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Introwww Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors.

Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming. There are 5 subtypes of schizophrenia naming; paranoid, disorganized, catatonic,undifferentiated, and residual. The prevalence of schizophrenia is thought to be about 1% of the population around the world; it is thus more common than diabetes, Alzheimer's disease, or multiple sclerosis. In the United States and Canada, patients with schizophrenia fill about 25% of all hospital beds. The disorder is considered to be one of the top ten causes of long-term disability worldwide. About 1.5million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net).Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americanssuffer from schizophrenia; fifty percent (50%) experience serious side effects from medications;and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of86,241,697 of Filipinos or approximately 0.8% are suffering from schizophrenia(cureresearch.com). Schizophrenia Ranks among the top 10 causes of disability in developed countriesworldwide (World Health Organization, www.who.int) Schizophrenia is a disease that typicallybegins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophreniaslightly earlier than women; whereas most males become ill between 16 and 25 years old, mostfemales develop symptoms several years later, and the incidence in women is noticeably higher inwomen after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onsetis quite rare for people under 10 years of age, or over 40 years of age (schizophrenia.com). The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symptoms that are remarkably stable over time but still may not fit one of the typical subtype pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome. Smoking is a common problem for patients with schizophrenia. The increased tendency of patients diagnosed with this disorder is to not only smoke, but to do so more heavily than the general public. This raises the possibility that nicotine may be acting as a treatment for some symptoms of schizophrenia.

Nicotine acts through two general classes of brain receptors, those with high and low affinity for nicotine. The low affinity class of nicotinic receptors contains the alpha-7 subunit, which is present in reduced numbers in people with schizophrenia. Two papers published in the January 1st issue of Biological Psychiatrysuggest that drugs that stimulate these alpha-7 subunit-containing nicotinic receptors might enhance cortical function and treat cognitive impairments associated with schizophrenia. In their study of healthy monkeys, Graham Williams and colleagues at Yale University and AstraZeneca found that very low doses of AZD0328, a novel drug that acts as an alpha-7 agonist, produced both acute and persistent improvements in their performance on a spatial working memory task.

OBJECTIVES Nurse-centered At the end of the nurse-patient interaction, the nurse shall have evaluated the developmental stage of the patient according to the theories of Erikson, Freud and Piaget; y y determined the etiologic factors (precipitating and predisposing) of the mental disorder;

evaluated the presence or absence of signs and symptoms seen in the patient in relation to the mental disorder; y y presented the psychodynamics of the clients diagnosis by recognizing its predisposing andprecipitating factors with appropriate rationales; To track down the significant eventsduring the clients developmental stage as shown in the psychodynamics;

Interpreted and analyzed nurse-patient interaction taken through spontaneous and effective use of therapeutic communication; y formulated effective, specific, measurable, attainable, realistic and time-bounded nursing care plans base on identified actual and potential nursing problems; y

rendered quality nursing care in line with the formulated nursing care plans;

Patient-centered At the end of the nurse-patient interaction, the patient shall have

PATIENTS DATA PERSONAL DATA: CODE NAME: Bob AGE: 40 SEX: Male BIRTHDAY: April 9, 1969 BIRTHPLACE: Cagayan de Oro City ADDRESS: Prk. 1 Rizalian, Bayugan Agusan del Sur Tulip Drive, Matina, Davao city ORDINAL RANK: 1st CIVIL STATUS: Single NATIONALITY: Filipino RELIGION: Catholic EDUCATIONAL ATTAINMENT: 2nd Year College undergraduate OCCUPATION: None NUMBER OF CHILDREN: 0 NUMBER OF BROTHERS: 2 NUMBER OF SISTERS: 2 MOTHER: Aina AGE: 58 EDUCATIONAL ATTAINEMNT: college undergraduate OCCUPATION: Businesswoman FATHER:Danni EDUCAIONAL ATTAINMENT: college undergraduate OCCUPATION: Businessman CLINICAL DATA: WARD/SERVICE: Crisis Intervention Unit/Psychiatry ADMITTING PHYSICIAN: GIOIA FE D. DINGLASAN, M.D ADMITTING DIAGNOSIS: Schizophrenia, undifferentiated PRINCIPAL DIAGNOSIS: Schizophrenia, undifferentiated DATE OF AMISSION: January 19, 2010

DATE OF DISCHARGE: January 21, 2010 INSTITUTION: Davao

Mental

Hospital

A. FAMILY HISTORY a. Maternal and Paternal Lineage Direct bilateral lineage of the patient show no conditions of mental illness. On the paternal side, prominent family illnesses only concern some members having hypertension. Aside from the condition, no other illnesses run the family. On the maternal line, no illness were reported to run in the family, except one family member having diabetes mellitus type 2, an illness condition occurring singularly to be considered familial. Generally, no mental illness can be traced on both sides of the family. b. Father The father is 59 years old; a known small time businessman in their place at Agusan; owning a small rice mill enough to support the needs of his family. He is a Civil Engineering Undergraduate and was able to finish only until 3rd year of the above course, due to his early fatherly obligation. He impregnated the patients mother, when he was only 19 years old, then eloped with her, thwarting him to finish his studies then at the University of Mindanao. As a father, he was lenient in his relationship with his children. Most of his time is spent in their rice mill and would only go home in the afternoon or at night. Moreover, he is a kind of father who would not spank or scold his children and he seldom verbalizes what he feels. He would only speak to his children wherever they do something incorrect.

