Capi

tol Medical Center Colleges

#4 Sto. Domingo Ave., Quezon City

A CASE PRESENTATION ON UNDIFFERENTIATED SCHIZOPHRENIA

In partial fulfilment of the requirements in NCMH Related Learning Experience

Submitted by: Nael, Dianne Grace Najera, Kristine Faye Nanquil, Richard Simon Neri, Lloyd Lawrence Nivera, Abigael Noble, Kristine Elaine Oba, Jian Odessa Obedoza, Katrina Maenne Obispo, Raphaella Oliveros, Krizell Anne

Level IV Section 5 Group 19 August 9, 2010

C.I.: Mrs. Mary Grace Gutierrez, RN, MAN

TABLE OF CONTENTS
I. Introduction-----------------------------------------------------------------------2 A. Background of the Study --------------------------------------------------------------------2 B. Objective of the Study------------------------------------------------------------------------2

II. Psychiatric Assessment-------------------------------------------------------3 A. Patients Profile---------------------------------------------------------------------------------3 B. Chief Complaint--------------------------------------------------------------------------------3 C. History of Present Illness -------------------------------------------------------------------3 D. Previous Illness -------------------------------------------------------------------------------3 E. Psychosexual History -----------------------------------------------------------------------3 F. Family History ----------------------------------------------------------------------------------4 G. Laboratory Tests ------------------------------------------------------------------------------4 H. Mental Status Examination -----------------------------------------------------------------5

III. Clinical Discussion of the Disease-----------------------------------------6 A. Psychodynamic-------------------------------------------------------------------------------6 B. Psychopathology-----------------------------------------------------------------------------9 C. Drug Study and Nursing Responsibilities ---------------------------------------------10 2

IV. Nursing Process -------------------------------------------------------------12 V. Therapies ---------------------------------------------------------------------15 VI. Process Recording ----------------------------------------------------------17 VII.

References---------------------------------------------------------------------26

I. INTRODUCTION
A. Background of the Study
Undifferentiated Schizophrenia is manifested by pronounced delusions,
hallucinations, and disorganized thought processes and behavior. Studies suggest that genetics, early environment, neurobiology, psychological and social processes are important contributory factors The undiffrentiated 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. Patients in this category have the characterisitcs positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized or catatonic subtypes. Onset of symptoms typically occurs in young adulthood with around 1.5% prevalence of the population affected. Increased dopamine activity in the mesolimbic pathway of the brain is commonly found in people with schizophrenia. The disorder is thought to mainly affect cognition, but it also usually contributes to chronic problems with behavior and emotion

 Diagnosis is based on the self-reported experiences of the person, and abnormalities in behaivor reported by family members, friends, or co-workers, followed by a clinical assessment by a mental health professional Diagnosis of undifferentiated subtype may best describe the mixed clinical syndrome.

B. Objectives of the Study

General Objective To provide comprehensive information about Undifferentiated Schizophrenia. Specific Objective To help in the clients psychological well being. To gain better understanding of the illness, which will aid in the nursing care planning To provide appropriate nursing care directed towards not only to the clients psychological but also his physical well being.

II. PSYCHIATRIC ASSESSMENT

A. Patients Profile
Name: Mr. Chiz Age: 27 Birthday: May 16, 1983 Gender: Male Religion: Roman Catholic Province: Western Samar Psychiatrist: Dr. Godines Admitting Diagnosis: Undifferentiated Schizophrenia Chief Complain: According to informant: sinusugatan ang sarili, pinapaso ung kamay, sinusunog ung damit, nagmamasturbate, hindi nakakatulog.

According to Patient: Hindi naman, Wala naman. Reliability of informant: Fair

B. History of present illness

The patient has been diagnosed with mental illness since September 2009 with previous admission on October 2009, He was discharged on December 2009 with unrecalled medicine to which he was noncompliant. 4

C. Personal History
He and his family moved to Cabalyog Samar. He was lost to follow up at home. He was non-functional. On and off relapses were observed but tolerated. Until 1 month, He was observed to have difficulty of sleeping and restlessness as he walked. He would pour water on himself repeatedly.

