Chapter I Introduction Schizophrenia is a disorder characterized by significant disorganization of thinking manifested by problems with communication and cognition; impaired

perceptions of reality manifested by hallucinations and delusions; and sometimes in significant decreases in functioning. Approximately 2.2 million people, or 1% of the world population, suffer from schizoprenia . Statistics indicate that approximately 40% of these individual (1.8 million people) do not receive psychiatric treatment on any given day, resulting in homelessness, incarceration, or violence.(National Advisory Mental Health Council,2005). The onset of schizoprhenia may occur late in adolescence or early in adulthood, usually before the age of 30. Although the disorder has been diagnosed in children, approximately 75% of person diagnosed as having schizoprhenia develop the clinical symptoms between ages of 16 and 25 years. Schizoprhenia usually first appears earlier in men, in their late teens or early twenties, than in women, who are generally affected in their twenties or early thirties. ( shives,2008) Age at onset appears to be an important factor in how the client fares: those who develop the illness earlier show worse outcomes than those who develop it later. Younger clients display a poorer premorbid adjustment, more prominent negative sign, and greater cognitve impairment than do older clients. Those who experience a gradual onset of the disease (about 50%) tend to have both poorer immediate and long term course than those who experience an acute and sudden onset (Buchanan and Carpenter, 2005)

Schizoprenia are classified into four types: Paranoid Schizoprhenia, Disorganized Schizophrenia, Catatonic Shizophrenia, Residual schizophrenia and Undifferentited type was charcterized by mixed shizoprhenic symptoms along with disturbances of thought, affect and behavior. This was a case of a 39 years old, female client from Sorsogon City, with an early onset of undifferentiated shizophrenia since 1990 and admitted at National Center for Mental Health in Pavillion 2 accompanied by her father, later on she was transferred in Unit 2, Pavillion 5 because of agitation and assultive behavior to other client. Theoretical Framework Different theorist in the past proposed theories to explain the possible cause and development of schizophrenia: Psychoanalysis theory by Sigmund freud postulated that shizophrenia resulted form development of fixation that occurred earlier that those culminating in the development of neuroses. These fixations produced defects in ego development and freud postulated that such defects contributed to the symptoms of schizophrenia. Ego intergration in schizoprhenia represent a return to the time when the ego was not yet , or had just begun to be established. Because the ego affects the interpretation of reality and control the inner drives such as sex and agression. These ego functions are impaired, thus , intrapsychic conflict arising from the early fixation and the ego defects which may resulted from early object relations, full of psychotic symptoms. (Kennedy,2007) Genetic predisposition theory suggest that the risk in inheriting schizophrenia is 10% to 20% in those who have one immediate family member with the disease, and approximately 40% if the disease affects both parents or an identical twins. (Shives, 2008).

Biochemical and neurostuctural theory includes the dopamine hypothesis: that an excessive amount of neurotransmitter dopamine allows nerves impulses to bombard the mesolimbic pathway, thye part of the brain normally involved in arousal and motivation. Normal cell communication is disrupted, resulting in the development of hallucinations and delusions, symptoms of schizoprhenia. The abnormalities of neurocircuitry or signals from nuerons are being studied as well. A defective circuit can result in bombardment of infiltered information, possibly causing negative and positive symptoms. Overwhelmed the mind makes errors in perception and hallucinates, draws incorrect conclusion, and becomes delusionals. To compensate for this barrage , the mind withdraws and negative symptoms develop. (Beuer,2006) Organic or Pathophysiologic Theory suggest schizophrenia is a functional deficit occuring in the brain caused by stressors such as viral infection, toxins, trauma or abnormal substances.( Well-connected,2006) Perinatal Theory suggest that the risk of schizophrenia exist if the developing fetus or newborn is deprived of oxygen during pregnancy or if the mother suffers from malnutrition or starvation during first trimester of pregnancy . The development of schizoprhenia may occur during fetal life at critical points in the brain development generally the 34th or 35th week gestation. The incidence of trauma and injury during the second trimester and birth also been considered in the development of schizoprenia. ( Well-connected,2006) Schisms and Skewed families by Theodore Lidz described two abnormal patterns of family behaviors. In one family type, with a prominant schism between the parents, one parent is overly close to a child of the opposite gender. In the other family type a skwed relationship between a child and one parent involves a power struggle between one parent. These dynamics stress the tenuous adaptive capacity of schizoprenic person.( Balllard 2009)

Pseudomutual and Psuedohostile families by Lyman Wynne, some families supress emotional expression by consistently using pseudomutual or psuedohostile verbal

communication. In such families, a unique verbal communication develops and when child leaves home and must relate to other persons, problems may arise the verbal communication may be incomprehensive to outsider( Brien 2007). Psychological or Experiential theory found that prefrontal lobes of the brain are

extremely responsive to stress. Individuals with schizophrenia experiences stress when family members and acquaintances respond negatively to the individuals emotional needs. These negative responses already vulnerable neurologic state, possibly trigerring and excerbating existing symptoms. Stressors that have been thought to contribute to the onset of schizophrenia include poor mother-child relationships, deeply disturbed family intrepersonal relationships, impaired sexual identity and body image, rigid concept of reality, and repeated exposure to double bind situation. A double-bind stuation is a no win experience, one in which there is no correct choice. (kolb,2005). Double bind concept by Gregory Bateson and Donald Jackson is to described the hypothetical family in which children receive conflicting parental messages about their behavior, attitudes and feelings. Children withdraw into a psychotic sate to escape the unsolvable confusion of double bind. (Ballard 2009). Environmental or cultural Theory state that person who develops schizoprhenia has a faulty reaction to the environment, being unable to respond selectively to numerous social stimuli. Theorist also believe that person who come from low socioeconomic areas or single-

parent homes in deprived areas are not exposed to situations in which they can achive or become succesful in life.

