schizophrenia paranoid

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A Case Study on SCHIZOPHRENIA PARANOID Submitted to: Ms. Melba Irene Gabuya, R.N. Clinical Instructor

Sumitted by: Glaiza Ayop Lev Jasper A. Blanco Kara Marise Cortez Arriane Noelle Gamalinda Lovely Ann Lim Lord Jacob Nique Kim Ryan Renejane Regine Saso Angelie Tan Kevin Tipon Charrae Zarragosa BSN-3D August 7, 2010

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TABLE OF CONTENTS Acknowledgement Introduction Objectives (General& Specific) Patient’s Data Genogram Health History Personal History Anamnesis Theories of Development Etiology Symptomatology Psychodynamics Mental Status Exam Multi Axial Diagnosis Definition of Complete Diagnosis Differential Diagnosis Anatomy and Physiology Doctor’s Order Drug Study Nursing Care plan and Nursing Theories Medical Management Prognosis Recommendations Significance of the Study Conclusion References

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ACKNOWLEDGEMENT

The group wishes to express their gratitude and appreciation to the people who supported the group in their works and helped in the success of this case study. First of all, the group would like to thank the almighty God who gave the group protection at all times. To the group’s clinical instructor, Ms. Melba Gabuya, R.N. for her patience, guidance and knowledge that she imparted to the group throughout the whole duration of the group’s psychiatric exposure. To Mrs. Anabel Bauzon, R.N., Ms. Magnolia Jadulang, R.N., M.N., and Mr. Richard Cheng, R.N., for their guidance and precence during the psychiatric exposure. To Mrs. Nancy Bargamento, R.N., M.N., for imparting her knowledge and preparing the whole class in our lectures on Psychiatric Nursing concept before the actual psychiatric exposure. The group would also like to thank the staff of Davao Mental Hospital, for the usage of the facilities and allowing us to read our client’s latest and previous charts. To the Lim family, the group is grateful for providing lodging and sustenance during the production of this group project. To the patient, for his cooperation and expressing his feelings and insights in relation to his illness during the interview that the group conducted. To our patient’s father, for the time he allotted in giving all the necessary information needed to complete this study. To our families and friends, thank you for the support and encouragement you have given to the group, without all of you, this report would not be a success. To the group members, thank you for your unwavering effort and unadulterated dedication for the commencement and completion of this project.

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INTRODUCTION Schizophrenia is a serious mental illness characterized by a disintegration of the process of thinking and of emotional responsiveness It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood, with around 1.5% lifetime prevalence of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behaviour. No laboratory test for schizophrenia currently exists. Schizophrenia Ranks among the top 10 causes of disability in developed countries worldwide (World Health Organization, www.who.int) Schizophrenia is a disease that typically begins in early adulthood; between the ages of 15 and 25. Men tend to get develop schizophrenia slightly earlier than women; whereas most males become ill between 16 and 25 years old, most females develop symptoms several years later, and the incidence in women is noticeably higher in women after age 30. The average age of onset is 18 in men and 25 in women. Schizophrenia onset is quite rare for people under 10 years of age, or over 40 years of age (schizophrenia.com). Approximately 1 percent of people develop schizophrenia at some time during their lives. Experts estimate that about 1.8 million people in the United States have schizophrenia. The prevalence of schizophrenia is the same regardless of sex, race, and culture. In the Philippines, the prevalence of schizophrenia is thought to be about 1% of the population. About 90% of patient in treatments is between 18-55 years old. (www.doh.gov) The group 2 of BSN-3D was given the opportunity to have a psychiatric exposure at the Davao Mental Hospital last July 26 until August 6, 2010. Within these dates the group was assigned to have the case of Kida which was diagnosed with schizophrenia paranoid. After the group’s initial research about his case we found out that he had several recurrent admissions at the institution. With this data the group ought to seek the factors that influenced his condition.

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OBJECTIVES The group formulated one general objective which serves as the main goal of the case study and a number of specific objectives which may lead to the completion of the study. General Objective: The group will be able to apply and relate the knowledge and skills gained from the nursing concept of Psychiatric Nursing to achieve a comprehensive and intensive learning experience on a case study. Specific Objectives: a. Choose a client to be the subject of the case study related to Mental Illness b. Establish rapport and good therapeutic relationship with the client and the family members to gain their trust and to attain relevant information in the process c. Gather necessary data through interview with the client and family members which will serve as the baseline data for the case study d. Trace the genogram of the client to be able to identify occurrence of the present condition of the client e. Know the past and present health history of the client and the family which will help in determining the factors that caused the condition of the client f. Present the anamnesis by thorough gathering of the client’s pertinent data, selected informants, and familial history taking. g. Determine if the client followed or achieved the theories of development by Eric Erikson, Robert Havighurst, Sigmund Freud and Jean Piaget h. Trace the psychodynamic of the final diagnosis including the etiology, symptomatology, the predisposing and precipitating factors i. Assess the client’s mental status thoroughly during the orientation and termination phase as well as the Multi-Axial diagnosis j. Interpret and analyze nurse-patient interactions taken through effective use of therapeutic communication

17 k. Give at least 3 definition of the complete diagnosis of the client l.

Arise with a differential diagnosis in relation to the client’s maladaptive behaviors.

m. Discuss the human anatomy and physiology of the organs involve in the client’s condition n. Present a doctor’s order with rationalization. o. Present diagnostic exams true to the condition of the client in order to know what complications the client had undergone as well as its clinical interpretation p. Review the drugs taken by the client including its classification, mechanism of action, indications, contraindications, drug interactions, side effects and adverse effects and nursing management of each medication that have been prescribed to the client q. Formulate at least 10 nursing care plans for the management and implementation of the different interventions for the client r. Arise to a prognosis s. Make recommendations t. Provide the significance of the study

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PATIENT’S DATA

Name

:

Kida

Age

:

36 years old

Address

:

Purok 1B, Hilltop Bajada

Birthday

:

October 6, 1974

Birth Place

:

Makilala, Cotabato

Gender

:

Male

Ordinal Rank

:

2nd child

Civil Status

:

Single

Nationality

:

Filipino

Religion

:

Roman Catholic

Educational Attainment

:

Secondary Level Undergraduate

Occupation

:

Unemployed

Source of Information

:

Client, Father, Cousin and neighbors

Father

Mother

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Name: Amakida

Name: Inakida

Age: 64 years old

Age: 59 years old

Occupation: Service Driver

Occupation: Midwife

Educ. Attainment: College Level

Educ. Attainment: College Level Medical Data

Date of Admission

:

March 23, 2010

Admitting Physician

:

Al Raymond Tupas, M.D.

Diagnosis

:

Schizophrenia Paranoid

Institution

:

Davao Mental Hospital

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GENOGRAM

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HEALTH HISTORY

Past Health History Kida was a shy type of child. He’s not fond of playing games with his siblings. During his elementary years, specifically in grade 6, he engaged in premarital sex. The lady he had made love with became pregnant. His parents did not know about it. When he was already in secondary level he engaged in gangsters. Due to the influence of these gangsters, his studies were affected. He used illegal drugs, specifically Marijuana. Aside from using drugs he also became alcoholic. His vices became chronic which led to a conflict in the family. Because of this behavior it became a problem in the family. Such behavior became a problem because Kida can no longer perform basic household chores.

Present Health History

Kida has been admitted for several times in the same institution. His last admission was last March 23, 2010 and was discharged July 20, 2010. At home Kida didn’t take his medicine two days prior to the incident when he hurt a 5 year old child. One day he became irritable and hostile which led to his admission.

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PERSONAL HISTORY Pre-natal Amakida said that his wife carried herself well and didn’t experience any bumps, falls and other accidents during pregnancy. His wife had her prenatal check-ups every month. His wife never experienced any sickness during her pregnancy to Kida. His wife didn’t have any problems experienced during her pregnancy with Kida and according to Amakida, his wife had normal pregnancy. His wife is very careful regarding to her pregnancy. The mother took vitamins and supplements every day. His wife eats nutritious foods during her pregnancy.

Birth According to Amakida, Inakida experienced a complete nine months of pregnancy. On October 6, 1974 in Makilala, North Cotabato, Inakida gave birth to Kida in the hospital through normal delivery without difficulty and no instrumental sequels. Attended by a doctor.

Infancy and Childhood Characteristics Kida is breastfed for only 3 months after birth because his mother needs to go back to work and after 3 months, they mix fed him. The feeding pattern during infancy is not normal because he had different feeding patterns. He was taken care by a “Yaya” and sometimes by his Lola. According to Amakida, Kida and his mother cuddles and hugs him always when she breastfeeds him. Kida completed the immunization. His first tooth came out when he was 1 year old. He started talking at age 1 and also walking at the same age. The toilet training started when he was 2 years old and it was mostly done by the mother and she was not strict in it. He does it independently but with a mother’s guidance. According to Amakida, Kida thumb sucks. He have fever for 2-3 days.

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Psychosexual History He got circumcised at the age of 10 and he started to become aware about sex is when he was 15 years old and at that age he also started to masturbate. He reads porn magazines and watches pornography. The age when his voiced lowered in pitch is when he is 18 years old.

Play Life According to his father, he’s a silent type of person, he’s not talkative. The games he mostly plays are basketball and “takyan”. He would play only in their yard together with his siblings and cousins. And he has few playmates, both boys and girls, because he has difficulty establishing rapport to other children. According to the father, when playing, he was a follower. When he was in Grade school, he does not leave school to play but when he was in High school he leaves school to play.

School History He started schooling at the age of 4 years old and he left school during his 2nd year in College at the age of 18 years old. He only completed his 1st year college and he stopped during his 2nd year in college. During Pre-school and Elementary, he studied in Jizon Elementary School but when his family transferred to Fatima Street, Guerrero, he continued his High School there. According to his father, Kida adjusted easily in school and in the community when they transferred. When he was in Elementary and in High school, he was focused in school, he does not skip classes and his performance in school is fair. He doesn’t have many friends, he is not talkative and he is shy. His favorite subject is Home Economics. During Elementary and High School, his grades were normal. Most of it were at 80 + but in College, his grades were just enough to pass the subject.

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Religious and Social Adaptability Kida has few selected friends, both male and female, and most of them are the same with his age. He is a shy boy but when he became a teen, he joined a Gang and learned vices like smoking Marijuana and drinking alcohol. His family goes to church but is not that religious. Occupational History Patient wasn’t able to experience employment. Unemployed.

Marital History Kida is not married. However, he did have relationships with the opposite sex. When Kida was 20 years old, he had his first girlfriend. And after that according to his father, they live for one month and decided to separate after his girlfriend got pregnant.

Onset of Present Illness According to the father, there are many reasons why he was readmitted. Two weeks prior to admission, he had positive late insomnia and he was noted to be violent to himself and started to harm other people. Furthermore, he also hit his youngest sister without any apparent reasons, thus Kida was restrained by his parents. This last incident prompted the father to seek for hospitalization.

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ANAMNESIS INFORMANTS 1.) Name: Amakida Age: 64 Civil Status: Married Address: Hilltop Bajada Relationship to patient: Father Length of time known to patient: Since birth Apparent understanding of present illness of patient: While Kida was still in college, his father started to suspect that he’s using illegal drugs. He observed the changes of Kida’s behavior such as destroying their bathroom, burning his clothes for no reasons, and stealing things that he doesn’t own and then sell them. After they noticed the changes of Kida’s behavior, they decided to bring Kida to the San Pedro Hospital to have a check-up. The result shows that he’s positive in using illegal drugs, so the family finally has confirmed that he was under the use of illegal drugs. The doctor just prescribed him a medicine. He doesn’t take his medications religiously, so Kida’s behavior worsened.

Other characteristics and attitude of informant: The informant was very accommodating and cooperative. He’s open in discussing about Ronaldo’s mental illness. He shows concern on his son’s condition. He’s willing to answer the questions that we asked.

2.) Name: Cuzkida Age: 35

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Address: 170 Fatima Street Guerero Relationship to patient: 1st Cousin Length of time known to patient: 30 years Apparent understanding of present illness of patient: Cuzkida said that Kida is a quiet person and not very open in saying what he feels. Kida don’t like to be asked with many questions. Kida’s family started to live with them in Fatima Guerero when he was still in elementary. During high school he started to drink alcoholic beverages and smoke cigarette. She said that kida’s illness only started during when he was at college. He would still asked money to his grandparents, even though his parents have already given him the money for the tuition fee. If his parents don’t give money, he would sell his clothes. She mentioned that he might be influenced by his group of friends in college on using drugs. Other characteristics and attitude of informant: The informant was accommodating and kind to us. She was very responsive in the conversation, and willing to tell the group everything that she knows about the patient. She has shared to us much information about kida.