D. Psychosexual History
He was irritable and aggressive to his mother and verbally assaultive at times. He was seen laughing to himself. He burned himself with cigarettes on his right arm and forehead. He burned his clothing too. When apprehended, He threatened them with rocks and masturbates in public.

E. Past Medical History

Patient has no history of seizure, hypertension, allergy or asthma but had a recent head trauma and was scheduled for ECT last 2009.

F. Family Medical History

There is no history of mental illness or suicide attempts in his family. His father has been diagnosed with a medical illness, lung disease.

G. Social History
The patient smokes 1 pack of cigarette everyday and drinks occasionally but denies the use of illegal drugs.

H. Laboratory results
Hematology Hemoglobin Hematocrit Results 143 0.44 Normal values Male: 140-180 Female:120160 Male: 0.400.54 Female:0.360.42 4-6 x10 12/L 5-10 x10 9/L Interpretation Normal Normal

Red blood Cell 4.87 (RBC) White blood Cell 10.5 (WBC)

Normal A increase in WBC signifies infection 5

Differentiated Count Neutrophil 0.76 0.45-.65 Elevated neutrophil can be caused by damage or inflammation of tissue e.g burn injuries 0.20-0.35 Decreased level of lymphocyte may indicate nerve damage or poor conduction of nerve impulses. 0.02-0.06 Elevated monocyte indicates infection. 150-450 x10 Normal 9 /L

Lymphocyte

0.17

Monocyte

0.07

Platelets

227

I. Mental Status Examination

1. GENERAL APPEARANCE AND BEHAVIOR The patient is average in terms of muscularity, with fair brown complexion, and has black hair. He also has scars on right and left arms and legs and a mole on the right lateral pat of the neck. On the first day of interaction with his student nurse, he had his clothes neat, but on the next day, his clothes were powdered, showing there is no consistency in his good grooming; but his feet are neat and clean. During the first interaction, he always taps his feet and has minimal eye contact with his interviewer but for the following NPI, he has now an eye contact and minimal taps of his feet. 2. AFFECT

The patient has blunted affect, and has appropriate affect. Objectively, he appears serious but he can smile at times when the topic is worth giving a smile. 3. MOOD The patient, during the interview looks serious at times but manages to give a single smile when appropriate.

4. THOUGHT PROCESSES The patient speaks spontaneously, and since he is just a high school graduate, he seldom speaks in English, but rather spoke spontaneously in Filipino, clearly. His thoughts are generally logical, and answer the questions being thrown to him by the student nurse. He has a poverty of speech because he seldom elaborates his answers, but it is direct. 5. THOUGHT CONTENT The client has disoriented thought content because he is claiming that he has 3 siblings, when in fact he has 4; other than that, there were no noted signs of hallucination, or illusion, or delusions. 6. COGNITIVE EVALUATION The patient is alert throughout the interview and is oriented to place, person, and date. He is also able to make simple mathematics calculations such as addition and subtraction. He was able to count 1 to 10 and backward. Patient was also able to spell Philippines and house correctly, and was able to recall 5 presidents of the Philippines spontaneously (ROXAS, QUIRINO, AQUINO, ESTRADA, ARROYO). The patient indeed has a good memory able to recall 3 objects after 5 minutes.

7. INSIGHT Patient is aware of his own responsibilities; he is a helper in the ward and does his duty diligently. He is also not able to identify the reason why he was admitted in the institution, but was able to cope up with it. He understands about his condition. 8. JUDGMENT The patient can make fair decisions regarding his everyday activities. He can cooperate with the staff but he did not participate in one of the activities due to his duty as the helper in the ward like the exercise inside the ward.

III. CLINICAL DISCUSSION OF THE DISEASE

A.

