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Perfe ct SCORE SCORE Score CDO DAVAO 1.) CONTENT 40 2.) PRESENTATION 30 a. Creativity and integrity (10) b. Ability to hold the interest of others (10) c. Ability to stimulate group participation (10) 3.) DELIVERY 10 a. Grooming (2) b. Poise (2) c. Voice (3) d. Diction (3) 4.) RESPONSE TO QUESTIONS 15 a. Making sound judgement (10) b. Ability to express self (5) 5.) ATTITUDE 5 a. Attitude towards comments
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d4 Cp Psyche

Mar 08, 2015

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Page 1: d4 Cp Psyche

Perfect SCORE SCORE

Score CDO DAVAO

1.) CONTENT 40

2.) PRESENTATION 30

a. Creativity and integrity (10)

b. Ability to hold the interest of others (10)

c. Ability to stimulate group participation (10)

3.) DELIVERY 10

a. Grooming (2)

b. Poise (2)

c. Voice (3)

d. Diction (3)

4.) RESPONSE TO QUESTIONS 15

a. Making sound judgement (10)

b. Ability to express self (5)

5.) ATTITUDE 5

a. Attitude towards comments and suggestions

TOTAL SCORE 100

GRADE

Case Study Rating Sheet

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Liceo de Cagayan UniversityCollege of Nursing

NCM501203A Care Study

PATIENT RR

Schizophrenia undifferentiated

Submitted to

Name of faculty

A Partial Requirement for NCM 501203

Submitted byYAP, ROY D. II

LAPURA, JUNILYN P.CAHILES, JOHANNA KHRYSTYNE C.

CELIZ, RUFFA CARLAOREJANA, MARICRIS

GALLENERO, CHARISSE MAEABENOJA, EXCELSIOR

MAYORDOMO, JC JAMESCREDO, MICHAEL ANGELO

SABANDO, RICK PAULDUCO, ANNACEL

GROUP D4

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Table of Contents

I. Introduction

A. Overview ………………………….. B. Objective and Purpose of the Study ………………………….. C. Scope and Limitation ………………………….. D. Spot Map ………………………….. E. Patient’s Profile …………………………...

II. Anamnesis

A. Maternal and Paternal Lineage …………………………… B. Parents …………………………… C. Subject ……………………………

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III. Course in the Hospital

A. Mental Status Exam …………………………… B. Progress Notes ……………………………

IV. Psychodynamics ……………………………

V. Laboratory Exam and Results Of Psychological Test

A. Neuropsychological Test …………………………… B. Laboratory test if any ……………………………

VI. Diagnosis ……………………………

VII. Multi-Axial Diagnosis ……………………………

VIII. Nursing Management ……………………………

IX. Medical Management ……………………………

X. Prognosis and Recommendation ……………………………

XI. Bibliography ……………………………

I. INTRODUCTION

D I. INTRODUCTION

A. Overview

Schizophrenia is a disease affecting the brain that causes distorted and

bizarre thoughts, perceptions, emotions, movements and behavior (Videbeck,

2001). Schizophrenia usually is diagnosed in late adolescence or early

adulthood. The peak incidence of onset is 15 to 25 years of age for men and 25

to 35 years of age for women (APA, 2000). There are 5 types of schizophrenia:

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The paranoid type, disorganized type, catatonic type, undifferentiated type, and

the residual type.

Schizophrenia causes distorted and bizarre thoughts, perceptions,

emotions, movements, and behavior. It cannot be defined as a single illness;

rather, schizophrenia is thought of as 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 a

dangerous and uncontrollable and causing wild disturbances and violent

outburst. Many people believed that those with schizophrenia needed to be

locked away from society and institutionalized.

No laboratory test is for schizophrenia currently exists. Although

schizophrenia affects men and women with equal frequency, the disorder often

appears earlier in men, usually in the late teens or early twenties, than in

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

treatments can relieve many symptoms, but most people with schizophrenia

continue to suffer some symptoms throughout their lives; it has been estimated

that no more than one five individuals recovers completely.

Schizophrenia affects about 24 million people worldwide. Schizophrenia

is a treatable disorder, treatment being more effective in its initial stages. More

than 50% of persons with schizophrenia are not receiving appropriate care and

90% of these are in developing countries. Care of persons with schizophrenia

can be provided at community level, with active family and community

involvement.

In the Philippines alone, out of 86, 241, 697 population, the

extrapolated prevalence is 697,543 – about .5% to 1% of the population as of

2004. Schizophrenia still ranks among the top causes of disability in the country;

however there are some variations in terms of incidence and outcomes for

different groups of people.

In Northern Mindanao, out of 2, 283, 272 population as of 2005,

there is an estimated number of schizophrenic patient, in every 1000 persons

there are 12 cases of schizophrenia.(Philippines Mental Health Country Profile).