3.) Name: Girkida Age: 38 years old Address: Fatima Street Guerrero Relationship to patient: Girlfriend Length of time known to patient: 18 years Apparent understanding of present illness of patient:

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Girkida and Kida met during college. Both of them have the same set of friends and she admitted that she has also tried using illegal drugs. They got lived in together for 1 month only, and then she decided to part ways with him. So, Kida went back to his family in Bajada. He didn’t know that she was already pregnant with his baby, until they heard about it and his family searched for her. Almost 10 years after, he saw his child. As what she knows about Kida is that he’s a quiet, good person, and an obsessive compulsive type of person. He never talks to her about his problems; he only kept it to himself. According to her, Kida’s group of friends was the main reason why he got addicted, because of their influenced to him to take illegal drugs. Other characteristics and attitude of informant: The informant was warm and welcoming to us. She was responsive and willing to answer our questions.

4.) Name: Anakida Age: 15 years old Address: Fatima Guerrero Relationship to patient: Kida’s son Length of time known to patient: 5 years Apparent understanding of present illness of patient: According to Anakida, he first met his father at the age of 10. They only see each other during weekdays. As what he knew also, his father was influenced by his friends in using drugs. Other characteristics and attitude of informant: He’s uncomfortable talking about his father’s condition, but somehow he was able to give us some information that we need. He quiet anxious when he had talked to us.

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FAMILY HISTORY Maternal and Paternal Grand Lineages According to the reports, there’s no history of mental illness in both sides of parents. Both on the maternal line and paternal line, no illness were reported to run in the family. Aside from Kida’s mother, his grandmother on mother’s side also took care of him since birth until he was 12 years old. When his mother is busy on her work, his grandmother is the one who takes care of him.

Father Amakida is now 64 years old. he works as a driver on Department of health According to the informants, amakida is good father to his children and he does everything he can to provide the needs of his family. He scold his children whenever they do something wrong, because he just want them to learn from their own mistakes. He believes that as a father he must give financial support to his family and security to his family. He thinks that he must also be a good role model to his children. Although he wasn’t able to finish his studies, he still does his best to give his family a good life. He only has the vices of drinking alcoholic beverages and smoking, occasionally.

Mother According to Kida’s father, his wife loves her children very much and she’s very supportive to him and his children. She works as a midwife at the Makilala to supplement her family’s needs. Whenever she’s on duty and his husband is on work, she would leave her children to her mother or to a “yaya”. She disciplines her children in a typical Filipino way. Her relationship with his husband is good, but they don’t see each other that much because both are busy in their works.

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Siblings The family is composed of four siblings; Brokida 1 being the eldest, followed by Kida, then Brokida 3, and lastly Siskida as the youngest. Kida was close to all of his brothers and sister, but much more closer with his sister, the youngest.

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THEORIES OF DEVELOPMENT

ERIK ERICKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY Erik Erickson’s developmental theory divides the human life cycle into eight distinct psychosocial stages, each with its own conflicts to be resolved, significant relationships, and favorable outcomes. Conflicts that are not resolved in a timely fashion cause difficulties and may be rewarding therapy * INFANCY (0 -1 ½ years old) – TRUST vs. MISTRUST During the first year of life, an infant depends on the parents for all their physiologic and psychological needs. Fulfillment of these needs is required for the infant to develop a basic sense of trust. Parents can enhance this sense of trust by responding consistently to an infant’s needs, providing a predictable environment in which routines are established and being sensitive to the infants needs and meeting these needs skillfully and promptly. TRUST In Kida’s case he was breastfed for the first 3 months of life and bottle-fed after because the mother needs to go back to work. Her mother is a midwife and is usually not at home. The maternal-infant bonding was met only on the first 3 months of life. Her mother is a midwife, so she wasn’t able to take care much of her children because of too much work. Also her father wasn’t available all the time because of work and so he wasn’t able to take care of Kida all the time. When his mother and father are not at home, his nanny and grandmother takes care of him. They fed him and give attention and care to the child. As a conclusion, the task was met in this stage which created mistrust to the infant. * TODDLER (1 1.2 – 3 years old) – AUTONOMY vs. SHAME and DOUBT\ Toddler begin to develop their sense of autonomy by asserting themselves with the frequent use of the word “no”. They are often frustrated by restraints to their behavior and between ages 1 and 3 may have temper tantrums. Parents need to have a great deal of patience coupled with an understanding of the importance of this developmental milestone. Caregivers

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need to give the child some measures of control and at the same time be consistent in setting limits so that the child learns the results of misbehavior. AUTONOMY In Kida’s case, he was able to meet the task because he was able to learn and explore more of his surroundings because of her mother giving measures of control and at the same time being consistent in setting limits to the child so we can say that he had met autonomy. The patient started talking when he was 1 year old and started walking on that age as well. The patient was toilet trained when he was 2 years old. Toilet training was mostly implemented by his mother, and she is not strict in it. Kida does it independently but with mother’s guidance. The child was able to master this kind of task in this stage, since he developed the sense of autonomy which he was able to handle things of his own. * PRESCHOOLER (4 and 5 years old) - INITIATIVE vs. GUILT During this stage, the child learns to take initiative and get ready for leadership and goal achievement roles. If adults encourage and support children’s efforts, while also helping them make realistic and proper choices, children develop initiative- independence in planning and undertaking activities. But if, adults discouraged the search of independent activities, children develop guilt about their needs and desire. GUILT According to his father, he’s a silent type of person, he’s not talkative. He would play only in their yard together with his siblings and cousins. And he has few playmates because he has difficulty establishing rapport to other children. According to the father, when playing, he was a follower. The child developed guilt. * SCHOOL AGE (6 -12 years old) – INDUSTRY vs. INFERIORITY At this time, children begin to create and develop a sense of competence and perseverance. School age children are motivated by activities that provide as sense of worth. They concentrate on mastering skills that will help them function in the adult world. If children

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have been successful in previous stage, they are motivated to be industrious and to cooperate with others toward a common goal. INDUSTRY He entered elementary at the age of 6yrs.old. During his school age, Kida is fine. He studies well and got average grades. He has no back subjects. He has met the expectations of his parents from him, which is to do well in his studies. * ADOLESCENCE (12 - 20 years old) – IDENTITY vs. ROLE CONFUSION During this stage, Adolescents help one another through this identity crisis by forming cliques and a separate young culture. Adolescents are usually concerned about their body, their appearance and their physical abilities. New sense of identity on self is established, commitment to career planning, sense of having a place in society, establishing relationship with opposite sex, fidelity to friends, developments of personal values, testing out adult roles and mature sexuality is achieved. ROLE CONFUSION Kida studied in Our Lady of Fatima during high school. According to his neighbor, which is his classmate as well, he joined a gang during high school. He started drinking and smoking because of peer pressure. Also, he started using marijuana, he’s cutting his class and because of his vices he always got low grades. He studied college in MATS and stopped on his second year for the reason that he prefers going out with his friends than going to school. His parents already doubt that Kida started using marijuana because of behavioral changes and going home late at night. At the age of 20, he was admitted to the Drug Detention Rehabilitation Center (DDRC) because his father couldn’t control kida anymore. He is already violent and steals their things to sell it in order to have money to buy marijuana. He developed role confusion. YOUNG ADULTHOOD (20-30 years old) INTIMACY VS. ISOLATION Trust is essential to establish intimate relationship. Intimacy involves mutual compassion, commitment and acceptance.

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Once people have established their identities, they are ready to make long-term commitments to others. They become capable of forming intimate, reciprocal relationships and willingly make the sacrifices and compromises that such relationships require. If people cannot form these intimate relationships--a sense of isolation may result. INTIMACY He had his first girlfriend at the age of 20. Their relationship did not last long but they had a child. He had intimate relationship with his friends who are also drug addicts and are usually with them most of the time. Kida developed intimacy because he was able to form intimate relationship with friends. MID-ADULTHOOD: (30-65 years old) GENERATIVITY VS. STAGNATION Generativity is occurred when adults gained enough self-sufficiency and motivity to be able to guide the next generation. Self absorption and caring for one is signs of stagnation. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by 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. STAGNATION The patient is not so productive due to his illness. He’s being dependent to his family. The little money he earned out of the stolen things he sold is being wasted for buying what is being prohibited for him to be used, like marijuana and cigarettes that contributes in worsening his illness. He doesn’t support his child that’s why he wastes his money for his own wants. He’s not helping the country to move forward since he had violated the Republic Act 6425 or the

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Dangerous Drug Act of 1972, Article III, Sec. 8 which is regarding the usage of the prohibited drugs.

SIGMUND FREUD’S PSYCHOSEXUAL THEORY Oral Stage (0 to 18 months) During the first stage of Sigmund Freud theory, the mouth is the major source of gratification, exploration and source of pleasure and satisfaction. During this stage, the child believes that his mouth is the source of pleasure because it is where he feeds and in turn brings comfort, security and happiness to him. The major source of pleasure comes from sucking, eating, biting, and chewing. If ever the child will not accomplish this pleasure then fixation can happen. In Kida’s case, his mother was able to supply him with regular Breast milk until 3months of life with proper duration and in time interval. After 3months, Kida was mixed fed because her mother is not at home all the time. Thumb sucking was evident. If his mother is not at home, her grandma and nanny take care of him. If ever Kida cries, they immediately fed him to supply his needs. The parent and the guardian were able to meet the pleasure site of the infant which is the mouth. Oral stage is achieved. Anal Stage (18 months to 4 years old) The second stage of psychosexual development is the anal stage which occurs from 18 months of the child up to 4 years; in this stage, the child begins to control his muscles from urination and defecation. The child explores his control on his body parts by either holding on or letting go of his bodily waste. Toilet training is crucial in this stage. If the training is too rigid, then the child may develop retentive personality in the future on which he becomes too rigid, obsessive orderly and stringent. On the other hand, if the parent is to loose on toilet training on which the child does not receive reward punishment at the right time then the child may develop expulsive personality on which the child’s future becomes disordered, destructive and careless.

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According to his father, they are not strict in Kida’s toilet training. They let Kida do it independently but his mother guide him. He was able to handle things of his own. Therefore, anal stage is achieved. Phallic Stage (3 to 7 years old) In this stage, the center of pleasure comes from the child’s genitals. The child now starts to know gender differences and becomes aware of his genitals. The child starts to touch and explore his body parts and it is in this stage that the child’s curiosity arises on masturbation. Oedipus complex appears on boys on which they have feelings of intimate sexual possessiveness for the mothers and Electra complex arises on the girls on which they also want to possess intimate sexual possessiveness to their father. The child develops fear of punishment by the parent of the same sex, guilt, and sexual identity. The child conflict is resolved when the child identifies with the parent of the same sex. Fixation occurs when he is unable to identify with the parent of the same sex and the child may exhibit reckless, resolute, self-assumed, narcissistic behavior in the future. Kida did complete the tasks identified in this stage. At this stage, he was able to learn that a boy is for a girl, and a girl is for a boy. According to his father, he saw Kida holding his penis while drinking milk and when taking a bath. Latency Stage (7 to 12 years old) In this stage, the child does not have any center of pleasure; the child uses most of his energy to gain new skills in social relationships and knowledge. It is in this stage; the child becomes more focused in dealing with friends and focuses on his academic performance. It is in this stage the child masters the sense of industry. He started to go to school by this time; he had gained few friends and few playmates. He got good grades and performing well in school. The child achieved this stage. Genital Stage (12 years up to 20 years old)

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During this stage the genitals again becomes the pleasure zone of the child. It is in this stage that the child builds a sexual relationship with the opposite sex. There will come a time that the child will now try to engage in sexual intercourse. The individual gains gratification from his or her own body. During this stage, the individual develops satisfying sexual and emotional relationships with members of the opposite sex. In Kida’s case he was able to experience attraction to the opposite sex. And He experienced sexual intercourse at the age of 20.