Patient Personal Data: Name: Patient JD Age: 39 yrs. Old Address: Sorsogon, City Sex: Female Date of Birth: July 12, 1971 Place of Birth: Pasig, City Race/Religion: Filipino/ Catholic Marital Status: Single Education: Highschool Graduate Occupation: none, former plywood cutter and Garments Factory worker Source of Refferal: The patient was brought to Ortho by social worker at Sorsogon, City because of assultive behavior with post inflammatory scar on both lower extremities and fever for first intervention then finally admitted to National Center forMental Health Pavillion 2 accompanied by her father, later on she was transferred in Unit 2, Pavillion 5 for further monitoring of behavior. Chief Complain: Nagwawala, Balisa, Ayaw uminom ng Gamot, mainitin ang ulo as verbalized by the Father. Diagnosis: Undifferentiated Schizoprenia History of Present Illness: Patient is on Unit 2, Pavillion 5 for further monitoring of behavior, She was on good mood state with normoproductive speech, She had poor recent, remote and immediate memory, she only remembers the memory when she was at the age of 16-33. She was disoriented in time and date but know what place she was. She denied any suicidal attempts and hurting others. She

said she had good sleeping pattern and also she denied any visual hallucination but sometimes she experience auditory and gustatory hallucination such as binubuyo niya akong saktan ang sarili ko pero di ko na pinapansin yun and walang lasa ang pagkain dito palagi.she also said she always complied to her medicine but complain of positive dizziness.she also had unusual mannerism and gesture such as scratching her plam and her head. Past Personal History: The patient was mentally ill since 1990s with previous admission at an ortho because of post inflammatory scar at both lower extremities, she was discharge as improved, following medication was initially complain. Patient was eventually loss to follow-up with the medication given because of low financial assistance. Few days prior to admission, patient was noted to be restless, agitated and have perceptual disturbances. January 15, 2008 family was decided to admit her at NCMH Pavillion 2 accompanied by her Father, after three months she exhibited normal cognition and physical state then later on she was transferred to Pavillion 5 unit 2 because of escape and suicidal attempts, assultive behavior to co-client,flight of ideas with looseness of association, poor impulse control, agitated, tangentially and visual and auditory hallucination.She had 2x2 cm 2x 1.5 contrusion hematoma on left Zygomattic area after having first fight last July 10, 2008. On October 29,2008 she was brought to restrain and undergo Electroconvulsive therapy on the following day. At Novemeber 7, 2008 another incidental report happen when the patient was on restlessness nd accidentally bumped her head on the cemented wall 3x4 cm contrusion on mid forehead. Family History: Her Father was 64 years old, jobless and her mother was 59 years old manicurista both live at Sorsogon, City and earn 2,400 a month. She had a older brother who had own his family. There is no data about history of having schizoprhenia in the family. But because of low financial assistant with on and off medication serves as the rooted of worse progression of patient diagnosis. Chapter II General Appearance

CRITERIA Good grooming Appropriate facial expression Appropriate posture Maintain eye contact

DAY 1

DAY 2

DAY 3

DAY 4

* * * * * * *

* * * *

During student nurse- patient interaction, the patients grooming was not good prior to morning care she wear dirty ward gown without slippers but on the second day and later part she improves and shows good grooming. Most of the time she exhibited appropriate facial expression and posture during interactions. She also displays and maintain good eye contact and show ineterest on the topic but she was easily get distracted by environmental stimuli such as other student nurse in the room or preparing something. As days passes by student nurse established rapport on the patient.
Motor Behavior CRITERIA AUTOMATISM HYPERKINESTHESIA WAXY FLEXIBILITY CATAPLEXY CATALEPSY STEREOTYPE COMPULSION PSYCHOMOTOR RETARDATION ECHOPRAXIA CATATONIC STUPOR CATATONIC EXCITEMENT DAY 1 DAY 2 DAY 3 DAY 4

TICS AND SPASMS IMPULSIVENESS CHOREIFORM MOVEMENTS

Analysis: Patient doesnt exhibit any problem in motor behavior.

C. Sensorium and Recognition

CRITERIA ORIENTATION TIME PLACE PERSON

DAY 1

DAY 2

DAY 3

DAY 4

* *

* *

* *

CONCENTRATION MEMORY REMOTE RECENT IMMEDIATE RETENTION

Analysis: During our NPI patient was oriented in place and people but not in time and date, lack of orientation may indicate possibility of a medical or nuerological brain disorder. Some patient also with schizophrenia may give incorrect or bizzare answer to the question. (Saddock,2007). Shes also has poor remote, recent, immediate retention in memory because shes doesnt recall her past past experiences it may be because of the cognitive impairment.She also exhibited poor concentration because she was easily distracted by environmental stimuli.. Patient with schizophrenia typically exhibit cognitive impairment in the domains of attention, working, recent, remote and immediate memory, this impairements cannot function as a

diagnostic tools but they are strongly related to the functional outcome of the illness. (saddock,2007) .
D.Perception CRITERIA HALLUCINATION VISUAL OLFACTORY AUDITORY TACTILE * DAY 1 DAY 2 DAY 3 DAY 4

GUSTATORY ILLUSIONS DELUSIONS

Analysis: The patient shows auditory hallucination during day 2 of nurse patient interaction, Any fives senses may be affected by hallucinatory experiences in patient with schizophrenia. The mosy common hallucination was auditory with voices that are often

threatening, obscene, accussatory or insulting. That may comment on the patients life behavior. ( Saddock, 2007) . On my patient her auditory hallucination was sabunutan daw po kita . as patient verbalized. Auditory Hallucination was under the categories of positive symptoms

schizophrenia where in Patient with Undifferentiated schizoprenia may experience it (Videbeck 2008).
E.ATTITUDE AND BEHAVIOR CRITERIA COOPERATION DAY 1 * DAY 2 * DAY 3 DAY 4 *

OUTGOING WITHDRAWN EVASIVE SARCASTIC AGGRESSIVE PERPLEXED APPREHENSIVE ARROGANT DRAMATIC SUBMISSIVE FEARFUL SEDUCTIVE UNCOOPERATIVE IMPATIENT RESISTANT IMPULSIVE

Analysis: The patient is cooperative throughout the exposure she cooperates well and interacts with us and participates in the activities.

