Introwww

Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic patients are typi-cally unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming.  There are 5 subtypes of schizophrenia naming; paranoid, disorganized, catatonic,undifferentiated, and residual.

The prevalence of schizophrenia is thought to be about 1% of the population around the world; it is thus more common than diabetes, Alzheimer's disease, or multiple sclerosis. In the United States and Canada, patients with schizophrenia fill about 25% of all hospital beds. The disorder is considered to be one of the top ten causes of long-term disability worldwide.About 1.5million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net).Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americanssuffer from schizophrenia; fifty percent (50%) experi-ence serious side effects from medications;and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of86,241,697 of Filipinos or ap-proximately 0.8% are suffering from schizophrenia(cureresearch.com).

Schizophrenia Ranks among the top 10 causes of disability in developed countriesworldwide (World Health Organization, www.who.int) Schizophrenia is a dis-ease that typicallybegins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophreniaslightly earlier than women; whereas most males become ill between 16 and 25 years old, mostfemales develop symptoms several years later, and the incidence in women is noticeably higher inwomen after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onsetis quite rare for peo-ple under 10 years of age, or over 40 years of age (schizophrenia.com).

The undifferentiated subtype is diagnosed when people have symptoms of schizophre-nia that are not sufficiently formed or specific enough to permit classification of the ill-ness into one of the other subtypes.

The symptoms of any one person can fluctuate at different points in time, resulting in uncertainty as to the correct subtype classification. Other people will exhibit symp-toms that are remarkably stable over time but still may not fit one of the typical sub-type pictures. In either instance, diagnosis of the undifferentiated subtype may best describe the mixed clinical syndrome.

Smoking is a common problem for patients with schizophrenia. The increased ten-dency of patients diagnosed with this disorder is to not only smoke, but to do so more heavily than the general public. This raises the possibility that nicotine may be acting as a treatment for some symptoms of schizophrenia.

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

OBJECTIVES

Nurse-centered

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

evaluated the developmental stage of the patient according to the theories of Erikson, Freud

and Piaget;

determined the etiologic factors (precipitating and predisposing) of the mental disorder;

evaluated the presence or absence of signs and symptoms seen in the patient in relation to the

mental disorder;

presented the psychodynamics of the client’s diagnosis by recognizing its pre-disposing andprecipitating factors with appropriate rationales; To track down the significant eventsduring the client’s developmental stage as shown in the psychodynamics;

Interpreted and analyzed nurse-patient interaction taken through spontaneous and effective use

of therapeutic communication;

formulated effective, specific, measurable, attainable, realistic and time-bounded nursing

care plans base on identified actual and potential nursing problems;

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

2

Patient-centered

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

PATIENT’S DATAPERSONAL DATA:CODE NAME: BobAGE: 40SEX: MaleBIRTHDAY: April 9, 1969BIRTHPLACE: Cagayan de Oro CityADDRESS: Prk. 1 Rizalian, Bayugan Agusan del Sur

Tulip Drive, Matina, Davao cityORDINAL RANK: 1stCIVIL STATUS: SingleNATIONALITY: FilipinoRELIGION: CatholicEDUCATIONAL ATTAINMENT: 2nd Year College undergraduateOCCUPATION: NoneNUMBER OF CHILDREN: 0NUMBER OF BROTHERS: 2 NUMBER OF SISTERS: 2MOTHER: AinaAGE: 58EDUCATIONAL ATTAINEMNT: college undergraduateOCCUPATION: BusinesswomanFATHER: DanniEDUCAIONAL ATTAINMENT: college undergraduateOCCUPATION: BusinessmanCLINICAL DATA:WARD/SERVICE: Crisis Intervention Unit/PsychiatryADMITTING PHYSICIAN: GIOIA FE D. DINGLASAN, M.DADMITTING DIAGNOSIS: Schizophrenia, undifferentiatedPRINCIPAL DIAGNOSIS: Schizophrenia, undifferentiatedDATE OF AMISSION: January 19, 2010DATE OF DISCHARGE: January 21, 2010INSTITUTION: Davao Mental Hospital

3

4

A. FAMILY HISTORYa. Maternal and Paternal Lineage

Direct bilateral lineage of the patient show no conditions of mental illness. On the paternal side, prominent family illnesses only concern some members hav-ing hypertension. Aside from the condition, no other illnesses run the family. On the maternal line, no illness were reported to run in the family, except one fam-ily member having diabetes mellitus type 2, an illness condition occurring sin-gularly to be considered familial. Generally, no mental illness can be traced on both sides of the family.

b. FatherThe father is 59 years old; a known small time businessman in their place at

Agusan; owning a small rice mill enough to support the needs of his family. He is a Civil Engineering Undergraduate and was able to finish only until 3 rd year of the above course, due to his early fatherly obligation. He impregnated the pa-tient’s mother, when he was only 19 years old, then eloped with her, thwarting him to finish his studies then at the University of Mindanao.

