
Graduate
Bachelor of Science in Elementary
Education
Work History: Worked as substitute
teacher whenever she is asked to.
However, when she doesnt teach, she
just stays home and be with her kids

Mrs. E.P.M was a carefree woman, gay,
outspoken and very sociable. She is conscious
about her heath and does not have any vices.
She is very religious and is active in the political
affairs of their community. In fact, shes
currently a member of their GKK as well as a
leader of their purok. However, when her kids
were still growing up her life revolved around
school and her kids. As a mother, Mrs. E.P.M
was not much of a disciplinarian. She related
that she doesnt spank her kids nor does she
have serious confrontation with them even when
they are going astray or even when they have
done something terribly wrong. She doesnt
really patch things up when there are
misunderstandings. Ginapasagdaan lang nako
sila, dili ko gusto ma stress na kaayo as
exclaimed by her.
36


COURTSHIP
Parents
Ms. E.P.M was 17 years old when she first met the dashing Mr. G.G.M, a
27 years old bachelor working in the field of radiography as a radio technician.
One day, Mr. G.G.M visited his cousin who was the husband of the aunt of Ms.
E.P.M. As fate would have it, Ms. E.P.M was then living with her aunt. It was
there that he was captivated by her charms. After that fateful encounter, Mr.
G.G.M started visiting Ms. E.P.M regularly, bringing with him flowers and gifts.
After months of courting, they eventually became lovers. Mrs. E.P.M fondly
recalled that she was the typical dalagang Filipina. She didnt go on dates at
night nor would she go to the cinemas with Mr. G.G.M, afraid that she would get
pregnant before they even marry. Her fear was that once shed give up her
virginity to Mr. G.G.M or if she was impregnated before marriage, Mr. G.G.M
would run away from the responsibilities. So he preserved her purity until after
their union

MARRIAGE
It wasnt long enough after they became lovers that Mr. G.G.M popped the
question. After a year of being together, Ms. E.P.M, now 18 years old can
already be legally wed. With her sweet Yes and the blessings from their
families, they got married in the Assumption Church of Davao during the year
1961. They live in the same roof here in Davao city and started to build their
family. But soon, they had to be separated since Mr. G.G.M got a new job in
PLDT as a transmitter. Due to this, he would have to go to different places and
sometimes it would even require him to stay in the office all night.
They were blessed with 7 children all of which were male. She shared that
she was busy with her schooling while his husband was busy with work, that
37

most of the time, her children would be left under the care of a nanny whenever
they are not present. His husband was plainly a provider; he did not share with
household chores. Despite the long distance relationship, Mrs. E.P.M shared that
it didnt strain their marriage.
One hurdle they had was when she found out that his husband was
cheating on him. She recalled that it broke her heart but she didnt do anything to
resolve the conflict. She didnt confront her husband neither did she confront the
mistress. She lived with it, until she was finally numb of the idea. She related
thats he didnt want to stress herself out, since boys, as she stereotyped, will be
always be boys. Despite his husbands infidelity, she remained faithful to him.
Sex, as described by Ms. E.P.M was satisfying. She shared that they dont
use any contraceptives one factor why they have 7 kids. Another factor is that
her husband wanted to have a girl. It was only on her 7
h
baby that she finally
decided to undergo ligation. Since at that time, Brokenshire did it for free. Though
her friends coaxed her not to do it, she remained unmoved. She related that 7
children were enough.



PRENATAL
Mrs. E.P.M was about 20 years old when she found out that she was
pregnant with Mr. M.P.M. Despite the fact that she was still a college student at
that time, she shared that it didnt really stressed her out and she didnt let all the
pressure get to her. She even fondly recalled that she had a bunch of classmates
who were pregnant as well. She shared how they would have morning sickness
while she felt perfectly fine. She described her pregnancy with Mr. M.P.M as
somewhat stress-free.
38

Mrs. E.P.M also related that she would religiously attend prenatal check-
ups at the old hospital located at Acacia St. before. Her fear of encountering
problems with the child, such as abnormalities or diseases kept her from being
too lax. She shared that she viewed prenatal check-ups as something very
important. She led a healthy lifestyle with no vices or hard drinks when she was
still pregnant with Mr. M.P.M. She even told us that when she had him, she was
very conscious with what she eats. She made sure that she eats a healthy diet,
including green leafy vegetables with substantial amount of meat. She reasoned
that she didnt want to get fat. She went on and explained that mothers usually
loose there figure after having a child due to increase food intake. She wanted to
prevent getting fat after she delivers Mr. M.P.M.

BIRTH
It was January 6, 1964 when Mr. M.P.M was born into this world. Born
through normal spontaneous vaginal delivery at the same hospital she goes to
have her prenatal check-ups. He came out in full term, healthy and without any
abnormalities. There was no dystocia nor was there any complication during the
delivery. Mrs. E.P.M related that everything went on smoothly. She even fondly
shared that her delivery was very much on her favor since she got home before
her bag of water ruptured. She was absent for a week to recuperate, after that
she went back to school immediately.

INFANCY
(0 12 months)
The first stage of Eriksons theory of psychosocial development occurs
between birth and one year of age and is the most fundamental stage life.
Because an infant is utterly dependent, the development of trust is based on the
39

dependability and quality of the childs caregiver. The developmental task for
infants is learning trust versus mistrust. Infants whose needs are met when those
needs arise, whose discomforts are quickly removed, who are cuddled, played
with, and talked to, come to view the world as a safe place and people as helpful
and dependable. However, when their care is inconsistent, inadequate, or
rejecting, it fosters a basic mistrust: infants become fearful and suspicious of the
world and of people. Such children can be stuck emotionally at this stage,
although they continue to grow and develop in other ways. Fortunately, because
not all children achieve developmental tasks readily, each task needs not to be
resolved once and for all the first time it arises. Given the second chance,
children may overcome early mistrust.
Freud termed the infant period the oral phase because infants are so
interested with oral stimulation or pleasure during this time. According to this
theory, infants suck for enjoyment or relief of tension, as well as for nourishment.
In the case of our client, Mr. M.P.M was nursed primarily by his nanny.
After his birth his mother hired a nanny to take care of him since her mother
continued her schooling. Sometimes, before she goes to school, she would pump
milk from her breast and leave it to the nanny for her sons use. But if she doesnt
and if all of the pumped milk is used up, her nanny would feed him formula milk.
So during his infancy stage he had mixed feeding. Her mother would only have
time to cuddle with his son or play with him, when she gets home from school or
during weekends. So she would make it a point to rock her baby to sleep at night
since most of the time, it was Mr. M.P.Ms nanny who took care of his needs
physically and emotionally. Since even the father of her child couldnt look after
him for him because he only goes home twice a week due to his work. During
the interview, we asked the mother if she knew how her nanny would take care of
her son, but she didnt know how exactly. However she claims that his needs
were given consistently. We asked her again, how she takes care of him when
she has the time, she shared that sometimes, it took time to provide the need
40

especially when it still needs to be prepared. She even shared that Mr. M.P.M
was a crybaby, or in her terms, iyakin.
Mr. M.P.M completed his immunization as claimed by his mother, who
brought him to the health center where he would have his shots. At the age of 1,
Mr. M.P.M started teething, talking and walking. Her mother shared that he
eventually learned these skills because she doesnt remember her teaching
these skills to him.
An adult who have developed mastery of trust would reflect attitudes such as
realistic trust of self and others, optimism and hope, confidence in others
including openness with them and effectiveness of relationships. Mr. M.P.M, as
how he was described by his mother and as how we have observed, was a shy
man, very secretive and sometimes withdrawn. He doesnt relate with others
effectively and openly. Therefore, we believe that Mr. M.P.M did not develop trust
during the early stage of his life.


Toddlerhood
(1-3 years old)
Erikson defines the developmental task of the toddler age as learning
autonomy versus shame or doubt. Autonomy (self-government or independence)
builds on children new motor and mental abilities. Children take pride in new
accomplishments and want to do everything independently, whether it is pulling
the wrapper off a piece of candy, selecting a vitamin tablet out of the bottle,
flushing the toilet, or replying, No! If parents recognize toddlers need to do what
they are capable of doing, at their own pace, at their own time, then children
develop a sense of being able to control their muscles and impulses during this
time. When caregivers are impatient and do everything for them, this enforces a
sense of shame and doubt. If children are never allowed to do things they want to
41

do, they will eventually doubt their ability to do them; they will stop trying and
cannot do them. If children leave this stage with less autonomy than shame and
doubt, they can be disabled in their attempts to achieve independence and may
lack confidence in their abilities to achieve well in their adolescence and
adulthood.
Freud described the toddler period as the anal phase because during
this time, childrens interest focus on the anal region as they begin toilet training.
Elimination takes on new importance for them. Children find pleasure in both the
retention of feces and defecation. This anal interest is part of the toddlers self-
discovery, a way of exerting independence, and probably accounts for some of
the difficulties parents may experience in toilet-training children of this age.
Mr. M.P.M was potty trained at the age of 2 years old. It was his mother
who trained him since during this time her nanny had already left. Her mother
shared that they had an arinola where Mr. M.P.M defacated or urinated. She
shared that they didnt exactly teach him how to do it in the real toilet; Mr. M.P.M
just knew about it eventually. Furthermore, there were no history of thumb
sucking, night terrors or falls as recalled by his mother.
Just like any toddler, Mr. M.P.M was very intuitive and adventurous. He
wanted to do things on his own such as eating or bathing. Her mother doesnt
have any issue with this because she would just let him be. He was spoiled as a
matter of fact not just with whims but with the things he wants, especially by his
father. He was left to explore on his own. We also asked the mother if there was
a time that he ever shamed Mr. M.P.M. She shared that there was no such
instance since she wouldnt even dare to raise a hand to any of them.
An adult who has developed mastery of autonomy would reflect attitudes
such as a realistic self-concept and self-esteem, self-control and will power, a
sense of pride and goodwill, simple cooperativeness as well as delayed
gratification when necessary. We found ideas conflicting during this stage. Since
42

his mother would claim that he was autonomous as a child but his current
behavior shows otherwise.
Mr. M.P.M, as how we have observed, had a low self-esteem, this would
explain why he is very shy and secretive. He also lacks self-control, as evidenced
by substance abuse, particularly alcohol. Her mother also testified that Mr. M.P.M
as an adult didnt want things to be delayed. For example, if he asks for money
so that he could buy some liquor. He wants to have it instantly, no questions
asked. If he does not get it, he would instantly become hostile. Yes, Mr. M.P.M
might have been autonomous while he was young, however, this poorly
developed autonomy have become nothing more than a childish whim. He was
also doubtful of his abilities such as when we had our perya2x. Before he even
tried doing it, he was already skeptical that he couldnt do it. This alone reflects
that Mr. M.P.M did not develop a proper autonomous attitude during his toddler
years