F.DEFENSE MECHANISM Criteria Day 1 Day 2 Day 3 Day 4

DENIAL REPRESSION SUPPRESSION RATIONALIZATION PROJECTION DISPLACEMENT INTROJECTION CONVERSION SYMBOLIZATION DISSOCIATION UNDOING REGRESSION SUBSTITUTION FANTASY REACTION FORMATION SUBLIMATION COMPENSATION * * *

Analysis: The patient show repression. Repression was excluding painful or anxietyprovoking thoughts and feelings from contious awareness, a person use this kind of defense mechanism to cover-up her fears (Keltner2007). She remember her memory when she was 33 years old and doesnt recall any previous experiences, she doesnt know why she was in NCMH. According to Frued it is unconscious defense mechanism in which unacceptable mental contents are banished or kept out of consciousness; important in psychological development and in neurotic ans psychotic symptoms formation( Saddock,2007).
G.AFFECTIVE STATE CRITERIA DAY 1 DAY 2 DAY 3 DAY 4

EUPHORIA FLAT AFFECT BLUNTING ELATION EXULTATION ECTSTASY ANXIETY FEAR AMBIVALENCE DEPERSONALIZATION IRRITABILITY RAGE LABILITY DEPRESSION *

Analysis: The patient does exhibit depresion on the first day, because when we talk about her family, she expresses feelings of loneliness and longing to go home. Depression may be part of the psychopathology of schizophrenia, and studies, on the average, have suggest that 25% or more of schizophrenic patient experience depression (keck, 2007)
H. SPEECH CRITERIA VERBIGERATION RHYMING PUNNING DAY 1 DAY 2 DAY 3 DAY 4

MUTISM

APHASIA UNUSUAL TONE RATES UNUSUAL VOLUME OF SPEECH UNUSUAL INTONATION UNUSUAL MODULATION

Analysis: The patient does not exhibit any problem of the speech behavior above.
I. THOUGHT PROCESS AND CONTENT CRITERIA BLOCKING FLIGHT IDEAS WORLD SALAD PERSEVERATION NEOLOGISM CIRCUMSTANTIALITY ECHOLAGIA CONDENSATION DELUSION PHOBIA OBSESSION HYPOCHONDRIAC * DAY 1 DAY 2 DAY 3 DAY 4

Analysis: The patient show flight of ideas during 4th day of exposure, One of the symptoms of Schizophrenia was flight of ideas where in there is a overproductivity of talk and verbal thinking skipping from one idea to another.Although talk is continously, the ideas are

fragmently. Connections between segment of speech often are determine between segment of speech.( shives, 2008). On Patient she answer the question about ahow many child she had then she answer it 3 then turn her answer about her husband eventhough she had no husband and children. Flight of ideas was of the disorder in thought process and it concern in the way ideas and language are formulated, thought control in which outsides forces are controlling what the patients thinks or feels.( Saddock, 2007)

Chapter III Book based

CAUSES: SCHIZOPRHENIA

Biochemical factors: -Increase dopamine activity in the limbic system

Neurostructural factors: -Enlarge ventricles -brain atrophy -decrease cortical blood flow in the prefrontal lobe

Genetics: -can be inherited because schizophrenia runs in the families.

Psychodynamic: -Developmental stage. -family relationship

Symptoms: Disturbance in perception Disturbance in thought process Disturbance in reality testing Disturbance in feeling ,behavior, attention

Decline in psychosocial functioning

Acute Phase: The patient experiences severe psychotic symptoms.

Stabilizing Phase: The patient gets better.

Stable Phase: The patient might still experiences hallucinations and delusion but the hallucination and delusion are not severe not as disabling as they were during acute phase.

Five types of schizophrenia: Paranoid schizophrenia, disorganized schizophrenia, Catatonic schizophrenia, Residual schizophrenia and undifferentiated schizophrenia.

According to Kelther (2007) there are different factors that causes Schizophrenia first the Biochemical factors in which there is increase dopamine activity that contibute in activating positive symptoms of schizophrenia, second was neurostuctural in which there is large ventricles, brain atrophy and has decrease in blood flow in prefrontal cortex of the brain, third the genetics which it can be inherited by a person who has schizoprhenia runs in the family and lastly the psychodynamic factors in which a person with schizophrenia has tendency that he or she had deprive in her or his developmental stage or a person may experienced conflict with family relationship. There are different psychotic symptoms that may be seen such as d
Disturbance in perception , thought process, reality testing, feeling ,behavior, attention which may be

result in decline of psychosocial functioning. There are three phase that the patient might be experienced first, in acute phase the patient experiences severe psychotic symptoms followed by stabilizing phase in which patient gets better and lastly the stable phase, in this phase the patient might experiences hallucination and delusion but the hallucination and delusion are not as severe nor disabling as were during acute phase.

Client based

Undifferentiated Schizophrenia diagnosed since 1990s Patient experiences agitation, restlessness, and perceptual disturbance She exhibit normal cognitive and physical state.

After three months she was been shown to be poor impulse control, agitated, tangentially with flight of ideas with looseness of association and visual and auditory hallucination, she revealed escape and suicidal attempts, assultive was diagnosis since The onset of patient shizophrenia behavior to co-client.1990, theres no data of any family members having schizophrenia except of her. The patient was brougth to ortho for her post inflammatory scar in both lower extremities , she was discharge as improved, following medication was initially complain. Patient was eventually loss to follow-up with on and off rooted complain because of low financial assistance. Few days prior to admission patient exhibited restlessness, agitation, perceptual diturbance. Then after three months she was been shown to be poor impulse control, agitated, tangentially with flight of ideas with looseness of association and visual and auditory hallucination, she revealed escape and suicidal attempts, assultive behavior to co-client.

Related literature Different studies are conducted to give possible explanation in the development of schizoprhenia: Gene Study Suggests New Target for Schizophrenia Tx Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner stated that defects in a pathway with a misleading name may underlie some cases of schizophrenia, according to researchers conducting a genetic study. Genomic variants known as microduplications in or near the gene for the vasoactive intestinal peptide (VIP) receptor were 14 times as common in a sample of patients with schizophrenia relative to normal controls, reported Jonathan Sebat, PhD, of the University of California San Diego, and colleagues, in the Feb. 24 issue of Nature.VIP is actually a multifunctional protein that is produced throughout the body and is active in a host of body systems. In addition to playing multiple roles in the intestinal tract and circulatory systems, VIP helps regulate vaginal secretions, prolactin release, and circadian rhythms. This last function is located in the brain, and previous studies have linked circadian rhythm disturbances with schizophrenia. They undertook the study because earlier studies had identified copy number gains involving large DNA sequences (more than 500,000 bases) that were more common in schizophrenic patients, and wondered if replication of shorter sequences might also be linked to the disorder.