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In this study, the main focus will be on Schizophrenia, Undifferentiated Type;

a type characterized by mixed schizophrenic symptoms along with disturbances

of thought, affect and behavior (Videbeck 2004). Atypical symptoms present do

not meet the criteria for the subtypes of paranoid, catatonic, or disorganized

schizophrenia. The client may be observed to exhibit both positive and negative

symptoms; odd behavior, delusions, hallucinations and incoherence (Shives and

Isaac 2002).

B. Objective and Purpose of the Study

The objectives of the study are as follows:

Develop a good working relationship with the client and her family.

Assess and determine the possible precipitating and predisposing factors

that contribute to the development of the disorder.

Assess the client with psychiatric disorder allowing the students to identify

the different abnormal behaviour under Schizophrenia Undifferentiated

Type.

Design a nursing care plan and implement nursing interventions

appropriate to the condition of the client.

The purposes of study are as follows:

Enhance the skills of the students involved and their knowledge by

understanding the essentials towards promotion of mental health.

It gives opportunity to learn different approaches in establishing a nurse-

patient relationship.

Let the family understand the apparent condition of the client.

Help client through the application of the nursing process.

Specific Objectives:

In order to meet the general objective, the group aims to:

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1. Gather pertinent data about the client through detailed chart taking, and

effective therapeutic communication and interaction with the client and his

significant others.

2. Commence the patient with his personal data and present and past health

history.

3. Assess client’s mental status thoroughly using axial diagnosis.

4. Determine the etiology factors (precipitating and predisposing) of the

mental disorder.

5. Present the medications given to the client, including their respective

modes of action, indications, contraindications, side effects, nursing

responsibilities, and importance to the client’s condition.

6. Render quality nursing care in line with the formulated nursing care plans;

7. Impart appropriate recommendations to the client, his significant others

and community, medical world, and the group as a part of the nurse’s

holistic care.

8. Establish a trusting nurse-patient relationship with the client and his

significant others through provision of holistic care toward the client and

use of appropriate verbal and non-verbal therapeutic communication skills

with the client and significant others during the data gathering.

C. Scope and Limitation

This study was conducted at Orochain Village Carmen Cagayan de

Oro City, which covers 4 days of visitation. The four days visit includes

gathering of the necessary data and interview of a minimum eight informants.

The said informants are composed of the patient’s family, neighbours, and

relatives.

There were limitations encountered by the group in the conduct of

this study. The home visitation covered only four days. The location of the

area contributed to the difficulty of the group to properly assess the patient

since only a maximum of five persons can enter their house. The patient and

her family resides a squatter’s area. The first 3 days was also limited since

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the group needs to conduct the said visit during 9:00-11:00 pm, since her

mother is available only during this time because her mother has a mini parlor

inside their house, thus a minimum of 2 hour was intended for the interaction

of the patient, her family and her neighbours. Information about the client’s

history of illness will be based only the interview with client, client’s mother,

her relative, and some of her neighbours. The expected outcomes of the

interventions initiated and implemented was dependent upon the cooperation

of the patient and her significant others.

The point of reference in locating the residence of Mr. RR, is

Liceo de Cagayan University located at R.N Pelaez Blvd., Carmen, Cagayan

de Oro City. The patient’s residence is approximately 500 meters and is

southwest of the point of reference. In order to reach the area, one has to

take a public utility vehicle, with the routed to Carmen Market, Cagayan de

Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is

Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5 minutes

if traffic is not that worse. But during rush hours, it usually takes around 5-10

minutes of commuting time to reach the area. Upon reaching the area, you

will see a Gasoline Station (Petron). The patient’s residence is approximately

30 meters away from the outpost. You need to start walking straight ahead

then turn right where you will pass by a mini store. After turning right, you

need to walk straight ahead again and turn left pass by 3 houses on the left

and on the right there’s a wall. After passing these houses on the left side the

fourth house from the point of intersection located on your left side is the

residence of patient RR.

The area where the patient is residing is congested urban since it is

described as a “squatter area”. The main sources of income of the people

living in the said area are mini parlor, vendors, by standers, sari-sari store’s

and laborers to name a few. The houses are made up of wooden structure

and are camped up in the area. The people’s past time in the area is

gossiping with their neighbours and singing videoke as well as playing cards.

The patient’s residence is made up of combination of concrete and wooden

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structure. Their house is composed of two storeys, the upper part is their bed

room and the lower part of their house is divided into three parts their kitchen,

bathroom, and dining area.

D. SPOT MAP

The point of reference is Northern Mindanao Medical Center Cagayan de Oro City. The patients reference is approximately half kilometer and is

southwest of the point of reference. In order to reach the area, one has to

take a public utility vehicle, with the routed to Carmen Market, Cagayan de

Oro City, particularly R1, Iponan, C2 and etc.. The regular fare going their is

Php 6.00 and Php 5.00 for students. The travel time usually takes 2-5

minutes if traffic is not that worse. But during rush hours, it usually takes

around 5-10 minutes of commuting time to reach the area. Upon reaching the

area, you will see a Gasoline Station (Petron). The patient’s residence is

approximately 30 meters away from the outpost. You need to start walking

straight ahead then turn right where you will pass by a mini store. After

turning right, you need to walk straight ahead again and turn left pass by 3

houses on the left and on the right there’s a wall. After passing these houses

on the left side the fourth house from the point of intersection located on your

left side is the residence of patient RR.