Psychodynamic
The Nervous System is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. The central nervous system contains the brain and spinal cord. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways. At a more integrative level, the primary function of the nervous system is to control the body. It does this by extracting information from the environment using sensory receptors, sending signals that encode this information into the central nervous system, processing the information to determine an appropriate response, and sending output signals to muscles or glands to activate the response. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The autonomic nervous system (ANS) is composed of both central and peripheral elements. 1. The CNS is composed of the brain and spinal cord. 2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. 3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia. The nervous system is primarily made up of two categories of cells: neurons and glial cells. Neurons send signals to other cells as electrochemical waves travelling along thin fibres called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons, situated either in the central nervous system or in peripheral ganglia, connect the nervous system to

muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support. Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and participate in signal transmission in the nervous system. In the human brain, it is estimated that the total number of glia roughly equals the number of neurons, although the proportions vary in different brain areas. Among the most important functions of glial cells are to support neurons and hold them in place; to supply nutrients to neurons; to insulate neurons electrically; to destroy pathogens and remove dead neurons; and to provide guidance cues directing the axons of neurons to their targets. Anatomy of the Brain: Structures The brain contains various structures that have a multitude of functions. Below is a list of major structures of the brain and some of their functions. Basal Ganglia Involved in cognition and voluntary movement Diseases related to damages of this area are Parkinson's and Huntington's

Brainstem Relays information between the peripheral nerves and spinal cord to the upper parts of the brain Consists of the midbrain, medulla oblongata, and the pons

Cerebellum

Controls movement coordination Maintains balance and equilibrium Cerebral Cortex

Outer portion (1.5mm to 5mm) of the cerebrum Receives and processes sensory information Divided into cerebral cortex lobes Cerebral Cortex Lobes Frontal Lobes -involved with decision-making, problem solving, and planning Occipital Lobes-involved with vision and color recognition

Parietal Lobes - receives and processes sensory information Temporal Lobes - involved with emotional responses, memory, and speech

Cerebrum

Largest portion of the brain Consists of folded bulges called gyri that create deep furrows Limbic System Structures

Amygdala - involved in emotional responses, hormonal secretions, and memory

Cingulate Gyrus - a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior Hippocampus - sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieves them when necessary Neurons and synapses

Major elements in synaptic transmission. An electrochemical wave called an action potential travels along the axon of a neuron. When the wave reaches a synapse, it provokes release of a puff of neurotransmitter molecules, which bind to chemical receptor molecules located in the membrane of the target cell. Synapses may be electrical or chemical. Electrical synapses make direct electrical connections between neurons, but chemical synapses are much more common, and much more diverse in function. At a chemical synapse, the cell that sends signals is called presynaptic, and the cell that receives signals is called postsynaptic. When the presynaptic terminal is electrically stimulated, an array of molecules embedded in the membrane are activated, and cause the contents of the vesicles to be released into the narrow space between the presynaptic and postsynaptic membranes, called the synaptic cleft. The neurotransmitter then binds to receptors embedded in the postsynaptic

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membrane, causing them to enter an activated state. Depending on the type of receptor, the resulting effect on the postsynaptic cell may be excitatory, inhibitory, or modulatory in more complex ways. The entire synaptic transmission process takes only a fraction of a millisecond, although the effects on the postsynaptic cell may last much longer (even indefinitely, in cases where the synaptic signal leads to the formation of a memory trace). Many synapses use more than one neurotransmittera common arrangement is forPREDISPOSING a synapse to use one fast-acting small-molecule neurotransmitter such as PRECIPITATING glutamate or GABA, along with one or more peptide neurotransmitters that FACTORS: FACTOR: play slower-acting modulatory roles. Gender: Male Lower socioeconomic Age: 27y/o status Genetic B. Psychopathology Decreased dopamine metabolism in the mesocortical pathway Decreased glutamate (decreased prefrontal cortical functions) Enlargement of ventricular system with subsequent decreased in brain volume; Reduced regional hippocampus, thalamus and frontal lobes Neuronal loss in some cortical areas Decreased cerebral blood flow Decreased metabolic activity Disturbance in 5 system areas: Anatomical systems (prefrontal, limbic, basal ganglia) Functional systems (language & learning ) Disturbances in thought & sensory perception Deteriorating personality Deterioration in psychosocial functioning

Nursing Diagnoses: Risk for self-mutilation Impaired verbal S/S: Delusions, hallucinations, communication disorganized speech & behavior, Altered sensory and negative symptoms perception Altered thought process Ineffective coping Personal identity disturbance 11 Disturbed self-esteem

UNDIFFERENTIATED

C. Drug Study

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Drug / Classification

Dosa ge 10mg BID

Indication Acute and chronic psychotic disorders including: schizophre nia, manic states, druginduced psychoses. Also useful in managing aggressive or agitated patients.