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT The Theory of Cognitive Development, one of the most historically influential theories was developed by Jean Piaget, a Swiss Philosopher (1896–1980). His genetic epistemological theory provided many central concepts in the field of developmental psychology and concerned the growth of intelligence meant the ability to more accurately represent the world and perform logical operations on representations of concepts grounded in interactions with the world. The theory concerns the emergence and construction of schemata — schemes of how one perceives the world — in "developmental stages", times when children are acquiring new ways of mentally representing information. The theory is considered "constructivist", meaning that, unlike nativist theories (which describe cognitive development as the unfolding of innate knowledge and abilities) or empiricist theories (which describe cognitive development as the gradual acquisition of knowledge through experience), it asserts that we construct our cognitive abilities through self-motivated action in the world. 1. The Sensorimotor Period (birth to 2 years) During this time, Piaget said that a child's cognitive system is limited to motor reflexes at birth, but the child builds on these reflexes to develop more sophisticated procedures. They learn to generalize their activities to a wider range of situations and coordinate them into increasingly lengthy chains of behaviour.

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The father of Kida remembered that they noticed that Ronaldo responds to different reflexes when he was a baby. He would move his body when both his parents touch him. He would grasp things when handed to him. Breastfeeding and bottle feeding are the food provided by his mother during her birth. When giving the bottle, the infant grasp it as a response of his hungriness. 2. Pre Operational Thought (2 to 6 or 7 years) At this age, according to Piaget, children acquire representational skills in the areas mental imagery, and especially language. They are very self-oriented, and have an egocentric view; that is, preoperational children can use these representational skills only to view the world from their own perspective. Kida was a silent son and brother. He wasn’t that expressive towards his feelings because he was not that open to everyone. 3. Concrete Operations (6/7 to 11/12) A opposed to Preoperational children, children in the concrete operations stage are able to take another's point of view and take into account more than one perspective simultaneously. They can also represent transformations as well as static situations. Although they can understand concrete problems, Piaget would argue that they cannot yet perform on abstract problems, and that they do not consider all of the logically possible outcomes. According to his father, Kida is a very organized person. His room and things are well arranged. But when he started taking marijuana, his father noticed that Kida is disorganized and breaks the things inside their house. 4. Formal Operations (11/12 to adult) Children who attain the formal operation stage are capable of thinking logically and abstractly. They can also reason theoretically. Piaget considered this the ultimate stage of development, and stated that although the children would still have to revise their knowledge base, their way of thinking was as powerful as it would get.

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The characteristics of this stage are: •

The person is capable of deductive and hypothetical reasoning.

•

The logical quality of the adolescent's thought is when children are more likely to solve problems in a trial-and-error fashion.

•

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

•

During this stage the young adult begins to entertain possibilities for the future and is fascinated with what they can be.

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, kay basig kailangan sa tag-iya ang kwarta.” He was able to draw conclusion from the given situation available. ROBERT HAVIGHURST’S DEVELOPMENTAL TASKS 1.

INFANCY AND EARLY CHILDHOOD (0-6yrs old)

*Learning to walk. * Learning to crawl. * Learning to take solid food. * Learning to talk. * Learning to control the elimination of body wastes. * Learning sex differences and sexual modesty. * Getting ready to read. * Forming concepts and learning language to describe social and physical reality. According to his Father, Kida was able to walk at the age of 1 year and able to eat solid foods at the age of 7months. Makes gurgling sounds when left alone and when playing. He was toilet trained and was able to control the elimination of body wastes. According to his father, Kida is able to distinguish right from wrong.

2.

MIDDLE CHILDHOOD (6yrs old-12 yrs old)

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*Learning physical skills necessary for ordinary games *Achieving personal independence * Developing fundamental skills reading, writing, and calculating: * Achieving personal independence: To become an autonomous person, able to make plans and to act in the present and immediate future independently of one's parents and other adults. The young child has become physically independent of his parents but remains emotionally dependent on them.

He was able to develop fundamental skills such as reading, writing and calculating. He was able to learn physical skills necessary for ordinary games: such skills as throwing and catching, kicking, and handling simple tools. Achieving personal independence: The young child has become physically independent of his parents but remains emotionally dependent on them. 3. ADOLESCENCE (12yrs old -18yrs old) •

Achieving new and more mature relations with age mates of both sexes. * Achieving a masculine or feminine social role. * Accepting one’s physique and using the body effectively. * Achieving emotional independence of parents and other adults. * Preparing for marriage and family life. * Acquiring a set of values and an ethical system as a guide to behavior. * Desiring and achieving socially responsible behavior.* Selecting an occupation. He was able to learn a socially approved adult masculine social role. He enrolled BS-MT

during college but stopped on his second year. He achieved new and more mature relations with age mates of both sexes. He was able to use his body effectively. 4.

EARLY ADULTHOOD (18yrs old-30 yrs old)

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*Selecting a mate. * Learning to live with a partner. * Starting family. * Rearing children. * Managing home. * Getting started in occupation. * Taking on civic responsibility. * Finding a congenial social group. Kida had a live in partner at the age of 20. Their relationship did not last long and they had one child. He has no occupation. He did not take responsibility to his own child.

5. MIDDLE AGE (30 yrs old- 60 yrs old) * Assisting teenage children to become responsible and happy adults. * Achieving adult social and civic responsibility. * Reaching and maintaining satisfactory performance in one’s occupational career. * Developing adult leisure time activities. * Relating oneself to one’s spouse as a person. * To accept and adjust to the physiological changes of middle age. * Adjusting to aging parents. In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

According to his father, Kida is not productive due to his illness. He’s being dependent to his family. He has no job and spends most of his time with his friends that are drug addicts. He doesn’t support his child that’s why he wastes his money for his own wants. “Wala na xay pulos ” as verbalized by his father.

.

17

ETIOLOGY

17

SYMPTOMATOLOGY

17

PSYCHODYNAMICS

17

MENTAL STATUS EXAMINATION Initial Name: KIDA

Diagnosis: Schizophrenia Paranoid type

Age: 36 years old

Physician: Al Raymond Tupas M.D.

Ward: Crisis Intervention Unit

Date of Examination: July 31, 2010

A. General description 1. Appearance: During our interview at the Crises intervention unit in Davao Mental

Hospital we observed that our client has a small body type, poorly groomed wearing old clothing. He has short hair and dirty nails in both feet and hands and open wounds due to insect bites on his left foot. He seemed to be healthy. No signs of anxiety noted. 2. Behavior and psychomotor activity: The client is ambulatory. No mannerisms, tics and spasms noted. 3. Speech: He can to talk with ease. No impairment in verbal communication noted such as stuttering, echolalia and mumbling of words were noted. 4. Attitude toward examiner: The client was cooperative throughout the whole interview.

B. Moods, feelings, and affect 1. Mood: Client has a euthymic mood or in the normal range of mood. No mood swing and signs of irritability were noted. 2. Affect: Client has an appropriate affect. Client is not in the state of agitation, tension, or panic.

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C. Perceptual Disturbance No signs of illusions were noted during the whole duration of the interview. Client claims that he was experiencing auditory hallucinations instructing him to do superfluous actions such as burning his own clothes.

D. Thought Process 1. Stream of thought: Client speaks spontaneously with some loosening of associations at some points during the interview. No circumstantiality, tangentiality, clang associations, and blocking were noted. 2. Content of thought: Client claims that he was experiencing delusion of persecution.

Client always tuck the linens of his bed indicating signs of obsessive compulsion. No suicidal ideation was noted.

E. Sensorium and Cognition 1. Consciousness: Client was alert throughout the whole duration of the interview. 2. Orientation: Client was asked “kung lunes gahapon miyerkules ugma, unsa adlaw karon?” Client was able to answer “martes” indicating orientation to time. Client was also oriented to the place that he is at the Mental Hospital. Client was able to identify and name the examiners. 3. Memory: Client was able to recall significant events of his life even during his childhood. He was able to remember his episodic admission at the institution for the last 15 years. 4. Information and Intelligence: Client was able to reach 2 nd Year College of formal

education.

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5. Concentration: Client was given simple mathematical tasks like subtracting 5 from 50 and keeps subtracting 5.

F. Judgment Patient said he knows his behavior why he was admitted. He also knows that his behavior would cause harm to other people that is why he would stop doing it, he will also not use things that will bring harm to other people.

G. Insight Client was able to manifest intellectual insight. Client is aware that he is ill and that it was a consequence of his actions in his past. Client understands his status but he does not apply his knowledge to future experiences such as taking his medications conscientiously upon his discharge.

H. Reliability We can fairly say that his statements are realistic enough. He is able to report to each questions are more likely to be accurate. He expresses his feelings and concerns honestly to the examiners.

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Final Name: KIDÀ

Diagnosis: Schizophrenia Paranoid type

Age: 36 years old

Physician: Al Raymond Tupas M.D.

Place of Interview: Hilltop Bajada, Davao City

Date of Examination: August 5, 2010

A. General description 1. Appearance: During our latest home visit at their own house we observed that Client has a small body type, groomed well wearing his old blue clothes. He still has short hair and his nails are now trimmed well in both feet and hands. He seemed to be healthy. He also seemed to look young for his age. Still no signs of anxiety noted. 2. Behavior and psychomotor activity: The client is ambulatory. No mannerisms, tics and spasms noted. No echopraxia and retarded motor activity were noted. No signs of agitation noted.

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3. Speech: He can to talk with ease and spontaneously. No impairment in verbal communication noted such as stuttering, echolalia and mumbling of words were noted. 4. Attitude toward examiner: Client was cooperative throughout the whole duration of the interview.

B. Moods, feelings, and affect 1. Mood: The patient was able to maintain a normal mood all through the home

visit. He was responding well to the conversation and his mood was appropriate for the discussion. 2. Affect: Client has an appropriate affect. His ideas are with harmony with his sppech. Client is not in the state of agitation, tension, or panic.

C. Perceptual Disturbance No signs of illusions were noted during the whole duration of the interview. During the whole visit client stated that he longer experiences hallucinations after he was discharged. D. Thought Process 1. Stream of thought: Client speaks spontaneously during the interview. No circumstantiality, tangentiality, clang associations, and blocking were noted. 2. Content of thought: No delusions or false beliefs were noted. No suicidal and homicidal ideation was noted. E. Sensorium and Cognition 1. Consciousness: Client was alert throughout the whole duration of the interview.

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2. Orientation: Client was asked the same question during our interview at the Davao Mental Hospital about his orientation to time, place, and person and he was able answer all question correctly. 3. Memory: Client was able to recall recent events that happened at the Davao Mental Hospital and the day he was discharged. 4. Information and Intelligence: Client was able to reach 2 nd Year College of formal

education. 5. Concentration The patient was given again given mathematical equations. Still, he

was able to answer all of them correctly and quickly. F. Judgment Client was given a situation to evaluate him. He was asked with “kung ginaaway og ginasunlog-sunlog sa mga bata diri tungkol sa imo pamilya unsa imu buhaton? He was able to answer awayon pud nako oi.

G. Insight The client still has the same understanding about his illness. He also insists that his vices especially smoking and drinking Coke, which the doctor prohibited, will not do any harm to him and will not do any effect on his illness. With these statements, we can say that he has a poor insight. H. Reliability We can fairly say that his statements are true to his emotions. His actions and statements reflect to his feelings and emotions. MULTIAXIAL DIAGNOSIS

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Axis I: Clinical Disorder Schizophrenia Paranoid Type This major type of Adult Schizophrenia is marked by one or more systematic persecutory delusions, auditory hallucinations with a single theme (Deborah Antai-Otong (2003). Psychiatric Nursing. Biological and behavioral concepts, 348) Axis II: Personality Disorder Schizoid Personality Disorder Individuals with this disorder demonstrate a pervasive pattern of detachment from social relationships and manifest a restricted range of emotional expression with others. The pattern is apparent by early adulthood in a variety of context. These loners choose solitary activities that do not require much participation with others. There is little interest in sexual activity with another person, and there is minimal pleasure sought from sensory, bodily, or interpersonal experience. There seems to be no direction in their lives and responses are passive to negative experiences. These persons may do well in work conditions where they are socially isolated and may perform well when left alone. (Deborah Antai-Otong (2003). Psychiatric Nursing. Biological and behavioral concepts, 383) Axis III: General Medical Condition The client was not experiencing any medical conditions and/or physical disorders. Axis IV: Psychosocial and Environmental Problem The client is not very open to his feelings and emotions. Almost all of his significant others are supportive to him but he is unable to respond to the support that his significant others are offering. The client could not easily cope up with several stressors in life. His father stated that he also had a history of substance abuse such as shabu and marijuana. He was once admitted at a rehabilitation center but later on he was transferred to Davao Mental Hospital due to financial constraints. He has an repetitive irregular admission at the institution for the past 15 years as stated by the client’s father. This was due to several episodes of his violent actions in their community.

