a4 final psyche cp

8/3/2019 a4 Final Psyche Cp

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I. INTRODUCTION

A. Overview

Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions,

movement, and behavior. It cannot be defined as an illness. Rather, Schizophrenia is

thought of a syndrome or disease process with many different varieties and symptoms,

much like the varieties of cancer for decades, the public vastly misunderstood

Schizophrenia, fearing it as dangerous and uncontrollable and causing wild

disturbances and violent outbursts. Only recently has the mental heath industry come to

learn and educate the community at large that Schizophrenia has many different

symptoms and presentation and is an illness that medication can control. (Videbeckfourth edition, 2008)

A particular mental disorder that is very common and dominant, especially in the

Philippines, is Schizophrenia. In laypersons term, it is not uncommon to hear the word

Schizophrenia defined as ³split personality.´ schizophrenia is not characterized b a

changing personality; it is characterized by a deteriorating personality. Therefore, this

popular notion of a dramatic personality change comes far short of capturing the

devastating effect Schizophrenia has on the life a person and the person¶s family.

Simply, Schizophrenia is one of the most profoundly disabling illness, mental or

physical, the nurse will ever encounter. (keltner, et al. 1999).

Schizophrenia is a psychotic disorder (or a group of disorder) marked by severely

impaired thinking, emotion, and behaviors. Schizophrenic patients are typically unable

to filter sensory stimuli and may have enchanted perception of sounds, colors, and other

feature of their environment. Most Schizophrenics, if untreated, gradually withdraw from

intersections with other people, and lose their ability to take care of personal needs and

grooming. No laboratory test has been found to be diagnostic of this disorder.

Interventions initiated and implemented was upon the cooperation of the patient and

significant others.

Despite the received wisdom that schizophrenia occurs at similar rates

throughout the world¶s, its prevalence varies across the world, within countries, and at



the local and neighborhood level. Schizophrenia affects men and women with equal

frequency, the disorder often appears earlier in men, usually in late teens or early

twenties, than in women, who are generally affected in the twenties to early thirties. In

the Philippines alone, out of 86,241,697 population used, the extrapolated prevalence in

697,543-about 5% to 1 % of the population. Schezophrenia still ranks among the top 10

causes of disability in country.

B. Objective and Purpose of the study.

Specifically, this study aims to:

1. Conduct a thorough assessment of the emotional status of the patient.2. Identify priority nursing problems.

3. Develop nursing care plans to the problems identified.

4. Apply intervention and diversion activities

5. Evaluate the care done and impart health teaching.

This study is conducted to provide the nursing studies an opportunity to be

exposed and care for a mentally challenged patient. Also, this will enable the studentsto apply the concepts learned in psychiatric nursing.

C. Scope and Limitation.

The study involves the care of a mentally challenged in Cagayan De Oro City.

The client must meet the following criteria: He/ She must have s diagnosed psychosis

and must have immediate family available as informant for the study. The study is

limited to 5 days of care with each session spanning only two hours. Information about

clients¶ history illness will be based only on the interview with the client, client¶s parent,

her relatives and some of her neighbor.



D. Spot Map

SPOT MAP:

The point of reference is Liceo de Cagayan University, located in Carmen,Cagayan de Oro City. The patient¶s house is approximately eight kilometers east of thereference. We must take a public utility vehicle from the reference point going tobarangay 35 near limketkai mall with a fare of six pesos for students and senior citizenand a seven pesos fare for the regular passengers. The length of time to travel usuallytakes ten minutes if traffic is moderate rate, but it could also take twenty minutes goingto the area if the traffic is very heavy.

From the Barangay 35 hall, walk twenty meters straight. Passing a small bridgeturn right and the third house from the bridge stand a two story wood house. The

patient¶s house is made up of woods near the creek and most of the houses within thearea is made up of woods. Bingo is played during their leisure time. The patient sleepsis under the house with her parents and siblings.



E. Patient¶s Profile

Initial name: J R

Address:Brgy,35 Limketkai Drive Cagayan de Oro City

Date of Birth:July 8, 1991

Age: 19 years old

Birthplace: Cagayan de Oro City

Civil Status: Single

Gender: Female

Nationality: Filipino

Religion: Roman Catholic

Siblings: 1 sister and 2 brothers

Children: none

Name of Mother: M.R

Name of Father: L.RHeight: 5¶11´

Weight: 44kgs

Income: None

Date of first Check-up: 2001

Admitting Diagnosis: Schizophrenia Undifferentiated



II. Anamnesis

A. GENOGRAM

GREGORIA

*NICOLAS

ISIDRO

SOLED

MARITES

*JR

ISIDRO

MOLY

JOLIE

JOCELYN ALLAN AZON

ROMEA

JEMUEL MICHELLE

J

MARILOU



Informants

NAME: Michelle Joy Regalado AGE: 15 years old

ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City

RELATIONSHIP TO THE PATIENT: Sister

LENGTH OF TIME KNOWN TO PATIENT: 15 years

APPARENT UNDERSTANDING OF PRESENT ILLNESS

³Sa akong nabantayan OK ra man siya pag maka inom ug tambal pero kung dili

gani mutukar dayon iya sakit, manghilabot sya sa amu ug usahay mukalit ra sya ug

hilak ug gusto ran a sya mag-inusara´

OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT

Michelle is a 3rd year High school student at Cagayan de Oro National High

School. At first she is very hesitant to answer the question but as we interviewed her,

she is very concerned about the condition of her sister.

NAME: Jemuel Regalado

AGE: 16 years old


RELATIONSHIP TO THE PATIENT: Brother



³Pag maka inom siya sa tambal OK ra sya, normal parehas sa ato pero kung dili

gani, mandapat jud siya. Usahay mag hilum-hilum, mag gawas-gawas, mag sulat-sulat

ug usahay mag sige ra sya katulog ug magkatawa dayon ug kalit. Gina pang labay pud

niya among mga gamit pag dugay siya maka inom ug tambal.



OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT:

Jemuel is a third year high school student at Cagayan de Oro National High

school. Like his sister, he is also very hesitant to answer the question being asked but

he is very accommodating and also he is very concerned about the condition of his

sister.