Contraindica tion

Side Effects

haloperidol (Haldol)
- antipsychotic

Hypersensitiv Seizures ity Extrepyram Narrow idal glaucoma reactions Bone marrow depression CNS depression. Confused Drowsiness Restlessnes s Constipatio n Dry mouth

chlorpromazi ne (Chlorproma nyl)

-antiemetics -antipsychotic

100m g BID

Acute and chronic psychoses, particularly when accompani ed by increased psychomot or activity. Nausea and vomiting. Intractable hiccups.

Hypersensitiv Neoleptic ity malignant syndrome Hypersensitiv ity to sulfites Sedation (injectable) or benzyl Hypotensio alcohol n (sustainedrelease Constipatio capsule) n Crosssensitivity with other phenothiazin es may occur Narrow-angle glaucoma Dry mouth Tachycardi a

Nursing Responsibilit ies -assess mental status (orientation, mood, behavior) prior to and periodically during therapy -monitor for tardive dyskinesia (uncontrolled ryhtmic movement of mouth, face, and extremities; lip smacking or puckering, puffing of cheeks; uncontrolled chewing, rapid or worm-like movements of tongue). Report immediately; may be irreversible. -assess mental status (orientation, mood, behavior) prior to and periodically during therapy -monitor patient for onset of akathisia (restlessness) and extrapyuramid al side effects. -monitor for tardive dyskinesia -assess parkinsonian and 13 extrapyramida l symptoms (restlessness or desire to

biperiden HCl (Akineton)

-antiparkinson agents

2mg OD

Adjunctive treatment of all forms of Parkinsoin s disease, including

Hypersensitiv Confussion ity Depression Narrow glaucoma Dizziness Bowel Headache

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V. THERAPIES
THERAPY 1. Recreati onal Therapy ( Pinoy Ako sing & dance ) DEFINITION Activity which is different that provides a change from the patients usual routine. Use of printed words or picture characters in modifying or stimulating emotions. PURPOSE E Revitalizes the patients interest & helps him to relax & refreshed. Able to follow the simple steps and sang well. RESPONS INTERPRETA TION Gerry was able to follow the steps with a slight difficulty and sang a little bit shy. The patient was able to verbalize his own understandi ng about the story. It shows that he attentively listening to the presentor of the bibliotherap y.

2. Bibliothe rapy ( Ang Langgam at ang Tipaklong )

Reading may help lift a depressed patient; to improve the attention span of the individual with power of concentratio n, to stimulate the imagination & ideas in patients.

Student Nurse : Anong masasabi ninyo sa ating kwento na ang langgam at tipaklong? Gerry: kailangan nating mag ipon habang maaga

(Proverbs) Ang mabigat ay gumagaan, kung

Gerry:

The patient was able to

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pinagtutulunga n

Halimbawa sa trabaho, kung magtutulungan tayo mas gagaang ang trabaho

3. Music & Arts ( Fast & Slow instrumental Song )

Use of unique properties & potential of music in a therapeuti c situation.

It encourage s a person to express & understand emotions through artistic expression & through creative process.

To change human behavior so that the individual affected will be able to function as worthwhile members of todays as well as tomorrows society. Use of music to aid relaxation. Helps in reconciling emotional conflicts as well as promoting selfawareness & personal growth.

read the proverbs and able to express his understanding that helping each other will make the work easier. Fast Music: It shows that he Gerry drew misses their their house house in the at the province province. He and his also draw family himself specially his together with sister. his sister. Ito yung bahay namin sa probinsya kasama ang aking kapatid na babae Slow Music: He drew coconut trees illustrating their house in the province. Maraming puno ng buko doon sa bahay namin sa Samar . Student Nurse: Anong masasabi ninyo tungkol sa ating tula na Ang Agila?