c. Mother The mother helps in their small rice mill. Pregnant at the age of 18, she was unable to finish her college education at the University of Mindanao. She was in her second year in college when she dropped out of her Chemical Engineering course. The mother says that she brought her children up in discipline and love; she said she doesnt spank her children because it does them no good. Like the father, she doesnt also believe in punishing her children through spanking and the like when they do something wrong. However, as she states, she left her children to the care of nannies when they were young. And put her children in their house in Davao City to pursue their education from elementary school, leaving them, still with a nanny, and visiting them once a week. According to her, this is the best way for her to offer the best education and life to her children and help improve their business in Agusan. d. Siblings The family is composed of five siblings; Bob being the eldest, followed by the second informant, Emman, then by Carmz, Denns and then Yose .

His relationship with his siblings is not so good. As a child, although they were the only ones that he would play with, he would still isolate himself when with them. He never shares his thoughts with them. Furthermore, when they grew up and the illness took place, the siblings gradually got irritated with him because of his hostility towards others.

III. Personality History a.) Prenatal Being the result of the early pregnancy of his mother, the patient was an unexpected child. Only 18 when she was impregnated, the mother was not ready and did not know what to do, so she eloped with the patients father without giving her parents the knowledge as to the reason why she ran away. The mother stayed with the fathers family in Cagayan for the whole duration of her pregnancy. On course of nine months, the mother has adequate prenatal check-ups at a nearby health center. Moreover, she was able to eat adequately because the parents of her husband supported them. They provided her with enough support for her pregnancy. b. Birth Bob was born in the Provincial Hospital in Cagayan de Oro City on the th 9 of April 1969 through Normal Spontaneous Vaginal Delivery. No complications took place in the delivery. The mother, Aina, described that her labor was very long, she started having labor pains in the morning and delivered in the afternoon. She did not also breastfeed the patient because she is having pain breastfeeding him and as reported, no breast milk would come out; so instead, she bottle fed the patient with a formula milk in a timed manner. Moreover, she hired a nanny named Nena to look after the baby because she did not have any experience in taking care of a baby, considering her age. c. Infancy and Childhood Characteristics After the birth, in June of 1969 Aina went back to Agusan to talk to her parents. She told them that she ran away because she was pregnant and apologized for everything that she has done. Her parents did accept her apology and welcomed her back. On the August of 1969, Aina and Danni married each other and decided to reside in Agusan. Trying their luck in a new business, the couple got busy with their rice mill that they decided to leave Bob in the care of Nena, Bobs nanny since birth, while they attend to their business. The nanny was very caring to the child, cuddling him always and looking after him. However, when Bob was almost five months, Nena went home to her province and was replaced by another nanny named Ging-ging.

Moreover, Aina instructed her nanny to continue the timed bottle feeding routine every three hours, a routine which continued until the patient was three years old. She instructed to feed the baby every three hours, believing that this would help the nanny attend to other tasks while taking care of the baby. In cases that the baby would cry Ging-ging would just give him a pacifier for him to stop crying. Bob was toilet trained when he was 2 years old. Toilet training was mostly implemented by the nanny Ging-ging, and she is not strict in it. As he had a nanny, Aina instructed the Ging-ging to teach him to urinate and defecate in a potty because it irritates her to find urine and stool just anywhere. Aina is very strict in toilet training. But on instances that Bob would pee or defecate anywhere, Ging-ging would just clean the mess, not correcting Bob. Bob started talking when he was a year old and started walking on that certain age more or less as reported. As to the strategies and the relationship of the nanny to the child, the mother did not exactly describe because according to her, she changed nannies several times. According to her, the relationship of the nanny was not so important to her as long as the needs of her children are met and her childrens safety is not harmed. She carefully instructed the nannies to give to the children everything they want to keep them from having tantrums that could hinder the nanny from doing other household chores. The mother could not remember whether or not the patients immunization is complete; but what she does remember is that the patient had measles before he was one year old. d. Psychosexual History The patients sexual awareness started when he was 16 years old, on his 4th year in high school. It was on this time that he started having a crush and actually had a girlfriend who after sometime broke up with him. This break-up with his only girlfriend bagged down his self esteem. In addition, his mother also keeps on teasinf him that his girlfriends teeth resembles that of a rat which further decreased his self-confidence and esteem as he tried to compare himself with the boys of his age. In his adolescence, he also engages in sexual activities with GROs. e. Play Life Bob does not engage so much in cooperative play and prefers solitary play. He would only sit by himself and play alone in a corner. His playmates were his siblings and would choose to play only in their yard. As a child, he is not talkative, he is uncooperative and becomes aggressive when forced to play with other kids. Furthermore, he likes being a follower in a game rather than a leader. f. School History The patient began preschool in June of 1974, when he was five years old where he was sent to Davao to study at Assumption up to second grade. He stayed in