The type of community that the patient is residing is an urban squatter’s area.

The main sources of income of the people living in the said area are mini

parlor, vendors, by standers, sari-sari store’s and laborers to name a few. The

houses are made up of wooden structure and are camped up in the area. The

people’s past time in the area is gossiping with their neighbours and singing

videoke as well as playing cards. The patient’s residence is made up of

combination of concrete and wooden structure. Their house is composed of

two storeys, the upper part is their bed room and the lower part of their house

is divided into three parts their kitchen, bathroom, and dining area.

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E.Patient’s Profile

Initial Name: Patient “RR”

Address: Orochain Village Carmen, Cagayan de Oro City

Date of Birth: January 22, 1982

Age: 29 yrs.old

Birthplace: Cagayan de Oro City

Civil Status: Single

Gender: Male

Nationality: Filipino

Religion: Roman Catholic

Educational Attaintment: Grade 1 (West City Central School)

Siblings: One Sister (Ms. “M”)

Name of Mother: Mrs. “ER”

Name of Father: Mr. “BR”

Height: 5’1”

Weight: 50 kgs.

Date of First Check-up: March 2008

Admitting Diagnosis: Schizophrenia Undifferentiated

Attending Physician: Dr. Eric Boromeo

High School : Not AttendedCollege: Not Attended

Arrest, Court States Probation : NoneVital Signs:

Blood Pressure : 110/80mmhgTemperature : 36.9 cRespiratory Rate : 20cpmPulse Rate : 73bpm

Date Admitted: NoneTime Admitted: NoneFood and drug allergy: (+) chickenUse of street drugs: (+) shabu, Marijuana Use of street alcohol: (+) hard liquors

Page 11: d4 Cp Psyche

II. ANAMNESIS

A. INFORMANTS

Informant #1

Name: ER

Sex: Female

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Age: 50 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: Mother

Length of time known to patient: 29 years

Apparent understanding of present illness:

“ Nabuang man na akong anak pag-uli nako. Buotan man na siya na bata

kung dili lage mahubog di man jud unta na siya mupalit ug mainom gadaog

daogon man gud na siya.”

Characteristics and attitude of informant:

Informant was very willing to answer the questions being asked. She

speaks openly about the client and is concern about the client’s condition. She is

aware of the unusual behaviour that her son has manifested.

Informant # 2

Name: TR

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Sex: female

Age: 82 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: grandmother

Length of time known to patient: 28 years

Apparent understanding of present illness:

“Nagkadipekto na siya sa pangutok sukad atong giburos pa lang na siya

kay iyang mama man gud gainom ug tambal, mao nag kain-ana na siya. Buotan

man na siya na bata kay gapatoo na siya pag sugoon. Dili man niya sala nga na

in-ana siya, sala jud sa iyang mama.gapanglimpiyo pa gani na siya ”

Characteristics and attitude of the informant:

Shows concern to the client and is aware of the unusual behaviours that

his grandson have. She also admits that the patient is very kind and that the

patient follows instructions.

Informant # 3

Name: MTC

Sex: female

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Age: 54 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: neighbor

Length of time known to patient: 28 years

Apparent understanding of present illness:

“ing-ana naman na siya pagbalik sukad pa sa bata pa ginapaskwela gani

na siya pero ang problema kay sige siya takas, ug adtong bata pa siya sige lang

siya ug hinoktok lang adtong 10 years old pa siya. “

Characteristics and attitude of the informant:

She has known the client well and she is aware of the unusual behaviour

that the client manifests though she is confused with what the patient’s problem.

Informant # 4

Name: W Y

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Sex: Female

Age: 20 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: Neighbor

Length of time known to patient: 14 years

Apparent understanding of present illness:

“buang man na siya kay mukalit di na siya maka istorya ug tarung unya dili

jud na siya. Luoy pa jud kayo na siya kay di na siya kabalo kung piso ba o dili.

Buotan kayo na siya na tao kay dali ra kayo masugo. ”

Characteristics and attitude of the informant:

The informant was aware of the unusual behaviors the patient portrays,

and was very concern to the client’s present condition.

Informant # 5

Name: E A

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Sex: male

Age: 37 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: neighbor

Length of time known to patient: since birth

Apparent understanding of present illness:

“ buang man na siya sukad bata pa kay sige gani na siya hinuktok unya

sige takas sa klase. Pero buotan pud kayo na siya na bata kay dali ra jud na

nimo masugo. Gakaluoy lagi ko ana niya na. pero grabi jud na siya kabuotan na

bata bisan unsaon ba bisan in-ana pa na siya.“

Characteristics and attitude of the informant:

The informant is very concern to the patient. And he knows much about

the patient. And he cooperates with the interview.