4. Remotiv ation Therapy ( Ang Agila )

Technique of very simple group therapy which aims to bridge

To stimulate patients to be fellow explorer of the real world.

The patient was able to state what the bird does in the story. He listened to

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the fantasy world of the psychotics to the real world.

5. Occupati onal Therapy ( Card Making )

Form of rehabilitation or any activity, mental or physical , prescribed & guided to suggested activities: Painting, sketching, toy making or card making.

To develop feelings of acceptance. To develop their ability to communicat e & share ideas & experiences with the other people. To promote group harmony & identification . To encourage patients to participate in selected activities that will equip them to function independently in everyday life, such as arts & crafts.

Gerry: Ang agila ay lumilipad pababa sa kabundukan

the poem attentively and shows that he understood it.

The patient drew a fish on the cover of the card and said: Mabitamina ang isda On the inside page he drew a sun above the mountain with 2 coconuts in it. He said: Dito kami kumukuha ng pangkabuhayan ng pamilya ko He drew this card for her mother. SN: Gano mo kamahal ang nanay mo? Gerry: higit pa sa buhay ko.

His perception is towards the benefits of eating fish and the occupation of him & his family in the province. It also shows that he misses his mother a lot and is the most precious and important person in his life.

VI. PROCESS RECORDING

Date: August 03, 2010 Time: 1.30-2.00 pm Name: Gerry B. Balero

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Age: 27 years old Description of patient: My patient is Gerry B. Balero 27 years old. He is alert and cooperative. His complexion is brown. He is well groom, with clean clothing. Hair is short and color black. His eyes are color black and have a poor eye contact. Nails are short and clean. He always taps his foot. He has no untoward behavior. Description of environment: Gerry is in pavilion 1 ward 7. There is no bed at the ward because they can be using it to harm their selfs or the other patients and the comfort room has no door so that the nurse on duty can see what they are doing inside. The first nurse patient interaction was happen at corridor because its raining. There are many trees surround the area so that they can inhale fresh air. Objectives: 1. To establish rapport 2. To orient the patient 3. To gather information

Nurse patient interaction Nurse: magandang umaga. Gerry: magandang umaga din.

inferences Client was sitting and looking at me in the eyes.

Nursing action Giving recognition to indicate that you are aware of him. Establishing rapport and offering your self- Giving Information to tell the client who you are.

Nurse: ako si abby from capitol medical center colleges. He was sitting still Ako ang magiging nurse mo looking at me in the simula ngayong martes, bukas eyes. (wednesday), at sa lunes at martes. Sa martes ang huli nating pagsasama. May mga activities tayong gagawin gaya ng pag exercise, music and art therapy, bibliotherapy, remotivation at occupational. nandito ako para gabayan ka sa mga activities na gagawin natin. Nurse: maari ko bang malaman ang pangalan mo? Gerry: ako si gerry b. balero Sitting while his eyes started to Look around and start tapping his foot.

Clarification-you clarify his name even though you knew it from the start. 20

Nurse: ngayon ay august 3, 2010. 1.30 ng hapon Nurse: kamusta ka naman? Gerry: ito ayos lang naman. Nurse: ilang taon ka na? Gerry: 27 years old Nurse: Saan ka nakatira? Gerry: sa Fairview. Nurse: Kailan ang birthday mo? Gerry: may 16, 1983. Nurse: my asawa ka na? Gerry: wala pa. Nurse: girlfriend? Gerry: wala din. Nurse: ano natapos mo? Gerry: high school graduate lang. dahil walang pera. Nurse: gaano kana katagal dito? Gerry: 2 months Nurse: ano ang dahilan sa pag punta mo dito? Gerry: hindi ko alam. Nurse: maaari mo bang idescribe sa akin ang iyong pamilya? Gerry: apat kaming magkakapatid. Bunso ako sa apat na magkakapatid. Nurse: sige kwentuhan mo pa ako sa pamilya mo. Ano ang mga pangalan nila? Gerry: reggie yong panganay,

Presenting reality to know that what really is true. Sitting with eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. He was smiling when ask about this question. Broad openings- to encourage the patient to talk. Giving information how old he is. Giving information where he lives. Giving information when his birthday

Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot.