As a father, he was lenient in his relationship with his children. Most of his time is spent in their rice mill and would only go home in the afternoon or at night. Moreover, he is a kind of father who would not spank or scold his children and he seldom verbalizes what he feels. He would only speak to his children wherever they do something incorrect.

c. MotherThe mother helps in their small rice mill. Pregnant at the age of 18, she was

unable to finish her college education at the University of Mindanao. She was in her second year in college when she dropped out of her Chemical Engineering course.

The mother says that she brought her children up in discipline and love; she said she doesn’t spank her children because it does them no good. Like the fa-ther, she doesn’t also believe in punishing her children through spanking and the like when they do something wrong.

However, as she states, she left her children to the care of nannies when they were young. And put her children in their house in Davao City to pursue their education from elementary school, leaving them, still with a nanny, and visiting them once a week. According to her, this is the best way for her to offer the best education and life to her children and help improve their business in Agusan.

d. SiblingsThe family is composed of five siblings; Bob being the eldest, followed by

the second informant, Emman, then by Carmz, Denns and then Yose .

5

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

III. Personality Historya.) Prenatal

Being the result of the early pregnancy of his mother, the patient was an unexpected child. Only 18 when she was impregnated, the mother was not ready and did not know what to do, so she eloped with the patient’s fa-ther without giving her parents the knowledge as to the reason why she ran away. The mother stayed with the father’s family in Cagayan for the whole duration of her pregnancy.

On course of nine months, the mother has adequate prenatal check-ups at a nearby health center. Moreover, she was able to eat adequately be-cause the parents of her husband supported them. They provided her with enough support for her pregnancy.b. Birth

Bob was born in the Provincial Hospital in Cagayan de Oro City on the 9th of April 1969 through Normal Spontaneous Vaginal Delivery. No compli-cations took place in the delivery. The mother, Aina, described that her la-bor was very long, she started having labor pains in the morning and deliv-ered in the afternoon. She did not also breastfeed the patient because she is having pain breastfeeding him and as reported, no breast milk would come out; so instead, she bottle fed the patient with a formula milk in a timed manner. Moreover, she hired a nanny named Nena to look after the baby because she did not have any experience in taking care of a baby, consider-ing her age.c. Infancy and Childhood Characteristics

After the birth, in June of 1969 Aina went back to Agusan to talk to her parents. She told them that she ran away because she was pregnant and apologized for everything that she has done. Her parents did accept her apology and welcomed her back. On the August of 1969, Aina and Danni married each other and decided to reside in Agusan. Trying their luck in a new business, the couple got busy with their rice mill that they decided to leave Bob in the care of Nena, Bob’s nanny since birth, while they attend to their business.

The nanny was very caring to the child, cuddling him always and looking after him. However, when Bob was almost five months, Nena went home to her province and was replaced by another nanny named Ging-ging.

6

Moreover, Aina instructed her nanny to continue the timed bottle feeding routine every three hours, a routine which continued until the pa-tient was three years old. She instructed to feed the baby every three hours, believing that this would help the nanny attend to other tasks while taking care of the baby. In cases that the baby would cry Ging-ging would just give him a pacifier for him to stop crying.

Bob was toilet trained when he was 2 years old. Toilet training was mostly implemented by the nanny Ging-ging, and she is not strict in it. As he had a nanny, Aina instructed the Ging-ging to teach him to urinate and defecate in a potty because it irritates her to find urine and stool just any-where. Aina is very strict in toilet training. But on instances that Bob would pee or defecate anywhere, Ging-ging would just clean the mess, not correct-ing Bob. Bob started talking when he was a year old and started walking on that certain age more or less as reported.

As to the strategies and the relationship of the nanny to the child, the mother did not exactly describe because according to her, she changed nannies several times. According to her, the relationship of the nanny was not so important to her as long as the needs of her children are met and her children’s safety is not harmed. She carefully instructed the nannies to give to the children everything they want to keep them from having tantrums that could hinder the nanny from doing other household chores.

The mother could not remember whether or not the patient’s immu-nization is complete; but what she does remember is that the patient had measles before he was one year old.

d. Psychosexual HistoryThe patient’s sexual awareness started when he was 16 years old, on his 4th

year in high school. It was on this time that he started having a crush and actu-ally had a girlfriend who after sometime broke up with him. This break-up with his only girlfriend bagged down his self esteem. In addition, his mother also keeps on teasinf him that his girlfriend’s teeth resembles that of a rat which further decreased his self-confidence and esteem as he tried to compare him-self with the boys of his age.