The researchers conducted the scans in a two-stage study. They first searched for copy number variants in 802 schizophrenia patients and 742 controls, which yielded positive findings in 114 genomic "regions of interest." In the second stage, Sebat and colleagues looked more closely at these regions in samples from 7,488 patients and 6,689 controls.They found that microduplications within a 362-kilobase region at chromosomal location 7q36.3 -- in or near the VIP receptor gene known as VIPR2 -were significantly more common in the patients, with an odds ratio of 14.1 (95% CI 3.5 to 123.9). "While duplications of VIPR2 account for a small percentage of patients, the rapidly growing list of rare copy number variants that are implicated in schizophrenia suggests that this psychiatric disorder is, in part, a constellation of multiple rare diseases," the researchers wrote. "This knowledge, along with a growing interest in the development of drugs targeting rare disorders, provides an avenue for the development of new treatments for schizophrenia." (http://www.medpagetoday.com/Psychiatry/Schizophrenia/25040?
utm_source=twitterfeed&utm_medium=twitter)

According to Dr. A Bassett of the university of Toronto,the first true etologic subtype of shizoprenia, the consequence of a chromosome deletion refered to as the 22q1deletion syndrome. Person with this syndrome have distinct facial appearance, abnormalities of the palate, heart defects, and immunologic deficits. The risk of developing shizoprhenia in the presence of this syndrome appears to be approximately 25%. Genetic locations of schizophrenia, believed to be on chromosomes 13 and 8. One study found thatmothers of client with schizophrenia had a high incidence of gene type H6A-B44 (shives,2008)

Drug study NAME Haloperidol ACTION Competitively blocks dopamine receptor s to cause sedation and also causes alphaadrenergic and anticholonergic blockade. It depressescerebral cortex, hypothalamus and limbic system, which control activity and aggression but also cause significant extrapyrimidal effects ADVERSE REACTION Management of Severe toxic CNS Glaucoma, Tourette depression or comotose seizure disorder, disorders; control states from any cause; hepatic and renal of adults; parkinson disease. impairment management of severe behavioral problems in children . long term antipsychotic therapy. INDICATION CONTRAINDICATION NURSING INTERVENTION asses pt. disorder and mental status before drug therapy. Reassses affect, orientation, mood, behavior, sleep pattern. Monitor possible adverse reaction such as CNS, severe extrapyramidal reactions. Monitor swallowing of oral administration medication and check for hoarding or giving meds to other client. Monitor vital signs. NURSING

NAME

ACTION

INDICATION

CONTRAINDICATION

ADVERSE

Chlorpromazine Thorazine

Blocks postsynaptics dopamine receptors in brain.

Management of manifestations pf psychotic disorders, to control nausea and vomiting, relief of restlessness and apprehension before surgery, acute intermittent porphyria, adjunct in the treatment of tetanus, to control manifestation of the manic type manic depressive illness, relief of intractable hiccups, treatment of severe behavioral problems in children marked by combativeness or hyperexcitable behavior.

Comatose states, presence of large amounts of CNS depressants, presence of bone marrow depression.hypersensitivity.

REACTION Drowsiness, jaundice, postural hypotension, extrapyrimidal effects. Persistent abnormal movement, cerebral edema, hematologic disorders, ECG changes.

INTERVENTION asses for mental status: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms before initial therapy Monitor swallowing of oral administration medication and check for hoarding or giving meds to other client.

Monitor input and output

NAME Biperiden

ACTION Synthetic anticholinergic drugs, block cholinergic response in the CNS.

INDICATION Parkinsonian syndrome especially to counteract muscular rigidity and tremor; extrapyrimidal syndrome.

CONTRAINDICATION Narrowangle glaucoma, mechanical stenoses in gastrointestinal and megacolon; prostatic adenoma and disease leading to perilous tachycardia. Hypersensitivity to biperiden.

ADVERSE REACTION CNS and peripheral effects, skin rashes, dyskinesia, ataxia, twitching, impaired speech, micturition difficulties.

NURSING INTERVENTION Document indication for therapy, onset of signs and symptoms and other agent tried and outcomeof therapy. Assess for parkinsonism, EPS: shuffling gait, muscle rigidity, involuntary movement, pill rolling, spasm and drooling during treatment.

Monitor constipation, cramping pain in abdomen and abdominal distention.Increa se fluids, add fiber to diet and excercise.

NAME Amoxicillin

ACTION

INDICATION

CONTRAINDICATION Hypersensitivity to penicilin, cephalosphorins,or imipenem. Not used to treat severe pneumonia, empyema, bactemeria, pericarditis, meningitis and purulent or septic arthritis during acute stage.

Prevents bacterial cell Treatment of wall synthesis during infections of replication.Bactericidal respiratory tract, skin and skin structures, genitourinary tract, otitis media, meningitis, septicemia,sinusitis bacterial endocarditis prophylaxis.

ADVERSE REACTION Dizziness, fatigue, insomia, reversible hyperacidity, urticaria, maculopapular to exfoliative dermititis.

NURSING INTERVENTION Obtain pt. history of allergy Asses pt. for sign and symptoms of infection, wound characteristic, sputum, urine stool, fever and WBC count. Monitor sign of nephrotoxicity: urine cast, oliguria, proteinuria, increase BUN

Monitor for bleeding, ecchymosis, bleeding gums, hematuria.

NAME Paracetamol

ACTION Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation.

ADVERSE REACTION Relief of mild to Hypersensitivity, Stimulation, moderate pain; intolerance totertazine, dowsiness, nausea, treatment of fever. alcohol, table sugar, vomiting, saccharin. abdominal pain, hepatoxicity, hepatic seizure, renal failure.

INDICATION

CONTRAINDICATION

NURSING INTERVENTION asses pt. fever or pain, location, intensity, duration, temperature, diaphoresis. Assess allergic reaction: rash, urticaria; if these occur, drug may have to be discontinued. Monitor liver and renal function., Check input and output ratio. Asses hepatoxicity.

NAME Vitamin C

ACTION

INDICATION body immune

CONTRAINDICATION

ADVERSE REACTION

Needed for wound Inhance healing, collagen natural synthesis, function. antioxidant, carbohydrate metabolism, protein, lipid synthesis, prent infection.

NURSING INTERVENTION asses pt. nurtitional status for inclusion of foods hign in vitamin C: citrus fruits. Monitor input and output: polyuria Monitor ascorbic acid levels throughout treatment.. Assess patient knowledge on drug therapy.