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Axis V: Global Assessment of Functioning 60-51: Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

DEFINITION OF COMPLETE DIAGNOSIS Schizophrenia

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Schizophrenia is an extremely complex mental disorder: in fact it is probably many illnesses masquerading as one. A biochemical imbalance in the brain is believed to cause symptoms. Recent research reveals that schizophrenia may be a result of faulty neuronal development in the fetal brain, which develops into full-blown illness in late adolescence or early adulthood. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as a single illness; rather thought as a syndrome or disease process with many different varieties and symptoms. It is usually diagnosed in late adolescence or early adulthood. Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. Source: http://nursingcrib.com/case-study/schizophrenia-case-study/

Schizophrenia - a serious mental illness, characterized by a disintegration of the process of thinking

and

of

emotional

responsiveness. It

most

commonly

manifests

as

auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood with around 1.5% lifetime prevalence of the population affected. Diagnosis is based on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists. Source: "schizophrenia" Concise Medical Dictionary. Oxford University Press, 2010. Oxford Reference Online. Oxford University Press. Maastricht University Library. 29 June 2010.

Schizophrenia paranoid

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Paranoid thinking is manifested by a persistent interpretation of the actions of others as threatening or demeaning. Paranoid themes can color delusions and hallucinations as well as the ordinary behavior of others. It is important for the student differentiate paranoid thinking associates with a paranoid personality disorder from paranoid delusions. Paranoid thinking is less severe than paranoid delusions. Paranoid thinking may be “corrected” with facts, whereas paranoid delusions are not. Source: Psychiatric Nursing 3rd edition Keltner, Schweke and Bostrom. Chapter 27 Schizophrenia and Other Psychoses page 359-360.

Paranoid schizophrenia is the most common type of schizophrenia in most parts of the world. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent. The course of paranoid schizophrenia may be episodic, with partial or complete remissions, or chronic. In chronic cases, the florid symptoms persist over years and it is difficult to distinguish discrete episodes. The onset tends to be later than in the hebephrenic and catatonic forms. Source: ICD-10 copyright © 1992 by World Health Organization.

Paranoid schizophrenia is a sub-type of schizophrenia as defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV code 295.1 It is the most common type of schizophrenia. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety (hearing voices), and perceptual disturbances. Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent. Source: Paranoid Schizophrenia DSM- IV http://en.wikipedia.org/wiki/Paranoid_schizophrenia.

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295.3X SCHIZOPHRENIA, PARANOID TYPE ESSENTIAL FEATURES The individual shows a disturbance in thinking characterized by persecutory or grandiose delusions or hallucinations with a persecutory or grandiose content. MANIFESTATIONS Physical Dimension Doubts about gender identity and Violence Emotional Dimension Unfocused anxiety, Anger, Argumentativeness, Fear of being thought of as homosexual, Intellectual Dimension Persecutory delusions, grandiose delusions, Delusional jealousy, Hallucinations, Social Dimension Stilted, formal social relations Source: adapted from American Psychiatric Association: Diagnostic and statistical manual of mental disorders (DSM – III – R), Washington, D.C., 1987, The Association. MENTAL HEALTH – PSYCHIATRIC NURSING A Holistc Life – Cycle Approach

DIFFERENTIAL DIAGNOSIS

17

ANATOMY AND PHYSIOLOGY

17

ANATOMY AND PHYSIOLOGY

The brain is a large mass of soft nervous tissue made up of both neurons and supporting neuroglial cells lying within the cranium of the skull. The brain contains both gray and white matter.

Gray

matter

is

primarily

nerve

cell

bodies,

whereas

white

matter

contains myelinated nerve cell processes, giving it a white appearance. White matter is mostly found in the cortex (shell) of the cerebral hemispheres. The brain has a highly complex appearance, with convolutions referred to as gyri and valleys referred to as sulci. These convolutions create a greater surface area within the same size skull.

Central nervous system The central nervous system is made up of the brain and spinal cord. The major divisions of the human brain are the brainstem, cerebellum, diencephalon, and cerebral hemispheres. The meninges cover and protect the brain and spinal cord.

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BRAINSTEM The brainstem, made up of the midbrain, pons, and medulla, sits at the base of the brain. The brainstem is involved in sensory input and motor output. Sensory input enters the brainstem from the head, neck, and face area, while motor output from the brainstem controls muscle movements in these areas as well. The brainstem also receives sensory input from specialized cranial nerves for olfaction (smell), vision, hearing, gustation(taste), and balance. The brainstem contains ascending and descending nerve pathways that carry sensory input and motor output information to and from higher brain regions, like a relay center. Ascending nerve pathways bring information through the brainstem into the rest of the brain, and descending nerve pathways send information back that coordinates many activities, including motor function. The brainstem also plays a role in vital functions such ascardiovascular and respiratory activity and consciousness. The medulla is a structure in the brainstem closest to the spinal cord. It is vaguely scoop shaped, with longitudinalgrooves indicating the presence of many nerve tracts. It is responsible for maintaining vital body functions such as breathing and heart rate. The pons is named after the Latin word for bridge. In appearance, the pons seems to be a bridge connecting the two hemispheres, but in reality the connection is indirect through a complicated nerve pathway. The pons is involved in motor control, sensory analysis, and levels of consciousness and sleep. Some structures within the pons are linked to the cerebellum, involving them in movement and posture. The midbrain, also called the mesencephalon, is the smallest and most anterior part of the brainstem with a tubular appearance. It is involved in functions such as vision, hearing, movement of the eyes, and body motor function. The anterior part of the midbrain contains the cerebral peduncle, a large bundle of axons traveling from the cerebral cortex through the brainstem. These nerve fibers (along with other structures) are important for voluntary motor function. CEREBELLUM The cerebellum, or "little brain," wraps around the brainstem. It is similar to the cerebrum in that it has two hemispheres with a highly folded surface (cortex). The

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cerebellum is involved in regulation and coordination of movement, posture, balance, and also some cognitive function. DIENCEPHALON The diencephalon, or "between brain," lies between the cerebral hemispheres and the midbrain. It is formed by the thalamus and hypothalamus, and has connections to the limbic system and cerebral hemispheres. The thalamus is a large body of gray matter at the top of the diencephalon, positioned deep within the forebrain. The thalamus has sensory and motor functions. Almost all sensory information enters this structure, where it is relayed to the cortex. Axons, or nerve endings, from every sensory system except olfaction come together (synapse) here as the last relay site before the information reaches the cerebral cortex. The synapse is the junction where nerve endings meet and communicate with each other using chemical messengers that cross the junction. The hypothalamus is a part of the diencephalon lying next to the thalamus. The hypothalamus is involved inhomeostasis, emotional responses, coordinating drive-related behavior such as thirst and hunger, circadian rhythms, control of the autonomic nervous system, and control of the pituitary gland. MENINGES AND VENTRICULAR SYSTEMS The meninges are membranes that cover and protect the central nervous system (CNS) along with a fluid called cerebrospinal fluid (CSF) that buoys up the brain. The brain is very soft and mushy; without the meninges and CSF, it would be easily distorted and torn under the effects of gravity. The meninges are divided into three membranes: the thick external dura mater provides mechanical strength; the middle web-like, delicate arachnoid mater forms a protective barrier and a space for CSF circulation; and the internalpia mater is continuous with all the contours of the brain and forms CSF. The dura mater contains six major venous sinuses that drain the cerebral veins and several smaller sinuses. Dural venous sinuses are formed in areas where the two layers of the dura mater separate, forming spaces. The sinuses are triangular in cross-section and lined with endothelium. There are six major dural sinuses that receive cerebral veins. The superior sagittal sinus, straight sinus, and right and left transverse sinuses meet in a structure known as the confluence of the sinuses. Venous blood circulation follows a pathway through the superior sagittal and straight sinuses into

17

the confluence, and then through the transverse sinuses. Each transverse sinus then continues as a sigmoid sinus, carrying the venous blood flow along an S-shaped course until it empties into theinternal jugular vein. The major dural sinuses also connect with several smaller sinuses. The inferior sagittal sinus,occipital sinus, and superior and inferior petrosal sinuses all empty into different parts of the major sinus system. The arachnoid mater follows the general shape of the brain, creating a space between the two membranes. The space between the arachnoid and pia mater is called the subarachnoid space and contains CSF. CSF enters venouscirculation through small protrusions into the venous sinus called arachnoid

villi.

The

pia

mater

forms

part

of

thechoroid

plexus,

a

highly convoluted and vascular membranous material that lies within the ventricular system of the brain and is responsible for most CSF production. The brain contains four ventricles. A pair of long, C-shaped lateral ventricles lies within the cerebral hemispheres. The lateral ventricles communicate with the narrow, slit-shaped third ventricle of the diencephalon. The third ventricle then communicates with the tent-shaped fourth ventricle of the pons and medulla, which protrudes into the cerebellum. The CSF of the brain flows in a specific pattern that allows newly formed CSF to replace the old CSF several times a day. The basic pattern of circulation is formation in lateral ventricles, flow into the third and then fourth ventricles, into basal cisterns, up and over the cerebral hemispheres, into the arachnoid villi, where drainage occurs into a venous sinus to return to the venous system. Some CSF diverts from the basal cisterns into the subarachnoid space of the spinal cord. Blockage of the circulation of CSF can cause a condition calledhydrocephalus, where the CSF pressure rises high enough to expand the ventricles at the sacrifice of the surrounding brain. Blockage of CSF circulation can occur at any point in the pathway. Hydrocephalus conditions are divided into two types, communicating and noncommunicating. The classification depends on whether both lateral ventricles are in communication with the subarachnoid space. Noncommunicating hydrocephalus involves blockage in the ventricular system, which prevents the flow of CSF to the

subarachnoid

space. Tumors

sometimes

causehydrocephalus,

through

instigating

either overproduction or physical obstruction of CSF. CSF circulation may also beobstructed in the subarachnoid space by adhesions that form as a result of meningitis.

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CEREBRAL HEMISPHERES The cerebral hemispheres are made up of the cerebral cortex, hippocampus, and basal ganglia containing the amygdala of the limbic system. The cerebral hemispheres are divided by the interhemisphericfissure and are involved in higher motor functions, perception, cognition (pertaining to thought and reasoning), emotion, and memory. The cerebral cortex is divided into four major lobes. The frontal lobe contains the primary motor cortex and premotor area involved in voluntary movement, Broca's area involved in writing and speech, and the prefrontal cortex involved in personality, insight, and foresight. The parietal lobe contains the primarysomatosensory cortex involved in tactile and positioning information, while remaining sections are involved in spatial orientation and language comprehension. The temporal lobe contains the primary auditory cortex, Wernicke's area involved in language comprehension, and areas involved in the higher processing of visual input, along with aspects of learning and memory associated with the limbic system. The occipital lobe contains the primary visual cortex and the visual association cortex. The limbic lobe is a subdivision consisting of portions of the frontal, parietal, and temporal lobes that form a continuous band called the limbic system. The limbic system, buried within the cerebrum, is also referred to as the "emotional brain." It includes the thalamus, hypothalamus, amygdala, and hippocampus. Through these structures, the limbic system is involved in drive-related behavior, memory, and emotional responses such as feeding, defense, and sexual behavior. The thalamus and hypothalamus are parts of the diencephalon, while the amygdala and hippocampus are parts of the cerebral hemispheres. The left and right cerebral hemispheres are not equal in their functionality. In the human brain, the left hemisphere is more important for the production and comprehension of language than the right hemisphere. Damage to the left hemisphere is more likely to cause language deficits than damage to the right hemisphere. Because of this variation in hemisphere contribution, the left hemisphere is most commonly referred to as the dominant hemisphere and the right hemisphere is referred to as the nondominant hemisphere. Nearly all right-handed people and most lefthanded people have a left-dominant brain. However, some people have a right-dominant brain or comparable language representation in both hemispheres.

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The hippocampus is a curved sheet of cortex folded in the basal medial part of the temporal lobe. It is divided into three multilayered sections, the dentate gyrus, hippocampus proper, and the subiculum acting as a transitional zone between the two. The dentate gyrus receives input from the cortex, and sends output to the hippocampus proper. The hippocampus proper then sends output to the subiculum, which is the principal source of hippocampal output. The hippocampus, referred to as the gateway to memory, is involved in learning and memory functions. The hippocampus converts short-term memory to more permanent memory, is involved in the storage and retrieval of long-term memory, and recalling learned spatial associations. The basal ganglia are masses of gray matter located deep in the cerebral hemispheres. The basal ganglia contain the corpus striatum, which is involved mostly in motor activity. The striatum is the major point of entry into basal ganglia circuitry, receiving input from almost all cortical areas. It is subdivided into three further divisions called thecaudate nucleus, putamen, and globus pallidus. The caudate nucleus is involved more with cognitive function than with motor function. Of all the striatum subdivisions, the putamen is the most highly associated with motor functions of the basal ganglia. The globus pallidus is a wedge-shaped section of the striatum responsible for most basal ganglia output. The basal ganglia also contain the amygdala, a portion of the limbic system involved in memory, emotion, and fear. The amygdala lies beneath the surface of the temporal lobe where it causes a bulge called theuncus. The basal ganglia collectively modulate the output of the frontal cortex involving motor function, but also cognition and motivation.