In his adolescence, he also engages in sexual activities with GROs.e. Play Life

Bob does not engage so much in cooperative play and prefers solitary play. He would only sit by himself and play alone in a corner. His playmates were his siblings and would choose to play only in their yard. As a child, he is not talka-tive, he is uncooperative and becomes aggressive when forced to play with other kids. Furthermore, he likes being a follower in a game rather than a leader.

f. School HistoryThe patient began preschool in June of 1974, when he was five years old

where he was sent to Davao to study at Assumption up to second grade. He stayed in their residence in Davao which is in 162, Interior Tulip Drive, Matina,

7

Davao City. He stayed in Davao together with his brother Emman and their nanny. The first days in school were terrible for Bob, he would cry inside their classroom and would not separate from his nanny. In his third grade, he was transferred to Our Lady of Fatima School, which he did not really approve that he cries in between classes just to be sent home. He is withdrawn from the rest of his classmates and would talk only to a few people. His grades were also af-fected by his isolation, he did not perform well in school and was not interested in studying.

He spent his high school days still at Fatima. In June of 1982, when he is 13 years old, he entered first year highschool, where he formed new set of friends which he grew much attached to. These friends of him were not of good influ-ence because when they started hanging out, he began cutting classes, extort-ing money from his parents and having low grades. He started drinking and smoking. Also, he started using marijuana.

His bad school records started worsening when his girlfriend in his fourth year high school broke up with him, these events pulled his confidence down, that he started isolating himself and increased his use of marijuana, drinking and smoking. Yet he is able to graduate from high school in the March of 1986.

Troubles in school were rampant, being evident even when he is already in college. He was occasionally caught brawling with classmates. Furthermore, his mother was once called by the Guidance Office because he threw an eraser to his teacher because the eraser hit him when the teacher threw the eraser at his classmate. He was also suspected of using marijuana during this time but is persistently denying the accusations, although it was really true. Peer pressure can be seen as a great contributing factor in his use of marijuana because his friends would tease him when he refuses to use marijuana.

In his college days, he spent his two years of college education at the Uni -versity

of Mindanao, in the Civil Engineering course. However, he did not have good grades and still continued cutting classes and indulging in his vices. On his sec-ond year, he finally decided to stop, claiming that he is already having difficulty catching up with the lessons.

g. Religious and Social AdaptabilityThe family is Roman Catholic. However, when he was in college, their family

converted to Seventh-day Adventists. However, the patient still follows the Catholic Faith and does not go to Seventh-day Adventist religious celebrations.

h. Occupational HistoryWhen the patient stopped studying during his second year in college, late in

the August of 1987, he stayed in Agusan and helped in their rice mill business. There, he would help in the loading and unloading sacks of rice and also in op-erating the mill. Bob doesn’t get regular salary because what he gets is ten per-cent of the day’s income.

i. Marital History

8

The patient is single. However, he is looking forward to marrying someday. According to his verbalizations, he wants to be married so badly that he would even marry their maid at home. According to him, he already told the maid that he wanted to marry her, but unfortunately, after telling her, the maid ran away.

j. Onset of the present illnessThe recent admission is already the third admission of Bob. Recurrence of

hostile behavior is the primary reason why Bob was admitted for three days in the CIU of Davao Mental Hospital. He suddenly shouted at a doctor in the hospi-tal upon having his monthly depot injection and check-up.

9

THEORIES OF DEVELOPMENT

These are just a few of the fascinating aspects of the field of “human development”: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each theory has its own perspective on the development of man.

ERIK ERIKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future.

LIFE STAGE INDICATORS OF POSITIVE RESOLUTION

INDICATORS OF NEGATIVE RESOLUTION

ASSESSMENT JUSTIFICATION

Middle Adulthood ( 35 to 65 years)Central task: Generativity vs. StagnationDuring middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by

Working towards the betterment of the society; being productive

Lack of productivity; not helping society to move forward

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

10

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

in worsening his illness. He has no own family to support that’s why he wasted his money for his own wants.

When he had free time, he went to the plazas or parks to eat or drink. He also loves to watch television shows. The client also adapt to his physical changes in his body and accepted this as part of him, about his disease, he hasn’t understand this fully and needs further explanation for him to understand. And as a Filipino citizen, he has done his part in becoming a good citizen, he is a registered voter and planned to vote for Noynoy Aquino in the coming election period, in a way he’s being productive because he has done his duty for

11

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

SIGMUND FREUD’S PSYCHOSEXUAL THEORYThe concept posits that from birth human have intellectual sexual appetites

(libido) which unfold in a series of stages. Each stage is characterized by erogenous zone that is the source of libidinal drive during that certain stage.LIFE STAGE CHARACTERISTICS IMPLICATIONS ASSESSMENT JUSTIFICATION

Genital (puberty and after)

Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment.

Encourage separation from parents, being independent and able to make right and good decisions

NOT ACHIEVED

He is not independent, until now , he still lives with his parents and being dependent to them, especially when it comes to his basic needs and as well as to meet his personal needs to gratify his desires, like asking money to have sexual gratification together with

12

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

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENTThis theory pertains to the nature and development of human intelligence.

LIFE STAGE CHARACTERISTICS ASSESSMENT JUSTIFICATIONFormal Operational Thought (12 years and above)

The person is capable of de-ductive and hy-pothetical rea-soning.