their residence in Davao which is in 162, Interior Tulip Drive, Matina, Davao City. He stayed in Davao together with his brother Emman and their nanny. The first days in school were terrible for Bob, he would cry inside their classroom and would not separate from his nanny. In his third grade, he was transferred to Our Lady of Fatima School, which he did not really approve that he cries in between classes just to be sent home. He is withdrawn from the rest of his classmates and would talk only to a few people. His grades were also affected by his isolation, he did not perform well in school and was not interested in studying. He spent his high school days still at Fatima. In June of 1982, when he is 13 years old, he entered first year highschool, where he formed new set of friends which he grew much attached to. These friends of him were not of good influence because when they started hanging out, he began cutting classes, extorting money from his parents and having low grades. He started drinking and smoking. Also, he started using marijuana. His bad school records started worsening when his girlfriend in his fourth year high school broke up with him, these events pulled his confidence down, that he started isolating himself and increased his use of marijuana, drinking and smoking. Yet he is able to graduate from high school in the March of 1986. Troubles in school were rampant, being evident even when he is already in college. He was occasionally caught brawling with classmates. Furthermore, his mother was once called by the Guidance Office because he threw an eraser to his teacher because the eraser hit him when the teacher threw the eraser at his classmate. He was also suspected of using marijuana during this time but is persistently denying the accusations, although it was really true. Peer pressure can be seen as a great contributing factor in his use of marijuana because his friends would tease him when he refuses to use marijuana. In his college days, he spent his two years of college education at the University of Mindanao, in the Civil Engineering course. However, he did not have good grades and still continued cutting classes and indulging in his vices. On his second year, he finally decided to stop, claiming that he is already having difficulty catching up with the lessons. g. Religious and Social Adaptability The family is Roman Catholic. However, when he was in college, their family converted to Seventh-day Adventists. However, the patient still follows the Catholic Faith and does not go to Seventh-day Adventist religious celebrations. h. Occupational History When the patient stopped studying during his second year in college, late in the August of 1987, he stayed in Agusan and helped in their rice mill business. There, he would help in the loading and unloading sacks of rice and also in

i.

j.

operating the mill. Bob doesnt get regular salary because what he gets is ten percent of the days income. Marital History The patient is single. However, he is looking forward to marrying someday. According to his verbalizations, he wants to be married so badly that he would even marry their maid at home. According to him, he already told the maid that he wanted to marry her, but unfortunately, after telling her, the maid ran away. Onset of the present illness The recent admission is already the third admission of Bob. Recurrence of hostile behavior is the primary reason why Bob was admitted for three days in the CIU of Davao Mental Hospital. He suddenly shouted at a doctor in the hospital upon having his monthly depot injection and check-up.

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THEORIES OF DEVELOPMENT These are just a few of the fascinating aspects of the field of human development: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each theory has its own perspective on the development of man. ERIK ERIKSONS PSYCHOSOCIAL STAGES OF DEVELOPMENT The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future.

INDICATORS OF POSITIVE RESOLUTION Middle Working Adulthood ( 35 towards the to 65 years) betterment of Central task: the society; Generativity vs. being Stagnation productive During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period,

LIFE STAGE

INDICATORS ASSESSMENT OF NEGATIVE RESOLUTION Lack of Stagnation productivity; not helping society to move forward

JUSTIFICATION

The patient is not so productive due to his illness. Hes being dependent to his family, though generating small income for helping in the Rice Mill, but still hes not being productive because the little money he earned is being wasted for buying what is being prohibited for him to be used, like marijuana and cigarettes that

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perhaps by raising a family or working toward the betterment of society, a sense of generativitya sense of productivity and accomplishme nt- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnationdissatisfaction with the relative lack of productivity. A person in this stage should have time for companionship and recreation. He also knows his responsibilities and knows that he is accountable of whatever actions he takes.

contributes in worsening his illness. He has no own family to support thats why he wasted his money for his own wants. When he had free time, he went to the plazas or parks to eat or drink. He also loves to watch television shows. The client also adapt to his physical changes in his body and accepted this as part of him, about his disease, he hasnt understand this fully and needs further explanation for him to understand. And as a Filipino citizen, he has done his part in becoming a good citizen, he is a registered voter and planned to vote for Noynoy Aquino in the coming election period, in a way hes being productive because he has

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done his duty for the betterment of the country. But still, hes not helping the country to move forward since he had violated the Republic Act 6425 or the Dangerous Drug Act of 1972, Article III, Sec. 8 which is regarding the usage of the prohibited drugs.