NAME: Victoria Martinez

AGE: 44 years old


RELATIONSHIP TO THE PATIENT: Neighbor


APPARENT UNDERSTANDING OF PRESENT ILLNESS:³Sa una OK ra man si JR pero nagsugod na adtong gikan dawn a siya sa

eskwelahan, kalit-kalit ra man mutukar iya sakit tapos iya gina reklamo iya ulo, sakit

daw kayo ug mag sige pud na sya reklamo nga murag ga dug-on daw siya tapos kung

feeling daw niya dug-on siya diha na mutukar iyahang sakit. Mag wild na siya, mag

lakaw-lakaw pero pagka taud-taud mubalik ra man dayon na siya.


Mrs. Victoria Martinez is a housewife and sometimes a part-time sweeper at the

Barangay but as of the moment, she gave up her work as a sweeper because she is

focusing in taking good care of her grandchildren. Mrs. Victoria Martinez is very nice to

us when we had our interview with her. She is very accommodating and like the other

neighbors of JR, she is very concerned about the condition of JR.

NAME: Marites Regalado

AGE: 37 years old


RELATIONSHIP TO THE PATIENT: Mother





³Sa akong nabantayan sa iya, pag dili gani na siya maka tumar sa tambal, mag

lasong gyod na sya pero kung maka tumar gani sa iyang tambal OK ra man dayon

siya.´


Mrs. Marites Regalado is the mother of JR. She is accommodating during the

time we interviewed he. She stays at home in the morning and during afternoon, she

sells foods in front of Cogon market just to support the needs of her family. She is the

one who really takes care of JR because through the entire visits, she was the one who

really answers the questions being asked.

NAME: Diosdada Calumbay

AGE: 74 years old


RELATIONSHIP TO THE PATIENT: Neighbor



³Sa akong nabantayanka niya, hilumon mana siya. Ga isturyahun pa man gani

naku na siya pero sugod anang iyang sakit, naka bantay ko nga mag hilak ra na siya ug

kalit. Pag mutukar na kana iyang sakit, mag wild gyod na siya. Ipang labay niya ang

mga gamit sa sapa bisan pag linung-ag sa silingan iya gyud ilabay. Mag lakaw-lakaw

pud na siya pero pagka taud-taud maka balik ra dayon na siya.´


Mrs. Diosdada Calumbay is very accommodating during the interview and like

the other neighbors of JR, she is very concerned about JR. Mrs. Calumbay is living with

her son and she helps in taking care of her grandchildren.



FAMILY HISTORY

A. MATERNAL AND PATERNAL GRAND LINEAGE

Based on the information handed to us by the client¶s mother, no one intheir family has a disorder like our patient. On the paternal side, the father confirms that

his mother has a brother of the same condition as our client.

B. FATHER

Lemuel is the father of our client and he is the fifth among his siblings.

Unfortunately, he was not able to finish his studies. He claimed the he studied until high

school but was not able to graduate. His occupation was ³trisikad´ driver.

c. MOTHER

Marites is the mother of JR. she is the youngest among the siblings and

like her husband, she was not able to finish her high school. She is the one who really

takes care of JR. During afternoon, she sells food at Cogon market just to make a living

and support the needs of her family.

d. SIBLINGS

JR has 3 siblings and all of the three are normal. Sibling rivalry occurs.

D. PERSONAL HISTORY

a. Pre-natal

The client¶s mother revealed to us that JR is the eldest in the family.

During this time she was able to undergo complete pre-natal check-up. During her

pregnancy she suffered emotional stress because during this time, she and her

husband were not able to get married.

b. Birth

JR was delivered full term, through normal spontaneous vaginal delivery

at home last July 8, 1991. She weighed 6 lbs.. it was the ³mananabang´ who helped her

deliver the baby. JR received complete immunization at Carmen Health Center.

c. Infancy and Childhood Characteristics



The mother believed that breastfeeding was good for babies but she failed

to have exclusive breastfeeding. JR was taken cared by her parents at their home. She

suffered cough, colds and fever during childhood. Her mother stated that JR was quiet

and shy during childhood.

d. Psychosexual Factor

JR can indentify her gender as female when asked.

e. Play Life

During childhood, JR was not able to get along with other children

because she is shy and quiet.

f. School History

During her elementary years, she studied and graduated at City Central

School, Cagayan de Oro City. During her high school days, she studied at Cagayan seOro National High school located at Nazareth, Cagayan de Oro city. During her school

years, she was observed as silent type of person. According to her mother, she had a

good relationship with her classmates as well as with her friends. Most of the time, she

wants to be alone rather than talking with her classmates and friends.

g. Religious and Social Adaptability

JR¶s family is a Roman Catholic. In the past, they go to church together

but as of this time, the family is so busy that¶s why they only go to church when they

have available time. However, JR was not sociable according to her mother. Every time

they have visitors, she immediately hides for she is shy and rather wants to be alone.

With regards to her relationship with her family, she is very close to her mother.

h. Occupational History

Our client never experienced working.

i. Marital History

Our client is still single, she never experienced any relationship towards

the opposite sex.

j. Onset of Present Illness

The onset of JR¶s present condition started at an early age. His father

found out that she didn¶t eat her food in school during lunch and snack time and also



according to the father when she was 8 years old he observed that JR was talking to

herself and suddenly laugh at herself.

³Pirmi mi gakasunugan tong una´ as verbalized by the mother this caused

traumatic experience to the patient.

When she was 11 years old, she experienced fever for 3 days and was

confined for 5 days and after 5 days she was released from the hospital. But she has

many complaints about herself that¶s why her Doctor referred her to Dr. Borromeo, a

psychiatrist at Northern Mindanao Medical Center and diagnosed that she had a mental

disorder and was given medications by Doctor Go.

At present JR was currently taking her medications.