The logical qual-ity of the ado-lescent's thought is when children are more likely to solve problems in a trial-and-er-ror fashion.

During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs and val-ues.

During this stage the young adult begins to entertain possi-bilities for the future and is fascinated with what they can

ACHIEVED During this stage, the client was able to understand what love means .He shared about his plans about getting married in the future if given a chance; he really wanted to marry their helper, according to him. Though he never courted the girl, he just directly asked her to marry him but the woman refused to answer him and went home to their hometown.In addition to that, when asked, “Kung makakita ka ug pitaka na punog kwarta, unsaon man nimo ang pitaka, iuli o gastuhon ang kwarta?”; he then replied “Iuli nako,

13

be. At this stage,

they can also reason logically and draw con-clusion from what informa-tion is available.

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

14

MENTAL STATUS EXAMINATION

INITIALName: Bob Diagnosis: Schizophrenia UndifferentiatedAge: 40 years old Physician: Gioia Fe D, Dinglasan, MDWard: Crisis Intervention Unit Date of Examination: January 21, 2009

I. PRESENTATIONA. General Apperance

The patient appears to be younger than his real age which is 40. During the interview at Crisis Intervention Unit in Davao Mental Hospital, he wore a green polo shirt, denim shorts, and a pair of slippers and is seated on bed with his mother and sister-in-law. The patient appears to be untidy. He has dirty clothing, unkempt hair, long fingernails and toe-nails with traces of dirt evidently seen on both. At the time of the inter-view, the patient was alert and responsive.

B. General Mobilitya. Posture and Gait – The patient slouches when seated but holds

himself erect when standing and walking. His mannerisms include manually hyper extending his fingers and scratching his head.

b. Activity – The patient’s movement are organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity.

c. Facial Expression – The patient’s facial expressions are very much appropriate to his verbal responses during the interview. He was composed and receptive to whatever the group asks him.

C. BehaviorThe patient was friendly and warm to us during the interview. He was sit-ting on bed calmly. He interacts well with the group and as what we had observed; he has a good relationship with his mother and his sister-in-law who were present at that time.

D. Attitude towards the Examiner The patient accepted the group warmly. He entertained our questions and answered almost all of them. However, his eye contact was poor. He often looks down.

II. STREAM OF TALKA. Characteristic of Talk – During our conversation with the patient, we no-

ticed that he is spontaneous most of the time. However, there are times in which blocking is evident in between his speech. His articulation words were clear but the content is slightly vague.

B. Organization of Talk – The patient was eager to talk with the group. He tries to answer every question the group asks him however, in his an-swers, we apparently observe succession of circumstantiality and tan-

15

gentiality. He provides an excessive amount of irrelevant detail before fi-nally arriving at the answer, or at times, he doesn’t arrive at the answer at all.

III. EMOTIONAL STATES AND REACTIONA. Mood – At the course of the interview, the patient’s mood was euthymic.

His feelings were appropriate to the situations as he relays his answers to the group. His mood was just appropriate and basing from his gestures and other nonverbal cues, his mood is fitting to the situation.

B. Affect – The patient’s affect is appropriate as well. There is a marked har-mony between thought content, emotional response, and expressive-ness. When asked, “Unsa may nabati nimu kadtong nagka-uyab mo?”, he replied, “Lipay kaayo ui. Alangan. Kaw gud daw magka uyab.” with a smile.

IV. THOUGHT CONTROLA. Perceptions – Throughout the interview, the group observed manifesta-

tions of illusions and hallucinations. When the patient was asked if he ex-periences any of the two, he told us that there are times that he hears someone whispering to him. “Naa may gahong-hong sa ako usahay na mag wild daw ko.”, as claimed by the patient. He denied that he had any visual hallucinations however, the mother and the sister-in-law attested that during tantrums, the patient verbalizes that he sees someone whom they cannot see.

B. Delusion – There are several types of delusions that are present in the patient as claimed by the patient himself, and confirmed by the mother who witnessed them all. First, the patient claimed that there is some sort of outside force controlling his thought, compelling him into the belief that somebody has aa plan to kill him – which is a clear sign of persecu-tory delusion. He also has a feeling that others, especially his friends, hate him because they are jealous of him.

V. NEUROVEGETATIVE STATEA. Sleep

The patient usually sleeps at 12 in the midnight and usually wakes up at 5am getting at least 5 hours of sleep. He says that he finds it hard to sleep at night and instead, he just spends his time watching television until he falls asleep. Five in the morning for the patient is too early for him to wake up that is why he attempts to go back to sleep, but then, he is unable to do such. This is a manifestation of late or terminal insomnia.

B. AppetiteThe patient has increased appetite. He eats a lot however, he is choosy in his food. “Ganahan man gud ko mukaon samot na kung lami ang sud-an.”, reported by the patient. “Kusog kaayo mukaon nang bataa na, pero pili-an lang jud ug sud-an.”, as verbalized by his mother.