SIGMUND FREUDS PSYCHOSEXUAL THEORY The concept posits that from birth human have intellectual sexual appetites (libido) which unfold in a series of stages. Each stage is characterized by erogenous zone that is the source of libidinal drive during that certain stage. LIFE STAGE CHARACTERISTICS IMPLICATIONS ASSESSMENT JUSTIFICATION Genital Energy is directed Encourage NOT ACHIEVED He is not (puberty and toward full sexual separation from independent, after) maturity and parents, being until now , he function and independent still lives with his development of and able to parents and skills needed to make right and being cope with the good decisions dependent to environment. them, especially when it comes to his basic needs and as well as to meet his personal needs to gratify his desires, like asking money to have sexual gratification together with

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some GROs and to buy marijuana or cigarettes. Hes not matured when it comes to his sexuality.

JEAN PIAGETS STAGES OF COGNITIVE DEVELOPMENT This theory pertains to the nature and development of human intelligence. LIFE STAGE CHARACTERISTICS ASSESSMENT JUSTIFICATION Formal Operational y The person is ACHIEVED During this stage, Thought (12 years capable of the client was able and above) deductive and to understand what hypothetical love means .He reasoning. shared about his y The logical plans about getting quality of the married in the future adolescent's if given a chance; thought is when he really wanted to children are marry their helper, more likely to according to him. solve problems Though he never in a trial-andcourted the girl, he error fashion. just directly asked y During this stage her to marry him but the young adult the woman refused is able to to answer him and understand such went home to their things as love, hometown. "shades of gray", In addition to that, logical proofs when asked, Kung and values. makakita ka ug y During this stage pitaka na punog the young adult kwarta, unsaon begins to man nimo ang entertain pitaka, iuli o possibilities for gastuhon ang the future and is kwarta?; he then fascinated with replied Iuli nako,

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what they can be. At this stage, they can also reason logically and draw conclusion from what information is available.

kay basig kailangan sa tag-iya ang kwarta. He was able to draw conclusion from the given situation available.

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Name: Bob Age: 40 years old Ward: Crisis Intervention Unit I. PRESENTATION A. General Apperance The patient appears to be younger than his real age which is 40. During the interview at Crisis Intervention Unit in Davao Mental Hospital, he wore a green polo shirt, denim shorts, and a pair of slippers and is seated on bed with his mother and sister-in-law. The patient appears to be untidy. He has dirty clothing, unkempt hair, long fingernails and toenails with traces of dirt evidently seen on both. At the time of the interview, the patient was alert and responsive. B. General Mobility a. Posture and Gait The patient slouches when seated but holds himself erect when standing and walking. His mannerisms include manually hyper extending his fingers and scratching his head. b. Activity The patients movement are organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity. c. Facial Expression The patients facial expressions are very much appropriate to his verbal responses during the interview. He was composed and receptive to whatever the group asks him. C. Behavior The patient was friendly and warm to us during the interview. He was sitting on bed calmly. He interacts well with the group and as what we had observed; he has a good relationship with his mother and his sister-in-law who were present at that time. D. Attitude towards the Examiner The patient accepted the group warmly. He entertained our questions and answered almost all of them. However, his eye contact was poor. He often looks down. STREAM OF TALK A. Characteristic of Talk During our conversation with the patient, we noticed that he is spontaneous most of the time. However, there are times in which blocking is evident in between his speech. His articulation words were clear but the content is slightly vague.

MENTAL STATUS EXAMINATION INITIAL Diagnosis: Schizophrenia Undifferentiated Physician: Gioia Fe D, Dinglasan, MD Date of Examination: January 21, 2009

II.

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III.

IV.

V.

B. Organization of Talk The patient was eager to talk with the group. He tries to answer every question the group asks him however, in his answers, we apparently observe succession of circumstantiality and tangentiality. He provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesnt arrive at the answer at all. EMOTIONAL STATES AND REACTION A. Mood At the course of the interview, the patients mood was euthymic. His feelings were appropriate to the situations as he relays his answers to the group. His mood was just appropriate and basing from his gestures and other nonverbal cues, his mood is fitting to the situation. B. Affect The patients affect is appropriate as well. There is a marked harmony between thought content, emotional response, and expressiveness. When asked, Unsa may nabati nimu kadtong nagka-uyab mo?, he replied, Lipay kaayo ui. Alangan. Kaw gud daw magka uyab. with a smile. THOUGHT CONTROL A. Perceptions Throughout the interview, the group observed manifestations of illusions and hallucinations. When the patient was asked if he experiences any of the two, he told us that there are times that he hears someone whispering to him. Naa may gahong-hong sa ako usahay na mag wild daw ko., as claimed by the patient. He denied that he had any visual hallucinations however, the mother and the sister-in-law attested that during tantrums, the patient verbalizes that he sees someone whom they cannot see. B. Delusion There are several types of delusions that are present in the patient as claimed by the patient himself, and confirmed by the mother who witnessed them all. First, the patient claimed that there is some sort of outside force controlling his thought, compelling him into the belief that somebody has aa plan to kill him which is a clear sign of persecutory delusion. He also has a feeling that others, especially his friends, hate him because they are jealous of him. NEUROVEGETATIVE STATE A. Sleep The patient usually sleeps at 12 in the midnight and usually wakes up at 5am getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and instead, he just spends his time watching television until he falls asleep. Five in the morning for the patient is too early for him to wake up that is why he attempts to go back to sleep, but then, he is unable to do such. This is a manifestation of late or terminal insomnia. B. Appetite

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VI.