Informant # 6

Name: J AS

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Sex: Female

Age: 58 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: Neighbor

Length of time known to patient: since birth

Apparent understanding of present illness:

“Pagbalik sa iyang mama dani murag nisamot bitaw ang iyang sakit murag

in-ana bitaw. Pero grabe jud na siya kabuotan na bata pero dali ra kayo na

sugoon kay mulihok jud na siya diretso pero mao pud lage sige lang siya ug

daog daogon. Perme na siya kilkilan sa mga tao dani “

Characteristics and attitude of informant:

Concern about the client’s condition and speaks about patient’s behaviour

openly and is cooperative in giving information regarding the client’s condition.

Informant # 7

Name: D H

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Sex: male

Age: 48 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: Neighbor

Length of time known to patient: since birth

“buotan kayo na siya na bata. Dali ran a siya masugo unya di pa jud

kabalo mureklamo. Mao raman pud ako nabantayan niya. Pirme man na siya sa

liceo dispatcher man na siya.”

Characteristics and attitude of informant:

The informant was aware that the client has this kind of mental illness

based on the unusual behaviour the client has shown but still shows some

disregard because he is one of those who keeps on dragging the patient to drink.

Informant # 8

Name: L F

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Sex: Female

Age: 22 years old

Address: Orochain village Carmen Cagayan de Oro City

Relation to patient: Neighbor

Length of time known to patient: 15 years

Apparent understanding of present illness:

“wala jud kayo ko kabalo adtong bata pa siya pero karon makiingon jud ko

na naa siya daot sa pangutok tungod kay di siya kabalo kung unsa ang piso unya

di siya kaistorya ug tarung. “

Characteristics and attitude of the informant:

Shows willingness and is cooperative in answering the questions,

she is aware of the present situation of the client.

III. Course in the Hospital

A. Mental Status Examination

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D1 D2 D3 D4

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I. GENERAL

APPEARANCE

Tidy Tidy Tidy Clean

II. GENERAL

MOTILITY

Posture Slouch Slouch Slouch Slouch

Activity Purposeful Purposeful Purposeful Purposeful

Facial expression Suspicious Suspicious Happy Happy

III. Behavior Shy Friendly Friendly Friendly

IV. Patient nurse

interaction

Distant Cooperative Cooperative Cooperative

V. SPEECH

Soft / / /

Loud

Hesitant /

Slurred

Superior

Humor

Frightened

VI. Stream of Talk

Spontaneous

Deliberate / / /

Pressured

Blocking /

VII. Organization of talk

Relevant

Irrelevant

Incoherent

Loose Association / / / /

Flight of Ideas

Tangentiality

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Circumstantiality

Perseverance

Clang Association

Neologism

Echolalia

Echopraxia

VIII. Mood and Affect

1. Mood

Euthymic

Depressed

Euphoric / / / /

2.Affect

Flat

Blunt

Angry

Elated / / /

Anxious /

Fearful

IX. Range of Affective

Expression

Consistent

Labile / / / /

Anhedonic

Appropriate to the

situation & feeling

verbalized

X. Perception

Hallucination

-auditory /

-visual /

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-olfactory

-gustatory

-tactile

Delusion

-grandeur

-persecutory

-reference

-others(specify)

Illusion

Derealization

Depersonalization

Identification

Thought broadcasting

Déjà vu

Jamais Vu

XI. Orientation and

Memory

1.Identifies date

correctly

No No No No

2.Estimate time of the

day

No No No No

3.Knows where he is Yes Yes Yes Yes

4.Knows the examiner No No No No

5.Recalls activities

done within 24 hours

No No Yes Yes

6.Recalls activities

done within 1 week

No No No No

XII. Neuro-vegetative

functioning

Sleep and Rest Pattern

-normal sleep / / / /

Page 24: d4 Cp Psyche

-early morning

awakening

-middle night

awakening

-hyper insomnia

-difficulty in falling

asleep

-interrupted sleep

-others

XIII. Elimination

Bowel 0 1x 1x 0

Bladder 2x 3x 4x 3x

XIV. Abstract Thinking

Ability

Poor Poor Poor Poor

XV. Judgment Poor Poor Poor Poor

B. Description of MSE Result:

First visit (January15, 2011)

I. Appearance and Movement

During our 1st visit, the client looks neat and clean.His gait was

coordinated and smooth. He sat at the doorway and shows

slouchiness in his movement.

II. Speech

He was not hesitant to speak. He was able to answer the questions

but some portrayed loose association that is why we can’t

understand some of what he is saying.

III. Emotional State and Reaction

Page 25: d4 Cp Psyche

He was relaxed during the interview

IV. Thought Control

During the first interview, the client cannot recall activities done

within 24 hours, he cannot identify the date correctly, and also he

cannot estimate the time of the day but he knows where he is. The

client wasn’t able to know the examiner well. he was able to listen

well with our conversation but he cannot maintain eye contact.