C. Diurnal Variation

16

The patient’s mood varies during the day. He is usually fine in the morn-ing and gets, uneasy, restless, and irritable as the day progresses. Other times, his day starts out worse in the morning and feels better later on.

VI. GENERAL SENSORIUM AND INTELLECTUAL STATUSA. Orientation

The patient is well oriented of the time, place and person. When asked during the interview if what date and time was it, he answered correctly. However, as the conversation progressed, we noticed that he is confused and not well oriented with the time. When asked, when did he last used marijuana, he answered, “Two months ago. Mga 2008.” The group finds this statement confusing since two months ago, basing on the date of the interview, is around November of last year (2009). The patient is also oriented with the situation since he knows that he is the Davao Mental Hospital for his treatment.

B. MemoryThe patient has difficulty recalling remote memories. When asked what his age when he went to Bukidnon was, he replied; “Ambot lang. Wala ko kahinumdom.” On the other hand, the patient has a good memory when it comes to remembering recent and immediate memories.

C. CalculationThe patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and the like. He was able to answer all of them but there we long pauses before he can finally give the answer.

D. General InformationThe patient knows basic general information like the current president of the Philippines and even of the United States. He know the capital of some Philippine provinces and he was able to name the national hero of the country.

E. Abstract Thinking, Judgement and ReasoningThe patient was given a maxim translated in Visaya to evaluate his rea-soning and abstract thinking. He was asked to explain the quote Try and try until you succeed. He was able to explain it but not profoundly. He said, “Maningkamot gud.” And when asked to elaborate, he refused to. He was also given a situation wherein someone left her wallet, and he was asked what he should do. He replied, “Akong i-uli. Di man na akoa so dapat nako i-uli.”

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

17

NURSING CARE PLANTIME AND DATE

CUES NEED NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

January 21, 2009 @ 12:30 P.M.

SUBJECTIVE:“Naay nagahung-hung sa akoa usahay nga mag-wild daw ko ug maglagot” as verbalized by the patient

OBJECTIVE Disoriented

to time Auditory

and visual hallucina-tions

Misinter-prets ac-tions of others

Inability to make sim-ple deci-sions

Inappropri-ate re-sponses

COGNITIVE-PERCEPTUAL

PATTERN

Disturbed sensory perception related to alteration in function of brain tissue

®It is the change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

Schultz, M.J.;Videback, S.L.; Lippincott’s Manual of Psychiatric

At the end of 2 hours of nursing care, the patient will be able to

maintain orientation to time, place, per-son, and circum-stances for specified period of time;

demon-strate accu-rate per-ception of the envi-ronment by responding appropri-ately to stimuli in the sur-roundings; and

lessen vis-ual and au-

1. Establish rapport and build trust with the client

® The client must trust the nurse be-fore talking about hallucinations and other sensory-per-ceptual alterations

2. Continuously ori-ent the client to actual environ-mental events or activities in a non-challenging way.®Brief, frequent orientation helps to present reality to the client with sensory-percep-tion disturbance

3. Reinforce and fo-cus on reality. Talk about real events and real people. Use real situations and events to di-vert client from long, tedious,

January 21, 2009 @ 2:30 PM

GOAL UNMET

The pa-tient was able to main-tain orienta-tion to time, place, person and situa-tion. “Huwebes karon. Mga udto na man siguro. Naa ko sa Mental hospital para magpacheck-up”

How-ever, the client was not able to demonstrate accurate per-ception of

18

Nursing Care Plans 7th

edition

ditory hallu-cinations repetitive verbal-

izations of false ideas® Working with reality lessens pa-tient’s initiation of his hallucinations.

4. Correct client's de-scription of inac-curate perception, and describe the situation as it ex-ists in reality® Explanation of,

and participation in, real situations and real activities interferes with the ability to respond to hallucinations.

5. Observe for verbal and nonverbal be-haviors associated with hallucinations® Early recogni-tion of sensory-perceptual distur-bance promotes timely interven-tions and allevia-tion of the client’s

the environ-ment as evi-denced by the presence of delusion and halluci-nation

Pres-ence of audi-tory halluci-nation is still evident.

19

symptoms.6. Describe the hallu-

cinatory behaviors to the client.® The client may be unable to dis-close perceptions and the nurse can openly facilitate disclosure by re-flecting on obser-vations of the client’s behaviors, which helps the client engage in more open discus-sion with the nurse, which in it-self brings relief.

7. Explore the con-tent of hallucina-tions to determine the possibility to harm self, others or the environ-ment® Exploring the content of the hal-lucination helps the nurse identify if the sensory-per-ceptual distur-

20

bance is threaten-ing or dangerous to the client, such as a command type of hallucina-tion that may be telling the client to harm or kill the client or others. The nurse can then reinforce treatment and safety precau-tions.