VII.

The patient has increased appetite. He eats a lot however, he is choosy in his food. Ganahan man gud ko mukaon samot na kung lami ang sud-an., reported by the patient. Kusog kaayo mukaon nang bataa na, pero pili-an lang jud ug sud-an., as verbalized by his mother. C. Diurnal Variation The patients mood varies during the day. He is usually fine in the morning and gets, uneasy, restless, and irritable as the day progresses. Other times, his day starts out worse in the morning and feels better later on. GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation The patient is well oriented of the time, place and person. When asked during the interview if what date and time was it, he answered correctly. However, as the conversation progressed, we noticed that he is confused and not well oriented with the time. When asked, when did he last used marijuana, he answered, Two months ago. Mga 2008. The group finds this statement confusing since two months ago, basing on the date of the interview, is around November of last year (2009). The patient is also oriented with the situation since he knows that he is the Davao Mental Hospital for his treatment. B. Memory The patient has difficulty recalling remote memories. When asked what his age when he went to Bukidnon was, he replied; Ambot lang. Wala ko kahinumdom. On the other hand, the patient has a good memory when it comes to remembering recent and immediate memories. C. Calculation The patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and the like. He was able to answer all of them but there we long pauses before he can finally give the answer. D. General Information The patient knows basic general information like the current president of the Philippines and even of the United States. He know the capital of some Philippine provinces and he was able to name the national hero of the country. E. Abstract Thinking, Judgement and Reasoning The patient was given a maxim translated in Visaya to evaluate his reasoning and abstract thinking. He was asked to explain the quote Try and try until you succeed. He was able to explain it but not profoundly. He said, Maningkamot gud. And when asked to elaborate, he refused to. He was also given a situation wherein someone left her wallet, and he was asked what he should do. He replied, Akong i-uli. Di man na akoa so dapat nako i-uli. INSIGHTS

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The patient understands that he needs to go to the hospital for his treatment. Since he was 18, he knew that there is a problem in him and he even asked his mother to bring him to the doctor. However, he does not have concrete understanding of what his illness is. He believes that there is a lube (grasa) in his brain that is why he is acting differently, thus, he has a fair insight.

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TIME AND DATE Janu ary 21, 2009 @ 12:30 P.M.

CUES

NEED

NURSING CARE PLAN NURSING GOAL OF CARE DIAGNOSIS Disturbed sensory perception related alteration function brain tissue At the end of 2 hours of nursing care, the patient will be able to y maintain orientation to time, place, person, and circumstanc es for specified period of time; y demonstrat e accurate perception of the environmen t by responding appropriate ly to stimuli in the surroundings ; and y lessen visual

INTERVENTIONS

EVALUATION

SUBJECTIVE: Naay nagahunghung sa akoa usahay nga magwild daw ko ug maglagot as verbalized by the patient

C O G N I T I V E OBJECTIVE y Disoriented P E to time R y Auditory and visual C hallucinatio E P ns y Misinterpret T s actions of U A others y Inability to L make P simple A decisions y Inappropria T T te E responses R

to in of

It is the change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli. Schultz, M.J.;Videback, S.L.; Lippincotts

1. Establish rapport January 21, 2009 and build trust with @ 2:30 PM the client The client must trust GOAL UNMET the nurse before talking about y The hallucinations and patient was other sensoryable to perceptual maintain alterations orientation to 2. Continuously orient time, place, the client to actual person and environmental situation. events or activities Huwebes in a karon. Mga nonchallenging udto na man way. siguro. Naa Brief, frequent ko sa Mental orientation helps to hospital para present reality to magpacheck the client with -up sensory-perception y However disturbance , the client 3. Reinforce and was not able focus on reality. to Talk about real demonstrate events and real accurate

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Manual of Psychiatric Nursing Care Plans 7th edition

and auditory hallucinatio ns

people. Use real situations and events to divert client from long, tedious, repetitive verbalizations of false ideas Working with reality lessens patients initiation of his hallucinations. 4. Correct client's description of inaccurate perception, and describe the situation as it exists in reality Explanation of, and participation in, real situations and real activities interferes with the ability to respond to hallucinations. 5. Observe for verbal and nonverbal behaviors associated with hallucinations

perception of the environment as evidenced by the presence of delusion and hallucination y Presenc e of auditory hallucination is still evident.