Chapter IV Psychotherapies Implemented

1. Exercise Therapy

Description

Goal

Procedure/Activities

Patient Role/Patient Analysis Patient follows the step and does the exercise.

Role of the Nurse I encourage her to do the exercise and assist her.

Is physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body.

To teach the Let have atleast one patient the some or two leader. exercises. -Set a joyful and 2. To assess lively music with a motor abilities beat. of the patients. -Let the client to 3. To give follow the Steps. Caution: Remind the simple condition of the instructions that clients to consider the patient can follow.
.

4. Safety is the priority. 5. To promote wellness

2. Dance Therapy Description Goal Procedure/Activities Patient Role/Patient Analysis Role of the Nurse Wemake dance steps together with my classmates and teach them the steps.

The therapeutic use of movement to further the emotional, social, cognitive, and physical integration of the individual in the treatment of a variety of social, emotional, cognitive, and physical disorders.

To teach the -Let atleast two to The patient follows patient the three students to lead the dance step and cooperates well. movements of the the step in the song. dance. -Have a good choice 2. To assess motor of music it should be lively. abilities of the patients. -Ensure the step must be applicable to the 3. To give simple clients. instructions that the patient can -Assure that most of follow. the extremities will move. 4. Safety is the priority.

3. Music and Arts Therapy

Description

Goal

Procedure/Activities

Patient Role/Patient Analysis The clients draw and share her drawing to everyone.

Role of the Nurse Provide drawing materials and explain again the procedure to the patient. Listen to the sharing of patients drawing. Appreciate patients sharing.

It is an interpersonal process in which uses music and all of its facets physical, emotional, mental, social, aesthetic, and spiritualto help clients to improve or maintain their health.

1. Appreciate the 1.Prepare all the music and put the material feeling of the drawing. 2. Be sure that all materials are adequate. 2. Discuss and 3. Gather all clients into show the drawing. one area. 3. Divert attention 4. Explain the purpose into something and procedure of the more productive. therapy. 5. Distribute materials. 6. Play music 7. Let the client to draw . 8. Inform clients to share the work later. 9. When drawing recognized client. 10. Repeat the music when needed.

4. Bibliotherapy Description Goal Procedure/Activities Patient Role/Patient Role of the

Analysis Bibliotherapy is rendered with the use of a story with elaborate images to be helpful for the client to imagine the story. 1.To develop -Prepare a story with an individual elaborate images. self-concept -Arrange the sits of 2. Increase the client into a good theatrical understanding. setting: setting is more 3. Foster an advisable. individual -Story telling must be honest selfin form of appraisal. monologue. -Someone should introduce the story. -At the end of the therapy the clients must share insights and thoughts about he story. The patient can express their learning about the story the heard. And give insight and comments on the different situation on the story.

Nurse Arrange the chairs in semi circle for the patients Listen to the learnings of patients Give appreciation or recognition.

5. Remotivation Therapy Description Goal

Procedure/Activities

Patient Role/Patient Analysis

Role of the Nurse Listen to patients sharing and give recognition.

A therapy of very simple group therapy of an objective nature used in an effort to reach the unwounded areas of the patients personality & get them moving back into the

1. To stimulate patient to be fellow explorer of the real world . 2. To develop the ability to communicate & share ideas & experience with other.

1 .Introduction

The patient can able to site example and 2. Ask any body what give comments on they can say about the the poem, also to the drawing and if drawing and give anybody see a forest. their learnings. 3. Poem reading Kalikasan ating Pagingatan 4. Evaluation Summary. and

reality.

3. To develop feeling of acceptance & Recognition.

6. Socialization

Description Is the primary means by which human infants begin to acquire the skills necessary to perform as a functioning member of their society, and is the most influential learning processes one can experience.

Goal

Procedure/Activities

Patient Role/Patient Analysis The patient enjoyed and participated in the games and activities. The patient increases self confidence and cooperate.

Role of the Nurse Arrange chairs and prizes. Assist patients in the games Join patient in dancing. Cleaning the place.

1. To develop 1. Introduction cooperation. 2. National anthem 2. Safety is prioritized. 3.Prayer 3. To develop 4Opening remarks interaction with other patients. 1. Exercises 4. To develop 6.Yell/ Cheer camaraderie with other 7.Intermission schools. numbers 8Games 9. Closing remarks

Chapter V Nurse Patient Interaction

Day 1 Nurse Response Hello Maam Analysis of Nurse Response Giving recognition Patients Response hello!(smile) Analysis of Patients Response The patient response through verbal by saying hello and non verbal communication which is smiling, it seems that shes a little bit shy to the student nurse during first interaction. ako po si Gia Borlongan, galling pos a URC sa malolos bulacan, ako po ang inyong student nurse. Kayo po maari niyo po bang ibigay ang inyong pangalan? And seeking information The patient responds directly in the question by stating her name and with smile on her face. The patient can able to answer the question. Giving information ako si patient JD

Ilang taon na po kayo?

Seeking information

33 years old.

Patient answered the question by stating her age with maintained eye contact to the student nurse. Patient answered the question by stating her birthday maintained with eye

Kailan

po

ang

Seeking

July 12, 1971

birthday niyo?

Information

contact to the student

nurse. The patient was oriented. Saan nakatira? po kayo Seeking Pasig, City Patient answered the question that by she stating only were she live.It seems remember the place where she grow up because according to the chart, the patient live in Sorsogon, city. May asawa po ba kayo? Seeking Wala. Patient answered the nurses question seriously with maintained eyecontact to the student nurse. The patient answer same on the data on the chart. May kapatid po ba kayo? Seeking oo. Isa. Kuya ko Patient answered the question directly and stating the relationship of the person to her. The patient still remember her siblings. Alam ninyo po ba oras ngayon? Seeking hindi ko alam eh! (yumuko) Patient answered the question with low tone of voice,then bow her head, it