Preschool Period
(3 5 years old)
Erikson defines the developmental task of the preschool period as
learning initiative versus guilt. Learning initiative is learning how to do things.
Children can initiate motor activities of various sorts on their own and no longer
respond to or imitate the actions of other children or of their parents. The same is
true for language and fantasy activities. Whether children leave this stage with a
sense of initiative outweighing sense of guilt depends largely on how parents
respond to self-initiated activities. When children are given much freedom and
opportunity to initiate motor play such as running, bike riding, sliding, and
wrestling, or are exposed to such playing materials as finger paints, sand, water,
and modeling clay, their sense of initiative is reinforced. Initiative is also
encouraged when parents answer childs questions and do not inhibit fantasy or
43

play activity. Those who do not develop initiative may later have limited brain-
storming and problem solving skills.
During the preschool period, childrens pleasure zone appears to shift
from the anal to the genital area. Freud called this period the phallic phase.
Masturbation is common during this phase
Mr. M.P.M loved playing outdoor Filipino games such as, tumba lata,
patintero, shatong and the likes with their neighbors kids. He played near their
home with children of different sexes, both younger and older than he was. He
was not much of a leader; he was more of a follower. He would typically start off
as a shy kid, but Mrs. E.P.M shared that once he is comfortable with the person,
he would smile or laugh a little more.
Discipline was not too enforced at home. Her mother even related that she
never remembered a time when she spanked Mr. M.P.M for being undisciplined
or disobedient. No matter how difficult they all get she doesnt rule them with an
iron fist. With no disciplinarian at home, since even their father wasnt much one
either, rules and discipline hanged loosed. Mr. E.P.M also wasnt strict with the
values she teaches her kids. She doesnt really sit with her kids and tell them
about it, only when she has time. Saying the magic words such as please,
sorry or thank you was taught in school, so she relied on the teachers to teach
her kids the basics. She related that during this time, Mr. M.P.M already had a
sense of what was right and what was wrong. He was a good kid who showed
appropriate social behaviors. When Mrs. E.P.M was asked whether Mr. M.P.M
had dreams as a child, she shared that she doesnt remember Mr. M.P.M telling
him about a particular one. Furthermore, Mr. E.P.M related that as a child, Mr.
M.P.M didnt ask a lot of questions. During this stage, Mrs. E.P.M doesnt recall
seeing her child fondle with his genitals.
An adult who has developed initiative is described as someone who has a
sense of direction, an adequate conscience, an initiative balanced with restraints,
appropriate social behaviors, curious and explorative, someone who is original
44

and has purposeful activities and lastly someone who enjoys a healthy
competition. Mr. M.P.M was not much of a driven man. He doesnt seem to have
a sense of direction his life. He stopped going to school back when he was still in
college for the reason that he doesnt want to continue anymore. He had wasted
years, instead of using it to look for a stable job; he spent it away with booze and
cigars. He didnt save his money nor did he have any regard for his future. He
didnt have an initiative, balanced with restraints. He did what he wanted to do
despite how destructive it was not only for him but for his family as well.


School Age Period
(6 12 years old)
Erikson viewed the developmental task of school, industry versus
inferiority. During the preschool period, children learned initiative how to do
something. During school age, children learn how to do things well. When they
are encourage in their efforts to do practical tasks or make practical things and
are praised and rewarded for the finished results, their sense of industry grows.
Parents who see their childrens efforts at making and doing things as merely
busy work or who dont show appreciation for their childrens efforts may cause
them to develop a sense of inferiority rather than pride and accomplishment.
During the elementary school years, a childs world grows to include the school
and community environment, and success or failure in those settings can have a
lasting impact.
Freud saw the school age period as the latent phase, a time in which
childrens libido appears to be diverted into concrete thinking. He saw no
developments as obvious as those in earlier periods appearing during this time.
Mr. M.P.M started school at the age of 6 years old. He would go to school
and come back home together with their neighbor who was a teacher. Due to
45

this, he never gets late. When we asked Mrs. E.P.M whether Mr. M.P.M enjoys
going to school, she said that she doesnt know exactly but she pointed out that
Mr. M.P.M doesnt complain, so she kind of assumed that Mr. M.P.M enjoyed
going to school. When asked whether her son would study when he goes home,
she shared that she doesnt see him study nor does she sees him doing his
home works. However, despite of these observations, his mother shared that she
never heard a complaint about her son. Furthermore, Mr. M.P.M not only
regularly attends class but he doesnt have any failing marks as well. She was
not called for misconduct or for any ill reasons.
She also shared that she doesnt recall Mr. M.P.M joining school activities.
She just remembers that he was a part of the Boy Scout. He was not part of the
classrooms officers or the schools student council neither a member of the
varsity team. When asked whether she knew the favorite subject of his son, or
the subject that he hates the most, whether at this time he had dreams he
wanted to pursue and stuffs that bother him. Mrs. E.P.M related that Mr. M.P.M
wasnt very vocal with her. As her mother would have it, hilomun man gud na
siya. Secretive ba. When we asked her whether she tried talking to him about it,
she would say that she didnt really bother. We also asked whether there were
projects that Mr. M.P.M was very proud of that he showed it to her, she said that
he never did show her his school works.
Mrs. E.P.M also shared that Mr. M.P.M, though a shy kid had many
friends. When asked whether her son ever asked her about puberty or sex. She
shook his head with a straight no. She hasnt seen him reading pornography
either. Mr. M.P.Ms role model at this time was his father, who would come and
visit them often.
An adult who has mastered industry will exhibit attributes such as a sense
of competence, completion of projects, and pleasure in efforts and effectiveness,
ability to cooperate and compromise, identification with admired others, balanced
of work and play, joy of involvement in the world. Mr. M.P.M as we have
observed was not much of an industrious man. He didnt continue his schooling
46

and he doesnt help out t in the bills either. Yes, he drove a tricycle as a source of
income, but most of his gains were used to fund his vices, even the time she had
a live-in partner. We also observed that during the therapies that we did in Dela
Cerna, we observed that he only does things that was within his comfort zone,

Adolescence
(13 20 years old)
Erikson believed the new interpersonal dimension that emerges during
adolescence is a sense of identity versus role confusion. To achieve this,
adolescents must bring together everything they have taught about themselves
as a son or daughter, an athlete, a friend, a student, a scout, and so on, and
integrate these different images into a whole that makes sense. If adolescents
cannot do so, they are left unsure of what kind of person they can become. Some
adolescents seek a negative identity: being identified as a drug abuser or
runaway may be preferable to having no identity at all.
Freud termed the adolescent period the genital phase. Freudian theory
considers the main events of this period to be the establishment of new sexual
aims and the finding of new love objects
Teenage years such as the case for most of us are one of the most trying
times in an individuals life. If toddlerhood up to school age is character building,
during adolescence phase, it is all about character testing. Now a teenager, Mr.
M.P,M was enrolled in Davao City High school and was assigned in the night
class slot. Night class would start at 2pm up until 9pm. His mom related that the
hurdle started when Mr. M.P.M was in second year high school. Every day, he
started going home early in the morning, around 3am or 5am wasted, drunk and
stunk of cigars and booze. His mother claimed that it was his barkada who have
influenced his child. She also shared that he was able to consume about 1 pack
per 2 weeks. Despite these, she wasnt that strict in implementing discipline in
47

their home. She would discipline them by talking to them and if they dont listen
she let them be. His father was the same thing. Mr. G.G.M could not tell his son
not to drink since he does the same thing. Mr. M.P.Ms father was not a good role
model since Mr. M.P.M sees him wasted and drugged as well. Mrs. E.P.M
doesnt know what kind of people Mr. M.P.M was rolling with since Mr. M.P.M
never introduced them to her. He also shared during one time that he tried using
Marijuana back when he was in 2
nd
year high school. He admitted that he was
influenced by his friends and he tried. He only had two pot sessions. After that he
stopped since he didnt want his father to know about it.
Mrs. E.P.M still wasnt able to point out the dreams and aspirations of Mr.
M.P.M. She shared that Mr. M.P.M doesnt share her anything about her goals.
She also failed to identify the characteristics that she liked most about him.
An adult who have developed a sense of identity will manifest confidence,
emotional stability, commitment to career planning and realistic long term goals,
sense of having a place in the society, establishing relationship with the opposite
sex, fidelity to friends and development of personal values. Mr. M.P.M was easily
influenced with other people. His drinking and smoking was primarily influenced
by his friends, was unconsciously reinforced by his dad. It was also discussed
earlier that Mr. M.P.M has low self-esteem, he also does not have a set career
plan and goals that he would want to achieve. After college, her mother shared
that Mr. M.P.M would just stay with his dad instead of trying to look for a job,
suggesting confusion where he is to place himself under the sun. Mr. M.P.Ms
lack of emotional stability is manifested whenever he suddenly displays hostility
when he does not get what he wants even when he is already older. Therefore,
Mr. M.P.M failed to achieve a sense of identity during this phase of his life.