III. Course in the Hospital

A. Mental status Exam

DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

A. GENERAL APPEARANCE

Untidy Tidy Clean Untidy Clean

B. GENERAL

POSTUREPosture Slouch Slouch Slouch Slouch Slouch

Activity Handwriting Purposeful Purposeful PurposefulPurposefu

FacialExpression

Suspicious Happy Happy Happy Happy

C. BEHAVIOR Negativistic Friendly Friendly Friendly Friendly

D. PATIENT NURSEINTERACTION

Distant Cooperative Cooperative Cooperative Cooperativ

E. SPEECH

Soft / / / / /

Loud



Hesitant /

Slurred

Superiority

Humor

Frightened

F. DOES HIS STYLE AND VOCABULARYCONVEY-Coyness

Suspiciousness /

Arrogance

Secrecy

Superiority

Humor /

Fear /

G. STREAM OF TALK / /

Spontaneous

Deliberate / /

Pressured /

Blocking

H. ORGANIZATION OFTALKRelevant / /

Irrelevant

Incoherent

Loose Association



Flight of ideas

Tangentiality

Circumstantiality / /

Perseveration /

ClangassociationNeologism

Echolalia

Echopraxia

I. MOOD AND AFFECT

1. Mood

Euthymic / /

Depressed /

Euphoric / /

2. Affect

Flat

Blunt

Angry

Elated / / / /

Anxious /

Fearful

3. Range of Affectiveexpression

Consistent / /

Labile

Anhedonic /



Appropriate tothe situationand feelingsverbalized

/ /

J. PERCEPTION

Hallucination

Auditory

Visual

Olfactory

Gustatory

Tactile / / / / /Delusion

Grandeur

Persecutory

Reference

Others(specify)

Illusion

Derealization

Depersonalization

Identification

ThoughtBroadcastingDéjà vu

Jamais vu

K. ORIENTATION ANDMEMORYIdentifies datecorrectly

yes yes yes yes yes



Estimated time of theday

no no no no no

Knows where she is yes yes yes yes yes

Knows the examiner no no no no no

Recalls activitiesdone within 24 hours

yes yes yes yes yes

Recalls activitiesdone within 1 week

no no no no no

L. Neuro-negativeFunctioningSleep and RestPattern:

Normal Sleeping / / / / /

Early morning AwakeningMiddle nightawakeningHyper insomnia

Difficulty of fallingasleepInterrupted

Others

M. Elimination

Bowel 1x 0 1x 1x 1x

Bladder 4x 7x 6x 5x 6x

N. Abstract Thinking Ability

poor poor poor poor Poor

O. Judgment poor poor poor poor Poor



Description of MSE

First Visit (April 28, 2011)

Appearance and Movement

During the first day of our visit to J.R, she was untidy, her nails in both feet and hands

are dirty and when she went out of the house to meet us she was barefooted. She sits

with a slouched back. She displays a suspicious behavior and she keeps on squeezing

her hands.

Speech The quality of her voice was soft and hesitant when speaking. Her speech was slightly

pressured. And she keeps on saying that she doesn't want to be interviewed by

students.

E motional State and Reaction The client was anxious during the interview, she kept on saying that students would just

visit her and do interviews but did not do her any help for the past few years.

T hought Control During the first interview the client was able to recall the activities she has done within

24 hours, she was able to identify the date correctly. She said that her feet and hands

are hurting. She could not even estimate the time of the day but she knows where she's

at. She could not recall out name but was able to recognize.

N euro-Vegetative functioning The patient said that she was able to sleep normally at night because she was able to

take her medicine.



SECOND VISIT (April 29, 2011)


On the second day of visit we stayed at their neighbor house, J.R appeared tidy. She just took a bath and her clothes are clean.During the interview she was seated 2 feet

away from the examiner and she slouch her back. After the interview, she laughed

outrageously and when asked what she was laughing about, she did not answer.

Speech The client talked vividly in soft and spontaneous speech. The organization of her

speech are relevant.

E motional state and Reaction She was very happy during our visit, especially when she received the fruits and bread.

And she even told us that she would be happy if we will visit her everyday.

T hought Control The client was able to recognize the date but doesn't know the time. She knows that weare at her neighbor's house and she was able to recall the activities she has done for 24

hours. She was still complaining that her feet and hands are hurting.

N euro-Vegetative Function The client said that she was able to sleep normally at night.

THIRD VISIT (April 30, 2011)




On our third visit the client looks clean, she just took a bath. She was very cooperative

during the interview. She said that she was happy to see us again. Her hair was well

fixed and her finger and toe nails were clean. She sits at a distance with a slouch.

Speech Still the client speaks in a soft and deliberate speech. She speaks at a normal pace and

answers the questions appropriately.

E motional State and Reaction She was happy and was very cooperative during the whole interview.

T hought Control She was able to recall the activities she has done for 24 hours but she was not able to

recall the time and date. She knows where she's at but doesn't recall the names of the

examiners.

N euro-Vegetative Function The client has a normal sleep pattern.

FOURTH VISIT (May 4, 2011)

Appearance and Movement During our fourth visit, the patient was busy watching the television. So we conducted

the interview inside their house. She looked very happy and he was well groomed. She

was very neat. She slouch her back.



Speech

The client speaks in a soft voice and talks spontaneously. The organization of talk is

relevant.

E motional state and Reaction She was happy to see us when we arrived at their house. She was calm and she reacts

appropriately in every situation especially when she was watching the television.

T hought Control Client doesn't show any maladaptive behaviors. The client reacts appropriate to the

situation and feelings verbalized.

N euro-Vegetative function The client has normal sleep pattern.

FIFTH VISIT (May 5, 2011)

Appearance and Movement During our fourth visit, the client was excited to see us. She looked neat and clean. She

was well groomed. She was seated with a slouched back.

Speech The client talked deliberately in a soft and she shows no hesitation when speaking.

E motional State and Reaction The client was in very happy and she keeps on smiling. And she portrays comfort and

interest during the whole interview.



T hought Control The client knows the date but does not know the time of the day. She was able to recall

activities she has done for 24 hours.

N euro-Vegetative Functioning The client has a normal sleep pattern

B. Progress Notes

Day 1: April 28,2011 (Thursday)

Specific Objectives:

1. To locate the residence of the client.

2. To establish trust and rapport with the client.

3. To have a verbal contract and consent both client and family.

4. To make an initial assessment.

5. To start the assessment for the mental status of our client.

6. Arrange the date for our next visit

On Wednesday, April 28, 2011 the group started LOOKING FOR UOR CLEINT.