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SPINAL CORD The spinal cord is a cord-like bundle of nerves comprising a major part of the central nervous system, which conducts sensory and motor nerve impulses to and from the brain and the periphery. It is a long tube-like structure extending from the base of the brain, through a string of skeletal vertebrae, to the small of the back. The spinal cord is continuous with the brainstem, and like the brain, it is encased in a triple sheath of membranes. Thirty-one pairs of spinal nerves belonging to the peripheral nervous system (PNS) arise from the sides of the spinal cord and branch out to both sides of the body. In addition to carrying impulses to and from the brain, the spinal cord regulates reflexes. Reflexes produce a rapid motor response to a stimulus because the sensory neuron synapses directly with the motor neuron in the spinal cord, so the impulse does not need to travel to and from the brain.

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NERVOUS TRACTS Tracts are groups or bundles of nerve fibers that constitute an anatomical and functional unit. Commissural tracts such as the corpus callosum connect the two cerebral hemispheres. Association tracts make connections within the same hemisphere. Projection tracts connect the brain with the spinal cord. Sensory tracts project upward from the spinal cord into regions of the brain, bringing sensory input from the periphery via ascending pathways. Motor tracts project down from the brain into the spinal cord, bringing motor output information to the periphery via descending pathways. The internal capsule is the major structure carrying ascending and descending nerve projection fibers to and from the cerebral cortex. It is a curved, funnel-shaped group of cortical projection fibers divided into five regions, based on each region's relationship to the putamen andglobus pallidus of the striatum. Peripheral nervous system The peripheral nervous system (PNS) is all of the nervous system outside the brain and spinal cord, including the spinal and cranial nerves. The PNS is divided into the somatic and autonomic subdivisions. The somatic nervous system, regulating activities that are under conscious control such as the voluntary movement of skeletal muscles, includes the spinal and cranial nerves and peripheral sensory receptors. Peripheral neurons that transmit information from the periphery toward the CNS are called afferent neurons, whereas those that transmit information away from the CNS toward the periphery are called efferent neurons. The 31 pairs of spinal nerves are each named according to the location of their respective vertebrae. Each spinal nerve consists of a dorsal root and a ventral root. The dorsal roots contain afferent neurons transmitting information to the CNS from various kinds of sensory neurons. The ventral roots contain the axons of efferent motor neurons transmitting information to the periphery. Information travels great distances via interneurons, which are neurons that connect neurons to each other. Spinal nerves have sensory fibers and motor fibers. The sensory fibers supply nerves to specific areas of skin, while the motor fibers supply nerves to specific muscles. A dermatome, which means "skin-cutting," is an area of skin supplied by nerve fibers originating from a single dorsal nerve root. The dermatomes are named with respect to the spinal nerves that

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supply them. Dermatomes form bands around the body. In the limbs, dermatome organization is more complex as a result of being "stretched out" during embryological development. There is a high degree of overlap of nerves between adjacent dermatomes. If one spinal nerve loses sensation from the dermatome that it supplies, compensatory overlap from adjacent spinal nerves occurs with reduced sensitivity. In addition to dermatomes supplying the skin, each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve. The muscle, in conjunction with its nerve, makes up a myotome. Although slight variations do exist, dermatome and myotome patterns of distribution are relatively consistent from person to person. Cranial nerves also carry sensory information from the periphery to the brain, and motor information away from the brain to the periphery. Humans have 12 pairs of cranial nerves numbered by the level at which they enter the brain. Seven of the cranial nerves specialize in information about olfaction, vision, hearing, gustation, and balance. The other cranial nerves control eye and mouth movements, swallowing, and facial expressions. Cranial nerve X is called the vagus nerve; it has effects on visceral gut function and has the ability to slow the heart when stimulatedthrough the parasympathetic nervous system. The autonomic nervous system includes further sympathetic, parasympathetic, and enteric subdivisions. The autonomic nervous system regulates activities that are not under conscious control but rather are involuntary, such as contractions of the heart and digestion of food. The autonomic nervous system is involved in maintaining homeostasis in the body. The sympathetic and parasympathetic subdivisions of the autonomic nervous system have opposite effects on the organs they control. Most organs controlled by the autonomic nervous system are under the influence of both the sympathetic and parasympathetic nervous systems, which strike a balance with each other to maintain proper body function. The sympathetic nervous system generally stimulates organs, whereas the parasympathetic nervous system generally suppresses organ function or slows it down. An example of this coordination of activity is seen in the fight-orflight response, which is the body's response to a sudden threatening or stressful situation in which excessive energy is needed to either deal with such an attack or run from it. In the fight-orflight response, both the sympathetic and parasympathetic nervous systems work in coordination with each other to produce the appropriate results. The sympathetic and parasympathetic nervous

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systems increase blood pressure and heart rate and slow digestion to enable the physical exertion necessary to respond to the threatening circumstance. The digestive system contains its own, local nervous system referred to as the enteric, or intrinsic, nervous system. The enteric nervous system is extremely complex and contains as many neurons as does the spinal cord. The enteric nervous system is divided into two networks, or plexuses, of neurons, both of which are embedded in the walls of the digestive tract and extend from the esophagus to the anus. The myenteric plexus is located between the longitudinal and circular layers of muscle in the tunica muscularis and is involved in digestive tract motility. Thesubmucous

plexus lies

buried

in

the submucosa.

Its

principal

role

is

regulating gastrointestinal blood flow and controlling epithelial cell function in response to the environment within the lumen. In regions where these functions are minimal, such as the esophagus, the submucous plexus is sparse. The enteric nervous system functions independently from other nervous systems, but normal digestive function requires communication between the enteric system, other PNS systems, and the CNS. Stimulation of the sympathetic nervous system causes inhibition of gastrointestinal secretions and motor activity, while the parasympathetic nervous system stimulates the same functions. Parasympathetic and sympathetic fibers connect either the central and enteric nervous systems or connect the CNS directly within the digestive tract. In this manner, the digestive system provides sensory information to the CNS, and the CNS is involved in gastrointestinal function. The CNS can also relay input from outside of the digestive system to the digestive system. An example is the sight or smell of food stimulating stomach secretions.

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DOCTOR’S ORDERS DATE

DOCTOR’S

RATIONALE

February 7,2010

ORDER Please admit patient

To establish a designated doctor

to CIU with watcher

to which all pertinent information

REMARKS DONE

regarding the patient will be referred to and for thorough patient monitoring. A watcher is needed for medical matters that have to deal formally and appropriately which the patient may not be capable of doing.

VS q4, then record

Vital signs are recorded to obtain

day

the patient’s baseline data and be useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for changes in the blood pressure to prevent tachycardia or bradycardia which may be subject to patient’s feelings and emotions.

DONE

17

DAT

To signify that the patient has no

DONE

restrictions regarding intake of solid or liquid foods. Meds:

Chlorpromazine is an

Chlorpromazine

antipsychotic. It is principally

200mg/TAB, ½

used in the treatment of

TAB in AM, 1 TAB

schizophrenia. Chlorpromazine

HS

blocks dopamine receptors.

Biperiden

Biperiden is given to control and

2mg/TAB, 1 TAB

prevent extrapyramidal

BID prn for EPS

symptoms secondary to the use of

DONE

DONE

flupentixol decanoate and chlorpromazine. Suicide/Homicide/

Patient is capable of doing so that

Escape Precaution

they will know better on how to

DONE

handle the patient since there is a possibility that he may become hostile and escaping tendencies. Restrain if necessary For the patient and everyone’s safety in case the patient becomes hostile. Refer

Referral is done to correct unusualities as soon as possible and to inform the attending physician of the patient's condition.

DONE

17

Continue meds

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February 08,

Meds:

Increasing the dose is done to

2010

↑ chlorpromazine

increase the therapeutic effects of

20mg/TAB, 1 TAB

chlorpromazine. BP precautions

BID with BP

are ordered to prevent some of

precautions

the adverse effects of

DONE

chlorpromazine which are orthostatic hypotension and tachycardia. To single cell

Isolation of the patient is

DONE

necessary to facilitate safety of the patient as well as the other patients and staff. This will also decrease the risk for a potential injury and violence. February 09,

Continue meds

2010

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February 10,2010

To open ward

Isolation has also negative effects such as low self esteem. It is necessary for the patient to be in

DONE

17

the open ward to facilitate socialization and recovery. Continue meds

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February

↑ chlorpromazine

Increasing the dose is done to

11,2010

200mg/TAB, 1 TAB

increase the therapeutic effects of

TID with BP

chlorpromazine. BP precautions

precaution

are ordered to prevent some of

DONE

the adverse effects of chlorpromazine which are orthostatic hypotension and tachycardia. February

Continue meds

12,2010

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February

Continue meds

13,2010

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February 14, 2010

Continue meds

All medications previously ordered by attending physician should be continued to hasten

DONE

17

patient's recovery. February 15,

Continue meds

2010

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery.

February

Continue meds

16,2010

All medications

DONE

Previously ordered by attending physician should be continued to hasten patient's recovery. Please inform the

Instructions and health reminders

Resident in charge if

must be relayed by the doctor

patient’s watcher

especially ones that concerns the

arrived.

medication and follow up check

DONE

up. MGH

The patient has already recovered

DONE

and the symptoms subsided and can be managed by home treatment. Home medication: chlorpromazine

Chlorpromazine is an

200mg/TAB, 1 TAB

antipsychotic. It is principally

TID

used in the treatment of schizophrenia. Chlorpromazine blocks dopamine receptors.

DONE

17

flupentixol

Flupentixol decanoate is an

decanoate

antipsychotic that may be

20mg/amp 1 amp

prescribed to alleviate psychotic

IM

features such as paranoia and

give 1 dose prior to

hallucinations.

discharge

Side effects are similar to many

DONE

other typical antipsychotics, namely extrapyramidal symptom s of akathisia, parkinsonian tremor and rigidity. Biperiden

Biperiden is given to control and

2mg/TAB, 1 TAB

prevent extrapyramidal

BID prn for EPS

symptoms secondary to the use of

DONE

flupentixol decanoate and chlorpromazine Check up at OPD

Follow up check provides

after 2 weeks.

constant monitoring of the

DONE

progress of the patient.

July 26, 2010 at

Please admit patient

To establish a designated doctor

11:20 am

to CIU with watcher

to which all pertinent information regarding the patient will be referred to and for thorough patient monitoring. A watcher is needed for medical matters that

DONE

17

have to deal formally and appropriately which the patient may not be capable of doing. Monitor VS now

Vital signs are recorded to obtain

and then q4

the patient’s baseline data and be

DONE

useful for further management. A temperature higher than normal may indicate the development of infection. Pulse & respiration is taken to watch out for changes in the blood pressure to prevent tachycardia or bradycardia which may be subject to patient’s feelings and emotions.

Meds:

Flupentixol decanoate is an

Flupentixol IM now

antipsychotic that may be

then q2 for two

prescribed to alleviate psychotic

weeks.

features such as paranoia and

DONE

hallucinations. Side effects are similar to many other typical antipsychotics, namely extrapyramidal symptom s of akathisia, parkinsonian tremor and rigidity.

Clozapine 100 mg 1

Clozapine is an anti-psychotic

DONE

17

tab OD

medication that works by blocking receptors in the brain for several neurotransmitters (chemicals that nerves use to communicate with each other) including dopamine type 4 receptors, serotonin type 2 receptors, norepinephrine receptors, acetylcholine receptors, and histamine receptors.

Halopenidol 5 mg

Haloperidol is an antipsychotic

IM now

medication. Haloperidol

DONE

interferes with the effects of neurotransmitters in the brain which are the chemical messengers that nerves manufacture and release to communicate with one another. It blocks receptors for the neurotransmitters (specifically the dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not "activated" by the neurotransmitters released by other nerves.

Suicidal/ Homicide/

To inform the nurses of what the

DONE

17

escape precautions

patient is capable of doing so that they will know better on how to handle the patient since there is a possibility that he may become hostile and escaping tendencies.

