Saint Louis University

Baguio City
School of Nursing
S.Y. 2018-2019

In Partial Fulfillment of the Course Requirement in NCM 105a:

Case Analysis

Submitted By:
Wyen C. Cabatbat

Submitted To:
Ma’am Diadem Depayso
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

I. Name of Student: CABATBAT, Wyen C.

II. Date and Time of Interaction: July 11, 12, 13, 2019 (6:00am-2:00pm)
III. Purpose/Objective of Interaction:
After 6 days of nursing interventions, the student nurse will be able to establish rapport with the client, set contract and explore
more about the patient and what can cause or trigger that client’s increase in anxiety causing him to be agitated. Client will able to
verbalize his concerns, feelings, and thoughts without any discomforts to the student nurse; enhance positive perception about himself
and be able to identify and perform appropriate interventions.
IV. Introduction
This is the case of “Genie”. Filipino, single, Methodist. Born on July 18, 1978 currently residing in Agno, Pangasinan;
admitted in BGHMC institution on June 7, 2019 under the service of Dr. Rebucat/DR. Dancel. The mother was the informant with an
85% reliability.
Chief Complaint
According to watcher: Difficulty of Sleeping
History of Present Illness
Patient was known case of paranoid schizophrenia since December 2000 and was previously admitted and discharges in the
BGHMC Institution in 2014 and in 2018 with medication of clonazapine 100 mg/tab BID, biperiden 2 mg/tab PRN for EPS and
flupentixol decanoate 20 mg/ampule deep IM. Patient was noted to be non-compliant after discharge and would become angry and
physically assaultive towards his mother if she asked him to drink his medications.
One month prior to consult, patient was observed to have delusions stating that his mother should bring food to his sibling in
their house but in reality, his sibling doesn’t live with them anymore, He also thinks that he would go abroad. Patient was also noticed
to be laughing alone. Mother claims however that he does not have visual and auditory hallucinations. He was also noticeably easily
irritated and gets angry often with his mother and almost becomes assaultive especially when she refuses to give him money for
cigarettes. Patient also is very unhygienic, fails to clean himself and also could not leave the house out of fear that his son might hurt
him.
Five days PTC, patient was ordered by a vendor in their local market to fetch water, but he got extremely violent. He fetched a
bolo and almost tried to assault the vendor. He was pacified by the police officers present in the area and spent one night in jail due to
the incident. This also prompted his mother to bring him for consult and henceforth was admitted.
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

Past Medical History

Medical/Surgical:
The patient’s mother claimed that the patient has completed his immunization. The patient does not have a history of
hypertension, diabetes mellitus, cerebrovascular disease, coronary artery disease or asthma. No surgical procedures done. No allergies
to food drug.
Psychiatric:
The patient was diagnosed with a mental illness since 2000 in the BGHMC Institution. Since his diagnosis, the patient had
been confined for at least 3x times until February 2018. Recent admission in this institution was on February 2018 due to violent
behavior like attacking his sister with a long knife because he was not given money to buy cigarettes; managed as a case of Paranoid
Schizophrenia and was discharged after 22 hospital days with home medication of clozapine 100mg/tab 1 tab before bed time.

Family History
No known family history of psychiatric illnesses, hypertension, CAD, CVD, bronchial asthma, malignancy, arthritis, DM, and
thyroid diseases on both sides of the family. Father is deceased, Mother is the watcher and present, has 7 siblings 3 male and 3 female
and the patient is the 3rd amongst the siblings.

The patient was born via NSVD assisted by a traditional birth attendant with no complications. He is the 3 rd child among 7
siblings. The patient is a wanted pregnancy. Developmental milestones were at par with age and with no developmental delays.
Patient hasd a childhood illness like chickenpox, measles and mumps. His mother claims that there were no feeding difficulties and he
was active and healthy kid. He was sociable and playful during his youth. In school, patient performed fairly and had good
interpersonal relationship with peers and family members.