Young Adulthood
48

(20 or 30 years old)
The developmental crisis of the young adult is achieving a sense of
intimacy versus isolation. Intimacy is the ability to relate well with other people,
not only with members of the opposite sex but also with ones own sex to form
long lasting friendships. A sense of intimacy grows out of earlier developmental
tasks, because people need a strong sense of identity before they can reach out
fully and offer deep friendship or love. Because there is always a risk of being
rejected or hurt when offering love or friendship, individuals cannot offer it if they
do not have confidence they can cope with rejection or if they did not develop a
sense of trust as an infant.
Mr. E.P.M shared that Mr. M.P.M had two major relationships at this stage
both were live in partners. She shared that both lasted only for months and that
both relationships ended up due to disagreement with money. Mr. M.P.M,
however, never had a child with any of them. Mrs. E.P.M failed to share more
about Mr. M.P.Ms love life.
When we asked Mrs. E.P.M whether she says I love you to his sons, she
said that she wasnt that verbal either. We also wondered how Mrs. E.P.M
handled her marriage given the fact that they do not live with each other most of
the time due to the work of Mr. G.G.M. Mrs. E.P.M shared that the distance didnt
bother her that much.
Mrs. E.P.M also shared that there was a time when Mr. M.P.M called her
while he was staying with his dad. He told her mother with much sadness that he
caught his father cheating. Mrs. E.P.M though hurt and depressed, didnt do
anything to resolve the conflict. She shared that she didnt thought about it that
much reasoning that she didnt want to be stressed out. She even quoted that
boys will always be boys.
An adult who has developed intimacy at this stage would exhibit an ability
to give and receive love, commitments and mutuality with others, collaboration in
work and affiliations, sacrificing for others and responsible sexual behaviors. We
49

didnt gather much information about Mr. M.P.Ms love life to declare whether he
has achieved intimacy of not. However, the fact that none of his relationship
lasted for more than 4 months and that both ended due to monetary
disagreements, suggests that Mr. M.P.Ms view on love was somehow
superficial. There was no collaboration to patch things up, nor compromising on
his part to save the relationship. Thereby Mr. M.P.M did not develop intimacy at
this stage.

Middle adulthood
(30 to 65 years)
The developmental task of middle age is to establish a sense of
generativity versus stagnation. People extend their concern from just themselves
and their families to the community and the world. They may become politically
active, work to solve environmental problems, or participate in far-reaching
community or world base decisions. People with a sense of generativity are self-
confident and better able to juggle their various lives. People without this sense
become stagnated or self-absorbed. Those who have devoted themselves to
only one role are more likely to find themselves at the end of middle age with a
narrow perspective and lack of ability to cope with change.
Our client might not be busy with civic or professional activities nor is he
altruistic. But after years of treatment, Mr. M.P.M is a much better man than he
was before he got in the mental institution. He isnt hostile and violent as before.
He is sober for more than a year. He is productive, constructive, creative and
cooperative inside the walls of Dela Cerna. He participates in our activities
though sometimes he tends to be shy and reserved. Thereby, we believe that
despite his situation, Mr. M.P.M has achieved generativity.


50
























Onset of illness
Onset of illness started back when he was in 2
nd
year college. It was December
and she vividly remembered telling his sons to go to sleep so that they could still go
and attend the simbang gabi. Mr. M.P.M however took off with their family car while
everybody was still asleep. He went drinking with his friends and when he was on his
way home, groggy and drunk; he accidentally hit an old man who was walking down
the street. It was still early in the morning; nobody was still around, so Mr. M.P.M went
off as if nothing had happened. When he arrived home, he didnt tell anybody. His
family wasnt able to go to the simbang gabi as planned since Mr. M.P.M used the car.
It was after a day that his family knew about the incident. Apparently, there were
witnesses who saw their car accidentally hitting the old man. Her mother shared that
they were alarmed but nobody really confronted Mr. M.P.M. Mrs. E.P.M shared that
they made some arrangements with the family of the deceased so as not to be reported
to the higher authorities. It was then that Mr. M.P.M eventually knew that his family
knew about it as well. Still, despite of the turning of the events, Mrs. E.P.M did not dare
to confront her son, her husband, Mr. G.G.M, the one Mr. M.P.M confided to, advised
to go out too often since he might be seen and be put into prison an advice that
made Mr, M.P.M weary. Since it was during these times, it was his dad whom he
confided too. Suddenly, behavioral changes started to occur; he would lock up in his
room and talk with himself, his drinking problems got from bad to worse. He would
become violent when her mother would fail to give her money for his drinking sessions.
Furthermore, he would kill cats, chicken or any sort of animals that would stray in their
home. A long chunky dospordos with nails driven in the edge was his weapon of
choice. But the scenario that sealed his fate was when his father died back in 2010.

They were very close as Mrs. E.P.M recounted. Among the children, it was Mr. M.M
who was much close with their father since it was Mr. G.G.M who spoiled him very
much. Her mother reminisced that during the wake, Mr. M.M did not shed a tear, he
even went to his coffin and said, asa na imong kwarta? His drinking worsened
making him hostile and violent in just a matter of seconds. Due to this, Mr. E.P.M
and his siblings decided to take him to a mental institution before he hurts anyone,
since every one of them are already fearful of Mr. M.P.Ms behavior.
51













If treated:
Art therapy
Music therapy
Dance therapy
Occupational therapy
Medicines:
1. Haloperidol
2. Chlorpromazine
hydrochloride
3. Biperiden
hydrochloride



If not treated:
Can become a threat
to others due to
hostility and violence
Decreased coping
capability.
Antisocial symptoms
Suicidal/Homicidal
tendencies
Personal or
occupational loss
GOOD
PROGNOSIS
BAD
PROGNOSIS

52

VI. Laboratory Examinations and results of Psychological Testing

Test Definition/Rationale Normal
Value
Result Indication

Serum
Glutamic
Pyruvate
Transaminas
e

An alanine aminotransferase (ALT) test is
often part of an initial screening for liver
disease.
to help diagnose infections of the liver such
as viral hepatitis (ALT levels are high with
acute hepatitis) or to monitor patients taking
medications that cause liver-related side
effects.

Normal: Within normal range

0-40 U/L



27 U/L

The farther from normal the test results are,
the more likely you are to have significant liver
disease.
Test Definition/Rationale Normal
Value
Result Indication

Serum
glutamic-

An aspartate aminotransferase (AST) test is
often part of an initial screening for liver

0-40 U/L


15 U/L

However, a high level of SGOT could be the
result of toxins such as drugs and alcohol,
53

oxaloacetic
transaminas
e
disease.
-to detect inflammation due to injury or
damage to the liver from any source.
Normal: Within normal range
gallbladder disease, hepatitis or infections
that occur in the liver. It may also be present
in the case of an inflamed liver which may be
enlarged due to an infection or due to chronic
drug and alcohol abuse. A high level of SGOT
may also be detected in patients undergoing
some medication. These medications may
cause damage to the liver or may temporarily
affect its functioning.
Test Definition/Rationale Normal
Value
Result Indication

Urinalysis
(Color)

Normal urine color is due to the presence of
a pigment called urochrome. Urine color
varies based on the urine concentration and
chemical composition. Normal urine can vary
from pale light yellow to a dark amber color.
Highly concentrated urine has a darker
yellow appearance.
-to easily reveal renal and systemic

Yellow
(light/pale
to
dark/deep
amber)


Yellow

Red
o Foods Beets, blackberries,
rhubarb
o Drugs Propofol,
chlorpromazine, thioridazine,
Ex-lax
o Medical conditions Urinary
54

pathologies tract infections (UTIs),
nephrolithiasis, hemoglobinuria
(rhabdomyolysis), porphyrias
(urine color, port wine)
Orange
o Foods Carrot, vitamin C
o Drugs Rifampin,
phenazopyridine
Green
o Food Asparagus
o Drugs Vitamin B, methylene
blue, propofol, amitriptyline
o Medical condition UTI
Blue
o Drugs Methylene blue,
indomethacin, amitriptyline,
triamterene, cimetidine
(intravenous), promethazine
(intravenous)
o Medical condition Blue diaper
55

syndrome (also known as
tryptophan malabsorption)
Purple
o Medical condition Bacteriuria
in patients with urinary catheters
(purple urine bag syndrome)
Brown
o Food Fava beans
o Drugs Levodopa,
metronidazole, nitrofurantoin,
primaquine, chloroquine,
methocarbamol, senna
o Medical conditions Gilbert
syndrome, tyrosinemia,
hepatobiliary disease
Black
o Medical conditions
Alkaptonuria, malignant
melanoma
White
56

o Drug Propofol
o Medical conditions Chyluria,
pyuria, phosphate crystals

Test Definition/Rationale Normal
Value
Result Indication

Urinalysis
(Transparen
cy)




Normal
urine is
transpare
nt or clear;
becomes
cloudy
upon
standing.


Clear

Cloudy urine may be evidence of phosphates,
urates, mucus, bacteria, epithelial cells, or
leukocytes.
Test Definition/Rationale Normal
Value
Result Indication
Urinalysis
(pH)
4.5-8.0 6.0

High protein diets increase acidity. Vegetarian
diets increase alkalinity. Bacterial infections
57

also increase alkalinity.

Test Definition/Rationale Normal
Value
Result Indication
Urinalysis
(specific
gravity)
The specific gravity of urine is a
measurement of the density of urine - the
relative proportions of dissolved solids in
relationship to the total volume of the
specimen
-measures the ability of the kidneys to
concentrate or dilute urine depending on
fluctuating conditions.

1.005-
1.030
1.015 Low specific gravity is associated with
conditions like diabetes insipidus, excessive
water intake, diuretic use or chronic renal
failure.
High specific gravity levels are associated
with diabetes mellitus, adrenal abnormalities
or excessive water loss due to vomiting,
diarrhea or kidney inflammation. A specific
gravity that never varies is indicative of severe
renal failure.

Test Definition/Rationale Normal
Value
Result Indication
Urinalysis
(protein)
Finding protein in the urine is not a normal
finding. Seriously elevated levels may
150 mg/d Negative Albumin is normally too large to pass through
glomerulus. Indicates abnormal increased
58

indicate that there is a problem with kidney
function.
permeability of the glomerulus membrane.
Non-pathological causes are: pregnancy,
physical exertion, increased protein
consumption. Pathological causes are:
glomerulonephritis bacterial toxins, chemical
poisons.

Test Definition/Rationale Normal
Value
Result Indication
Urinalysis
(glucose)
Finding glucose in the urine is not a normal
finding. Typically, this is found in patients
with diabetes.