V. Neuro-Vegetative Functioning

The client has a normal sleep pattern

Second Visit (January 17, 2011)

I. Appearance and Movement

On the second day, the client appears to be tidy. His gait was

coordinated and smooth but tends to slouch most of the time and

doesn’t have an eye to eye contact to us all the time. Conversation

was done at the same venue and the client was interested to talk

with a group and always smiles.

II. Speech

The client talked vividly in soft and low tone. he portrayed loose

association.

III. Emotional State and Reaction

He was more relaxed and feels happy when he sees us.

IV. Thought Control

The client still cannot identify the date correctly and cannot

estimate the time of the day. But he knows where he is.

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V. Neuro-Vegetative Function

The client has a normal sleep pattern.

C. Progress Notes

Day 1: January 15, 2011

Specific Objectives:

1. To locate the area

2. To establish trust and rapport with the client and her family.

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

4. To make initial assessment.

5. Arrange for the next schedule visit

It was on a Saturday morning when the group went to Orochain

Carmen CDOC to find for a potential client for our care study. We went to

the outpost of the baranggay to ask for any potential client and fortunately

we were given one. Before we arrived to our client’s house we planned

what we do, including the most important assessment. We conducted a

mental status examination.

The consent was obtained from the mother and the client as they

permitted the group to conduct series of interviews with them. The clients

name was patient “RR” and her mother was “Mrs. ER”. We gained the

necessary data’s that we needed from the client, her mother and relatives.

We gather the client’s profile and some other important information

regarding the client.

A verbal contract was made about the number of days we were going

to conduct the interview, health teaching, nursing intervention and length

of time of our visit.

Page 27: d4 Cp Psyche

Day 2: January 17, 2011

Specific Objectives:

1. Continue establishing rapport to the client.

2. Continue with the mental status exam.

3. Determine the factor that causes the clients disorder.

4. Trace the client history.

5. Ask the client’s neighbor for some relevant information.

During the second visit, the group continued the mental status exam.

The client cooperates with the group by answering questions being asked

from her although she speaks in a low tone. The group was able to get

some information regarding the client’s condition. Her mother is also very

approachable and friendly to us and never hesitates to answer all our

questions about her son.

IV. PSYCHODYNAMICS

a. Tabular presentation of Predisposing Factors.

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FACTORS PRESENT RATIONALE

A. GENETICS There were no traces of

mental illness on the

patient’s maternal side.

On the paternal side

however, it is unknown

due to separation of

patient’s parents and the

patient’s mother does not

have knowledge on

whether or not the

patient’s father has any

family history of being

mentally challenged.

Videbeck (2001) stated

stated that several theories

and studies seem to indicate

that several disorders may

be limited to a specific gene

or a combination of both

genes. According to Colleen

Sullivan, suite 101.com;

close relatives of individual

who have disorders are at

high risk. If you have a

parent, sibling, or a child with

a disorder, there is a 7-10%

chance that you may develop

the same disorder and 8-

10% to develop depression.

B. SEX Patient is an adult male. Sex determines the

community’s expectation of a

person.

C. AGE The patient exhibited mild

onset of illness during his

early childhood. The

worse part of his

condition was clearly

observed when he was in

his mid-twenties, during

which his mother was not

able to personally care

for him as she worked

abroad and the patient

Age of onset seems to be an

important factor in how well

the client fares. Those who

develop the illness earlier

have worse outcomes than

those who developed it later.

(Buchaman and Carpenter,

2000) According to Hagop S.

Akistol M.D. are higher in

younger age groups

especially in the stage

Page 29: d4 Cp Psyche

was left to relatives who

didn’t really looked after

his needs.

because of having role

confusion and identity crisis.

b. Tabular presentation of Precipitating Factors

FACTORS PRESENT RATIONALE

A. ENVIRONMENTAL

FACTORS

Lower

socioeconomic

status

Living in large cities

Stressful events

during childhood

Mother is the

breadwinner and only

income earner in the

family.

Patient’s parents

separated when he was

still young. During his

parent’s marriage, his

parents always quarreled

which led to separation.

When a person is insufficiently

provided with his basic needs,

his chances of getting

Schizophrenia increases.

People living in high-density

urban areas are 50 percent

more likely to develop the

disease than people in rural

areas, and economic factors

such as homelessness,

unemployment and poverty

also contribute to the chances

of having the disease.

Studies show that children

growing up in abusive or

otherwise dysfunctional

families are six times more

likely to develop schizophrenia

than their normal counterparts.

Page 30: d4 Cp Psyche

Drug and alcohol

intake

During his mother’s

absence, the patient was

left in the care of relatives

who didn’t really looked

after him and just allowed

him to go anywhere and

anytime he desires. He

abused this liberty by

alcohol intake and drug

abuse.

Prohibited drugs such as

cocaine have effects similar to

the positive symptoms of

schizophrenia. These drugs

can also trigger schizophrenia.

There is an increasing amount

of evidence that cannabis

damages the brain and can

lead to schizophrenia. It is

thought that cannabis doubles

a person's risk of

schizophrenia. Alcohol is the

substance most often abused

by people with schizophrenia.