Sitting with no eye contact and tapping his foot.

Listening- allow him to compose words that he want to say.

Sitting with no eye contact and tapping his foot.

Exploring- so can dig deeper about his family.

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gina ung pangalawa at si gerlie yong pangatlo. Validation the clients answer Nurse: ilang taon na sila? Gerry: reggie- 38 years old, gina- 31 years old at gerlie- 29 years old. Nurse: iyong mga magulang mo? Gerry: mama ko pangalan niya ay si lilbeth. 55 years old. Papa ko ay si Gerry sr. ay 63 years old tapos nag dradrive ng bus. Sitting with no eye contact and tapping his foot.

Sitting with no eye contact and tapping his foot.

Nurse: dumadalaw ba sila dito? Gerry: oo, yong mama at papa Sitting with no eye contact and ko. tapping his foot. Nurse: anong masasayang alaala mo ang natatandaan mo? Gerry: pag nag pupunta kami Sitting with no eye contact and sa luneta. tapping his foot. Nurse: ibig mo bang sabihin na ang pamamasyal sa luneta ang ang masayang alaala mo? Gerry: oo Nurse: sino mga kasama mo? Gerry: pamilya ko. Nurse: ano ang madalas nyong gawin sa luneta? Gerry: kumain at mag laro ng basketball. Nurse: Anong posisyon ang nilalaro mo? Gerry: guard. Nurse: sinong idol mo sa paglalaro ng basketball? Gerry: si James Yap at Kobe Bryant. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot.

Giving information to know the the people who are visiting him. Clarification- clarifying an important event in his life.

Sitting with no eye contact and tapping his foot.

Validation- pt is asked to give feedback about the accuracy of the nurses perception.

Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot.

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Nurse: ano nagagawa ng pamamasyal sayo? Gerry: nakakatanggal ng pagod at bonding din. Sitting with no eye contact and tapping his foot. Nurse? Pagod saan? Gerry: sa trabaho. Nurse: ano ba ang trabaho mo na nakakapagod sa iyo? Gerry: gumagawa ng karton. Nurse: ano pa ang mga pabortio mong libangan? Gerry: mag luto at kumanta. Nurse: anong paborito mong lutuin at kantahin? Gerry: pinakbet,at mga prito paborito kung kantahin ang Iwill always love you pero di ako masyadong magaling kumanta. Nurse: sige Gerry dito na natatapos ang ating pag uusap. Bukas ulit. Salamat. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot. Sitting with no eye contact and tapping his foot.

Listening- to allow him to compose want he want to say.

Paraphrasing- restatement of what the pt has said.

Listening- to give him a time to speak.

Evaluation and remarks: My goals are partially met. I was able to orient and gather some information of the client. To know if the establishing rapport is met, we will see if with the coming days he will go to open up with me. My patient is a serious type of person. He was just answer what you are going to ask about him. Date: August 04, 2010 Time: 10.30-11.00am Name: Gerry B. Balero Age: 27 years old Description of patient: My patient is Gerry B. Balero 27 years old. He is alert and cooperative. His complexion is brown. He has a good hygiene. He knows the proper tooth brushing. He put powdered on his clothes and cologne on his neck. Hair is short and color black.

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His eyes are color black and have a poor eye contact. Nails are short and clean. He always taps his foot. He has no untoward behavior. Description of environment: Gerry is in pavilion 1 ward 7. There is no bed at the ward because they can be using it to harm their selfs or the other patients and the comfort room has no door so that the nurse on duty can see what they are doing inside. The second nurse patient interaction was happen under the trees after the therapies that we did. There are many trees surround the area so that they can inhale fresh air. Objectives: 1. to establishing trust 2. to assist him 3. to gather more information

Nurse patient interaction

Inferences

Nursing action Giving recognition to indicate that you are aware of him

Nurse: magandang umaga Sitting with eye contact. Gerry: magandang umagaa din. Nurse: ngayon ay august 4, 2010. 10.30 ng umaga