130 mg/d
Negative Glycosuria is the condition of glucose in urine.
Normally the filtered glucose is reabsorbed by
the renal tubules and returned to the blood by
carrier molecules. If blood glucose levels
exceed renal threshold levels, the
untransported glucose will spill over into the
urine. Main cause: diabetes mellitus

Test Definition/Rationale Normal
Value
Result Indication
Urinalysis The presence of blood in the urine is an RBCs/hp 0-3/HPF Hematuria is the presence of intact
59

(RBC) abnormal finding. However, it is not possible
to determine the cause of the bleeding
without further testing. Common causes
include infection, trauma, kidney stones,
cancer, surgery on an area of the urinary
tract, kidney disease, trauma related to the
insertion of a urinary catheter, and many
other causes.
f erythrocytes. Almost always pathological.
Causes: kidney stones, tumors,
glomerulonephritis, physical trauma
Test Definition/Rationale Normal
Value
Result Indication
Complete
Blood Count
(Hemoglobin
)
It measures the amount of the oxygen-
carrying protein in the blood.
M: 135-
175g/L
146g/L The results of your red blood cell count,
hemoglobin and hematocrit are related
because they each measure aspects of your
red blood cells.
If the measures in these three areas are lower
than normal, you have anemia. Anemia
causes fatigue and weakness. Anemia has
many causes, including low levels of certain
vitamins or iron, blood loss, or an underlying
60

condition.
A red blood cell count that's higher than
normal (erythrocytosis), or high hemoglobin or
hematocrit levels, could point to an underlying
medical condition, such as polycythemia vera
or heart disease.

Test Definition/Rationale Normal
Value
Result Indication
CBC
(Hematocrit)
It measures the percentage of a person's
blood that consists of red blood cells.
0.40-0.50 0.44 Usually mirrors RBC results
Usually mirrors RBC results; most
common cause is dehydration

Test Definition/Rationale Normal
Value
Result Indication
CBC
(White Blood
Cells)
White blood cell (WBC) count is a count of
the total number of white blood cells in a
person's sample of blood.
- to determine if there is infection, elevated
5-10 9.1 A low white blood cell count (leukopenia) may
be caused by a medical condition, such as an
autoimmune disorder that destroys white
blood cells, bone marrow problems or cancer.
61

with systemic
steroid use, decreased with autoimmune or
some blood diseases among other causes

Certain medications also can cause white
blood cell counts to drop.
If your white blood cell count is higher than
normal, you may have an infection or
inflammation. Or, it could indicate that you
have an immune system disorder or a bone
marrow disease. A high white blood cell count
can also be a reaction to medication.

Test Definition/Rationale Normal
Value
Result Indication
CBC
(SEGS or
segmented
neutrophil
count)
Neutrophils are the most active cells and
respond to tissue damage or infection. They
are phagocytes that provide an early, rapid
removal of cellular debris and large number
of bacteria.
35-80% 73% Low count:
Known as neutropenia
Severe, overwhelming infection
(sepsis)
Autoimmune disorders
Reaction to drugs, chemotherapy
Immunodeficiency
62

Myelodysplasia
Bone marrow damage (e.g.,
chemotherapy, radiation therapy)
Cancer that spreads to the bone
marrow
High Count:
Known as neutrophilia
Acute bacterial infections
Inflammation
Tissue death (necrosis) caused by
trauma, heart attack, burns
Physiological (stress, rigorous
exercise)
Certain leukemias (e.g., chronic
myeloid leukemia)
Test Definition/Rationale Normal
Value
Result Indication
CBC A lymphocyte is a type of white blood cell 0.25-0.35 0.26 Low Count:
63

(Lymphocyte
s)
present in the blood. When the general
defense systems of the body have been
penetrated by dangerous invading
microorganisms, lymphocytes help provide a
specific response to attack the invading
organisms. A microorganism is a tiny
organism made of one cell that is usually too
small to be seen without using a microscope.
Lymphocytes help to protect the body
against tumors (tissues that grow more
rapidly than normal). However, lymphocytes
can also cause the rejection of tissues during
organ transplants because they interpret
these tissues as foreign invaders.
Known as lymphocytopenia
Autoimmune disorders (e.g., lupus,
rheumatoid arthritis)
Infections (e.g., HIV, viral hepatitis,
typhoid fever, influenza)
Bone marrow damage (e.g.,
chemotherapy, radiation therapy)
Corticosteroids
High Count:
Known as lymphocytosis
Acute viral infections (e.g., chicken
pox, cytomegalovirus (CMV), Epstein-
Barr virus (EBV), herpes, rubella)
Certain bacterial infections (e.g.,
pertussis (whooping cough),
tuberculosis (TB))
Toxoplasmosis
Chronic inflammatory disorder (e.g.,
64

ulcerative colitis)
Lymphocytic leukemia, lymphoma
Stress (acute)

Test Definition/Rationale Normal
Value
Result Indication
CBC
(Eosinophils)
An absolute eosinophil count is a blood test
that measures the number of white blood
cells called eosinophils.
0.02-0.04 0.01 Low Count:
Alcohol intoxication
Over production of certain steroids in
the body (such as cortisol)

High Count:
Asthma, allergies such as hay fever
Drug reactions
Inflammatory disorders (celiac disease,
inflammatory bowel disease)
Some cancers, leukemias or
65

lymphomas

66

VII. Diagnosis/ Differential diagnosis/ diagnostic impression

A. Mental Disorder

1. A mental disorder is a syndrome characterized by clinically significant
disturbance in an individual's cognition, emotion regulation, or behavior
that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning. Mental disorders
are usually associated with significant distress in social, occupational, or
other important activities. An expectable or culturally approved response
to a common stressor or loss, such as the death of a loved one, is not a
mental disorder. Socially deviant behavior (e.g., political, religious, or
sexual) and conflicts that are primarily between the individual and society
are not mental disorders unless the deviance or conflict results from a
dysfunction in an individual.

Bibliography: Videbeck, Psychiatric Mental Health Nursing, 2
nd
edition,
Lippincott
Williams and Wilkins, Philadelphia, 2007 Page 448
2. A mental disorder is a behavioral or psychological syndrome or pattern
that occurs in an individual that reflects an underlying psychobiological
dysfunction. The consequences of which is clinically significant distress
(e.g., a painful symptom) or disability (i.e., impairment in one or more
important areas of functioning). It must not be merely an expectable
response to common stressors and losses (for example, the loss of a
loved one) or a culturally sanctioned response to a particular event (for
example, trance states in religious rituals) and that is not primarily a result
of social deviance or conflicts with society.
Bibliography: Szasz, T. The Myth of Mental Illness: Foundations of a Theory
of
67

Personal Conduct (rev. Ed.). New York: Harper & Row
2012 Page 771

3. A mental disorder or psychiatric disorder is a mental or behavioral pattern
or anomaly that causes distress or disability, and which is not
developmentally or socially normative. Mental disorders are generally
defined by a combination of how a person feels acts, thinks or perceives.
This may be associated with particular regions or functions of the brain or
rest of the nervous system, often in a social context. The recognition and
understanding of mental health conditions have changed over time and
across cultures and there are still variations in definition, assessment
and classification, although standard guideline criteria are widely used.

Bibliography: Varcarolis, Essentials of Psychiatric Mental Health Nursing, 4
th

Edition,Lippincott Williams and Wilkins, Philadelphia, 2012 Page 309

4. Mental disorder refers to a wide range of mental health conditions
disorders that affect your mood, thinking and behavior. Examples of
mental illness include depression, anxiety disorders, schizophrenia, eating
disorders and addictive behaviors. Many people have mental health
concerns from time to time. But a mental health concern becomes a
mental illness when ongoing signs and symptoms cause frequent stress
and affect your ability to function. A mental illness can make you
miserable and can cause problems in your daily life, such as at work or in
relationships. In most cases, mental illness symptoms can be managed
with a combination of medications and counseling (psychotherapy).
Bibliography: http://www.mayoclinic.org/diseases-conditions/mental
illness/basics/ definition/con-20033813

68

5. Mental disorder refers to all of the diagnosable mental disorders and is
characterized by abnormalities in thinking, feelings, or behaviors. Some of
the most common types of mental illness include anxiety, depressive,
behavioral, and substance-abuse disorders. There is no single cause for
mental illness. Rather, it is the result of a complex group of genetic,
psychological, and environmental factors. While everyone experiences
sadness, anxiety, irritability, and moodiness at times, moods, thoughts,
behaviors, or use of substances that interfere with a person's ability to
function well physically, socially, at work, school, or home are
characteristics of mental illness or disorder.
Bibliography:
http://www.medicinenet.com/mental_health_psychology/article.htm

B. Behavioral Disorder

1. Behavioral Disorder is a Learning disorder characterized by specific
behavior problems over such a period of time, and to such a marked
degree, and of such a nature, as to adversely affect educational
performance, and that may be accompanied by one or more of the
following; an inability to build or to maintain interpersonal relationship;
excessive fear of anxieties; a tendency to compulsive reaction; an inability
to learn that cannot be traced to intellectual, sensory, or any health
factors.

Bibliography: Videbeck, Psychiatric Mental Health Nursing, 2
nd
edition,
Lippincott Williams and Wilkins, Philadelphia, 2007 Page 289

2. Behavior Disorders or BD are conditions that are more than just disruptive
behavior. They are related to mental health problems that lead to
69

disruptive behavior, emotional and social problems. Attention Deficit
Disorder (ADD) is an example of a behavior disorder. Children with
behavior disorders typically need a variety of professional interventions
including medication, psychological treatment, rehabilitation, or possibly
other treatments.

Bibliography: Mohr, Psychiatric Mental Health Nursing, 6
th
edition, Lippincott
Williams and Wilkins, Philadelphia, 2008 Page 209

3. Behavioral Disorder is a general term under which both oppositional
defiant disorder and conduct disorder are housed. This disorder can
present itself in a variety of ways. What a parent may write off as a normal
stage of childhood behavior could actually be a sign of behavioral
disorder. Every child is different and behavioral disorder affects each child
in a different way.

Bibliography: Pedersen, Essentials of Psychiatric Mental Health Nursing 6
th

edition, Lippincott Williams and Wilkins, Philadelphia, 2008 Page 704
4. Behavioral or personality disorders are conditions in which an
individual differs significantly from an average person, in terms of
how they think, perceive, feel or relate to others. Changes in how a
person feels and distorted beliefs about other people can lead to odd
behaviour, which can be distressing and may upset others.

Bibliography: http://wiki.answers.com/Q/What_the_definition_for_behavior_
disorder_of_childhood?#slide=4

5. Behavioral Disorders are also called disruptive because affected children
literally disrupt the people and activities around them (including at home,
at school and with peers). Young people can have mental, emotional, and
behavioral problems that are real, painful, and costly. These problems,
70

often called "disorders," are sources of stress for children and their
families, schools, and communities.

Bibliography: http://www.childrenshospital.org/health-
topics/conditions/disruptive behavior-disorders

C. Substance use

1. Substance use or abuse can be defined as using a drug in a way that is
inconsistent with medical/ social norms and despite negative
consequences. Substance use/abuse denotes problems in social,
vocational, or legal areas of the persons life, whereas substance
dependence also includes problems associated with addiction such as
tolerance, withdrawal, and unsuccessful attempts to stop using the
substance.