We were referred by a previous batch that there were psyh client in barangay 35,

Limketkai Drive Cagayan de Oro City. So we grabbed the chance and without any

hesitation we immediately went to said client. When we arrive at the area, we

immediately asked permission in the barangay council¶s office and were glad that they

have allowed us to conduct our study in their barangay,. They referred us to JR wholives near the creek.

When we arrived at the client house, the consent was obtained from the mother

and the client as they permitted the group to conduct series of interview with them. We

cannot disclose the names of the client and her family members for security purposes.

We gained the important data¶s that we needed from the client, her parents, relatives



and neighbour. We gathered the clients profile and some other important information

regarding the client¶s situation.

A verbal contact was made about the number of days we were going to conduct

the interview, health teaching, nursing intervention and length and time of visit.

DA Y 2: April 29, 2011 ( Friday )

,


1. Introduced ourselves to our client.

2. Continue establishing rapport to the client.

3. Continue with the mental status exam with the client.

4. Determine the factor that causes the client disorder.5. Trace the client history

6. Ask the client neighbour for some relevant information.

On our second visit, the client was very cooperative during our interview. She

was very happy because we brought her a fruits and bread.

Our group continued the assessment and traced her family history, The situation

that has occurred prior to admission and we even ask the neighbour about fact that may

help us on our care study.

DA Y 3: April 30, 2011 ( Saturday)


1. Asses the client for some changes.

2. Identify more problems of the client.

3. Obtain enough information regarding the client

4. Continue to gather more information from other sources, such as:

Neighbors.



On our third visit, the patient has continued to cooperate. We continued the

assessment and observe for possible development of her reaction towards us.

We continue interviewed the selected neighbours about their reaction and

awareness about JG¶s situation. And we were glad that the neighbors were cooperative

and friendly.

DA Y 4: May 4, 2011 ( wednesday )

Specific Objective:

1. Re-establish rapport with the client¶s family.

2. Perform the Mental Status Examination ( MSE)

3. Assess our client in a holistic manner

On our fourth visit, we found our patient and family busy watching television.

When she saw us, she immediately called her mother and informed her of our arrival.

The patient was in a calm and normal mood. She react opportunity to any situation,

especially when she was watching the television, she shows appreciation when we

gave her a bag of fruits.

DA Y 5: MA Y 5, 2011 (Thursday )


1. Continue with the final assessment.

2. Continue interviewing the family members with our clinical instructor.

3. WE introduce our CI to our patient.

4. We inform our client that this will be our last visit to her.

5. We gave health teaching to our clients and to her family.

On our final visit, we continued the final assessment and continue interviewing

the family member and neighbour as well to fill in the lacking information for our client¶s

data. We also imparted important health teaching about proper hygiene, proper

nutrition, maintenance of medication regimen, and follow up checkups every month.



We also ended our contract with the patient along with her family that this will be

our final visit and final assessment. And we thanked them for their participation to make

this care study possible.

IV. Psychodynamics

A1. Tabular Presentation on the Predisposing Factors

Factors Present Rationale

1. Predisposing

a. Hereditary

b. age

c. Sex

Present in paternal side.

Onset early manifestationof Schizophrenia.

Increases prevalence of female

According to Sheila L.

Vinebeck, family studiesare used to comparewhether a trait is morecommon among first-degree relatives ( parents,siblings, and children )thanamong more distantrelatives or the generalpopulation.

Age of onset seems to bean important factors in howwell the client fares. Thosewho develop the illnessearlier go worse outcomesthan those who develop itlater. (Buchaman andCarpenter, 2000) accordingto Hagop S. Akistol M.D arehigher in younger agegroups especially in the

stage because of having aroe confusion and identitycrisis.

Sex determines thecommunity¶s expectation of a person.



A2. Tabular Presentation on the Precipitating Factors

Factors Present Rationale

1. Precipitating

a. Post-traumaticexperience

b. Environment factor

c. Skipping of meals

Client

Client don¶t heve close

friend always stay in thehouse

Client unintentionallyskipped meals during days.

According to Shiela L.Videbick, post-traumaticstress disorder is adisturbing pattern of behaviour demonstrated bysomeone who hasexperienced a traumatic

event such as naturaldisaster, combat or anassault. The person withPTSD was exposed to anevent that posed a threat of death or serious injury andresponded with intensefear, helpless, or terror.

Peers are a big factor in

molding the factorspersonality.

According to Stuart andSundeem ( 1995 ). Povertyand society could abuseSchizophrenic to cope theinsanity of mother world.



B. Schematic Presentation

Biological Factors

Genetics

Father Mother

No gender factor There is history of psychosisin paternal side

Incr

Inc



y Loweconomicstatus

y

Mother experiencedstress

y Completeprenatal

PRE-NATAL INFANCY TOODLER PRESCHOOLER

y Mixedbreastfeedand bottle

feedy Early

weaningy Mother is too

busy lookingfor additionalincome

y Minimalinteractionwith

neighborsand frieds

y Wants to goto school

y Aloof

Shame andDoubt

Mistrust Guilt

PSYCHOSOCIAL FACTORS



SOCIOCULTURAL

Internal e

Mother Father Siblings

Poor parental

role

Lack of familysupport

y Surry Lacky No k

subs

y Doedrinkand

Non-



Probability of mental illness Weakened Ego Functioning

Low self-esteem

Use defense mechanism-withdrawal

Precipitating Factor:Skipping mealsPost-traumatic experience

Environmental factor



C.Analogy

Life is like an endless highway. It is full of views on its own way--- the road is a

thoroughfare, route, or way between two places. Roads like our journey of life are

normally smoothed, paved, or otherwise prepared to allow easy travel, although

historically many roads as it is like our lives were simply recognizable routes or left

uncared as without any formal construction or maintenance.

This is the journey of Gellyn, an introvert teenager from Barangay 35, Cagayan De

Oro City.

The first two builders, had struggled in gathering the necessary materials for an ideal

automobile. Due to very limited resources, lacked of support from the crew and novice

builders, the materials acquired for building were substandard. At the very beginning,

there was already a problem with regards to the quality of the parts of the automobile.