Presenting the reality Nurse: Gerry: maari mo bang sabihin sa akin kung ano ang aking pangalan? Gerry: abby Nurse: galing naman, Ilang taon ka na? Gerry: 27 years old Nurse: ilan kayong magkakapatid? Gerry: apat Nurse: Gerry, kwentuhan mo naman ako tungkol sa buhay mo? Gerry: simple lang naman ang buhay ko. Nurse: ikwento mo naman sa akin itong drinawing mo kanina?(fast song) Gerry: yan yong bahay naming sa samar. Nurse: ano itong palaruan at itong mga tao? Sitting with eye contact. Clarification- if he knows who you are.

Sitting with eye contact.

Validation to confirm if the client said is true. Broad openings- to encourage the patient to talk.

Sitting with no eye contact and begins tapping his foot.

Validating- pt is asked to give feedback about the accuracy of the nurses perception Sitting with eye contact and pointing the drawing where he and his sister love to play. 24

Gerry: ako yan at yong ate gina ko naglalaro sa seesaw. Nurse: itong susunod n drawing?(slow song) Gerry: sa samar din yan,, madaming puno ng buko sa amin. Nurse: so ang ibig mo bang sabihin na itong mga drawing mo ay sa probinsya nyo? Gerry: oo sa probinsya naming sa samar. Nurse: ilang taon ka tumira sa samar? Gerry: mga halos isang taon lang. Nurse: anong pinagkakaitaan nyo doon? Gerry: yong mga bunga ng niyog. Nurse: ibig mong sabihin sa bunga ng niyog kayo kumuha ng pantustos nyo sa kabuhayan nyo? Gerry: oo, hinihintay naming maging brown yong buko saka pinipitas. Pag katapos bibilad at kinuha yong laman nito. Nurse: magkano naman ang benta nyo dito? Gerry: mga isang sako 500 pesos. Nurse: salamat Gerry sa oras binigay mo sa akin ngayon sa araw na ito. Sa lunes at martes ulit. Tapos sa martes na yong huling araw namin ditto. August 09, 2010 25 Sitting with eye contact. Sitting with eye contact and pointing out the coconut trees. Sitting with no eye contact and tapping his foot Validation- pt is asked to give feedback about the accuracy of the nurses perception

Clarification- to know if you get the message properly.

Sitting with no eye contact and tapping his foot

Sitting with no eye contact and tapping his foot

Sitting with no eye contact and tapping his foot

Validating- pt is asked to give feedback about the accuracy of the nurses perception

Sitting with eye contact and tapping his foot

Nurse: magandang hapon Gerry Gerry: magandang hapon din. Nurse: Gerry, ano name ko? Gerry: galing naman ni Gerry. Nurse: Anong araw ngayon? Gerry: lunes, august 08, 2010 Nurse: ngayon ay lunes august 09, 2010. Nurse: Gerry ilan kayong magkakapatid? Gerry: apat Nurse: Gerry, ano ang dahilan ng pagpunta mo ditto? Gerry: hindi ko alam. Nurse: anong nangyari sa mga peklat mo dyan sa mga kamay mo? Gerry: hindi ko alam kung saan ko nakuha itong mga ito. Nurse: may mga bisyo ka ba? Gerry: sigarilyo lang at paminsan minsan umiinom din pag may okasyon. Nurse: ilang sticks ang nauubos mo per day? Gerry: isang stick lang Nurse: Gerry, mahal mo ba ang nanay mo?

Sitting with eye contact and smiling

Giving recognition to indicate that you are aware of him

Sitting with eye contact

Sitting with eye contact

Presenting the reality

Sitting with eye contact

Clarification- to know if you get the message properly.

Sitting with eye contact

Sitting with eye contact

Clarification- encourages recall of particular experience.