While alcohol can cause a

relapse of symptoms, there is

no evidence to suggest that

alcohol use causes

schizophrenia.

B. LIFESTYLE

C.

Skipping of Meals The patient started to

skip meals when his

mother went to work

abroad. Because he had

the freedom to do

anything he wanted, he

spent his time loitering

around the city and

getting drunk.

According to Stuart and

Sundeem (1995). Poverty and

society could abuse

Schizophrenic or some

individuals choose to be

Schizophrenic to cope the

insanity of mother world.

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V. Laboratory Exam and results of Psychological Test

Our client has not undergone laboratory exam and psychological testing.

VI. Diagnosis

Schizophrenia, Undifferentiated Type

VII. MULTI-AXIAL DIAGNOSIS

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AXIS I SCHIZOPHRENIA, UNDFFERENTIATED TYPE

Schizophrenia is characterized with the following1. anger2. disorganized speech3. inability to take care of personal needs4. incoherence5. hallucinations

Our client Mr. RR manifested negative symptoms which is inability to take care of personal needs and auditory hallucination, which is also a manifestation of undifferentiated schizophrenia.

AXIS II BORDERLINE PERSONALITY DISORDER

A persistent pattern of instability in interpersonal relationship and affects.

1. Frantic effort to avoid real or imaged abandonment. (“di sya ganahan nga pasagdan ra sya, kay katong naa pa ko dubai, gnapasagdan ra man sya iya mga uncle ug ante, murag wala ra sila pakialam sa iya” as verbalized by the mother.)

2. Impulsivity in or at least two areas that are self damaging such as cigarette smoking and substance abuse.

3. Affective instability due to marked reactivity (easily got mad and hitting others with anything he gets to)

4. Inappropriate, intense anger or difficulty controlling anger (“gawild gapamunal ug kahoy”as verbalized by the mother)

5. transient, stress-related paranoid ideation or severe dissociative symptoms (“ feeling niya gainterviewhon siya sa tanang tao pag mangutana sa iya” as verbalized by the mother)

AXIS III FOR GENERAL MEDICAL CONDITIONS

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NONE

AXIS IV PROBLEM RELATED TO SOCIAL ENVIRONMENT

RVR has difficulty making friends due to his condition since birth

AXIS V GLOBAL ASSESSMENT OF FUNCTIONING

The GAF scaling of RVR. is 51-60

Moderate symptoms RVR has inability to take care of personal needs

Moderate difficulty in social functioningRVR has only few friends

Substance induce psychotic disorder

A. prominent hallucination or delusion. Note: Do not include hallucination if the persons has insight that they are substance induced.

B. there is evidence from the history, physical examination or laboratory findings of :

the symptoms in criterion a developed during or within a month of substance Intoxication or withdrawal

medication is etiologically related to disturbance

C. The disturbance is not better accounted for by a psychotic disorder that is not substance induce. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induce might include the following:

The precede the onset of the of the substance use ( medication use)

The symptoms persist for substantial period of time (about a month)After the cessation of acute withdrawal or severe intoxication, or are substantial in excess of what would be expected to be given the type or amount of the

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substance used or duration of use: or there is other evidence that suggest the existence of independent non-substance-induce Psychotic disorder

D. the disturbance does not occur exclusively during the course of delirium

Note:this diagnosis should be made instead of diagnosis of substance Intoxication or substance withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficient severe to warrant independent clinical attention.

VIII. NURSING MANAGEMENT

A. IDEAL NURSING MANAGEMENT

1.) Disturbed thought processes related to physiologic changes due to substance abuse

INTERVENTION: RATIONALE

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►Be sincere and honest when communicating with the client. Avoid vague or evasive remarks.

Delusional client are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.

►Do not make promises that you cannot keep.

Broken promises reinforce client’s mistrust to others.

►Encourage client to talk with you but do not pry for information.

Probing increases the client suspicion and interferes with the therapeutic relationship.

►Recognize the client delusion as the client’s perception of the environment.

Recognizing the client perceptions can help you understand the feelings she’s experiencing.

►Initially, do not argue with the client or try to convince the client that delusions are false or unreal.

Logical argument does not dispel delusional ideas and can interfere with the development of trust.

►Interact with the client on the basis of real things; Do not dwell on the delusional materials.

Interacting about reality is healthy for the client.

2.) Ineffective Family Coping related to exhausted supportive capability of family members

INTERVENTION: RATIONALE

Assess family history; explore roles of family members, circumstances involving drug use, strengths, and areas for growth.

Determines areas for focus, potential for change.

Explore hoe the significant others has coped with the

Co-dependent also suffers from the same feelings as the patient (e.g

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addict’s habit, e.g denial, repression, rationalization, hurt, loneliness, projection

anxiety, self-hatred, helplessness, low self-worth, and guilt) and needs help in learning new effective coping skills.