Remove any hazards This will decrease the tendency prior to entry to CIU

DONE

for violence and injury among the patients.

Continue meds

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery. SGPT

Laboratory studies are necessary

DONE RESULTS

CXR-PA

to provide data regarding the

NOT

CBC

patient’s health status and

ATTACHED TO

condition. SGPT is for liver

CHART

function test to determine liver injury. CXR is for the visualization of the lobes of the lungs. CBC stands for complete blood count necessary to establish a data for the cellular make up of the blood. Continue meds July 27, 2010

All medications previously ordered by attending physician should be continued to hasten patient's recovery.

DONE

17

July 28, 2010

Continue meds

All medications previously

DONE

ordered by attending physician should be continued to hasten patient's recovery. 7:30 am

Possible for

A possibility for home treatment

discharge in AM

again after the presence of a

DONE

watcher or significant others.

July 29, 2010

Defer discharge

Discharges are deferred if

DONE

minimum requirement before a patient is discharged are not met. 12:05 am

For counseling c/o

Counselling is necessary for the

Psychologist

patient to be fully assessed

DONE

medically and psychologically before being discharged. Continue meds

All medications previously ordered by attending physician should be continued to hasten patient's recovery.

DRUG STUDY

DONE

17

17

NURSING CARE PLANS DISTURBED THOUGHT PROCESS Date &

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Subjective:

C

Disturbed thought

Within days span of

1. Utilize safety measures to

" naa gusto mag

O

processes related to

therapeutic interaction, protect client or others, if client

disintegration of

the patient will:

Time

patay sa akoa” as verbalized by the patient

G N I

Objective:

•

Delusion of Persecuti on • Restlessn

cognitive process as

himself against specific person.

evidenced by

Precautions are needed.

presence of delusions

V

 Schizophrenia alters thought process causing

E P

A. maintain usual reality orientation

T I

believes he needs to protect

disruption in

 client's delusional thinking might dictate to him that he has to hurt others in order to be safe.

B. minimize episodes of

2. Offer self and listen with

delusion.

regard.

cognitive operation.

 to show that you're available

Most schizophrenic

and there for the patient. This

patients manifest

lessens anxiety.

delusion which is a

Evaluation

17

ess noted

E R

hallmark of the mental illness.

briefly. Focus on real people and

C

real events

E

 presenting reality allows

P

patient to recognize what is present and what is happening

T U A L P A

3. Present reality concisely and

Videbeck, S. Psychiatric Mental health nursing.

around and helps distinguish from what is unreal. Makes them in touch with the reality.

Chapter 14, p289 4. Do not argue with delusions.  Arguing tends to reinforce delusions and can make the

T

patient angry. This will also

T

increase client's defensive position.

E R 5. Avoid whispering or laughing

17

N

around the patient unless they can hear what is said.  patient may misinterpret it and may aggress. it will minimize persecutory delusion

6. Do not touch the patient; use gestures carefully.  a psychotic person might misinterpret touch as either aggressive or sexual in nature and might interpret gestures as aggressive moves. Schizophrenic patients particularly the paranoid type need a lot of personal space.

7. Refrain from forcing activities or communications.

17

 Patient may feel threatened and may withdraw or rebel.

8. Allow and encourage verbalization of feelings and thoughts. Interact with the patient on the basis of things in the environment.  to guide them in staying in touch with reality and it reduces anxiety.

9. Help patient to identify the stressors that might precipitate hallucinations or delusions.  this effort might lead to identification and avoidance of triggering events.

17

10. Observed keenly for situations that trigger hallucination or delusion and immediately gets the patient's attention.  to limit or avoid delusions.

17

DISTURBED SENSORY PERCEPTION Date &

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Subjective:

C

Disturbed sensory

Within days of span of

1.Decrease environmental stimuli

As verbalized

O

perception:

care, the patient will be when possible (low noise,

“auditory” related

able to:

Time

by the patient “ naay naga ingon sa akoa na naay gusto mulason sa akoa”

G N

•

Change

in usual response to

exaggerated emotional

to schizophrenia.

A. Identify personal

that might trigger hallucinations. Helps calm client.

interventions

2. Stay with client when he is

 the sensory input

that decrease or

starting to hallucinate, and direct

of schizophrenic

lower the

them to verify to his significant

individuals,

intensity and

others for what he sees. Repeat

including sight and

frequency of

often in a matter-of-fact manner.

sound, are sent as

hallucination

fragments, with no

such as

chronology or

socialization

® Clients can learn to distinguish

P

order, to the brain.

and

real from unreal by verification

E

Normally, what we

participating in

of the objects he sees to his

see and what we

group activities

significant others.

I V E -

stimuli such as

® Decrease potential for anxiety

reception secondary

I T

Objective:

to altered sensory

minimal activity)

Evaluation

17

response •

Change

in behavioral pattern •

Restlessn

R C E P

ess •

Auditory

hallucination

T U

s A L P A

hear come together to the brain.

T

based topics of conversation. Help client focus to one idea one

possibility that if

at a time.

what is heard and what is seen are sent as separate fragments, the brain conjures and fills in

® Client’s thinking might be confused and disorganized; this intervention helps patient to focus and comprehend.

pieces of information that are missing. An error in circuitry from

4. Explore how the client experiences the hallucinations.

within the brain the processing of sensory input from the external

E

environment. There

R

is a possibility that the "voices" they

N

cognition

3. Keep simple, basic, reality-

However, there is a

regions may impair T

B. Improve level of

hear of people

®Exploring the hallucination and sharing the experience can help give the person a sense of power that he might be able to manage the hallucinatory voices.

17

talking to them are

5. Helps client to identify times

their own conscious,

that the hallucinations are most

automatic thoughts

prevalent and frightening.

and inner speech perceived as external. This is

® Helps both nurse and client

probable occurrence

identify situations that increases

as there are many

the level of anxiety of the client.

reports of auditory hallucinations by people who are

6. Engage client in simple

placed in solitary

physical activities or tasks that

confinement or

channel energy such as jogging

isolation.

inside the premises of crisis intervention unit.

http://serendip.bryn mawr.edu/bb/neuro/

® Redirecting client’s energies to

neuro02/web3/schan

acceptable activities can decrease

.html

the possibility of acting on hallucinations.

17

7. Work with the client to find which activities help reduce anxiety and distract the client from hallucinatory material. Practice new skills with client.

® diversional activities will decrease the possibilities of acting up to hallucinations.

8. Monitor Drug Regimen

® to identify medications with effects or drug interactions that may exacerbate sensory perceptual problems

17

9. Avoid Isolation of the client.

® there are many reports of auditory hallucinations by people who are placed in solitary confinement or isolation. And may exacerbate the current condition

10. Interpret stimuli/offer feedback to patient

® to assist client separate reality from fantasy/altered perception

17

RISK FOR VIOLENCE Date & Time

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

17

Subjective

S

“ hapit na niya

E

sunugon among balay ”, as verbalized by the father

L F

•

auditory hallucina tions reported

•

history of

Within day span of

Self/other related to

nurse-patient

history of aggressive interaction, the client behavior secondary

E R C E P

violence against

T

others

I

will be able to :

Use calm and firm approach ® Provides structure and control for a client who is out of control.

to mental health problem

P

Objective:

Risk for violence:

a. Demonstrate the ability to

Use one-on-one or appropriate

® Paranoid

control aggressive

level of observation to monitor

schizophrenia

impulses and delay

rising levels of anxiety;

individuals are often

gratification

determine emotional and situational triggers.

tense, suspicious and guarded and may be

b. Demonstrate

argumentative,

respect for the

hostile and

rights of others

aggressive.

c. Demonstrate

® External controls are needed for ego support and to prevent acts of aggression and violence.

selfcontrol/relaxed/

O N

demonstrate Source: 2002. Shives, L.R.,

nonviolent behavior

Remove all dangerous objects from client’s environment.

17

S

Basic Concepts of

® Removal of dangerous objects

Psychiatric- Mental

client, in an agitated, confused

Health Nursing.

state, from harming self or

Philadelphia PA.

others.

E L F

4. Maintain a consistent approach, employ consistent expectations, and provide a

-

structured environment.

C

® Clear and consistent limits and

O

expectations minimize potential for client’s manipulation of staff

N C E P T

5. Remain neutral: avoid power struggles and value judgments. ® Clients can use inconsistencies and value judgments as justification for arguing and

17

P

escalating mania

A T T E

6. Decrease environmental stimuli ® Helps decrease escalation of anxiety and manic symptoms

R N

7. Assess client’s behavior frequently for signs of increased agitation and hyperactivity

® Early detection and intervention of escalating mania might help prevent harm to self or others, and decrease need for seclusion.

8. Process incidents with the

17

client to make it a learning experience. ® Reality testing, problem solving and testing new behaviors are necessary to foster cognitive growth.

9. Encourage feelings of concern for others and remorse for misdeeds. ® Development of empathy is a therapeutic goal.

10. Give positive reinforcement for client’s effort. ® encourages continuation of desired behaviors.

17

RISK FOR INJURY Date & Time

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

17

J

Subjective:

U L Y 3

H Objective: History of aggressive behavior

0, 2 0 1

7AM

A

With medical order for restraint

H H E

With history of single cell isolation

A L T

-open wounds due to scratching

Within our 5 hour span 1.) Establish Rapport with patient

July 30, 2010

related ti history of

of duty, our patient

@12pm

aggressive behavior

will not experience

secondary to mental

injury towards self as

health problem

manifested by:

H M

® Facilitates cooperation in the treatment plan

GOAL MET After 5 hours span of care,

L T

0 @

E

Risk for injury

A. Maintain in safe ® Paranoid

and calm

schizophrenia

environment

individuals are often

B. Enumerate

2.) Establish good and open communication/therapeutic communication with the patient.

tense, suspicious and

traits that

guarded and may be

promotes injury

argumentative,

free

® promotes trusting situation in

hostile and

environment

which the client is face to be open

aggressive. (2002. Shives, L.R.,

and be honest with self and therapist.

Basic Concepts of psychiatric nursing)

our patient was not able to experience injury as manifested by: a. Maintenanc e of safe and calm environmen t. b. Enumerate

3.) Assess the environment for

d

events that may trigger

behavioral

violence

traits that promote an

17

A - redness around affected area.

N

® maintaining a safe environment

injury free

will lessen the incident of injury.

environmen t such as

A G

calmness 4.) Assess client’s mood, and personality styles

E M E N T

® provide data for warning signs and appropriate therapy 5.) Assess client’s emotional and behavioral responces to violence. ® Determines client’s view of own and others safety and provides

P A

appropriate intervention from the nurse.

T T E

6.) Assess for any history of selfinflicted injury. ® provides measure for

and patience.

17

R

prevention of reoccurrence

N 7.) Provide healthcare within a culture of safety such as maintaining bed/chair in lowest position.

®this will reduce impact of injury if it occurs.

8.) Inform patient of ways to avoid sel-inflicted injury such as calmness and patience. ® knowledge of the patient can be a good source for personal wellness.

9.) Encourage participation in

17

self-help programs such as a positive self image ®Activities that enhance selfesteem can lessen conflicts among patients.

10.)

Refer to other support

facilities such as counseling, and psychotherapy

®professional help aides in the promotion of psychological wellness.

NONCOMPLIANCE Date & Time

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

17

J

Subjective:

U

“dili mn ko

L Y 3

ganahan maginom ug tambal kay mubalik akong sakit”

0, 2 0 1

7AM

E A

Objective: -recurring symptoms noted

H P E R

-failure to keep appointments

C E P

- multiple admissions to recovery center for 17 years

Within our 8 hour span 11.)

drug regimen

of duty, our patient

related to

will be able to express

unwillingness of

compliance to drug

patient secondary to

therapy as manifested

paranoia

by:

Establish Rapport with

patient

T I

July 31, 2010 @12pm GOAL MET

® Facilitates cooperation in the treatment plan

L T

0 @

H

Noncompliance to

After 5 hours spa of care, our patient was

C. Enumerate ® There are

disadvantages

persistent psychotic

of

symptoms,

noncompliance

especially paranoia,

D. Make SMART

grandiosity,

goals for the

disordered thinking,

recovery

and lack of

E. Verbalize

12.)

Establish good and open

communication/therapeutic communication with the patient.

willingness to comply with drug therapy as manifested by:

® promotes trusting situation in which the client is face to be open and be honest with self and

awareness of illness.

commitment to

These kinds of

mutually agreed therapist.

symptoms lead to

upon goals and

active medication

treatment plan.

refusal because they

able to express

c. Enumerate d disadvantag es of noncompliance

13.)