Bibliography: Videbeck, Psychiatric Mental Health Nursing, 2
nd
edition,
Lippincott Williams and Wilkins, Philadelphia, 2007 Page 681.

2. Substance use or abuse can be defined as characterized by presence of
at least one specific symptom indicating that substance use has interfered
with the persons life. People cannot meet the diagnosis of substance use
or abuse for a particular substance if they have ever met the criteria for
dependence on the same substance.
Bibliography: Kaplan & Sadock, Synopsis of Psychiatry: Behavioral Sciences
Clinical Psychiatry, 8
th
edition, Lippincott Williams and Wilkins, Philadelphia,
2008, Page 497.

3. Substance use or abuse is the repeated use of alcohol or other drugs
leading to functional problem; however, it does not include compulsive use
or addiction. A person diagnosed with substance abuse or use does not
71

experience the withdrawal syndromes that accompany substance
dependence. Conversely, substance dependence is diagnosed when a
person continues using alcohol or other drugs despite negative
consequences such as significant functional problems in daily living. A
person with substance dependence is likely to experience tolerance as the
use of the substance escalates and withdrawal when he or she stops the
substance abuse.

Bibliography: Mohr, Psychiatric Mental Health Nursing, 6
th
edition, Lippincott
Williams and Wilkins, Philadelphia, 2008 Page 381.

4. Substance use is a shortened version of the term used in the ICD-10
Mental and behavioural disorders due to psychoactive substance use.
The term encompasses acute intoxication, harmful use, and
dependence syndrome, and withdrawal state, withdrawal state with
delirium, psychotic disorder and amnesic syndrome. For a particular
substance these conditions may be grouped together as, for example,
alcohol disorders, cannabis use disorders, stimulant use disorders.
Psychoactive substance use disorders are defined as being of clinical
relevance; the term psychoactive substance use problems is a broader
one, which includes conditions and events not necessarily of clinical
relevance.

Bibliography: http://www.who.int/substance_abuse/terminology/definition4/en/

5. Substance use is the consumption of low or infrequent doses of alcohol or
drugs, such that damaging consequences are rare or minor. In reference
to alcohol, this means drinking in a way that does not impair functional or
leads to negative consequences, such as violence. In reference to
prescription drugs, use involves taking medications as prescribed by a
physician. Regarding over-the-counter medications, use is defined as
72

taking the substance as recommended for alleviating symptoms. Some
people who choose to use substances may use them periodically, never
use them to an extreme, or never experience life consequences because
of their use.

Bibliography: https://www.childwelfare.gov/pubs/usermanuals/substanceuse/
chaptertwo.cfm

D. Alcohol

1. Alcohol is a central nervous system depressant that is absorbed rapidly
into the bloodstream. Initially the effects are relaxation and loss of
inhibitions with intoxication, there is slurred speech, unsteady gait, lack of
coordination, and impaired attention, concentration, memory, and
judgment. Some people become aggressive or display inappropriate
sexual behavior when intoxicated. He person who is intoxicated may
experience a black out. A black ot is an episode during which the person
continues to function but has no conscious awareness of his/her behavior
at the time nor any later memory of the behavior.

Bibliography: Videbeck, Psychiatric Mental Health Nursing, 2
nd
edition,
Lippincott Williams and Wilkins, Philadelphia, 2007 Page 683.

2. Alcohol abuse and dependence are among the most serious U.S. public
problems. Known chemically as ethanol and sometimes abbreviated as
ETOH. It is legal chemical substance or drug; that is, the commercial
distribution of alcohol-containing beverages differs from the more tightly
regulated sale of other classes of drugs. Ethyl alcohol has pharmacologic
properties that produce mind-and-mood altering effects. It is a CNS
depressant similar to barbiturates and ether.
73

Bibliography: Kaplan & Sadock, Synopsis of Psychiatry: Behavioral Sciences
Clinical Psychiatry, 8
th
edition, Lippincott Williams and Wilkins,
Philadelphia, 2008, Page 498.

3. Alcohol is a drug. It is classed as a depressant, meaning that it slows
down vital functionsresulting in slurred speech, unsteady movement,
disturbed perceptions and an inability to react quickly. As for how it affects
the mind, it is best understood as a drug that reduces a persons ability to
think rationally and distorts his or her judgment. Although classified as a
depressant, the amount of alcohol consumed determines the type of
effect. Most people drink for the stimulant effect, such as a beer or glass
of wine taken to loosen up. But if a person consumes more than the
body can handle, they then experience alcohols depressant effect. They
start to feel stupid or lose coordination and control.

Bibliography: Mohr, Psychiatric Mental Health Nursing, 6
th
edition, Lippincott
Williams and Wilkins, Philadelphia, 2008 Page 382.

4. Alcohol is the most frequent used brain depressant in most cultures and
a cause of considerable morbidity and mortality. Drinking alcohol-
containing beverages is generally considered an acceptable and common
habit in United States. Alcoholic beverage, any fermented liquor, such
as wine, beer, or distilled spirit that contains ethyl alcohol, or ethanol
(CH
3
CH
2
OH), as an intoxicating agent.

Bibliography: http://www.drugfreeworld.org/drugfacts/alcohol.html

5. Any fermented liquor, such as wine, beer, or distilled liquor, that contains
ethyl alcohol, or ethanol, as an intoxicating agent. When an alcoholic
beverage is ingested, the alcohol is rapidly absorbed in the stomach and
intestines because it does not undergo any digestive processes. It is
74

distributed to the rest of the body through the blood and has a pronounced
depressant action on the brain. Under the influence of alcohol, the drinker
is less alert, less able to discern objects in the environment, slower in
reacting to stimuli, and generally prone to sleep.

Bibliography: http://www.answers.com/topic/liquid-courage#ixzz2qLuIr6E7

DSM V DIAGNOSIS

Diagnostic Criteria for Alcohol Use Disorder

A problematic pattern of alcohol use leading to clinically significant impairment or
distress, as manifested by atleast 2 of the following, occurring within a 12- month
period:
CRITERIA PRESENT
1. Alcohol is often taken in larger amounts or over a longer
period than was intended.


2. There is a persistent desire or unsuccessful efforts to cut
down or control alcohol use.


3. A great deal of time is spent in activities necessary to
obtain alcohol, use alcohol, or recover from its effect.


4. Craving, or a strong desire or urge to use alcohol.


5. Recurrent alcohol use resulting in a failure to fulfil major
role obligations at work, school, or home.

75


6. Continued alcohol use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.


7. Important social, occupational, or recreational activities are
given up or reduced because of alcohol use.


8. Recurrent alcohol use in situations in which it is physically
hazardous.


9. Alcohol use is continued despite knowledge of having
persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of alcohol.


10. Tolerance, as defined by either of the following:
a. A need for markedly increase amount of alcohol to
achieve intoxication or desired effects.

b. A markedly diminished effect with continued use of the
same amount of alcohol.



11. Withdrawal, as manifested by either the following:
a. The characteristic withdrawal syndrome for alcohol. (a.
Cessation of alcohol use that has been heavy and
prolonged; b. 2 or more of the following developing within
several hours to a few days after the cessation of alcohol
use described as: autonomic hyperactivity, insomnia,
nausea and vomiting, transient visual, tactile, or
hallucinations, or anxiety).


76

b. Alcohol (or closely related substance, such as a
benzodiazepine) is taken to relieve or avoid withdrawal
symptoms.



Specify current severity:
305.00 (F10.10) MILD: Presence of 2-3 symptoms
303.90 (F10.20) MODERATE: Presence of 4-5 symptoms
303.90 (F10.20) SEVERE: Presence of 6 or more symptoms

Differential Diagnosis for Alcohol use disorder
A. Nonpathological use of alcohol The key element of
alcohol use disorder is the use of heavy doses of alcohol
with resulting repeated and significant distress or impaired
functioning. While most drinkers sometimes consume
enough alcohol to feel intoxicated, only a minority (less
than 20%) ever develop alcohol use disorder. Therefore,
drinking, even daily, in low doses and occasional
intoxication do not by themselves making this diagnosis.


B. Sedative, hypnotic, or anxiolytic use disorder the
signs and symptoms of alcohol use disorder are similar to
those seen in sedative, hypnotic, or anxiolytic use
disorder. The two must be distinguished, however,
because the course may be different, especially in relation
to medical problems.

77


C. Conduct disorder in childhood and adult antisocial
personality disorder Alcohol use disorder, along with
other substance use disorders, is seen in the majority of
individuals with antisocial personality and preexisting
conduct disorder. Because these diagnoses are
associated with an early onset of alcohol use disorder as
well as worse prognosis, it is important to establish both
conditions.




Our group decided to have the final diagnosis of Mr. M. M. is Severe Alcohol use
disorder with Nonpathological use of alcohol. Today, his signs and symptoms of
disorder are not seen any more but he is still in medication for continuous
treatment.

VIII. Medical Management

A. Actual Therapies

1. Occupational Therapy
Occupational therapy is defined as the art and science of directing a persons
participation in selected activity to diminish or correct pathological problems and
promote and maintain health. It is a discipline that aims to promote health by
enabling people to perform meaningful and purposeful activities. Occupational
therapists work with individuals who suffer from a mentally, physically,
developmentally, and/or emotionally disabling condition by utilizing treatments
that develop, recover, or maintain clients' activities of daily living.
78

Actual:
Paper gift Bag Making This allows the client to do something meaningful
and to improve basic motor functions. It allows the client to develop fine motor
activity and accuracy. It also helps the clients have independent, productive, and
satisfying lives.
2. Play Therapy
Play therapy is a technique whereby play is used as a therapeutic method
to assist client in coping with emotional stress or trauma.
Actual:
All of the games brings fun in a form of exercise, socialization with others,
cooperation, diverting patients attention; promote sportsmanship and healthy
competition among the patients. It enables the individual to have a unique
opportunity to be relieved from tension or stress by discharging strong emotions
in a secure atmosphere.
Games done:
1. Hockey caps
The game allows the use of 3 bottle caps and 1 stick. Clients were
grouped into 4 groups. Each team consists of five players and is given 1
stick to move there 3 bottle caps together at the same time. The first team
to finish the game is the winner.