Determine understanding of current situation and previous method of coping with life’s problems

Provides information on which to base present plan of care

Assess current level of functioning of family members

Affects individual’s ability to cope with the situation

Determine extent of “Enabling” behaviours being evidenced by family members, explore with patient

“Enabling” is doing for the patient what he needs to do for self. People want to be helpful and do not want to feel powerless to help their loved one to stop drinking and change to behaviour that is so destructive. However, the substance abuser relies on others to cover up own inability to cope with daily responsibilities.

Provide information about enabling behavior, addictive disease characteristics for both user and non-user co-dependent

Awareness and knowledge provide opportunity for individuals to begin the progress of change.

Provide factual information to the patient and family about the effects of addictive behavior on the family and what to expect after discharge.

Many patients/ significant others are not aware of the nature of the addiction. If the patient is using legally obtained drugs, may believe this does not constitute abuse.

Encourage significant others to be aware of their own feelings, look at the situation with perspective and objectivity. They can ask themselves. “am I being conned?” am I acting out of fear, shame, guilt or anger? Do I have a need to control?”

For self awareness of the significant others, to be able for them to handle situations involving the patient.

3.) Sleep pattern disturbances related to psychological stress

INTERVENTION:

Consult psychiatrist in arranging medication regimen

- to maximize night time and minimize day time sedation

Give sleep medication as - Provide rest.

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needed. Teach relaxation technique

Encourage day time activity and discourage day time naps.

- This will exhaust the patient during the day time which will give them the opportunity to rest well at night.

Determine normal sleep habit and changes that are occurring

-assesses need for and identifies appropriate interventions

Obtain comfortable bedding, provide some of own possessions ex. Pillow

-increases comfort for sleep as well as physiologic/ psychologic support

Establish sleep routine suitable to old pattern and new environment

-when new routine contains as many aspects of old habits as possible, stress and related anxiety maybe reduced.

Encourage some light physical activity during the day, make sure patient stops activity several hours before bedtime

-daytime activity can help patient expend energy and be ready for night time sleep. However, continuation of activity close to bedtime may act as a stimulant, delaying sleep

Provide warm bath and massage, warm milk, wine or brandy at bedtime

-promotes a relaxing soothing effect. Note; milk has no prolific qualities, enhancing synthesis, and neurotransmitter that helps patient fall asleep faster and sleep longer.

B. ACTUAL NURSING MANAGEMENT

S

“Oo gamata-mata ko pag tungang gabii kay naa koy makit-an na tigulang ug bata” as verbalized by the client.

O

Weak & Drowsy Inattentive, irritable Midnight awakening Less than 8 hours of sleep

ASleep Pattern Disturbance related to psychological stress as evidenced

by visual hallucination

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P

Short term: At the end of 1 hour, the client will be able to express the feeling of being well rested.

Long term: At the end of 4 days, the client will specify the number of hours of sleep without interruption.

I

Independent:

1) Discouraged naps during the day

2) Instructed to restrict intake of caffeine (eg. coffee, tea, cocoa, cola drinks)

3) Encouraged to engag in physical activities/exercise during morning and afternoon. Instructed to restrict activity in the evening prior to bedtime

4) Allowed the client to identify the circumstances that interrupted her sleep and frequency

5) Evaluated level of stress/orientation as day progresses.

Rationale

Not to alter the sleep pattern at night

May stimulate CNS, interfering with relaxation and ability to sleep

Enhances sense of fatigue and promotes sleep/rest, evening activity may actually stimulate client and interfere with/delay sleep

To evaluate sleep pattern and dysfunctions

Increasing confusion, disorientation, and uncooperative behaviors may interfere with restful sleep pattern

EAt the end of 4 days, the client was able to establish adequate normal sleeping pattern.

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S

“Gi- kapoy na gyud ko og ayo. Kadugayan naluoy na cguro siya sa ako, kadugayan miingon siya nga-higti nlng ko ma para di ka kapoyan.” As verbalized by the mother.

O Financial instability

AIneffective Family coping related to exhausted supportive capability of

family members

P

Short term: At the end of 1 hour, the client’s family will be able to identify resources within themselves deal with the situation.

Long term: at the end of 4 days, the client’s family will be able to visit regularly and participate positively in care of the client, within limits of abilities.

IIndependent:

1) Had established rapport and acknowledged difficulty of the situation for the family.

2) Determined current knowledge of the situation.

3) Discussed underlying reasons for the client’s behavior with the family during visit.

4) Encouraged the family members / SO to provide support through visitations.

Dependent 1) Refer to appropriate

resources for assistance as indicated (e.g., counselling, spiritual support)

Rationale May assist family to accept

what is happening and be willing to share problems with caregivers.

Lack of information or unrealistic perceptions can interfere with family members/ client’s response to illness.

When family members know why client is behaving in different ways, it helps them understand and accept/ deal with situation.

It provides the family opportunity to talk with the client, thus, reducing the anxiety and allows expression, as well as opportunity to make future plans and share support.

May need additional assistance in resolving family issues.

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EAt the end of 4 days, the family expresses more realistic understanding and expectations of the client

S“Maligo raman siya kung ganahan pero ang gasabonan ra kay ulo ug

abaga. Pero ako jud magligo niya.” As verbalized by the mother.