Information

Information

Information

kung anong araw at Information

seems that shes feels Ngayon po ay Providing ah, ganun ba shy on her answer. Patient get oriented in time and date, and deeply listening to the information given by Seeking the student nurse . Nagtrarabaho ako sa Patient answer the pasig Plywood cutter, question with tas sa Antipolo irrelevent information sinulid mula sa impossible that she nagtatangal ng mga because it is sobrang damit hanggang oras at araw Ilang taon na po kayo dito sa NCMH? Seeking tatlong taon na lunes works as plywood works in the garment in same time and days. Patient answered the question while counting with the used of her fingers.the patient was thinking Sino po nagdala sa inyo dito? Seeking yung tatay ko before answering. Patients answered the question by stating the person who brought her to NCMH with sadness on her face. It seems that she was Alam ninyo po ba kung bakit nadala dito? Asking relate hindi (umiling) ko depress. alam. The patient answered the question by saying she didnt know and

huwebes, ika-17 ng information, febrero 2011, at 11:15 orientation na po ng umaga anu po trabaho

ninyo dati

Information

biyernes, cutter at the same time

7:00-7:00.parehong

Information

Information

kayo question, clarifying.

non verbal communication by turning his head a gesture that means she doesnt know the May gusto po ba kayong akin? sabihin Encouraging answer. gusto ko na umuwi Patientanswered the sa amin, miss ko na questioned by nga sila, kelan ba ako expressing her maaring umuwi?. feelings of longing to her family members with sadness on her face. Also seeking for information about the time were she can go home.It seems that she has strong desire to go home, because since the time she was admitted in NCMH, anu daw po ba ang dito? Asking and no one visited her. Sabi matagal pa daw, Patient answered the kasi nasa probinsya question by giving daw sila, dito muna details on what she daw ako. ( with teary had been heard eye) explanation from other health care provider. While telling this to the student nurse it seems siguro po pag mabuti Giving opinion and okey naman that she want to cry. ako, Patient give detailed

sa patient to express feelings

sabi ng doctor at nurse clarifying information through the use of questioning

na

ang

inyong seeking for

ayos na ako matulog, information about her at iniinom ko naman condition, and she ang gamut ko. explained to the student nurse what that she doesnt experiences difficulties unlike before . ikaw si Gia, student Patient answered the nurse kita question with smilling, and she was able to remember the student nurse name. It seems that she can recall the name of the person shes ineract with. Patient answered the question through smile and argees to cooperate in the activities. It seems that the patient was interested with the incoming activities. Patient answeres through non verbal communication by smiling and waving , it is a gesture saying goodbye. The patient also expecting the

kalagayan, papayagan information na po kayo umuwi, kamusta na po kayo?

Maam pakibigay po ulit ang

testing if the

akin patient are oriented to clarifying previous in interaction

pangalan, natatandaan the person interacted, ninyo pa po ba?

bukas po, may mga therapy po gagawin,maaasahan paglahok?.

Giving

Oo, sigeh(smile)

tayong information, encouraging the activities.

ko po ba ang inyong patient to join to the

bukas

po

ulit

Thanking for

(smile)

maam, salamat pos a the information she pagbabahagi impormasyonng inyong sarili gathered.

student nurse in the next exposure.

Day 2 Nurse Response Hello Maam, kamusta na po kayo? Tanda ninyo po ba ako? Analysis of Nurse Response Giving recognition and testing client if she remember the nurse Patients Response ok naman!(smile). Ikaw si gia Analysis of Patients Response The patient answered the question with smile and shes also stating the name of the student nurse which means that she still remember the student nurse. The patient answered the question nagustuhan ninyo po seeking information ba ang mga activity ngaun? oo, sumayaw nga ako, tas nagdrawing pa correctly. The patient answered the question by sating what shve done on the activity, It means that there is acceptance, recognition and it seems that she enjoyed the activity.

Ilang taon na po ulit kayo?

clarifying information

33 years old.

Patient answered the nurses question same as the previous interaction in student

nurse with maintained eye Kailan po ang clarifying July 12, 1971 contact. Patient answered the nurses question same as previous interaction with maintained eye contact to the student nurse. Saan nakatira? po kayo clarifying Information Pasig, City Patient answered the nurses question same as previous interaction witha maintained eye contact to the student nurse. May asawa po ba kayo? clarifying Information Wala.(yumuko) Patient answered the nurses question same as previous interaction with maintained eye contact to the student nurse while having a gesture of turning her head side to side as a sign that she doesnt have. May kapatid po ba kayo? clarifying Information oo. Isa. Patient answered the nurses question same as previous interaction with maintained eye contact to the student

birthday niyo?

Information

nurse. Ano po ang Seeking yung kwento ni Patient answered the nurses question in interesting manner with smile on her face. It seems that she really liked the story bakit po?

pinakagustong activity na ginawa?

Information

maria makiling!

Asking the

in the activity. kasi iba yung pag- She answered the iibigan nila ni gat question by giving the dula, tsaka yung qualities of the and also telling a part of the story. It seems that she can relate the character of the story to her qualities. Patient answered the pagmamahal niya sa character in the story magulang nya

patient to elaborate the answer

anu pong paguugali ihalintulad sa inyo herself

Asking the

mapagmahal

at

ni maria ang maaring patient to relate it to

mapagalaga magulang, pa

sa question with smile maganda and giving her same qualities base on the qualities of the character and her. It seems that she can relate on the qualities

may gusto pa po ba kayong kwento? tauhan

Seeking

of the character. si gat dula, para Patient answered the siyang si cocoy question and giving example of specific person that she knows that has the same qualities to the

sa Information

character of the story. Sino po si cocoy? Seeking yung crush ko, Patient providing information about a specific person that she knows from the past with smile on her face .It seems that she Nagkatuluyan po ba kayo? Asking hindi kaming piloto un. kasi likes this person. pareho Patient answered the what happen to her and to the person may gusto pa po ba kayong ibahagi? Encouraging yung maria, din ako?. tatay involve. ko Patient answer the

Information

gwapo kasi un

information

mahiyain, question, by stating

patient to express feelings

katulad ng tatay ni question in which she pinapagalitan relate the qualities of the father to the qualities of the character in the story. It seems she had childhood experiences where she experienced repremmanded by her father. na Patient answered the question with smile and agreed to the opinion of the student nurse. It seems that she approved to the opinion of the student

baka naman po kayo napapagalitan

Giving

oo

ganun

kasi opinion and seeking

nga(smile)

may mali po kayong for information nagawa., madalas po ba napapagalitan? kayo

nagustuhan pop la lahat

ninyo Summarizing and ng asking question.