2. Hula-hoop relay
Clients were grouped into 4 groups. Each group consists of 5
players. Each group also needs to form a circle and hold hands. Players
must use their bodies to pass the hula-hoop to the other players until they
could do it for 4x. The first team to finish is the winner.

3. Art Therapy
79


Art therapy is a form of psychotherapy that uses art media as its
primary mode of communication. It is the therapeutic use of art making,
within a professional relationship, by people who experience illness,
trauma or challenges in living, and by people who seek personal
development. It is also used as a diagnostic tool and treatment modality.
Through creating art and reflecting on the art products and processes,
people can increase awareness of self and others cope with symptoms,
stress and traumatic experiences; enhance cognitive abilities; and enjoy
the life-affirming pleasures of making art.

Actual:
The client was asked to make his own head dress in line with the
theme Sinulog. He made a colorful and attractive one. He said while
choosing colored papers that he wanted to have bright colors so that it
would be attractive to the eyes of others. He used bright colors such as
yellow, sky blue and green on his head dress. Through head dress
making, we can somehow assess clients thought content through the
colors he used. It also helps the patient to express his/her thoughts and
emotions through his/her designed head dress, to help the patient gain
relief from anxiety by graphically representing conflicts and aggressive
and traumatic material without guilt, to provide a socially acceptable outlet
for fantasy and wish fulfillment, and to help the patient develop more
dexterity.

4. Remotivational Therapy

Remotivation is a technique of simple group therapy, objective in
nature, used with a group of patients in an effort to reach the unwounded
areas of each patients personality and to get them thinking about reality in
80

relation to themselves. Remotivation differs from other therapies because
it focuses on the patients abilities rather than disabilities.
Actual:
Dela Cernalympics (Olympics) was the theme of the said activity
wherein clients were able to experience playing games present in an
Olympic like volleyball and basketball and compete for each other.
5. Music and Dance Therapy

Music therapy is a type of psychotherapy in which the patient is
encouraged to utilize music to improve interpersonal and communication
skills in ways that regular dialogue is limited. There are usually both active
and receptive parts of the therapy, meaning that at times music is listened
to and at other times there is the use of musical improvisation or creation.
Dance therapy is a method of psychological treatment in which movement
and dance are used to express and deal with feelings and experiences
both positive and negative.



Actual:
The clients were able to dance during our SINULOG theme with
their own personalized head dresses plus the traditional SINULOG
dance and music.

B. Possible Therapies

1. Group Therapy

Group therapy is a form of psychosocial treatment where a small
group of patients meet regularly to talk, interact, and discuss problems
81

with each other and the group leader (therapist). Group therapy attempts
to give individuals a safe and comfortable place where they can work out
problems and emotional issues. Patients gain insight into their own
thoughts and behavior, and offer suggestions and support to others. In
addition, patients who have a difficult time with interpersonal relationships
can benefit from the social interactions that are a basic part of the group
therapy experience.

2. Family Therapy

Family therapy involves a whole family, or several family members,
all meeting with a therapist. Family therapy can be helpful if a family is
having problems getting along. It can also be used with one family
member has a problem, and family relationships may be contributing to or
maintaining the problem. In many cases the problem may be exhibited by
a child, but this is not always the case.
C. Pharmacological Therapies
Date ordered: 5 / 23 / 10

Generic Name: Haloperidol
Brand Name: Haldol, Haldol
Decanoate
Classification: Therapeutic:
Antipsychotics
Pharmaceutic: Butyrophenones
Pregnancy Category: C

Mode of Action:
May block postsynaptic dopamine receptors in the limbic system and increase
brain turnover of dopamine, producing an antipsychotic effect.
82

Indication:
Acute and chronic psychotic disorders including: schizophrenia, manic states,
drug-induced psychoses. Schizophrenic patients who require long term
parenteral (IM) antipsychotic therapy. Also useful in managing aggressive or
agitated patients. Tourettes syndrome. Severe behavioral problems in children
which may be accompanied by: unprovoked, combative, explosive
hyperexcitability, hyperactivity accompanied by conduct disorders (short-term
use when other modalities have failed). Considered second-line treatment after
failure with atypical antipsychotic.
Contraindication:
Blood dyscrasias, bone marrow depression, cerebral arteriosclerosis, coma,
concurrent use of large amounts of other CNS depressants, coronary artery
disease, epilepsy, hepatic dysfunction, hypersensitivity to haloperidol or its
components, Parkinsons disease, severe hypertension or hypotension, severe
CNS depression, subcortical brain damage.
Ordered Dose: 10 mg tab b.i.d.
Side effects:
The side effects of the drug are drowsiness, restlessness, sedation, lethargy,
insomnia, vertigo and tardive dyskinesia. While the adverse effects of the drug
are seizure, neuroleptic malignant syndrome, agrunocytosis and leukocytosis.
Drug interaction:
DRUGS
amphetamines: Possibly decreased stimulant effects of amphetamines
and decreased antipsychotic effect of haloperidol
anticholinergics, antidyskinetics, antihistamines: Increased anticholinergic
effect and risk of decreased antipsychotic effect of haloperidol.
anticonvulsants: Possibly decreased effectiveness of anticonvulsants and
decreased blood haloperidol level
bromocriptine: Possibly decreased effectiveness of bromocriptine
bupropion: Lowered seizure threshold, increased risk of major motor
seizure
83

CNS depressants: Increased CNS depression and risk of respiratory
depression and hypotension diazoxide: Possibly hypoglycemia
dopamine (high-dose therapy): Possibly decreased vasoconstriction
ephedrine: Possibly decreased vasopressor effect of ephedrine
epinephrine: Possibly severe hypotension and tachycardia
fluoxetine: Increased risk of severe and frequent extrapyramidal effects
guanadrel, guanethidine: Decreased hypotensive effects of these drugs
levodopa, pergolide: Possibly decreased therapeutic effects of these
drugs
lithium: Increased risk of neurotoxicity
MAO inhibitors, maprotiline, tricyclic antidepressants: Increased sedative
and anticholinergic effects of these drugs
metaraminol: Possibly decreased vasopressor effect of metaraminol
methoxamine: Decreased vasopressor effect, shortened duration of
methoxamine action
methyldopa: Possibly disorientation, slowed or difficult thought processes
phenylephrine: Decreased vasopressor response to phenylephrine

ACTIVITIES
alcohol use: Increased CNS depression and risk of respiratory depression
and hypotension.
Nursing Interventions/Responsibilities:
Advise patient to take haloperidol exactly as prescribed and not to stop
abruptly because withdrawal symptoms may occur.
Caution patient to avoid skin contact with oral solution because it may
cause a rash.
Advise patient to take tablets with food or a full glass of milk or water to
reduce GI distress.
Instruct patient to consume adequate fluids and to take precautions
against heatstroke.
84

If sedation occurs, caution patient to avoid hazardous activities.
Instruct patient to report repetitive movements, tremor, and vision
changes.
Monitor blood pressure (sitting, standing, lying) and pulse prior to and
frequently during the period of dose adjustment. May cause QT interval
changes on ECG.
Monitor intake and output ratios and daily weight. Assess patient for signs
and symptoms of dehydration (decreased thirst, lethargy,
hemoconcentration), especially in geriatric patients.
Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth,
face, and extremities;lip smacking or puckering; puffing of cheeks;
uncontrolled chewing; rapid or wormlike movements of tongue, excessive
eye blinking). Report immediately; may be irreversible.
Monitor for development of neuroleptic malignant syndrome (fever,
respiratory distress,tachycardia, seizures, diaphoresis, hypertension or
hypotension, pallor, tiredness, severe muscle stiffness, loss of bladder
control). Report symptoms immediately. May also cause leukocytosis,
elevated liver function tests, elevated CPK.
Monitor CBC with differential and liver function tests periodically during
therapy.

Date ordered: 5 / 23 / 10

Generic Name: Biperiden
Brand Name: Akineton, Akidin
Classification: Therapeutic:
Anticholinergic, antidyskinetic
Pharmaceutic: Tertiary amine
Pregnancy Category: C

Mode of Action:
85

Blocks acetylcholines action at cholinergic receptor sites. This action restores
the brains normal dopamine and acetylcholine balance, which relaxes muscle
movement and decreases rigidity and tremors. Biperiden also may inhibit
dopamine reuptake and storage, which prolongs dopamines action.
Indication:
Use adjunct in the therapy of Parkinsonism
Contraindication:
Achalasia, bladder neck obstruction, hypersensitivity to biperiden, myasthenia
gravis, narrow-angle glaucoma, prostatic hypertrophy, pyloric or duodenal
obstruction, stenosing peptic ulcer, toxic megacolon.
Ordered Dose: 2 mg 1 tab b.i.d.
Side effects:
The side effects are as follows: Tachycardia, palpitation, rash, blurred vision, dry
mouth, constipation and urinary retention.
The adverse effects of this drug are dysuria, hallucinations, delusion, delirium
and euphoria.
Drug interaction:
DRUGS
amantadine: Possibly increased adverse anticholinergic effects
digoxin: Possibly increased serum digoxin level
haloperidol: Possibly increased schizophrenic symptoms, decreased
serum haloperidol level, and development of tardive dyskinesia
levodopa: Possibly decreased levodopa effectiveness
phenothiazines: Possibly reduced phenothiazine effects and increased
psychiatric symptoms
Nursing Interventions/Responsibilities:
Assess muscle rigidity and tremors for the effectiveness of the drug.
Assess patients gait and balance for the effectiveness of the drug.
Advice patient to avoid activities that require alertness, may cause
dizziness, drowsiness and blurring of vision.
86

Urge patient to avoid extremely hot and humid conditions to reduce risk of
heatstroke and severe hyperthermia.
Emphasize the need for periodic eye examinations and intraocular
pressure measurement because biperiden may cause narrow-angle
glaucoma and increase intraocular pressure.
Caution patient to rise slowly from sitting or recumbent position to
minimize orthostatic hypotension.
Advice patient to take frequent sips of water to decrease drying of mouth.
Give with food to prevent GI upset.