V. Nurse-Patient Interaction
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

CUES THEORIES NURSING GOAL AND INTERVENTIONS

DIAGNOSIS OBJECTIVES
Observations:  Impaired Social STO:
 Noted patient  Erik Ericson’s Interactions Within 8 hours of RATIONALE:
is isolated theory Autonomy related to nursing intervention
from the vs Shame and disturbed the client will be  Identify with client  Increased anxiety
others. doubt. He is shy thought able to: symptoms he /she can intensify
or in doubt into experiences when he or agitation,
 Patient is process.  Respond to she begins to feel aggressiveness, and
what he wants to
sleeping or  Social Isolation simple anxious around others. suspiciousness.
share so he
even sitting related to questions.
isolates himself.
most of the Alteration in  Establish rapport  Develop a therapeutic  Presence,
Mental Status
time.  Affect (flat, with the client. nurse-client relationship acceptance and
 Self-Care through frequent, brief conveyance of
 Silent when inappropriate) is  Verbalize
Deficit contacts and an positive regard
not asked or one of the present thoughts and accepting attitude. Show enhance the client’s
talked to. symptoms of the feelings unconditional positive feelings of self-
 Poor Eye patient which comfortably. regard. worth.
Contact. included to the
 Social LTO:  If client is unable to  An interested
 Staring into space respond verbally or in presence can
Isolation After 3 days of
is a form of a coherent manner, provide a sense of
 Blank Facial nursing
dissociation, a spend frequent, short being worthwhile.
expression state between interventions, the
period with clients.
being asleep and patient will be able  Even simple
 Appears upset, awake. to improve social  If client is delusional activities help draw
agitated, or Individuals go interaction with or hallucinating or is client away from
into a dissociative family, friends and delusional thinking
anxious when having trouble
into reality in the
others come state because the cell mates by being concentrating at this
nervous system is environment.
too close in able to: time, provide very
overly stimulated. simple concrete
contact or try Dissociation is a  Participating in activities with client.
to engage him survival
in an activity. Occupational  Recognition and
mechanism that
gives the body a appreciation go a
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

 Poor Hygiene temporary sense Therapy.  Remember to give long way to

and Grooming of numbness to acknowledgment and sustaining and
decrease feelings  Make eye recognition for increasing a
of distress. positive steps client specific behavior.
 Irritable contact.
takes in increasing
social skills and
 Restless  Respond to appropriate
social interactions with
conversions. others.

 Initiate
conversations

Subjective:  Erick Burne’s  Disturbed  Initially do not argue  Arguing will only
C: “Kailan ako Theory: Thought STO: with the client’s beliefs increase client’s
or try to convince the defensive position,
lalabas? Okay feelings Process related Within 8 hours of client that the delusions thereby reinforcing
naman ako ah” experienced to nursing intervention are false and unreal. false beliefs. This
during that event overwhelming the client will: will result in the
C:”Nung nsa is stored in the stressful events. client feeling even
labas ako brain. The event  Divert attention more isolated and
misunderstood.
tumutulong ako sa feelings are away from
 Encourage Healthy  All are vital to help
amo ko, tapos locked up hallucinations keep the client in
Habits to optimize
nagkaroon hindi together. Patient functionality: remission.
pagkaintindihan express  Identify
kaya naaway ko. emotions and activities that o Maintain medication
At hindi na rin thoughts on would help keep regimen.
ako bumalik dahil problem. attention away.
dun. o Maintain
 He cannot recall LTO: regular sleep pattern
C: Hindi ko .
the events After 3 days of
maalala kung bat before nursing
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

ako nandto, basta  The client’s

alam ko lng hindi admission. interventions, the o Maintain self-care. delusion can be
distressing.
ako makatuklog Schizophrenics patient will be able Empathy conveys
ng maayos. also results in to: o Reduce alcohol and
your caring, interest
cognitive drug intake.
and acceptance of
C: “Hindi ako impairment,  Be oriented to time, the client.
 Show empathy regarding  During acute phase,
makatulog pa ng memory loss place, person and the client’s feelings;
maayos, dahil ang and attention circumstances. client’s delusional
reassure the client of thinking might
ingay rin dun sa deficits, your presence and dictate to them that
kabila, yung mga resulting in  To realize self- acceptance. they might have to
babae. Kaya difficulties in thoughts and hurt others or self in
nilalakad ko na day to day realization.  Utilize safety measures order to be safe.
lng antok ko functioning and to protect clients or External controls
others, if the client might be needed.
kapag maaraw learning. believe they need to  Important clues to
na”. protect themselves underlying fears and
C: “Nandun nga against a specific person. issues can be found
mga kapatid ko sa Precautions are needed. in the client’s
bahay eh iniintay  Attempt to understand seemingly illogical
the significance of these fantasies.
ako tas nagpadala beliefs to the client at the
rin sila ng time of their
pagkain sa presentation.
bahay.”

References:
Berg, L. S. (2018). Learning Center. Retrieved from Adolescence:
http://highered.mheducation.com/sites/0072917873/student_view0/chapter10/chapter_overview.html
Saul, M. (2014). Simply Psychology. Retrieved from Carl Rogers: https://www.simplypsychology.org/carl-rogers.html
SHEILA L. VIDEBECK, P. R. (2004). Psychosocial Theories. In Psychiatric–Mental Health Nursing FIFTH EDITION. Wolters
Kluwer Health | Lippincott Williams & Wilkins.
 Saint Louis University
Baguio City
School of Nursing
S.Y. 2018-2019

(n.d.). Retrieved from http://currentnursing.com/pn/

https://journals.sagepub.com/doi/10.1177/1524500416672439
https://www.funeralzone.com.au/blog/the-grieving-process, https://nurseslabs.com/schizophrenia-nursing-care-plans/