Assess level of perception

prevent the person

or understanding of the

from having insight

condition

such as expensive cost, absence of

17

O N H E A L T H M A N A G E

into the need for medication. (http://www.schizop

immediate ® helps to identify factors of noncompliance

hrenia.com/family/c

family once readmitted and reoccurrenc

ompliance1.html) 14.)

Assess level of compliance

to the drug therapy by asking how many dose the patient’s receive, describe the drug

e of symptoms. d. Made SMART goals after

® indicates if the patient is mindful of his drug/medicine intakes 15.)

recovery such as being with family and

Assess factors/conditions

continue

that interfere with taking

drug

medications such as

therapy to

depression and alcohol use.

fully

® indicates conditions that can interfere with the action of drug or the willingness to take medications

recover. e. Verbalized commitmen

17

M E N T

t to 16.)

Encourage binding a

verbal contract with patient to adhere with treatment plan ® this will enhance commitment of patient to follow through.

T T

17.)

Educate the client

regarding effects of noncompliance such as recurring of symptoms and readmission.

E R N

agreed upon goals and treatment plan by saying:

P A

mutually

®knowledge of consequences can motivation for the patient to adhere

18.)

Discuss with patient about

future plans after discharge. ® this can intensify the will of the

“Dili na nao kalimtan mag-inom og tambal aron mayo n a jud ko”

17

patient to recover and comply with the drug therapy.

19.)

Instruct client to

paraphrase instruction heard about the drug therapy. ®To facilitate learning of the client and understanding about the drug regimen

20.)

Ensure that support

systems will be available after discharge ®Support systems are necessary for the patients full recovery such as family and support groups

17

Date

July

Cues

Need

Subjective:

R

30,

I

2010 @ 7am

Objective:

• Presence

S

of

K

Nursing

Objective

Diagnosis

Care

Risk for infection Within related to open hours wounds secondary insect bites.

of Nursing

Evaluation

Interventions over of

5

July

1. Establish

span

rapport

care, our patient

patient.

30,

2010

with 12:00 pm

to will not be able to have infection

Facilitates wound ® as cooperation in the

GOAL MET

@

17

mosquito bites noted

F O R

®

Rash

from

mosquito bite is a form of severe reaction.

The

rash

has

appearance I N F E C

similar to blisters or bruises, with redness itching

and around

the bitten areas. (http://www.buzz le.com)

manifested by:

treatment plan

a. Disinfected

2. Establish good and

wound; b. Clean

open and

dry

wound;

®

N

Promotes

which the client is face to be open and be honest with self and therapist.

3. Assess area of skin

wound

or

damage. ®

was

able

have

to

Baseline

therapy

for and

provides knowledge extent

of

of

not an as

a. Disinfected wound;

trusting situation in

I

patient

manifested by:

with the patient.

of

span of care, our

rapeutic

odor on affected d. Absence of fever.

hours

infection

communication

area

5

communication/the

c. Absence of foul

T

O

After

the the

b. Clean

and

dry

of

foul

wound; c. Absence

order on affected area; d. Absence of fever.

17 problem

4. Observe

for

baseline infections. ®Provides

proper

documentation and formal

action

of

intervention

for

patient’s wellness.

5. Observe

for

existence

of

causative factor. ® Risk factors for the aggravation of the condition must be eliminated.

6. Provide remedy

basic

such

as

disinfection of the wound.

17 ®

Cleaning

the

wound

will

minimize

risk

for

infection.

7. Inform patient of the benefit of maintaining

good

hand hygiene. ®

This

minimize for

will

the

risk

infection

and

transfer of bacteria.

8. Instruct not to frequently

touch

nor scratch insect bites. ® Frequent contact wounded skin can aggravate condition.

9. Encourage

the

17

intake of oral fluids such as water. ® Frequent water intake cleanses the body thus excreting bacteria.

10. Encourage intake of food high vitamin

c

improve

to body

resistance. ®

Elevated

resistance minimize infection.

body can

risk

for

17

FAYE ABDELLAH’S 21 NURSING PROBLEM “Although Abdellah spoke of the patient-centered approaches, she wrote of nurses identifying and solving specific problems. This identification and classification of problems was called the typology of 21 nursing problems. Abdellah’s typology was divided into three areas: (1) the physical, sociological, and emotional needs of the patient; (2) the types of interpersonal relationships between the nurse and the patient; and (3) the common elements of patient care. Adbellah and her colleagues thought the typology would provide a method to evaluate a student’s experiences and also a method to evaluate a nurse’s competency based on outcome measures.” (Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115). Abdellah’s Typology of 21 Nursing Problems are as follows: 1. To promote good hygiene and physical comfort 2. To promote optimal activity, exercise, rest, and sleep 3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 4. To maintain good body mechanics and prevent and correct deformities 5. To facilitate the maintenance of a supply of oxygen to all body cells 6. To facilitate the maintenance of nutrition of all body cells 7. To facilitate the maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic responses of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory function 12. To identify and accept positive and negative expressions, feelings, and reactions 13. To identify and accept the interrelatedness of emotions and organic illness 14. To facilitate the maintenance of effective verbal and nonverbal communication 15. To promote the development of productive interpersonal relationships 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying physical, emotional, and

17

developmental needs 19. To accept the optimum possible goals in light of physical and emotional limitations 20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in the cause of illness

17

IMPAIRED VERBAL COMMUNICATION Date &

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Impaired verbal

After days of

1.) Determine patient’s primary

communication

rendering nursing

language spoken

related to

care, the patient will be

unrealistic thinking

able to:

Time Subjective: R O L Objective:

E

-Loose association noted

contact noted

by constantly

important to ensure that the

mental status as evidenced by loose

a. Communicate

association of ideas

appropriately

R

L A T

- Refused to talk

® Determining language is patient is able to understand the nurse during conversation

and

E -Poor eye

and alterations in

I

comprehensibly ® Patients with unrealistic thinking and alterations in mental status experience problems

factors that would affect b. Gain client’s

because of the

patients interest in talking

interest in conversation

® Patient may not want to participate if there is presence of

in verbal communication

2. Asses surroundings for

c. Establish eye contact

unwanted objects, noise, improper lighting, and the like

Evaluation

17

facing away from the nurse during conversation

O N S H

- with no and inappropriate response to

I P

questions

negative changes in the cognitive field of the brain, delay in

3.Note presence of anger

the developmental task or events

® Emotional disturbance may

causing emotional

affect communication with patient

pain affecting speech and expression of

4.Keep sentences simple and

thoughts

short

P A T T E

http://serendip.bryn mawr.edu/bb/neuro/ neuro02/web3/schan .html

® This would help the patient to understand more what the nurse is saying. It provides easier understanding for the patient so he/she can make appropriate responses.

R N

5.Maintain eye contact during conversation ® To have a trusting relationship

17

with the patient so he/she can express concerns to the nurse without any hesitations

6. Promote patient participation in special activities and discussions preferred by the patient in a setting that the he/she views as safe ® To have an avenue conducive for patient’s expression of thoughts

7. Orient client to reality as required. Call the client by name. Validate those aspects of communication that help differentiate between what is real and not real.

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®These techniques may facilitate restoration of functional communication patterns in the client

8. Maintain a calm, unhurried manner and give sufficient for the client to respond. Avoid frequent corrections. ® client may talk more easily when they are calm and relaxed.

9. Provide positive reinforcement when client makes moves toward making conversation with others ®Encourages continuation of efforts

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10. Refer to therapist as appropriate ®To facilitate patient’s progress

SELF-ESTEEM DISTURBANCE

17

Date &

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Self esteem

Within my weeks span

1. Establish rapport/therapeutic

disturbance r/t

of care my patient will

relationship with the patient.

feeling of different

be able to;

Time Subjective:

S E

“ dili ko ganahan ug daghan tao” as verbalized by the patient.

L F

E R

withdrawn behavior noted

•

 Mental health

 Participate in

trusting relationship with the

activities/therap

patient and to increase the level

ies being

of participation.

conducted

research shows that depression and low

 Demonstrate

2. Establish good and open

positive

communication/therapeutic

hand-in-hand with

behaviors

communication with the patient.

mental illness.

towards self-

Several research

image as

P

studies refute claims

evidenced by

T

that stigma is

social

relatively

interaction and

inconsequential. In

improved social

E

I dull affect

social interaction.

self esteem goes C

•

 To have a good working and

evidenced by poor

P

Objective:

from others as

fact, studies suggest

 Promotes trusting situation in which client is free to be open and be honest with self and therapist.

Evaluation

17

noted

O N

•

aloof

S E L F C O

that stigma strongly influences the selfesteem of people who have mental

C

because you have a mental illness, you are repeatedly rejected as a friend,

related to current situation.

 Current crises may exacerbate long-standing feelings and selfevaluation.

an employee, a neighbor, or an intimate partner and devalued as a person who is less intelligent, and less competent, it’s difficult to feel good

E

about yourself and

P

the situation you find yourself in.

T

Determine factors of low esteem

illness. When,

trustworthy, less N

skills.

Discuss client perceptions of self.  Addressing issues openly provides opportunity for change.

Encourage participation ingroup activities/therapies being conducted.

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P A T T E R N

http://www.healthy

 To develop and enhance

place.com/other-

patient’s social

info/mental-health-

interaction/increase self esteem.

newsletter/low-selfesteem-and-mentalillness/menu-id1902/

Involve in activities/exercise, programs and promote socialization.

 Enhances sense of well being/ help energize patient, increases chances to participate on activities/therapies.

Give positive reinforcement for progress noted.

 Positive words of encouragement promote

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continuation of efforts and enhance patients self esteem.

Emphasize importance of grooming and personal hygiene.

 People feel better about themselves when they present a positive outer appearance.

Conduct learning activities such as communication skills/ positive self-image activities.

 To assist with learning new skills and to promote self-esteem.

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Model behaviors being taught, involving client in goal setting and decision-making.

 Facilitates clients developing trust in own unique strengths.

INEFFECTIVE THERAPEUTUC REGIMEN DATE CUES

NEED NSG DX:

GOAL OF CARE

INTERVENTIONS

EVALUTAION:

17

J

S:

H

U

“Makalimot man gud ko inom usahay kay walay nagahatag.”

E

L Y

L T

O: 30,

-

2

-

0

-

1 0

A

-

Unable to take medication in the right time. Medications taken only if available. Less number of nurses available. 5 nurses is to 50 patients.

H

Ineffective Therapeutic Regimen Mgt related to complicated healthcare system as evidenced by lack of medicine supply.

P E R C E

@

P

7:00

T

AM

I O N

R: Use requires that patients receive the appropriate medicine, in the proper dose, for an adequate period of time.

Within our 5 hours span of care our patient will have effective therapeutic regimen mgt as manifested by: a. self-awareness of the medication; demonstrate behavioral changes necessary for maintaining therapeutic regimen such as willingness to take the drug.

1.) Establish rapport with patient. R: Facilitates cooperation in the treatment plan. 2.) Establish good and open communication/therapeutic communication with the patient. R: promotes trusting situation in which the client is face to be open and honest with self and therapist. 3.) Assess knowledge of px regarding to the condition & therapeutic regimen. R: enables patient to be aware of own self-needs & medication need. 4.) Assess the effect of the problem such as

July 30, 2010 12:00 PM

GOAL MET!

After 5 hours span of care, our patient was able to have effective therapeutic regimen as manifested by: a. Self- awareness of the time of medication. b. Demonstrate behavioral changes necessary for maintaining therapeutic regimen.

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recurrence of symptoms. H E A L T H

M A N A G E M E N T

R: facilitate proper identification of the extent of the effect of the problem to the client’s progress. 5.) Assess availability of the drug. R: lack of supply leads to ineffective therapeutic management. 6.) Assess availability of primary caregivers. R: presence of a caregiver is necessary to provide monitory of the maintenance of the therapy. 7.) Instruct client to paraphrase instruction heard about the drug therapy. R: facilitate learning of the client & understanding

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about the drug regimen. P A T T E R N

8.) Educate client about consequences of ineffective therapeutic management such as slow progress. R: this will promote understanding that can lead to wellness of the client. 9.) Refer to counseling or therapy to a group or psychologist, as prescribed. R: professional guidance from an expert or sharing of experiences with copatients can ease understanding and wellness. 10.) Identify home and community based nursing services for follow up or assistance. R: this will enhance

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confidence of the patient the there are people who can support him outside the center.