8. Use clear, direct, verbal communi-cation rather than unclear or nonver-bal gestures®Unclear direc-tions or instruc-tions can confuse the client and pro-mote distorted perceptions or misinterpretations of reality.

9. Modify the client’s environment to decrease situa-tions that provoke

21

anxiety®Decreased anxi-ety can reduce the occurrence of hal-lucinations

10.Reassure the client (frequently if necessary) that the client is safe and will not be harmed®Alleviation of fear is necessary for the client to begin to trust the environment and to feel safe.

22

TIME AND DATE

CUES NEED NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

January 21, 2009 @ 7:00 A.M

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

OBJECTIVE Delusion of

persecution Delusion of

paranoia Thought inser-

tion Incoherent

speech Demonstrates

a disturbance in sleep pat-tern

Presence of au-ditory halluci-nations

COGNITIVE-PERCEPTUAL

PATTERN

Disturbed thought process related to disintegration thinking.

®It is the disruption in cognitive operations and activities. Cognitive processes include those mental processes by which knowledge is acquired. These mental processes include reality orientation, comprehension, awareness, and

At the end of 2 hours of nursing care, the patient will be able to

Maintain reality orienta-tion;

Demon-strate re-ality based thinking in verbal and non-verbal behavior; and

Demon-strate the ability to abstract, conceptu-alize, rea-son and calculate consis-tent with ability to

1. Be sincere and honest when communicating with the client.

®Clients are ex-tremely sensi-tive about oth-ers and can rec-ognize insincer-ity. Evasive re-marks reinforce mistrust.

2. Assess client’s nonverbal be-havior, such as gestures, facial expression and posture.

®This assess-ment may help to meet the client’s needs that cannot be conveyed through speech.

3. Encourage the

January 21, 2009 @ 12:30 PM

GOAL PARTIALLY MET

The client was able to main-tain real-ity orien-tation. He is ori-ented to time when asked what day it is. But he is still preoccu-pied with his delu-sions about his being jealous to him

The client

23

judgment. A disruption in these mental processes may lead to inaccurate interpretations of the environment and may result in an inability to evaluate reality accurately. Alterations in thought processes are not limited to any one age group, gender, or clinical problem.(http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=53.01)

client to express feelings and do not pry cross ex-amine for infor-mation

®Probing in-creases client’s suspicion and interferes with the therapeutic relationship

4. Show empathy to the client’s feelings, reas-sure the client of your pres-ence and accep-tance

®The client’s experiences can be distressing. Empathy con-veys acceptance of the client your caring and interest.

5. Avoid laughing, whispering, or talking quietly

was not able to demon-strate re-ality-based thinking in verbal and non-verbal re-sponses. His man-nerism is largely observed and he wasn’t able to establish eye con-tact with any of the inter-viewer.

However, he was able to exhibit a positive abstract, reason, judgment and calcu-

24

where client can see but not hear what is being said.

®Suspicious clients often be-lieve others are discussing them, and se-cretive behav-iors reinforce the paranoid feelings.

6. Give simple di-rections using short words and simple sen-tences.

® Giving simple directions lessen or prevent con-fusion of the pa-tient

7. Never convey to the client that his delusions and hallucina-tions are real

lation abilities.

25

®The delusion or hallucination would be rein-force if it’s ac-cepted.

8. Maintain reality oriented rela-tionship and en-vironment

® Maintaining reality based re-lationship and environment lets the patient know that the relationship is temporary and prevents sepa-ration anxiety

9. Give positive feedbacks and acknowledge the client

®Positive feed-back enhances sense of well-being and makes a more positive situa-

26

tion for the client.

10.Do not judge or belittle client’s beliefs.

®What the client feels or thinks is not funny for him. The client may feel rejected if approached by attempts of hu-mor.

27

TIME AND DATE

CUES NEED NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

.January 21, 2010 @ 12:30 PM

SUBJECTIVE:“Maulaw man gyud ko basta ing-ana”

OBJECTIVE: Lacking eye

contact Lack social in-

teraction Has little inter-

est in activities Talks only

when asked

SELF-PERCEPTION

Situational low self-esteem related to cognitive impairment

It is the state in which an individual who previously had positive self-esteem experience a negative feeling towards self due to a certain situation

Handbook of Nursing Diagnosis by Lynda Juall Carpenito-Muyet

At the end of 2 hours of nursing care, the pa-tient will:

Verbalize under-standing of things that pre-cipitate current situation; and

Demon-strate be-haviors that show positive self-es-teem

1. Encourage client to express hon-est feelings in relation to loss of prior level of functioning. Ac-knowledge pain of loss. Support client through process of griev-ing.

® Client may be fixed in anger stage of grieving process, which is turned inward on the self, resulting in diminished self-esteem.