Wala na

nurse. Patient answered the question and seems she dont want to open another conversation about the topic. Patient answered the question directly by stating the name of her drugs.this means that she was aware on the drugs shes taking. Patient respond question was Auditory Hallucination was under the categories of positive symptoms schizophrenia in Patient Undifferentiated schizoprenia experience (Videbeck 2008). may it where with with by the stating

activity, may gusto pa ba kayong ibahagi? Ako naman po ang magtatanong, gamut? ninyo po ba inyong Seeking thorazine

alam information

ngayon

po

Seeking

Oo,

nakakaranas pa po ba information kayo ng pagbulong?

yes,which means she experienced auditory hallucination.

anu naman po ang binubulong sa inyo

Seeking

Sabi daw

sabunutan

ka Patient respond to the question by stating her auditory hallucination.

information

It seems that she hallucination symptoms are not yet ano po ulit ang sabi? Clarifying Hindi ngayon nawawaqla na dati subsiding. yun, Patient answered the medyo question by trying to cover up what shes been heard. It seems Silence silence Napapagod pwede pumasok na na ba that she withrawn it. ako Patient Expresses ako what she feel and she want to go back in the ward. It seems that it is her way to escape reality that she had O sige po respond to the Smile auditory hallucination. Patient respond with nonverbal communication by means of smiling.

information

patient question

Day4 Nurse Response Hello Maam, kamusta na po kayo?.tanda ninyo po ba ako? Analysis of Nurse Response Giving recognition and testing client if she remember the nurse Patients Response ok naman!(smile). Ikaw si gia Analysis of Patients Response The patient answered the question with smile and recall what the name of her student nurse. The patient can still remember the student

nurse. It seems that the student nurse established rapport may socialization po tayo ngaun, sana po makilahok kayo sa mga laro Giving information and encouraging to join to the activity. oo, sigeh, may sayaw ba dun? well. Patient agrees to the suggestion and asked information with interesting manner by knowing what activities she may cooperates and she also smiles.It seems that she was excited on upcoming activities.

Nagenjoy po ba kayo sa socialization?

seeking information

oo

Patient answered the n question directly about what she feel on the activity. It seems that she enjoyed the activity well. Patient answered the nurses question same as previous interaction she had a week before. The patient answered it correctly

Kailan

po

ang

clarifying

July 12, 1971

birthday niyo?

Information

Saan nakatira?

po

kayo clarifying Information

Pasig, City

Patient answered the nurses question same as previous interaction

a week before with maintained eye contact on the student nurse. May asawa po ba kayo? clarifying Information meron. Patient answered the nurses question different from the previous interaction because previously she tells she had no husband with smile on her face. It seems that she experiencing delusion. May kapatid po ba kayo? clarifying Information oo. Isa. Patient answered the nurses question same as previous interaction with maintained eye contact on the student nurse. anu po pangalan ng asawa ninyo ? Seeking cocoy! Patient answered the nurses question with the smile and giving the name of the person Di ba po sabi ninyo wala kayong asawa? clarifying she talking about. meron, tatlo nga Answered question anak namin eh. with explanation, and giving information about the person. The patient answer was new to the student

Information

Information

nurse, she had different answer on the previous anu po mga pangalan ng anak ninyo? seeking joan, anna, miguel ineraction. Patient aswered the question with smile and stating the name of the sibling she had.This is part of her delusions because she ilan taon na sila? Seeking had no children. di ko alm eh, piloto Patient answer the si cocoy, question with light of ideas, the answer was not connected to each other. Because the question of student nurse was focused on the children she answered it is irrelevant to the kasal nap o ba kayo ni cocoy? Seeking question. hindi, di ko alm kung Patient answer the nasaan sya. question with Flight of ideas, it is not related to each other with maintained eye contact. flight of ideas where in there is a overproductivity of talk and verbal thinking skipping

information

Information

Information

from one idea to another(shives,2008). It is sign of disturbed Ito po ang huling thanksgiving araw naming dito, ako poy lubos kayo na at sa nagpapasalamat nagbahagi akin. thought process. salamat din sa mga Giving thanks, and natutunan ko, alam ko expressing what she na kailanagn maglinis learned from the ng katawan lagi at student nurse with salamat nabubusog ako kasi smile on her face and shaking hand with her , a gesture of thanks giving and saying goodbye.

Nursing Care Plan ASSESSMENT Objective Data: PLANNING After Nursing exposure the patient -Patient wears dirty Self care deficit will be able to: ward gown and related to poor without slippers personal hygiene. a. Participate in self care activities -bad breath -patient odor has foul b. Demonstrate independence DIAGNOSIS INTERVENTION RATIONALE EVALUATION 2. Explain task -A complex task After the exposure in short simple will be easier for the patient able to : manner. the client it is broken down into a. Participated series of steps. in self care activities. 3. Allow patient -It may take sufficient time to longer to complete any complete task task. because of lack of b. Can able to concentration and perform self short attention care activities span. on her own 4. Remain with the client throughout the task: do not attempt to hurry the client 5. Gradually withdraw assistant and supervision to the patient grooming and other self care skills. -trying to rush the patient will frustrate him/her and make completion of the task impossible. It is important for the client to gain independence as soon as possible.

Nursing Care Plan ASSESSMENT Subjective Data: Hindi ko alm kung anung oras na o anung araw na ngayon, kanina sinabi nung nurse pero di ko na maalala as verbalized by the patient Sabi daw niya sabutan daw po kita as verbalized by the patient PLANNING After Nursing exposure the patient Disturbed thought will be able to: process related to auditory a. Oriented in hallucination, time and date. disoriented in time and date. b. Present reality. into DIAGNOSIS INTERVENTION 1. Reorienting the patient. RATIONALE EVALUATION -help patient After the exposure maintain her level the patient able to : of orientation; increase her a. Can state ability to become the right time more oriented. and date.