Hence, a weak foundation was molded.

In relation with Gellyn, the substandard materials represent the biological factors.

Both the grandfather and father had nervous breakdown. In addition, the weakfoundation is the imbalance of neurotransmitter dopamine & serotonin. This increases

Gellyn¶s vulnerability to mental illness.

The builders started to construct the engine of the automobile: the keel but during

the process of building conflicts arose. The primary builder seemed not interested and



lacked commitment to his responsibilities. He was impulsive, quick-tempered towards

his submissive partner and he even attempted to hit her despite the fact of all of her

hardships to make a keel of distinctive attribute that will be the central structural basis of

the hull---- a framework for buoyancy.

During the conception of Gellyn, the parents had frequent quarrels. The mother

suffered from the abuses from his husband ± the emotional sufferings led to intra

psychic trauma.

The imperfect engine influenced much the chassis which provides the buoyancy of

the automobile. As it is the body of the automobile, chassis is basic and crucial for a car

to have a good foundation. Alone the secondary builder made the chassis that would

stand still amidst the robust and rough roads. But the builder was unknowledgeable and

unskilled to do so, thus a small hole slipped & buoyancy was uncertain.Baby Gellyn was dissatisfied from sucking and feeding as the mother abruptly

terminated breastfeeding. The mother still with emotional problems, could not give

consistent care to the baby. The inconsistency of care promotes mistrust.

For the automobile to move forth, a gasoline is necessary to start the engine. The

gasoline must be of its full tank, heated and clutched to start firmly the engine. However

the builder was not able to execute such things. Those features were neglected, as a

result, the engine overheated.

Similarly to a toddler whose toilet training was lax. Consequently, shame and doubt

marked instead of autonomy.

As the building process continued, disputes between the two builders were clearly

inevitable. The unreliability and wrath of the primary builders were unpleasantly evident.

For this, some parts of the automobile were enfeebled. The hood itself has no protection

from a cold or heated temperature. Its size and shape was disregarded, making the

effectiveness of its steering and turning abilities incompetent just before the untamed

roughness of the road.

T his can be compared to a lonesome and shy preschooler who had few

playmates. With this, guilt resulted when initiative should have been the

product.



To set the automobile¶s course, a hydraulic power steering is essential. It serves as

a lever of the steering wheel to maneuver the direction and reach the inaccessible

portion of the road.

Analogous to an introvert and mediocre pupil ± the target of the bullies who did not

learn to fight back. At this point, inferiority prevailed over industry.

Now as the automobile was about to park at the viewing park, the engine was

crafted to serve as a propulsion system. This manipulates the powers and the speed of

the automobile. During the travel lightning flashed and hit it¶s hood. Moreover thunders

roared and storms poured down stronger and stronger which inflicted damages to the

automobile.

In her adolescent stage, she stopped schooling until grade-6 due to financial

constraints and family turmoil. Lightning symbolizes the catastrophic events of her life.The damaged automobile searched for a repair shop to seek for refuge. The engine

was opened to be able to be fixed. But unfortunately, the engine gears were affixed

loosely to the soft and loose oils, this made the automobile to exhibit radical side-to-side

motions. Furthermore, because of the piercing voltage coming from the lightning a fire

surged the repair shop and reached the automobile. The automobile did not yield in

easily, it struggled for its survival.

The Repair Shop signifies her home. Their home was unstable and there was

unloving environment between them.

The automobilet was wrecked but not beyond repair. The owner exerted efforts to

restore what had been damaged. Will the automobile survive and run again? Or will it

be brought to ruin? No one can tell.

Likewise, the family of Gellyn is making an effort to help her with her illness. Will she

survive? Only time can tell.

V. Laboratory Exam and results of Psychological Test

Our client has undergone laboratory exam and psychological testing but all theresult were lost.



VI. Diagnosis

Schizophrenia, Undifferentiated Type

VII. Multi-Axial Diagnosis

AXIS 1Clinical Disorder

Major Psychiatric Disorder y Schizophrenia, undifferentiatedy Patient J.R manifested distortion of

reality, hallucination and disorderedthinking

AXIS 2Personality Disorder and Mentalretardation

y The client has a disorganizedpersonality disorder and shows lessdepressive emotion

AXIS 3General Medical Condition y None as observe

y AXIS 4Psychosocial and Environment Factors y Patient J.R µs family live below

poverty liney Patient J.R stopped from schooling

due to mental illness that sheencountered

y The family cannot avail with theneeded health care services due tounaffordable of such

y Family failed to encourage therereinforce positive behavior and self-esteem



VIII. Nursing Management

A. Ideal Nursing Management

Nursing Diagnosis: Impaired social interaction related to altered sense or interpretationof reality with difficulty with social skills.

Nursing Management Rationale

1. Assess and document past experience

and patterns of social activity alteration

y For Previous level of functioning and

types of activities enjoyed are

identified

2. Assess current strengths and problem

area regarding social interactions

y For Areas of strength to reinforce

and build upon are identified as well

as problem areas that can be

improved

3. Identify with the patient. goal for

increase social interaction

y For Compliance is increased when

that patient is part of the decision -

making process.

4. Support and reinforce efforts and

success in social interaction

y To positive reinforcement, even for

slight movement toward the

expected behavior change, is very

reinforcing and encouraging when

patients are trying to master a new

behavior.

5. Teach essential components of appropriate social interaction. Begin with

simple steps of social interaction, such as

making eye contact during conversation,

productive patterns of speech

y

To address gaps in knowledge of social skills



6. Provide emotion support as patient tries

to reach goals

y To have low self esteem and may

be discouraged by their own

performance or the reactions of

others to their efforts to socialize

and communicate. Empathetic

listening and support can enhance

verbalization without criticism while

listening a new behavior.

7. Provide a group situation to improve

social skills

y To provide an opportunity to

practice skills for social interaction in

a less threatening and more

supportive environment

8. Evaluate the care plan as needed, and

at regular intervals, to ensure that the

direction and method of treatment is

appropriate

y To ensure that the goals are neither

too advanced nor too basic for

patient's needed and that the

opportunities for skills development

match the need symptom

Nursing Diagnosis: Anxiety related to maladaptive reaction to an identifiable stress

stressor.