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IMPAIRED SKIN INTEGRITY Date &

Cues

Needs

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Impaired skin

Within our 5 hour span 21.)

integrity related to

of duty, our patient

insect bites as

will be able to have

manifested by open

improved skin integrity

wound due to

as manifested by:

Evaluation

Time J

Subjective:

U

“Daghan man

L Y 3

gud lamok mamaak. Katol kayo, kiloton pud nko”

0, 2 0 1

7AM

U T

Objective: -mosquito bites noted at the lower extremity

T I O N

-open wounds due to scratching

scratching

R I

0 @

N

A L-M

Establish Rapport with

patient

® Rash from a

G. Enumerate

® Facilitates cooperation in the treatment plan

After 5 hours spa of care, our patient was

22.)

Establish good and open

communication/therapeutic

mosquito bite is a

ways of

form of severe

prevention of

reaction. The rash has

the problem

appearance similar to

such as

blisters or bruises,

maintaining

® promotes trusting situation in

with redness and

good hygiene

which the client is face to be open

communication with the patient.

able to have improved skin integrity as manifested by: f. Wounds

itching around the

and be honest with self and

bitten areas.

therapist.

(http://www.buzzle.

@12pm GOAL MET

F. Wounds are disinfected

July 30, 2010

were disinfected and kept dry and clean

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E - redness around affected area.

T A B O

com/articles/insectbite-rashes.html)

g. Enumerate 23.)

Assess extent of skin

injury

C

such as

health problem

trimming nails and maintaining

24.)

Assess underlying factors

causing skin injury

P

causative factors.

A

25.)

T E R

the

® Establish proper assessment of

® facilitates extermination on the

T

preventing problem

L I

d ways of

Assess other medical

condition that can aggravate the condition such as diabetes mellitus. ® other medical disorder can trigger and even exacerbate the skin injury.

cleanliness.

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N 26.)

Assess blood supply and

sensation on affected area. ® evaluates the actual impairment of circulation

27.)

Ascertain attitude of

patient to the condition

®provides a baseline for patient’s will to cooperate in the regimen.

28.)

Educate the patient

regarding the effects of having wounds. ® this will open the mind of the patient and will eventually participate in the treatments.

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29.)

Provide first aid remedy

such as disinfecting and cleansing ®Ensure that the risk for infection will be minimal

30.)

Instruct patient on how to

minimize the problem such as keeping a well trimmed nails and frequent washing. ®Good hygiene can prevent occurrence of infection

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MEDICAL MANAGEMENT Milieu Management

Hospitalization It is a primary mode of treatment for people with mental illness. The highest priority for admission to hospital-based care is safety for self and others, necessitating 24-hour supervision in a secure environment. This includes recognition of individuals who are actively suicidal, selfmutilating, or threatening others with harm. Hospitalization provides thorough medical and psychiatric evaluation to identify the underlying cause of their symptoms. The goal of hospitalbased care is to assist individuals with attaining initial stabilization and safe level of functioning and to assess for appropriate referrals for aftercare.

Milieu Therapy Milieu (or environment) management is a proactive approach to care that forges therapeutic benefits from patients’ surroundings, whether in the home, hospital, or out-patient setting. The concept of milieu therapy involved clients’ interactions with one another, that is, practicing interpersonal relationship skill, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems. Milieu therapy was one of the primary modes of treatment in the acute hospital setting. In today’s health care environment, however, in-patient hospital stays are often too short for clients to develop meaningful relationships with one another. Therefore, the concept of milieu therapy receives little attention. Management of milieu, or environment, is still a primary role for the nurse in terms of providing safety and protection for all clients and promoting social interaction.

Therapeutic Management

17

Psychotherapy The goal of a psychotherapy group is for members to learn about their behavior and to make positive changes in their behavior by interacting and communicating with others as a member of a group. Groups may be organized around a specific medical diagnosis, such as depression, or a particular issue, such as improving interpersonal skills or managing anxiety. Group techniques and processes are used to help group members also learn they have responsibilities to others and can help other members achieve their goal. Psychotherapy groups are often formal in structure, with one or two therapists as group leaders. One task of the group leader or the entire group is to establish the rules of the group. These rules deal with confidentiality, punctuality, and attendance, and social, contact between members outside of group time.

Play Therapy It is a form of therapy that brings fun and form of exercise, socialization with others cooperation, diversion of attention, promote sportsmanship and express feelings and thoughts. It is an activity that makes it possible for the client to express himself freely. Free play enables the individual a unique opportunity to discharge strong emotions in a secure atmosphere.

Music Therapy This therapy is a purposeful use of music as a participative or listening experience in the treatment of patients to improve and motivate the patients’ mental and emotional state. Its activity is for socialization and self-expression and sometimes realization through musical activities. It is also a process of letting the patients express their feelings and thoughts through various artistic means like drawing, sketching, painting and many more. Music therapy significantly diminishes patients' negative symptoms, increased their ability to converse with others, reducing their social isolation, and increasing their level of interest in external events.

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Art Therapy This is a form of expression by which emotionally and mentally ill patients can communicate their problems by expressing it through drawings and paintings. It is a tool for stimulating self-expression, as a diagnostic therapy from which modifications in treatment can be made, it facilitates group process, it provides opportunities for self-esteem, and it promotes personal growth.

Biblio-Therapy It is a non-physical psychotherapeutic technique in which the patient is induced to read books or any reading materials. Literature is a means of achieving therapeutic goals. The therapy makes use of literature, films, creative writing, and group discussion to promote expression of thoughts and feelings. It aims to stimulate psychological, social and aesthetic values from books in relation to human character, personality and behavior. This provides stimuli for the memory to compare events with other patients. The purposes of this therapy are: to widen cultural horizon, to lift up depressed feeling, educate the patient, improve the span of attention of the individual with limited concentration, and to stimulate imagination.

Occupational Therapy This therapy is a manual, recreational and creative technique to facilitate personal experience and increase social responses and self-esteem. In this therapy, the process and not the product is of greater importance. It is also rehabilitative procedure that diverts patient’s attention and this develops their creative abilities for a purposeful living and lead to the mastery of self and environment. This is also a method of treatment in which patients are given some kind of light work, directed towards meeting patients to work through unconscious conflict through the mechanism of sublimation or acting it out.

Group Therapy

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The goal of group therapy is the alteration of behavioral patterns of group members through the development of new and more effective ways of coping with stress. In group therapy, clients participate in sessions with a group of people. The members share a common purpose and are expected to contribute to the group to benefit from others in return. Group rules are established that all members must observe. These rules vary according to the type of group. Being a member of a group allows the client to learn new ways of looking at a problem or ways of coping with or solving problems and also helps hi or her to learn important interpersonal skills. For example, by interacting with other members, clients often receive feedback on how others perceive and react to them and their behavior. This is extremely important information for many clients with mental disorders, who often have difficulty with interpersonal skills.

The therapeutic results of group therapy include the following: •

Gaining new information and learning

•

Gaining inspiration and hope

•

Interacting with others

•

Feeling of acceptance and belonging

•

Becoming aware that one is not alone and that others share the same problems

•

Gaining insight into one’s problems and behaviors and how they affect others

•

Giving of oneself for the benefit of others (altruism)

Remotivation Therapy This is to make an individual’s most basic psychological needs are to be loved ( to be involved ) and to feel worthwhile ( to have respect from self and others ). These needs must be met responsibly and within the context of reality. Responsibility is fulfilling one’s needs without interfering with others who are fulfilling their needs. This therapy can be used in any situation,

17

regardless of the length of time the client has been hospitalized, his age or the reason of his illness and sex. This aims to stimulate clients to think about something and talk about himself, develop the ability to communicate and share idea and experience with others and to develop feeling of acceptance and recognition.

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PROGNOSIS

POOR

FAIR

GOOD

JUSTIFICATION

His illness started last 1993 and she was 19 years old on that year. According to Ama 1.) Duration of Illness

Kida, the continuous signs 

last for at least 6 months. At present, he is 36 years old and so it is 17 years that she has the illness. She was admitted via his father. Kida first symptoms of schiazophrenia appeared when he was 19 years old. It was mentioned by his father that Kida started to move suspiciously and schizophrenia paranoid type

2.) Onset of Illness



set in before the age of 25. It typically first occurs in adolescence or early adulthood, at time during which brain maturation is almost complete.

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Paranoid type is more common in single persons than married ones. He does 3.) Civil Status



have a girlfriend but they separated.

Precipitating factors include interpersonal influences, major life events, and social environment. The girlfriend of Kida got pregnant, but unfortunately, they separated. He tends to 4.)Precipitating



Factors

choose his friends. According to the informants, when they migrated in Fatima they live in a place were addiction is very prone. They have a good housing condition.

5.)Mood and Affect

All throughout the activity Kida showed calmness and he is much behaved. He 

shows blunted affect. At times so you really need to repeat the question to get her

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attention. She has this blunted affect since from the start of the therapy.

He only had few friends and he intensely chooses the friends he wanted to have. 6.)Premorbid

Schizophrenia can cause a

Personality

diminished energy level (anergia), which complicates



social interactions.

Schizophrenia does not manifests depressive disorders and depressive features are not visible. However he is observed to 7.)Depressive

have denials. Kida is

Features

changing the topic when the 

student nurse focuses on love life; it is his way of defense mechanism.

8.)Attitudes and Willingness to Take



Kida is not willingly to take the medicines and

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treatments. He has a negative behavior in the Medicines and

accomplishing the treatment

Treatment

regimen.

The immediate family of Mr. Kida gave their full emotional and financial support to him. The family tries to understand Mr. Kida’s despite of his 9. ) Family Support



condition. They concerned to Ms. Kida by bringing him to Davao Mental Hospital for proper treatment and management.

Computation Good 4 x 3 = 12 Fair

3x2=6

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Bad

2x1=2 = 20/9 = 2.22

Range Good = 1.0 – 1.6 Fair

= 1.7 – 2.3

Poor

= 2.4 – 3.0

General Prognosis The computation illustrates that Mr. Kida has fair prognosis. It suggests that he has a higher chance of recovering in this condition. If Mr. Kida will continue in complying the treatment and as long as the immediate family members will still support Mr. Kida, without hesitation, it will aid in his recuperation process.

RECOMMENDATIONS TO THE CLIENT:

17

1. Encourage the client to continue the prescribed medication even after the symptoms. 2. Persistent information regarding the signs and symptoms about the illness, adverse or side effects and contraindication of the medications should be given to the client. 3. Assist the client to join in psychotherapy activity like individual psychotherapy, group therapy, family therapy, music therapy, etc. 4. Encourage the patient to verbalize thoughts and feelings to know the patient’s need and able to perform and take appropriate actions for it. 5. Encourage the importance of proper hygiene, because it promotes and keeps him free from infection.

TO THE FAMILY AND SIGNIFICANT OTHERS: 1. Encourage the family to truly accept the real situation and condition of the client to lessen the emotional burden. 2. Give the actual information about the illness, so that they will be aware of the present condition that will reduce anxiety and can support optimum decision making will make them accept the situation. 3. Describe symptoms and problems that should be reported or expected to provide prompt care. 4. Have support groups available for families to help them deal with living with a member having mental illness. 5. Encourage family members to observe and evaluate significant changes and progress of the rehabilitation of their mentally ill love one. 6. Information about the community resources and organization should be given to family for client’s benefit. 7. Family member’s significant other should be given health teachings, in order to help the client cope up with his problems, anxieties, frustrations, and help him to become productive member of the society.

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8. Every member of the family should operate as a whole including communication and manipulation of the environment for problem solving.

TO THE COMMUNITY: 1. Encourage the community members to be more open and understanding in dealing with mentally ill client. 2. Avoid arguing with patient about content of mood disorders because it may get irritated or frustrated and may exhibit aggressiveness toward self and others. 3. Maintain a kindly attitude and avoid being over friendly toward the client because it may affect the patient’s sense of independence and may withdraw or become aggressive. 4. Tell the neighbors not to tolerate the patient during mood disorders, but rather help the patient. 5. The community should be educated to recognize how feelings affect behavioral and influence relationship. 6. Information should be provided on how to support the mentally ill client without criticism or judgment.

TO THE STUDENTS AND FUTURE RESEARCHERS: 1. Proper assessment and evaluation of the patient must be done. 2. Future researchers are encouraged to develop sense of empathy, understanding and be compassionate to the mentally ill patient. 3. Future researchers should provide reliable and factual information to avoid false result of the conducted research study. 4. They are encouraged to understand the goals, objectives and methods of research

to have a reliable nursing intervention and management. SIGNIFICANCE OF THE STUDY

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REFERRENCES

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