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Early recognition of sensoryperceptual disturbance promotes timely interventions and alleviation of the clients symptoms. 6. Describe the hallucinatory behaviors to the client. The client may be unable to disclose perceptions and the nurse can openly facilitate disclosure by reflecting on observations of the clients behaviors, which helps the client engage in more open discussion with the nurse, which in itself brings relief. 7. Explore the content of hallucinations to determine the

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possibility to harm self, others or the environment Exploring the content of the hallucination helps the nurse identify if the sensoryperceptual disturbance is threatening or dangerous to the client, such as a command type of hallucination that may be telling the client to harm or kill the client or others. The nurse can then reinforce treatment and safety precautions. 8. Use clear, direct, verbal communication rather than unclear or nonverbal gestures Unclear directions or instructions can confuse the client

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and promote distorted perceptions or misinterpretations of reality. 9. Modify the clients environment to decrease situations that provoke anxiety Decreased anxiety can reduce the occurrence of hallucinations 10. Reassure the client (frequently if necessary) that the client is safe and will not be harmed Alleviation of fear is necessary for the client to begin to trust the environment and to feel safe.

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TIME AND DATE Janu ary 21, 2009 @ 7:00 A.M

CUES

NEED

NURSING DIAGNOSIS Disturbed thought process related to disintegration thinking. It is the disruption in cognitive operations and activities. Cognitive processes include those mental processes by which knowledge is acquired. These mental processes include reality orientation, comprehensio n, awareness, and judgment. A

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE Magpatambal ko. Kani man gud akong utok, naa niy grasa. as verbalized by the patient

OBJECTIVE y Delusion of persecution y Delusion of paranoia y Thought insertion y Incoherent speech y Demonstrates a disturbance in sleep pattern y Presence of P auditory A hallucinations T T E R N

C O G N I T I V E P E R C E P T U A L

At the end of 2 hours of nursing care, the patient will be able to y Maintain reality orientatio n; y Demonstr ate reality based thinking in verbal and nonverbal behavior; and y Demonstr ate the ability to abstract, conceptu alize, reason and calculate consistent with

1. Be sincere and January 21, 2009 honest when @ 12:30 PM communicating with the client. GOAL PARTIALLY MET Clients are y The client extremely was able sensitive about to others and can maintain recognize reality insincerity. orientatio Evasive remarks n. He is reinforce mistrust. oriented to time 2. Assess clients when nonverbal asked behavior, such what day as gestures, it is. But he facial expression is still and posture. preoccupi ed with his This assessment delusions may help to about his meet the clients being needs that jealous to cannot be him conveyed through speech. y The client

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disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately. Alterations in thought processes are not limited to any one age group, gender, or clinical problem. (http://www1. us.elsevierhea lth.com/MERLI N/Gulanick/C onstructor/ind ex.cfm?plan= 53.01)

ability to 3. Encourage the client to express feelings and do not pry cross examine for information Probing increases clients suspicion and interferes with the therapeutic relationship 4. Show empathy to the clients feelings, reassure the client of your presence and acceptance The clients experiences can be distressing. Empathy conveys acceptance of the client your caring and interest.

was not able to demonstr ate realitybased thinking in verbal and nonverbal responses. His manneris m is largely observed and he wasnt able to establish eye contact with any of the interviewe r. However, he was able to exhibit a positive abstract,

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5. Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said. Suspicious clients often believe others are discussing them, and secretive behaviors reinforce the paranoid feelings.

reason, judgment and calculatio n abilities.

6. Give

simple directions using short words and simple sentences. Giving simple directions lessen or prevent confusion of the patient

27

7. Never convey to the client that his delusions and hallucinations are real The delusion or hallucination would be reinforce if its accepted. 8. Maintain reality oriented relationship and environment Maintaining reality based relationship and environment lets the patient know that the relationship is temporary and prevents separation anxiety 9. Give positive

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feedbacks and acknowledge the client Positive feedback enhances sense of well-being and makes a more positive situation for the client. 10. Do not judge or belittle clients beliefs. What the client feels or thinks is not funny for him. The client may feel rejected if approached by attempts of humor.

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TIME AND DATE .Janu ary 21, 2010 @ 12 :30 PM

CUES

NEED

NURSING DIAGNOSIS Situational low self-esteem related to cognitive impairment It is the state in which an individual who previously had positive self-esteem experience a negative feeling towards self due to a certain situation Handbook of Nursing Diagnosis by Lynda Juall CarpenitoMuyet

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE: S Maulaw man gyud ko E basta ing-ana L F OBJECTIVE: y Lacking eye P E contact y Lack social R C interaction y Has little interest E P in activities y Talks only when T I asked O N

At the end of 2 hours of nursing care, the patient will: y Verbalize understan ding of things that precipitat e current situation; and Demonstr ate behaviors that show positive selfesteem

1. Encourage client
to express honest feelings in relation to loss of prior level of functioning. Acknowledge pain of loss. Support client through process of grieving. Client may be fixed in anger stage of grieving process, which is turned inward on the self, resulting in diminished selfesteem.