O

Inability to keep body clean

Inability to dress appropriately

Poorly combed hair

A

Self-care deficit related to perceptual and cognitive impairment as

evidenced by difficulty keeping body clean and dressing

appropriately.

P

Short term: At the end 30 minutes, the client will be able to

demonstrate proper hygiene.

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

care and ADL’s at highest level of adaptive functioning possible.

I

1. Identified

presence/severity of

factors that affect

client’s capacity for self-

care.

2. Discussed personal

appearance/grooming

and encouraged

dressing in bright

colors, attractive

clothes. Gave positive

1. Impairment in these

areas can alter client’s

ability/readiness for

self-care.

2. Appearance affects

how the client sees

self. A rundown,

disheveled

appearance conveys a

sense of low self-

worth, whereas an

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feedback for efforts.

3. Assisted client with care

of fingernails and

toenails as required.

4. Encouraged client to

perform minimal oral-

facial hygiene after

rising as possible.

5. Encouraged client to

comb own hair,

suggested hair styles

that are low

maintenance.

attractive, well-put-

together appearance

conveys a positive

sense of self to the

client as well as to

others.

3. To promote sense of

well-being

4. To promote sense of

well-being

5. This enables the

client to maintain

autonomy for as long as

possible.

E

The goal was partially met since the client was able to perform self-

care and ADL’s at level of adaptive functioning possible.

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IX. Medical Management

Drug Study

Brand Name: LargactilGeneric Name of Ordered Drug: Chlorpromazine HydrochlorideClassification: AntipsychoticDate Ordered: April 2, 2007Dose/ Frequency/ Route : 100mg/tab/PO/ODMechanism of Action: Blocks the post synaptic dopamine receptors in the brain.Specific Indication: To prevent occurrence of psychosis, mania.Contraindications: Hypersensitivity to drugs in those with CNS depression, bone marrow suppression or subcortical damage.Side effects/ Toxic Effects:

CNS: Seizures, Nueroleptic Malignant Syndrome G.I: Dry Mouth, Constipation HEMATOLOGIC: Aplastic Anemia

Nursing Precaution:

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Largactil can pass into the breast milk and cause drowsiness and unusual muscle movements in the baby. Therefore, it is not recommended for nursing mothers.

This medicine should not be given to patients diagnosed with Parkinson’s disease, narrowangle glaucoma, cardiovascular disease and epilepsy.

It should not be used concomitantly with other drugs that can cause sedation.

Largactil should not be taken if you are hypersensitive to it.

IX. PROGNOSIS

CRITERIA GOOD PROGNOSIS POOR PROGNOSIS

a. ONSET OF ILLNESS X

b. DURATION OF

ILLNESSX

c. PRECIPITATING

FACTORSX

d. MOOD and AFFECT X

e. ATTITUDE AND

WILLINGNESS TO TAKE

MEDICATION AND

X

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TREATMENT

f. ANY DEPRESSED

FEATURESX

g. FAMILY SUPPORT X

On the criteria listed above, six out of seven criteria shows that our client

represents a poor prognosis. His onset of illness is early that is when he is 20

years old. The duration is persistent / recurring whenever client can’t take his

medication or triggered by other depressant factors such as family problems, and

lack of financial support. There are some precipitating factors identified that

contributes to his condition such as poor guidance and family support. His mood

is inappropriate with flat affect evidenced by absence of facial expression that

would indicate emotions. He religiously takes his medications and participates in

minimal therapeutic conversations.

RECOMMENDATION

The group recommends that the client should stay inside their home and

family should provide emotional support and guidance to alleviate client’s

misconceptions regarding his environment, this would provide a therapeutic

outcome to possibly lessen the stressor that would trigger client’s condition.

Support from family members in addition is a huge factor that will encourage

client to take his medications and to provide security to the client. Peer group can

also help client feel as part of the community and as a functioning individual.

Lastly, providing small tasks to the client to divert client’s attention to any factors

that may trigger his condition.

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XI. Bibliography

Videbeck Sheila L., Psychiatric Mental Health Nursing 2nd Edition,

Lippincott Williams and Wilkins, 2001, pp 297 – 301

Deglin, Judith H. Davis Drug Guide for nurses, 9 th Edition, 2005 by F.A

Davis company, Philadelphia

Doesnges, Marilyn E., Nursing Care Plan, Guidelines for individualizing

Patient Care, 6th edition, 2002 by F.A Davis Company Philadelphia

F.A Davis, Taber’s Encclopedia Medical Dictionary, 20th Edition, 2005 by

Lippincott Williams and Wilkins, Philadephia.

Keltner et. Al, Psychiatric Nursing 3dr edition 1999.

Nursing Drug Handbook. 27th edition 2007

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Sparks, Sheila M, Nursing Diagnosis Reference manual, 5th edition, 2001

by Springhouse Corporation, Pennsylvannia.

The Lippincott Manual of Nursing practice. 7th Edition. Vol.2