2. Continue - It promoted and therapeutic nurse- strengthens trust patient alliance. between the patient and nurse. -It increases 3. Use short simple patient ability to directions and understand and explanation. follow.

b. Presented into reality

Chapter VI Journal

Day 1: February 17, 2011 At first I feel combination of nervous and excitement because I dont know what type of client I will handle. I dont know what kind of approach I will give to be able to gain rapport and I feel also shock to the kind of environment they were staying because Im expecting it was like ward I was seen in the movie. I learned that in interacting them to gain rapport we should not force to answer all our question and we need to ask them little by little, because it is not easy for them to open up especially like us stranger or newly met, and there are lots of painful of experience they encounter, and that their emotional coping mechanism was not that stable. I also learned that Im blessed because I have my family to support me in times of problem that can help me to cope. I also feel lucky that Im not craving for food like them and I was in good condition. As a future nurse someday I learned that in handling patient during initial interaction we should maintain eye contact, let the patient feel that you are not harmful to them that you can lend your ears to hear their feelings and lastly face them with optimism appearance even though they had poor hygiene. And it is nice to know and hear about different qualities I didnt found to myself that other could see it. Day 2: February 18, 20011 On the second day of the exposure Im quite comfortable to the place, first we arrange the table and the chairs that weve been using for the different therapy. At first we do the routine of patient hygiene, exercise, dance therapy where I know I discovered my dancing talent and think simple step in a short time, music and arts and bibliography. Im gently listening to their sharing about the learning and the meaning of the drawing they draw and Ive learned that partly the activity or the therapy they connected it to the previous experience they have. During the patient inter action I was shocked when my patient tell me about her auditory hallucination sabi daw sabunutan kita then I stop talking but maintaining my eye contact to her then I asked clarification question like anu po ulit yung naririnig ninyo? then she said wag ka mag-alala di ko na sila pinapansin and I learned that it is nice to help the client express her feelings and be calm enough to interact to them even if you are afraid about what they are saying.

Day 3: February 23, 2011 This was the third day of the duty; we are all excited for the Ms. Valentine pageant, we are tasked to design the sash that been using at the pageant, I know in this simple tasked I used again my artistic talent in designing the sash. In this duty we all witness the talent and question and answer portion. I can say that by this type of motivation it helps the client to gain their confidence and boost their talent. They touched my heart about the question and answer especially when they were given the time to give thanks to the audience, I can see their hope and their happiness in their eyes. I learned also only their mind can betray them but on the other side of it their hope and feelings that they want to be free from their disease. Day 4: February 24, 2011 This was the last day of the exposure. The grand socialization, we are all busy preparing in this day. And the very good thing I established camaraderie to other student nurse from the different school. The greatest learning Ive learned about is the talk of our C. I that socialization is not intended only for the residents but also to the student as well, so that they know how to mingle to others, how to give and take knowledge and strategies, it is not about completion about other schools but learning how to interact with them. I realized from this that our group may be together now but after we are graduated and pass the board exam we go different way and it is better to practice camaraderie not only to our group because we did established it but to others also, because some point in time we may cross our path and be my co- health workers in the future. After the socialization we have is interaction to the patient, Im glad to know that even in a short time my patient can know my name even without looking at my name tag. And it is nice to know that she learned something on me, me as well.

Appendices Definition of terms

Definition of terms Automatism - repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. Psychomotor Retardation - overall slowed movements. Waxy Flexibility - maintenance of posture or position over time even when it is awkward or uncomfortable. Delusion - a fixed false belief not based in reality. Hallucination - false sensory perception or perceptual experiences that do not really exist. Flat Affect - showing no facial expression. Echolalia - the clients imitation or repetition of what the nurse says. Compulsion - ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety. Echopraxia - imitation of the movements and gestures of someone an individual is observing. Cataplexy - is a sudden and transient episode of loss of muscle tone, often triggered by emotions. Catalepsy - is a nervous condition characterized by muscular rigidity and fixity of posture regardless of external stimuli, as well as decreased sensitivity to pain. Catatonic Stupor - is a motionless, apathetic state in which one is oblivious or does not react to external stimuli. Catatonic excitement - is a state of constant purposeless agitation and excitation. Individuals in this state are extremely hyperactive, although, as aforementioned, the

activity seems to lack purpose. Choreiform movement - is characterized by repetitive and rapid, jerky, involuntary movements that appear to be well-coordinated, but are rather performed involuntarily by the patient afflicted with such a disorder. Impulsiveness - is a personality trait characterized by the inclination of an individual to initiate behavior without adequate forethought as to the consequences of their actions, acting on the spur of the moment. Regression - a defensive reaction to some unaccepted impulses. Suppression - is the process of deliberately trying to stop thinking about certain thoughts. Euphoria - is the process of deliberately trying to stop thinking about certain thoughts. Blunting - lack of emotional reactivity on the part of an individual. It is manifest as a failure to express feelings either verbally or non-verbally, even when talking about issues that would normally be expected to engage the emotions. Depersonalization - is a malfunction or anomaly of the mechanism by which an individual has self-awareness. Word Salad - flow of unconnected words that convey no meaning to the listener. Neologism- invented words that have meaning only for the client. Phobia - an illogical, intense, and persistent fear of specific object or social situation that causes extreme distress and interferes with normal functioning. Aphasia - deterioration of language function. Mutism - is a speaking disorder in which a person, most often a child, who is normally capable of speech, is unable to speak in given situations, or to specific people.

Patient output

The patient drew a house using the color blue which indicates severe depression. Using the blue color, she also drew a human stick that she labeled as Cinderella. Using the same color, she drew two cats and two kids playing piko. Around and in between the pictures she had drawn, she had shade it with the color violet which reflects depression, she also used that color to write her name at the top of the paper. As the drawing specifies, the patient reminisces the past especially her childhood. From all her experiences, she insisted that she was only 33 years old but in reality she is already 39 years old.

Bibliography

Sadock M.D et. al (2007). Synopsis of Psychiatry. Lipprincott& Williams.United State of America. Kelther N.(2007). Psychiatric Nursing( 5th ed). Elvevier Piecta. Singapore. Kaufman (2006). Essentials of Abnormal Psychology. John Wiley& Sons Inc. United State of America. Videbeck, S. L. (2008). Psychiatric Mental Health Nursing. (5th ed). Wolters Kluwer Health. Shives, L. R. (2008). Psychiatric Mental Health Nursing. (7th ed). Lippincott Williams & Wilkins. Kennedy P. (2008) Psychiatric Mental Health Nursing. Jones and Barlett Publishers, Inc. United State of America.

Internet sources: http://www.medpagetoday.com/Psychiatry/Schizophrenia/25040?utm_source=twitterfeed &utm_medium=twitter http://www.nursingscrib.com http://psychopathology.wikispaces.com/Schizophrenia

University of Regina Carmeli Catmon, City of Malolos College of Allied Medical Sciences

In PartialL Fulfillment in NCM 105 RLE PSYCHIATRIC CASE STUDY

Submitted to: Mrs. Perlita Espinoza

Submitted by: Borlongan, Gia Pauline A. BSN3