Sitting with eye contact Confrontation Sitting with eye contact

Sitting with eye contact Confrontation- if he love his mother

Sitting with eye contact Sitting with eye contact

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Gerry: oo higit pa sa buhay ko. Nurse: ang tatay mo? Gerry: ganon din. Nurse: ano naman ang nararamdaman mo ditto sa loob? Gerry: Masaya Nurse: sino yong mga kaibigan mo ditto? Gerry: sila carlito at yong iba pa. Nurse: Gerry ano itong drinawing mo ditto sa card? Gerry: isda kasi mabitamina Nurse: itong mga puno? Gerry: puno ng niyog kung saan kami kumukuha ng kabuhayan ng pamilya ko. Sitting with eye contact

Clarification- clarifying what he feels toward his co patient.

Listening- allow time to the client to compose what he want to say. Sitting with eye contact

Evaluation of cognitive development

Sitting with eye contact

Nurse: Gerry magbibigay ako ng 3 object tapos sabihin mo siya ulit sa akin after 5 minutes. Gerry: sige. Nurse: paper, pencil and Sitting with eye contact eraser. Gerry: paper, pencil and eraser Nurse: ngayon magbilang naman tayo ng 1-10. Gerry: 1-2-3-4-5-6-7-8-910. Nurse: ngayon pabaliktad naman. Gerry: 10-9-8-7-6-5-4-32-1.

Evaluation of cognitive development

Evaluation of cognitive development Sitting with eye contact

Evaluation of cognitive development 27

Nurse: ngayon spelling naman ng word na Philippines. Gerry: p-h-i-l-i-p-p-i-n-e-s Nurse: pabaliktad naman. Gerry: s-e-n-i-p-p-i-l-i-h-p Nurse: ngayon yong word na house naman. Gerry: h-o-u-s-e Nurse: pabaliktad naman Gerry: e-s-u-o-h

Sitting with eye contact

Evaluation of cognitive development

Nurse: ngayon bigyan mo naman ako ng limang president. Gerry: roxas, quirino, ninoy Aquino, estrada at arroyo. Nurse: ngayon ang present nating president ay si ninoy Aquino. Nurse: ngayon ay mag addition naman tayo. 1+1 Gerry: 2 Nurse: 2+2 Gerry: 4 Nurse: 4+4 Gerry: 8 Nurse: 8+8 Gerry: 16 Nurse: 5+5 Gerry: 10 Nurse: ngayon mag subtraction naman tayo. 6-6 Gerry: 0 Nurse: 3-2 Gerry: 1 Nurse: 11-5 Gerry: 6 Nurse: 4-2 Gerry: 2 Nurse: 7-4

Sitting with eye contact

Evaluation of cognitive development

Sitting with eye contact

Evaluation of cognitive development

Sitting with eye contact

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Gerry: 3 Nurse: ngayon basahin mo naman itong salawikain tapos ipaliwanag mo kung ano ang natutunan mo sa binasa mo Gerry: ang palay ay hindi kusang lalapit sa manok. Ang ibig sabihin lahat ng bagay ay pinaghihirapan natin. Hndi ito basta basta nakakamit. Nurse: ngayon sabihin mo na sa akin yong tatlong object kanina? Gerry: paper, pencil and eraser. Nurse: galling, galling naman ni Gerry. Nurse: Gerry, salamat sa pagbibigay ng impormasyon sa akin. Alis na kami. Bukas ang huli nating araw at magkakaroon tayo ng socialization. Participate tayo ha. Gerry: oo, salamat din.

Sitting with eye contact and smiling.

Evaluation of cognitive development

Evaluation and remarks: Client was able to talk about his life. He was able to participate in all activities we did. He can able to explain his drawing. Client still doesnt talk if you dont ask him questions. Patient is still denial about the reason why he consults to the institution.

VII. REFERENCES
Psychiatric Nursing Biological and Behavioral Concepts. Second Edition. Deborah Antai-Otong. 2008 Psychiatric Nursing. Third Edition. Keltner, Schwecke, Bostrom. 1999 http://psychcentral.com/lib/2006/undifferentiated-schizophrenia/. Retrieved August 07, 2010

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http://medicaldictionary.thefreedictionary.com/undifferentiated+schizophrenia. Retrieved August 07, 2010 www.wikipedia.com

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