Date ordered: 5 / 23 / 10

Generic Name: Chlorpromazine
Brand Name: Thorazine
Classification: Therapeutic:
Antiemetic, antipsychotic,
tranquilizer
Pharmaceutical: Propylamine
derivative of phenothorazine
Pregnancy Category: C

Mode of Action:
Depresses brain areas that control activity and aggression, including the cerebral
cortex, hypothalamus, and limbic system, by an unknown mechanism. Prevents
nausea and vomiting by inhibiting or blocking post synaptic dopamine receptors
in the medullar chemoreceptor trigger zone and peripherally by blocking the
vagus nerve in the GI tract. May relieve anxiety by indirect reduction in arousal
and increased filtering of internal stimuli to the reticular activating system in the
brain stem.
87

Indication:
Second-line treatment for schizophrenia and psychoses after failure with atypical
antipsychotics. Hyperexcitable, combative behavior in children. Nausea and
vomiting. Intractable hiccups. Preoperative sedation. Acute intermittent porphyria.
Contraindication:
Hypersensitivity; Hypersensitivity to sulfites (injectable); Cross-sensitivity with
other phenothiazines may occur; Angle-closure glaucoma; Bone marrow
depression; Severe liver/cardiovascular disease; Concurrent pimozide use.
Ordered Dose: tab h.s.
Side effects:
The side effects of the drug are sedation, drowsiness, tardive dyskinesia,
pseudoparkinsonism, tachycardia, hypotension, blurred vision, constipation, dry
mouth and urinary retention. While the adverse effects of the drug are seizures,
neuroleptic malignant syndrome, haemolytic anemia, and thrombocytopenia.
Drug interaction:
DRUGS
amphetamines: Decreased amphetamine effectiveness, decreased
antipsychotic effectiveness of chlorpromazine
antacids (aluminum hydroxide or magnesium
trisilicate gel): Decreased chlorpromazine absorption and effectiveness
barbiturates: Decreased plasma level and, possibly, effectiveness of
chlorpromazine
CNS depressants: Prolonged and intensified CNS depression
metrizamide: Possibly lowered seizure threshold
oral anticoagulants: Decreased anticoagulation
phenytoin: Interference with phenytoin metabolism, increased risk of
phenytoin toxicity
propranolol: Increased plasma levels of both drugs
thiazide diuretics: Possibly increased orthostatic hypotension

88

ACTIVITIES
alcohol use: Prolonged and intensified CNS depression
Nursing Interventions/Responsibilities:
Monitor Lab test for bilirubin, CBC and liver function tests.
Advice patient to report any development of sore throat, body malaise,
fever, bleeding and mouth sores.
Give with full glass of water or with meal to decrease GI upset.
Advice patient not to chew time released tablet.
Advice patient to avoid activities that require alertness, may cause
dizziness, drowsiness and blurring of vision.
Avoid excessive exposure to sun light due to photosensitivity.
Teach patient to do good oral hygiene to prevent drying of mouth.
Inform patient that urine may turn pink or red.








89

IX. Nursing Care Plan

Disturbed Sleep Pattern related to major depressive with psychotic features

Date
and
Time

Cues Need Nursing Diagnosis Nursing Objectives Interventions Evaluation

D

E

C

E

M

Subjective:
Usahay dili ko
katulog, kung
makatulog ko,
magputol-putol
pud siya,
Usahay pud
makipag istorya
na lang ko
sakong kauban
kay dili ko

S
L
E
E
P
-
R
E
S
T
Disturbed Sleep
Pattern related to
major depressive with
psychotic features

Rationale:
Patients with major
depressive disorders
can experience a
range of sleep
disturbances including
Within my 7 days span of
nursing care, my patient
will improve sleeping
pattern as evidenced by:

a. ability to
concentrate during
the interaction;

b. participate
properly in the
1. Establish rapport to
the patient.

R: to gain the trust
and cooperation of
the patient.

2. Perform assessment
of the patients sleep
disorder problems,
characteristics and

December 14,
2013
@ 5pm

Goal Partially
Met


At then of 5 days
span of care, my
90

B

E

R


7,


2013

katulog, as
verbalized by
the patient.


Objective:
-visible eyebags
-age:49 years
old
-decrease
concentration
-yawning

P
A
T
T
E
R
N
intermittent
awakenings which
makes the patient
under stress and
insufficient rest
allowing them to
become sleepy during
the day, weak,
disoriented, inability to
concentrate, frequent
yawning and having
big eyebags.



Reference
Videbeck, S. (2012).
Psychiatric Mental
Health Nursing. 5
th

Edition. Lippincotts
activity;


c. absence of
yawning; and

d. verbalization of
improved sleep
pattern
causes of lack of
sleep.

R: Provide basic
information to
determine a plan of
nursing.

3. The state of the bed,
the pillows were
comfortable and
clean.

R: Improve comfort
while sleeping.

4. Prepare for a nights
sleep.

R: Set the sleep
patient was able
to improve
sleeping pattern
as evidenced by:

a) Ability to
concentrate
during the
interaction;

b) Participated
properly in the
activity;

c) Verbalization
of Okay lang
man akong
tulog, as
verbalized by
the client.
91

Williams and Wilkins. pattern.

5. Identify factors
known that interferes
the sleeping pattern
such as current
illness,
hospitalization and
sick family members
at home.

R: Sleep problems
can arise from
internal and external
factors and may
require assessment
overtime to
differentiate specific
cause.

92

6. Encourage the client
to drink a glass of
milk before bedtime.

R: Milk is best known
for getting you
relaxed enough to
get some sleep.









93

Date
and
Time

Cues Need Nursing Diagnosis Nursing Objectives Interventions Evaluation

D

E

C

E

M

B

E

R


S:----

O:
Low self-
esteem
Loneline
ss
Sets
himself
away
from the
group
Depressi
on


R
O
L
E

R
E
L
A
T
I
O
N
S
H
I
P
Dysfunctional Family
Process related to
family history of
alcoholism.

Rationale:

History of alcoholism
can affect
psychosocial, spiritual,
and physiological
functions of a person.
This may lead to
conflicts, ineffective
problem solving and
series of self-
perpetuating crises.

Within our 7 days span of
nursing care, my resident
will demonstrate
improvement in behavior
as manifested by:

a. Participation in
individual or group
treatment
programs
;

b. Identify effective
coping behaviors;

c. Verbalization of
lifestyle changes
such as diverting
7. Establish rapport.

R: to gain the trust
and cooperation of
the resident.

8. Determine extent
and knowledge of
behavior.
R: Knowing the
residents behavior
can give you an idea
what to expect and
what interventions to
give.

9. Identify behaviors of
family members.

December
14, 2013
@ 5pm

Goal Met


After our 7
days span of
care our
resident
demonstrated
improvement
s in behavior
as manifested
by:

94

7,


2013

@
3pm

P
A
T
T
E
R
N





Reference
Videbeck, S. (2012).
Psychiatric Mental
Health Nursing. 5
th

Edition. Lippincotts
Williams and Wilkins.
attention through
social interaction
and activities.
R: Issue of
secondary gain
(conscious or
unconscious) may
impede recovery.

10. Encourage resident
to participate in
group activities
during programs.
R: This will divert his
attention and would
encourage of
personal progress.

11. Discuss effective
coping mechanisms
such as interacting
with other residents.
R: Involvement of
a. He
particip
ated in
the
progra
m
conduc
ted by
the
studen
t
nurses
;

b. He
was
able to
identify
coping
behavi
95

group socialization
provides healthy
models and practice
of healthy skills.

12. Provide information
regarding the effects
of addiction on mood
or personality.
R: Helps individual
understand and cope
with negative
behaviors without
being judgmental.

13. Encourage resident
to express feelings
towards his
situationa and family.
R: To help resident
ors
such
as
sociali
zing
with
his co-
reside
nts,
activel
y
particip
ating in
games
and
openly
expres
sing
his
feeling
96

cope easily. This will
also give us an idea
of his mood and
feelings.

14. Discuss current/ past
methods of coping.
R: To identify
methods that will be
useful in the current
situation.
s to his
studen
t nurse
assign
ee;

c. Pag
makag
awas
ko diri
dili nko
mag
inom
inom
kay
makad
aot sa
lawas,
as
verbali
97














zed by
the
reside
nt.
98

DATE
AND
TIME
CUES NEE
D
NURSING
DIAGNOSIS
`OBJECTIVES
OF CARE
NURSING
INTERVENTIONS
EVALUATION
D
E
C
E
M
B
E
R

07
,
2
0
1
3

@

OBJECTIV
E:
Slee
p
distur
banc
es
Depe
nden
ce on
alcoh
ol
Does
not
talk
frequ
H
E
A
L
T
H

P
E
R
C
E
P
T
I
O
N
Ineffective health
maintenance r/t
inability to
identify help to
maintain help
secondary to
alcohol abuse

Rationale:
Altered health
maintenance
reflects a change
in an individual's
ability to perform
the functions
necessary to
maintain health
That within 4
weeks span of
care will use
available
resources by:

Agreeing
to
participate
in
treatment
program;
Establishi
ng a
balance of
rest,
sleep, and
Complete a client
assessment.
Monitor clients
health status based on
standards.

Identify cause of
anxiety, involving
patient in the
process. Explain
that alcohol
withdrawal
increases anxiety
and uneasiness.
Reassess level
of anxiety on an
ongoing basis.
January 11, 2014
@
4:30 pm
Goal Met
Within 4 weeks
span of care patient
was able to use
available resources
by:

Agreed to
participate in
treatment
program;
Establised a
balance of
99

4PM ently

-
H
E
A
L
T
H

M
A
N
A
G
E
M
E
N
T

P
or wellness. The
patients who are
most likely to
experience more
than transient
alterations in
their ability to
maintain their
health are those
whose age or
infirmity (either
physical or
emotional)
absorb much of
their resources.


activity;
Identify
needed
health
resources.
Person in acute
phase of
withdrawal may be
unable to identify
and/or accept what
is happening.
Anxiety may be
physiologically or
environmentally
caused. Continued
alcohol toxicity will
be manifested by
increased anxiety
and agitation as
effects of
medication wear
off.
Develop a
trusting
relationship
through frequent
contact being
rest, sleep,
and activity;
Identified
needed
health
resources.





Judee Andrea B. De
Dios, St. N







100

A
T
T
E
R
N

honest and
nonjudgmental.
Project an
accepting
attitude about
alcoholism.
Provides patient with
a sense of
humanness, helping to
decrease paranoia
and distrust. Patient
will be able to detect
biased or
condescending
attitude of caregivers.
Inform patient
about what you
plan to do and
why. Include
patient in
planning process












101

and provide
choices when
possible.
Enhances sense
of trust, and
explanation may
increase
cooperation/reduc
e anxiety. Provides
sense of control
over self in
circumstance
where loss of
control is a
significant factor.