2. Devise methods for assisting client to express feelings prop-erly..

® To explore

January 21, 2010 @ 2:30 PM

GOAL UNMET

The pa-tient was un-able to ver-balize under-standing of things that lead to cur-rent situation

The pa-tient was un-able to demonstrate behaviors that show positive self-esteem as evidenced by inability to have an eye-contact as well as look-ing down at during the in-terview.

28

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

3. Encourage client's attempts to communi-cate. If verbal-izations are not understandable, express to client what you think he or she in-tended to say. It may be neces-sary to reorient client fre-quently.

® The ability to communicate effectively with others may enhance self-esteem.

29

4. Encourage remi-niscence and discussion of life review. Also dis-cuss present-day events. Sharing picture albums, if possi-ble, is especially good. ® Remi-niscence and life review help the client re-sume progres-sion through the grief process as-sociated with disappointing life events and increase self-es-teem as suc-cesses are re-viewed.

5. Encourage par-ticipation in group activities. Caregiver may need to accom-pany client at first, until he or she feels secure that the group

30

members will be accepting, re-gardless of limi-tations in verbal communication.

® Positive feedback from group members will increase self-esteem.

6. Offer support and empathy when client ex-presses embar-rassment at in-ability to re-member people, events, and places. ® Focus on accomplish-ments to lift self-esteem.

7. Encourage client to be as inde-pendent as pos-sible in self-care activities.

® The ability to perform independently

31

preserves self-esteem.

8. Listen to pa-tient’s concerns and verbaliza-tions without comment or judgment.

®It enables the client to develop trust and thereby establish communication

9. Provide feed-back to client’s negative feel-ings.

®To allow the client experience a different view.

32

TIME AND DATE

CUES NEED NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

January 21, 2010 @12:30 PM

SUBJECTIVE:The clarified when exactly was the 2 months he was referring about his last used of marijuana, he verbalized “Kadtong 2007 man to, aw 2008 diay”

OBHECTIVE: Disorientation

to time Observed ex-

perience of forgetting

Scratches his head when he is unable to recall infor-mation

Inability to determine if a behavior is performe

COGNITIVE-PERCEPTUAL

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

At the end of 3 day nursing care, the patient will be able to:

Verbalize aware-ness of memory prob-lems; and

Accept limita-tions of current condition

1. Provide opportu-nities for remi-niscence or re-call past events®Long-term memory may persist after loss of recent mem-ory. Reminis-cence is usually an enjoyable ac-tivity for the client.

2. Encourage the client to use written cues such as calen-dars or note-books®Written cues decrease the client’s need to recall activities, plans and so on from memory.

3. Encourage ven-tilation of feel-ings of frustra-tion, helpless-

January 21, 2010 @ 2:30 PM

GOAL MET The pa-

tient was able to verbalize aware-ness of memory problems as he verbal-ized “Us-ahay gyud makalimot na ko”

The pa-tient was able to verbalize accep-tance of his limi-tations due to his condi-

33

memories. ness, and so forth. Refocus attention to ar-eas of focus and progress.®To lessen feel-ings of power-lessness/hope-lessness

4. Provide for proper pacing of activities and having appropri-ate rest®To avoid fa-tigue

5. Allow the client to do tasks on his own, but do not rush him to do it. Make the client feel that he can still do things indepen-dently.®It is important to maximize in-dependent func-tion, assist the client when memory has de-teriorated fur-ther.

tions

34

6. Assist the client deal with func-tional limitations and identify re-sources.®To meet indi-vidual needs, maximizing in-dependence.

7. Provide single step instructions when instruc-tions are needed.®Client with memory impair-ment cannot re-member multi-step instructions

8. Do not contra-dict the client who experi-ences an illu-sion. Instead, simply explain reality, and find some practical solutions to the problem®Therapeutic responses pro-mote reality while offering

35

solutions that help enhances the client’s sense and may reduce fear, anxiety, and confusion.

9. Monitor client’s behavior and as-sist in use of stress-manage-ment tech-niques®To reduce frustration

10.Determine client’s re-sponse to medi-cation medica-tions prescribe to improve at-tention, concen-tration, memory process and to lift spirits and modify emo-tional re-sponses.®Helpful in de-ciding whether quality of life is improved when using the medi-

36

cations pre-scribed.

TIME AND DATE

CUES NEED NURSING DIAGNOSIS

GOAL OF CARE INTERVENTIONS EVALUATION

January 21, 2010 @ 12:30 P.M.

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

OBJECTIVE:Unkempt hair notedfood stains visible on clothinguntrimmed fingernails and toenails with visible dirt noted

ACTIVITY-EXERCISE

PATTERN

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

After 2 hours of nursing care, the client will be able to:

a) verbalize self care need

b) Demon-strate tech-niques to meet self-care needs

1. Establish rapport.

R: to gain client’s trust and facili-tate a good working rela-tionship.

2. Identify reason for difficulty in self-care.

R: underlying cause affects choice of interventions/ strategies.

3. Determine hygienic needs and provide assistance as needed with activities like care of nails and brushing teeth.

R: basic hygienic needs may be forgotten.