1. Assess level of anxiety; provide

supportive nurse patient relationship and

opportunities

for ventilation regarding feelings of anxiety

and their etiology. Provide opportunities for

patient to learn to master feelings through

y Supportive nurse patient

relationship will assist the patient

exploring the root causes of his or

her anxieties, and once this is done,

the patient will have the strength

and courage to learn to master



regular counseling or therapy sessions;

daily journal keeping; development of

appropriate release activities such as

physical exercise, yoga, relaxation training,

medication, art work, and volunteer work

these feelings

2. Assess appetite and weight loos or gain

assist patient in meal planning and

counseling

y Assess appetite disturbance can

lead to making the patient fell worse

and also negatively alter his or her

self-concept. Nutritional counseling

and assistance with meal planning

often including vitamin

supplementation, is necessary to

assist the patient in regaining a

state of wellness

3. Assess sleep patterns and assist the

patient in reestablishing her normal sleep

pattern

y Sleep pattern disturbance such as

difficulty falling asleep, midnight

awakening impact negatively on

one's overall wellness and need to

be attended to in order to assist the

patient in regaining an overall state

of wellness

Nursing Diagnosis: Post-trauma response related to past history of physical and

emotional


1. Assess the nature of the past y This allows for individualized care

based upon the most dysfunctional

symptoms



2. Determine the response to the event

both currently and in the past

y An atmosphere helps correct

distortions and misperceptions of

the environment

3. Assess whether there is any current

contact with the perpetrator and the nature

of the relationship

y Non- reality based thinking may

increase when anxiety level

increases

4. Ascertain the coping mechanisms used

to deal with the memories of trauma

y Concerns or fear may be expressed

as safety

5. Remind that flashbacks may be

memories of emotions as well of physical

acts

y Distortions in thinking may place

patients risk for injury to harm

themselves or others

6. Provide the opportunity to relate the

story of the abuse, including the emotions

as well as physical acts

y Technique such as humming, using

radio, or telling the voices to ³go

away´ can be used for symptom

7. Provide opportunity to relate the story of

the abuse, including the emotions

involved. Assure that the therapy happens

in a safe, structured setting and that the

patient has social or emotional supportafter the session

y To relate details of the event and

the emotions of the event and the

emotions involved in a supportive

environment

8. Continually check for safety for issues y Whether the patient is becoming

overwhelmed is elevated

9. Reorient to place, person, and time at

end of session

y Disorientation may occur when

relating intensely emotionally

charged events from the past

10. Provide emotional support on the unit if life review work is being done in individual

or group therapy

y

Continued safety duringhospitalization and between

sessions is ensured

11. Evaluate extent of intrusion thoughts

about event into daily life

y The effectiveness of the

intervention is evaluated



Nursing Diagnosis: Self care deficit related to perceptual or cognitive impairment


1. Assess and document current level of

functioning and possible reasons for the

deficits

y For a foundation of capabilities is

established and problem areas

identified which may include skill

deficits as well as the etiology of the

behaviour

2. Individualize a care plan to support

current level of functioning and increase

independence in completing the bathing or

hygiene regimen

y Bathing and hygiene levels are

maintained while promoting

increasing independence for self

care. This may start with physical

assistance and move to minimal or

absent verbal prompting

3. Teach about social and health benefits

or bathing and hygiene

y An opportunity is provided to

reinforce the care plan and address

any unique concerns

Nursing Diagnosis: Dressing or Grooming Self care deficit related to cognitive or perceptual impairment


1. Assess and document the patient¶s

current strengths and deficits in areas

y For a foundation of capabilities is

established and problem areas

identified which may include skill

deficits as well as the etiology of the

behaviour

2. Assess any special meanings that

dressing or grooming in a circular manner

y It is important to know any special

meanings attached to dressings or

grooming behaviour that is



problematic

3. Assure easy access to clothing, toilet

mirror other dressing and grooming needs

y Patients with thought disorders can

be easily overwhelmed if

preparatory activity is too complex,

they also need sufficient time to

complete the activity at their own

pace

4. Proved support needed to complete

grooming or hygiene activity

y Physical assistance may be

required when first admitted or

when more psychotic. Verbally

direction should be clear, concise,

simple and repeated often

5. Establish a group specifically to address

dressing/grooming deficits.

This is to decreases the intensity of one

interaction ,which may be uncomfortable

and provides a supportive group of peers

to enhance both socialization opportunities

and learning.

6.Indicate about appropriate dress for

further conditions.

Patients may be less sensitive to

temperature changes because of their illness and the effects of medication and

may be at risk for heat or cold injury.

Nursing Diagnosis: Self care deficit related to disorganized thought and responses the

limit the ability to follow through with activities that involve steps


1. keep messages short and simple;

redirect and refocus when confusion

increases

Brief and clear communication simplifies

messages received when there is difficulty

in interpreting verbal and non-verbal

information.



2. Orient to the environment through signs,

interactions with family, objects or other

interactive group.

Appropriate communication assists in

maintaining orientation and reduces loss of

ability to take ction in life skills.

3. Provide consistency in schedule bathing

and activities.

Consistent routines promote further

orientation to time and place.

4. Provide adequate nutrition and rest

periods and periodic checks of change in

bowel or bladder elimination.

Due to loss of ability to process

environment and own physical cues, the

patient needs assistance in the basic

activities of daily living.

5.Administer medications as prescribed for

agitation and depression

Medication can assist in regaining control

of impulses, reduce agitation from

psychosis, and treat depression.

6. Assess risk factors for falls or harming

others due to loss of functioning;

environmental controls.

Safety precautions assist staff and patient

to maintain safe environment yet supports

maximum level of independence.

Nursing Diagnosis: Sleep pattern disturbance related to disruption in brain center

which controls ³wakefulness´ and circadian rhythm.


1. Document sudden problems with

restlessness and difficulty sleeping during

the night or wandering which are changes

from usual sleep cycles.

Onset is sudden; often the night sees first

signs, via alterations in sleep cycle.

2. Assees for hallucination which

contribute to difficulty of sleep.