Reorient
frequently.
Patient may
experience periods of
confusion, resulting in
102

increased anxiety.
Determine
patient's motives
for failing to
report symptoms
reflecting
changes in
health status.
Patient may not want
to "bother" the
provider, or may
minimize the
importance of the
symptoms.
Compliment
patient on
positive
accomplishments
.
To reinforce
103

behaviors.
Help the client to
choose a healthy
lifestyle.
Healthy lifestyle
measures, such as
exercising
regularly,
maintaining a
healthy weight, not
smoking, and
limiting alcohol
intake, help reduce
the risk of cancer
and other chronic
illnesses.
Discuss with the
client and
support person
realistic goals for
changes in
104

health
maintenance.
The importance
of personalized
goals and social
support in
designing health
interventions for
older adults is a
unique predictor
of health goal
attainment.
Provide patient
with a means of
contacting health
care providers.
Who are
available for
questions or
problem resolution.
105

Cues Need Nursing Diagnosis Goal Of Care Intervention Evaluation
106


Subjective:
maulaw man
ko sa akong
mga igsuon
kay nahuman
sila iskwela
unya ako pag
gawas na ko
diri basig walay
mutanggap sa
akoa.
As verbalized
by the patient.
Objective:
-poor eye
contact
-lack of self
confidence
-being silent
the whole time

C
O
G
N
I
T
I
V
E
-
P
E
R
C

Situational low
self- esteem r/t
lack of recognition
by the family
members

R.
Self-esteem is the
degree to which
we view our
worthiness as a
person.
Furthermore, self-
esteem is
something more
fundamental than
the normal ups
and downs
associated with
situational
changes such as
lack of attention
given by the family
members. And for
people with poor

That within4 weeks
span of care patient be
able to increase self-
esteem as manifested
by
a. active
participation in
activities of
daily living.
such as
therapeutic
activities.

b. verbalization of
feelings of self-
worth

c. verbalization of
positive future
plans


1. Assess for signs and
symptoms of a self-
concept disturbance
(e.g. verbalization of
negative feelings about
self, withdrawal from
significant others, lack of
participation in activities
of daily living, lack of
plan for adapting to
necessary changes in
lifestyle)

R.To have an
intervention appropriate
to the condition of the
patient.

2. Implement measures to
assist client to increase
self-esteem (e.g. limit
negative self-
assessment, encourage
positive comments


January 11, 2014
@
4:30 pm
Goal Met
Within 4 weeks span
of care patient was
able to improve self-
esteem as manifested
by:
a) patient was
able to
participate in
activities of
daily living
actively such
as therapeutic
activities.
b) Verbalization
of Makagawas
n unta ko para
makapangeta
107

E
P
T
U
A
L

P
A
T
T
E
R
N
self-esteem, these
ups and downs
drastically impact
the way they see
themselves.
Reference:
Doenges, K.
(2010) Nursing
Care Plan. 4
th

edition.
Philadelphia: USA
about self, assist to
identify strengths, give
positive feedback about
accomplishments).

R. This will boast
patients confidence.

3. Assist client to identify
and use coping
techniques that have
been helpful in the past.

R. For the patient to
cope for the future
stressor that led to
decrease self-esteem.

4. Support behaviors
suggesting positive
adaptation to changes
that have occurred (e.g.
daun ko og
work
c) Kung
makatrabaho
ko mutabang
jud ko sa
akong mga
igsoon kay
ulaw na kayo
as verbalized
by the patient
108

verbalization of feelings
of self-worth,
maintenance of
relationships with
significant others).

R. This will will enhaced
patients readiness in
coping to his current
conditon

5. Assist client's and
significant others'
adjustment by listening,
facilitating
communication, and
providing information.

R.Giving support from
significant others will
help patients to regain
his self-worthiness.

109

6. Encourage visits and
support from significant
others.

R.this will help the
patient gain self-esteem.


7. Encourage client to
continue involvement in
interests and hobbies if
possible.

R. With this, patients
attention will be diverted
and that he will find
meaning to his life
through involvement to
different activities.

110


Date/
Time

Cues

Need

Nursing Problem

Objectives of Care

Nursing Intervention

Evaluation

D
e
c
e
m
b
e
r

7,

2
0
1
3

@

4 PM



Subjective:
tanan sa akong
anak
nakagraduate
siya lang gd ang
dili nahuman

Objective:
Favoritism
of the
mother
Mistrust to
his father
History of
throwing
objects


C
O
P
I
N
G

-

S
T
R
E
S
S

T
O
L
E
R
A
N

Ineffective coping
r/t support system
as evidenced by
client lack of
communication with
family members.
R: it is the inability
to form a valid
appraisal of the
stressors. How one
responds to such
stressors depends
in part on the
persons coping
resources this
includes support
system especially
among family
members through
open
communication.

At the end of our
duty, our client will be
able to improve
communication as
evidenced by:


a) Client will
describe previous
stressors and
coping
mechanisms used
as measured by
verbalization of at
least two stressful
circumstances
and how he coped
with them;
b) verbalization of
feelings of anger,
frustration or
confusion;
c) acknowledge

1. Build trusting
relationship.
Familiarity with and
trust can decrease
fear and facilitate
communication.

2. Observe for early
signs of anxiety.
Irritability, pacing,
and lack of
cooperation all may
be sign of increasing
anxiety.


3. Remove all objects
that can harm the
environment around
the patient.
If the patient is in a
state of confusion,
patients will not use

January 11, 2014
GOAL MET

Within our four
weeks span of
nursing care, the
patient was able to
improve
communication as
evidenced by;
a) Client was
able to
describe his
previous
stressors such
as the other
woman of his
father and was
able to
verbalized that
his way of
111

C
E

P
A
T
T
E
R
N

Referce:
Doenges,M. (2010)
Nursing Care Plan.
3
rd
edition. New
York: Rochester.

realities of the
situation; and

these objects to
endanger yourself or
others.

4. Collaborate with the
client to identify
personal strengths.
this would help
build trusting
relationship

5. Maintain
straightforward
communication.
To avoid reinforcing
manipulative
behavior and
enhances positive
interactions.
6. Accept clients anger
without reacting on
emotional basis.
Responding with
anger is not helpful in
resolving the situation
and may result in
coping with
the stressor
was drinking
alcohol and
smoking.

b) Verbalization
of di man gud
mi close sa
akong mama
busy man d
gud na siya sa
trabaho
c) Verbalization
of murag
dugay dugay
pa ko diri nag
wild man gud
ko sa among
balay



112

escalating the clients
behavior.

7. Help client identify
more appropriate
solutions/behaviors
such as motor
activity/exercise.
To promote release
of energies in
acceptable ways.

8. Give positive
reinforcement for
clients effort.
Encourages
continuation of
desired behaviors..

9. Discuss
consequences of
actions if patient were
to follow through on
intent.
To discuss other
options to deal with
the problem.
113


10. Maintain and convey
a calm attitude to
client.
Anxiety is
contagious and can
be transmitted from
staff members to
client.



114

X. Prognosis
Criteria Poor Fair Good Justification
Onset of
Illness


We rate this criterion as good, since he is
admitted at the institution for almost 3 years
now and is exhibiting progress. At present,
no signs of hallucination and delusion were
noted.
Duration of
Illness


We rate this criterion as fair since it has been
3 years and he seems progressing.
Age

We rate this as fair since studies shows that
people in who drinks at 20-55 years old may
influence the expression of genes which
increase the risk of alcohol dependence.
Precipitating
Factor
We rate this criterion as fair since there are
some factors that are considered to trigger
his behavior.
Mood and
Affect


We rate this criterion as fair since sometimes
when he joins the activity in the afternoon he
does not seem to take interest at times.
However, as for interaction he is well with his
co-residents and student nurses.
Attitude and
Willingness
to take
Medication


We rate this criterion as good since he takes
his medications when it is being given. He
has no problems of not complying with his
medications.
Family
Support
We rate this as poor since the client
verbalizes that hes family especially his
mother does not support him anymore.
Based on our interview, his mother admits
that she still fears what his son might do to
115



We rate sir M with fair prognosis. Considering that, he was able to
cope up with his illness and is continue to show progress and recovery.
Although he admits that he is still angry with his mom, he continued living
his life inside the institution. With proper interventions, and continuous
intake of medications the recovery of Mr. M is very possible.
XI.















her.
116

XII. Bibliography

American Psychiatric Association, (2013). Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Arlington, VA: American
Psychiatric Publishing.
Deglin, J. H., PharmD. Daviss DRUG GUIDE FOR NURSES. F. A. Davis
Company. 2011, 12th edition.
Kaplan & Sadock, Synopsis of Psychiatry: Behavioral Sciences Clinical
Lippincott Williams and Wilkins, Philadelphia, 2008 Page 704
Lippincott Williams and Wilkins, Philadelphia, 2012 Page 309
Mohr, Psychiatric Mental Health Nursing, 6
th
edition, Lippincott
Pedersen, Essentials of Psychiatric Mental Health Nursing 6
th
edition,
Personal Conduct (rev. Ed.). New York: Harper & Row 2012.
Page 771 Psychiatry, 8
th
edition, Lippincott Williams and Wilkins,
Philadelphia, 2008, Page 497.
Shiela Videbeck, (2011). Psychiatric-Mental Health Nursing. 5th ed.
Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams &
Wilkins, 2011.
Skidmore-Roth, L. (2011). Mosbys 2011 Nursing Drug Reference (24th
ed.). St. Louis: Elsevier/Mosby.
Szasz, T. The Myth of Mental Illness: Foundations of a Theory of
Varcarolis, Essentials of Psychiatric Mental Health Nursing, 4
th
Edition,
Williams and Wilkins, Philadelphia, 2008 Page 381.
Webliography:
http://www.mayoclinic.org/diseases-conditions/mental illness/basics/
definition/con-20033813
http://www.medicinenet.com/mental_health_psychology/article.htm
http://wiki.answers.com/Q/What_the_definition_for_behavior_disorder_of_
childhood?#slide=4
117

http://www.childrenshospital.org/health-
topics/conditions/disruptivebehavior-disorders
http://www.who.int/substance_abuse/terminology/definition4/en/
https://www.childwelfare.gov/pubs/usermanuals/substanceuse/ chapter.
118