4. Discuss on

January 21, 2009 @ 2:30 PM

GOAL PARTIALLY MET

After 2 hours of nursing care, the client was able to:

a) verbalize self care need

b) but was unable to demon-strate tech-niques to meet self-care needs.

37

importance of hygiene.

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

5. Orient client to different equipment for self-care like various toiletries.

R: increases the client’s aware-ness of different materials for self-care.

6. Let the patient enumerate his ideas on the im-portance of hy-giene.

R: Encourages the patient to un-derstand the need for hy-giene.

7. Discuss the pos-sible negative implications of not taking a

38

bath such as in-fections and odor.

R: Broadens the pa-tient’s idea about the prob-lem and encour-ages him to meet the need.

8. Encourage client to perform self-care to the maximum of ability as defined by the client. Do not rush client.

R: promotes inde-pendence and sense of control, may decrease feelings of help-lessness.

9. Allot plenty of time to perform tasks.

R: cognitive impair-ment may inter-fere with ability to manage even simple activi-

39

ties.

10.Assist with dressing neatly or provide colorful clothes.

R: Enhances es-teem and con-vey aliveness.

40

RECOMMENDATIONThe group 1 of section 3H would like to recommend the following:

To the patient: He is advised to take part in complying with the treatment; the medication and

therapeutic regimen designed for his rehabilitation. He should realize the importance of complying with his medication and the benefits this practice would bring to the improvement of his well-being.

To the patient’s family: The patient’s family plays an important role in the patient’s mental illness and recovery. The family should make themselves physically present so that the patient would feel their support and concern. They are encouraged to continue interacting with the patient so that ideas of violence towards self and others will be diverted. In addition, it is of prime importance that they are oriented and educated regarding the patient’s mental illness so that they will understand him even better and assist him in his daily activities.

To the Ateneo de Davao University- College of Nursing:The faculty and staff are encouraged to continue improving the standards of the

Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be equipped with the knowledge and skill that they may impart to student nurses. They are challenged to not just teach but impart to us as well nursing experiences that we may apply in the course of caring for our future patients.

To the Davao Mental Hospital: The group recommends that they should improve their facilities in treating the

mentally-ill patients, because still they deserve due treatment. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must provide a safe and therapeutic environment to the patients and staff. Address the needs of each patient by first assessing the level of severity of the patient’s condition; let every patient be submitted for history and physical examination and be evaluated by a psychiatrist, so that appropriate care is rendered to them. The proponents recommend that the psychiatric team would work together in order to provide mental health care service that promotes rehabilitation of the patient. Also they are recommended to know the latest trends in improving therapeutic communication between them and the patients.

To the student nurses: Even if nursing students find it difficult to establish therapeutic relationships

with mentally-ill patients because of the relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to our patients; and improve

41

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

42

REFERENCES 1. DSM-IV-TR.4th edition. American Psychiatric Association. Book promotion and

services Ltd.2. Handbook of Psychodiagnostic Testing by Kellerman and Burry3. Kozier. Fundamentals of Nursing 6th edition.4. Keltner, Psychiatric Nursing 5th Edition.5. Drug & Drug Abuse. 2nd edition. Addiction research oundation by Cox et. Al6. Lippincott’s Manual of Psychiatric Nursing care Plans. 7th edition by Schultz and

Videbeck7. Human Anatomy & Physiology 11th edition by Tortora and Derrickson8. Clinical Handbook of Schizophrenia. Edited by Mueser and Jeste9. Concepts of Anatomy and Physiology 4th edition. By Graaft & Fox10. Psychiatric Nursing: a textbook and reviewer.maria Evangelista –Sia

c2004;p.23411.Psychiatric nursng care plans. Fortinash & Holoday Norret.4th

edition..p113.mosby inc. St Louis,Missouri12.Psychiatric Nursing. Norma.Keltner,et.al.pte Ltd. C200713.Abnormal Psychology. P.186 by Jefnar Mahmud. APH. Pulishing corp. New delhi

c200214.Abnormal psychology: current perspective. Larren Alloy,et.al c1996. McGraw-hill

inc.15.Psychia nursing:biological &behavioural concepts (Deborah Antai-

Drong)p.351.thomson/Delmar learning;c200316.Abnormal psychology. James Hansen; Lisa Damour. Hobeken, NJ: Willey c2005 17.Scizizophrenia:chemistry,metabolism & Treatment. J.R. Smythies. Illinois, Thom-

son c196318.http://positivenewsmedia.net/am2/publish/Health_21/P4-

M_Davao_mental_hospital_multi-purpose_building_to_rise_next_year.shtml)19.http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=8805&cn=720.(http://www.cureresearch.com/s/schizophrenia/stats-country.htm).21.http://www.schizophrenia.com/szfacts.htm22.http://www.ppa.ph/files/PPA%20Research%20Abstracts.pdf

43