January 2010 @ PM

21, 2:30

GOAL UNMET

2. Devise methods
for assisting client to express feelings properly.. To explore

The patient was unable to verbalize understandin g of things that lead to current situation y The patient was unable to demonstrate behaviors that show positive selfesteem as evidenced by inability to have an eyecontact as well as

30

the feelings of the client thereby allowing him to acknowledge his own strength and weakness.

looking down at during the interview.

3. Encourage
client's attempts to communicate. If verbalizations are not understandable, express to client what you think he or she intended to say. It may be necessary to reorient client frequently. The ability to communicate effectively with others may enhance self-

31

esteem.

4. Encourage
reminiscence and discussion of life review. Also discuss presentday events. Sharing picture albums, if possible, is especially good. Reminiscence and life review help the client resume progression through the grief process associated with disappointing life events and increase selfesteem as successes are reviewed. 5. Encourage participation in group activities. Caregiver may need to

32

accompany client at first, until he or she feels secure that the group members will be accepting, regardless of limitations in verbal communication. Positive feedback from group members will increase selfesteem.

6. Offer

support and empathy when client expresses embarrassment at inability to remember people, events, and places. Focus on accomplishment s to lift selfesteem.

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7. Encourage client
to be as independent as possible in selfcare activities. The ability to perform independently preserves selfesteem.

8. Listen

to

patients concerns and verbalizations without comment or judgment. It enables the client to develop trust and thereby establish communication

9. Provide
feedback to clients negative feelings.

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To allow the client experience a different view.

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TIME AND DATE Januar y 21, 2010 @12:30 PM

CUES

NEED

NURSING DIAGNOSIS Impaired memory related to neurological disturbances Impaired memory is directly related to effects of general medical condition or ongoing effects of substance. Depending o n the areas of the brain, the client are unable to recall information, either remote or recent. The client may confabulate to fill in those

GOAL OF CARE

INTERVENTIONS

EVALUATION

SUBJECTIVE: The clarified when exactly was the 2 months he was referring about his last used of marijuana, he verbalized Kadtong 2007 man to, aw 2008 diay OBHECTIVE: y Disorientation to time y Observed experience of forgetting y Scratches his head when he is unable to recall information y Inability to determine if a behavior is performe

C O G N I T I V E P E R C E P T U A L

At the end of 3 day nursing care, the patient will be able to: y Verbalize awarenes s of memory problems; and y Accept limitations of current condition

1. Provide January 21, 2010 opportunities for @ 2:30 PM reminiscence or recall past GOAL MET events y The Long-term patient memory may was able persist after loss to of recent verbalize memory. awarenes Reminiscence is s of usually an memory enjoyable problems activity for the as he client. verbalize d 2. Encourage the Usahay client to use gyud written cues such makalimo as calendars or t na ko notebooks y The Written cues patient decrease the was able clients need to to recall activities, verbalize plans and so on accepta from memory. nce of his 3. Encourage limitations

36

lost memories.

ventilation of feelings of frustration, helplessness, and so forth. Refocus attention to areas of focus and progress. To lessen feelings of powerlessness/h opelessness 4. Provide for proper pacing of activities and having appropriate rest To avoid fatigue 5. Allow the client to do tasks on his own, but do not rush him to do it. Make the client feel that he can still do things independently. It is important to maximize independent function, assist

due to his condition s

37

the client when memory has deteriorated further. 6. Assist the client deal with functional limitations and identify resources. To meet individual needs, maximizing independence. 7. Provide single step instructions when instructions are needed. Client with memory impairment cannot remember multistep instructions 8. Do not contradict the client who experiences an illusion. Instead, simply explain

38

reality, and find some practical solutions to the problem Therapeutic responses promote reality while offering solutions that help enhances the clients sense and may reduce fear, anxiety, and confusion. 9. Monitor clients behavior and assist in use of stressmanagement techniques To reduce frustration 10. Determine clients response to medication medications prescribe to improve attention, concentration, memory process

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TIME AND DATE Januar y 21, 2010 @ 12:30 P.M.

CUES

NEED

NURSING DIAGNOSIS Self care deficit: bathing / hygiene related to lack of motivation The patient has an impaired ability to provide self care requisites due to environmental and psychological

GOAL OF CARE

and to lift spirits and modify emotional responses. Helpful in deciding whether quality of life is improved when using the medications prescribed. INTERVENTIONS EVALUATION

SUBJECTIVE: Makatamad usahay maligo. Wala pa gani ko ligo ron. Kapoy pud manlimpyo ug kuko, as verbalized by the patient.