Environmental, even familiar objects, my

be misinterpreted at night because low

lighting can cause shadows.

3. Discourage naps during the day To promote a regular sleep cycle during

the night.



4. Ask family about bedtime routine and

maintain as close s possible.

Familiar routine can be both reassuring

and orienting as to the time of day.

Nursing Diagnosis: Ineffective individual coping related to poor cognitive skills.


1. assess and document current coping

mechanism

Strengths and problem areas are identified

and staff allowed to set realistic and staff

allowed to set realistic expectation for

behaviour

2. Patient identifies high-risk situations and

develops alternate ways.

When situation that may precipitate an

increase in symptoms are identified

strategies to avoid or decrease the

stimulus or resulting anxiety may

developed

3. Teach steps in problem solving process A step by step structure is helpful for people whose thoughts are disorganized

4. Provide practise situation to use

problem solving skills

Using skills in field test situation helps

build confidence and provide opportunities

to generalize the use of the skills.

Nursing Diagnosis: Altered thought processes related to vulnerability to increased

stress levels.


1. Assess and document mental status

and identify how symptoms interfere with

y This allows for individualized care

based upon the most dysfunctional



daily functioning symptoms

2. Provide a reality oriented milieu y An atmosphere helps correct

distortions and misperceptions of

the environment

3. Be attentive to the themes from

hallucinations

y Non-reality based thinking may

increase when anxiety level

increase

4. Be attentive to the themes from

hallucinations, and other cognitive

distortions

y Concerns or fear may be expressed

as safety

5. Provide a safe environment y Distortions in thinking may place

patients risk for injury to harm

themselves or others

6. Teach how to cope with distressing

hallucinations

y Technique such as humming, using

radio, or telling the voices to ³go

away´.

S ³dili ko ganahan naa lain tao´ as verbalized by the patient

Oy Expressed feeling of alonenessy Insecurity in publicy Inappropriate or immature interest in activitiesy Lack of family support, social groups and friendsy Lack of purpose in life

A Impaired social interaction related to altered sense or interpretation of reality or difficulty with social skills.

PShort term: At the end of 15 minutes of nursing intervention,

the patient will be able to verbalized willingness to engage in

social interactions.

Long term: At the end of 4 days, the client will be able to

indulge in activities with others in the environment.



I

1. Encouraged the client to engage in social activities that were

within the client¶s physical capabilities and tolerance level.

2. Intervened with the client demonstration hallucination and

impaired verbal communication such as engaging the client in

brief, clam social contacts throughout the day.

3. Spent brief intervals with the client each day, engaging in

meaningful, non-challenging interactions.

4. Helped the client compare the difference between social

isolation and desire for solitude or privacy.

5. Provided the client with progressive activities according to

level of tolerance and cognitive and effective functioning such

as simple group activities.E The goal was partially met since the client was able to have an

improved reality orientation but still manifests visual

hallucinations and was not able to exhibit logical organization

of thoughts.

S

O

y Anxious

y Depressed

y Frequent urination

y Dysfunctional eating pattern

y Restlessness

A Anxiety related to maladaptive reaction to a identifiablestressor

P

Short term: The patient will be able to recognize and handle

feelings of anxiety appropriately.

Long term: The patient will be able to manage anxiety-

provoking situations and develop coping skills.

1. Assisted client to recognize own anxiety



I

2. Promoted insight into anxiety and related factors.

3. Provided opportunity for learning new, adaptive coping

responses.

4. Involved client and family in educational or support activities.

E The goal was partially met since the client was able to identify

resources yet it is not used effectively.

S

Oy Discomfort

y Unpleasant odor

y Unfixed hair

y Dry skin

y Dirty nails

A Self care deficit related to perceptual or cognitiveimpairement

PShort term: At the end of 15 minutes the patient will be able to

safely perform to maximum ability self care activities.

Long term: At the end of 5 days, the patient will be able to

identify resources which are useful in optimizing autonomy and

independence.

I

1. Established rapport on the patient.

2. guided and supported the patient and let her performed the

procedure.

3. Used consistent routines and allow adequate time for patient

to complete tasks.

4. Provided privacy.

5. Provided positive reinforcement for all activities attempted.

E The goal was partially met since the patient was albe to



perform self care activities.

S

Oy Denial

y Depression

y Verbalizing inaccurate information

A Knowledge deficit related to present health condition.

PShort term: At the end of 15 minutes the patient will be able to

demonstrate motivation to learn.Long term: At the end of 5 days patient will be able to identify

perceive learning needs.

I

1. Provided physical comfort for the learner.

2. Provided an atmosphere of respect, openness, trust and

collaboration.

3. Allowed for and support self-directed, self-designed learning.

4. Assisted the learner in integrating information into daily life.

5. Encouraged questioning.

E The goal was partially met since the client was able to

verbalized understanding of learning.



IX. Medical Management

DRUG STUDYName: JR

Generic Name: AkinetonBrand Name: Biperiden

Date Ordered: December 08,2010

Classification: Antiparkinsonian

Dose/ Frequency/ Route: 2 mg/qd

Mechanism of

Action

Specific

Indication

Contraindication Side Effects/

Toxic Effects

Nursing

Precaution

Acts as an

anticholinergic,

principally in the

CNS, returning

balance to the

basal

gangliaandreducing the

severity of

rigidity,

akinesia, and

tremors,

peripheral

anticholinergic

effects help to

reduce

droolingand

other secondary

Adjunctive

therapy of

parkinsonism,

relief of

symptoms of

extrapyramidal

disorders thataccompany

phenothiazine

theraphy.

Hyper sensitivity

to drugs in those

with GI

abstruction,

narrow-angle

glaucoma,

genitourinary(GU)obstruction, and

prostatic

hypertrophy.

CNS;

disorientation,

confusion,

memory loss,

nervousness,

light

headedness,EEFT: blurred

vision,

mydriasis,

GI: dry mouth,

constipation

GU: urinary

retention,

flushing,

decreased

sweating.

y Monitor

bowel

function

and

institute a

bowel

program.y Ensure

that the pts

voids

before

taking the

drug.

y

Establishsafety

measures

if CNS or

vision



effects of

parkinsonian

changes

occur.

Generic Name: Carbamazepine

Brand Name: Carbatrol

Date ordered: December 8, 2010

Classification: Antiepileptic

Dose/ Frequency/ Route: 100mg od

Mechanism of

Action

Specific

Indication


Toxic Effects

Nursing

Precaution

Inhibits

polysynapticresponses and

blocks post-

titanic

potentiation,

mechanism of

action is not

understood,related to the

tricyclic

antidepressant.

Treatment

of refractoryseizure

disorders,

including

partial

seizures

with

complexpatterns,

tonic-clonic

seizures.

Hypersensitivity to

drugs in those withbone marrow

depression and

severe hepatic

dysfunction.

Drowsiness,

ataxia,dizziness,

nausea,

vomiting, CV

complication,

hepatitis,

hematological

disorder.

y Administer

the drug with

food.

y Monitor CBC

before and

periodically

during

therapy.

y Discontinue if skin rsh, bone

marrow

suppression

and

personality

changes

occur.



Generic Name: Haloperidol

Brand Name: Haldol


Classification: Anti psychotic

Dose/ Frequency/ Route: 50 mg BID

Mechanism of

Action

Specific

Indication


Toxic Effects

Nursing

Precaution

Blocks post

synaptic

dopamine

receptors inthe brain,

depress those

parts of the

brain involved

in wakefulness

and emesis.

Management

of psychotic

disorders.

Hypersensitivity to

drugs in those with

CNS depression,

Circulatory collapse,Parkinson¶s

disease, severe

hypotension and

bone marrow

suppression.

Drowsiness,

insomnia,

vertigo,

extrapyramidalsyndrome,

orthostatic

hypotension,

photophobia,

blurred vision,

nausea,

vomiting, drymouth, urinary

retention,

anorexia.

y Monitor

patients for

dehydration,

sedation anddecreased

thirst related

to CNS effects

can lead to

severe

dehydration.

y

Providesafety

measures

such as

siderails and

assistance

with

ambulation if

CNS effects

occur.



Generic Name: Diphenhydramine

Brand Name: Benadryl


Classification: Antihistamine

Dose/ Frequency/ Route: 50 mg

Mechanism of

Action

Specific

Indication


Toxic Effects

Nursing

Precaution

Competitively

blocks the

effects of histamine at H1

receptor sites,

has atropine-

like antipruritic

and sedative

effects.

Treat as a

nighttime

sleep aid.

Hypersensitivity to

drugs in those with

narrow- angleglaucoma, peptic

ulcer, bronchial

asthma renal or

hepatic impairment.

Drowsiness,

sedation,

dizziness,epigastric

distress

thickening of

bronchial

secretions,

urinary

frequency rash,bradycardia.

y Have the

patient void

before eachdose.

y Provide

safety

measures if

CNS effect

occurs.

y

Increasehumidity and

push fluids.



X.Prognosis and recommendation

CRITERIA GOOD

PROGNOSISPOOR

PROGNOSIS

a. ONSET OF ILLNESS ¥

b. DURATION OF ILLNESS ¥

c. PRECIPITATINGFACTORS ¥

d. MOOD and AFFECT ¥

e. ATTITUDE ANDWILLINGNESS TO TAKEMEDICATION ANDTREATMENT

¥

f. ANY DEPRESSEDFEATURES ¥

g. FAMILY SUPPORT ¥

Onset of Illness

Since when she was in her elementary years, the patient manifested gradual

changes in her personality. A poor rating was given in his aspect because it started at

early age.



Duration of Illness

The duration is persistent/ recurring since it always comes back whenever she

can¶t take her medication. Patient having auditory hallucination and manifest

circumstantialities. She was given the proper support by her family and even admitted

her in German Doctors Hospital. She was given medication and after five (5) days was

released from the hospital. A good rating given to this aspect.

Precipitating factors

JR¶s illness according to her mother started when she was 11 years old due to

traumatic experiences. They transfer 3 times and all houses were burned down. She

started to manifest the symptoms after the incident, stated by the informant. A poor

rating was given to this aspect.

Mood and affect

Our patient was cooperative, coherent and participates in all our visits. She was

able to answer our questions and even told us her story since her younger age. A good

rating was given to this aspect.

Attitude and willingness to take medication

She is willing to take her medications and treatment, and even willing to go to her

doctor for check up. A good rating was given to this aspect.

Any depressive features

Patient doesn¶t manifest any depressive symptoms. She doesn¶t know how to

cope up with her sadness. A poor rating was given to this aspect.

Family support

The family gives her proper support and care, but her mother only shows more

affection to the patient. A good rating was given to this aspect.



Recommendation

After five (5) days of exposure and interaction with JR and with the data gathered

through direct observation, an interview with the patient and information gathered from

her significant others. The group A4 therefore concludes and recommends the family to

recognize and reinforce steps in terms of her social, cognitive, behavioral, and

psychological achievements that the client need to overtime.

Treat the patient as a normal individual.

Family should be sensitive with the clients needs and develop a honest and

genuine mental relationship with the patient.

The patient will promote good hygiene and consistently appear clean and well

groomed.

Never give false assurance to the patient. Avoid stressful situations.

Support for family members is important. As ordered by the patients JR¶s

physician the guardian of the patient should get her medications in German

Doctors Hospital in order to stabilized patients current health status.



XI.Bibliography

y Videbeck, Sheila L., Psychiatric Mental Health Nursing, Lippincott Williams and Wilkins,2001.

y American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders(4th ed.). Washington , DC :APA

y Corrigan, P.W., and Storbach, D.M (1993). Behavioral interventions for alleviatingpsychotic symptoms. Hospital and community psychiatry, 44(4), 341-346

y Cooper, K.H (1984). Territorial Behavior among the institutionalized: A nursingperspective. Journal of Psychiatric Nursing, 22(12)6-12

y Doenges, M., and Moorehouse, M. (1998). Nursing diagnosis with interventions.Philadelphia , .PA: Davis

y Hamera, E.et al.(1992). Teaching hospitalized patients with serious, persistent mental

illness. Journal of Psychiatric Nursing, 6(6), 324-330

a4 final psyche cp

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