A C T I V I T Y E OBJECTIVE: X Unkempt hair noted food stains visible on E R clothing untrimmed fingernails C and toenails with I S visible dirt noted E

After 2 hours of nursing care, the client will be able to: a) verbalize self care need b) Demonstr ate technique s to meet self-care needs

1. Establish rapport.
R: to gain clients trust and facilitate a good working relationship.

January 21, 2009 @ 2:30 PM GOAL PARTIALLY MET

After 2 hours of reason nursing care, the for difficulty in client was able self-care. to: R: underlying cause a) verbalize affects choice of self care interventions/ need strategies. b) but was unable to 3. Determine demonstr hygienic needs ate and provide

2. Identify

40

factors. P A T T E R N

assistance as needed with activities like care of nails and brushing teeth. R: basic hygienic needs may be forgotten.

technique s to meet self-care needs.

4. Discuss

importance hygiene. R: makes client aware of how hygiene is vital in caring for oneself.

on of

5. Orient client to
different equipment for self-care like various toiletries. R: increases the clients awareness of different materials for selfcare. 6. Let the patient enumerate his ideas on the

41

importance of hygiene. R: Encourages the patient to understand the need for hygiene. 7. Discuss the possible negative implications of not taking a bath such as infections and odor. R: Broadens the patients idea about the problem and encourages him to meet the need.

8. Encourage client
to perform selfcare to the maximum of ability as defined by the client. Do not rush client. R: promotes independence

42

and sense of control, may decrease feelings of helplessness. plenty of time to perform tasks. R: cognitive impairment may interfere with ability to manage even simple activities. with dressing neatly or provide colorful clothes. R: Enhances esteem and convey aliveness.

9. Allot

10. Assist

43

RECOMMENDATION The group 1 of section 3H would like to recommend the following: To the patient: He is advised to take part in complying with the treatment; the medication and therapeutic regimen designed for his rehabilitation. He should realize the importance of complying with his medication and the benefits this practice would bring to the improvement of his well-being. To the patients family: The patients family plays an important role in the patients mental illness and recovery. The family should make themselves physically present so that the patient would feel their support and concern. They are encouraged to continue interacting with the patient so that ideas of violence towards self and others will be diverted. In addition, it is of prime importance that they are oriented and educated regarding the patients mental illness so that they will understand him even better and assist him in his daily activities. To the Ateneo de Davao University- College of Nursing: The faculty and staff are encouraged to continue improving the standards of the Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be equipped with the knowledge and skill that they may impart to student nurses. They are challenged to not just teach but impart to us as well nursing experiences that we may apply in the course of caring for our future patients.

To the Davao Mental Hospital: The group recommends that they should improve their facilities in treating the mentally-ill patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the patients and staff. Address the needs of each patient by first assessing the level of severity of the patients condition; let every patient be submitted for history and physical examination and be evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend that the psychiatric team would work together in order to provide mental health care service that promotes rehabilitation of the patient. Also they are recommended to know the latest trends in improving therapeutic communication between them and the patients. To the student nurses: Even if nursing students find it difficult to establish therapeutic relationships with mentally-ill patients because of the relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to our patients; and improve our

44

therapeutic technique in caring for our patients; that we may play a part in the rehabilitation of our mentally-ill patients.

45

1.

DSM-IV-TR.4th

REFERENCES edition. American Psychiatric Association. Book promotion and

services Ltd. 2. Handbook of Psychodiagnostic Testing by Kellerman and Burry 3. Kozier. Fundamentals of Nursing 6th edition. 4. Keltner, Psychiatric Nursing 5th Edition. 5. Drug & Drug Abuse. 2nd edition. Addiction research oundation by Cox et. Al 6. Lippincotts Manual of Psychiatric Nursing care Plans. 7th edition by Schultz and Videbeck 7. Human Anatomy & Physiology 11th edition by Tortora and Derrickson 8. Clinical Handbook of Schizophrenia. Edited by Mueser and Jeste 9. Concepts of Anatomy and Physiology 4th edition. By Graaft & Fox 10. Psychiatric Nursing: a textbook and reviewer.maria Evangelista Sia c2004;p.234 11. Psychiatric nursng care plans. Fortinash & Holoday Norret.4th edition..p113.mosby inc. St Louis,Missouri 12. Psychiatric Nursing. Norma.Keltner,et.al.pte Ltd. C2007 13. Abnormal Psychology. P.186 by Jefnar Mahmud. APH. Pulishing corp. New delhi c2002 14. Abnormal psychology: current perspective. Larren Alloy,et.al c1996. McGraw-hill inc. 15. Psychia nursing:biological &behavioural concepts (Deborah AntaiDrong)p.351.thomson/Delmar learning;c2003 16. Abnormal psychology. James Hansen; Lisa Damour. Hobeken, NJ: Willey c2005 17. Scizizophrenia:chemistry,metabolism& Treatment. J.R. Smythies. Illinois, Thomson c1963 18. http://positivenewsmedia.net/am2/publish/Health_21/P4M_Davao_mental_hospital_multi-purpose_building_to_rise_next_year.shtml) 19. http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=8805&cn=7 20. (http://www.cureresearch.com/s/schizophrenia/stats-country.htm). 21. http://www.schizophrenia.com/szfacts.htm 22. http://www.ppa.ph/files/PPA%20Research%20Abstracts.pdf

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