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Undifferentiated Schizophrenia

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

(Nursing Care Management 104)

Submitted By:

ARIOLA, Jenny Babe O.

ARORA, Sachi Sujit E.
BERNABE, Abriel C.
CAJIGAN, Ryan A.
NGAYOS, Shyrlyn Mae C.
PILUDEN, Raquel B.
RAHHAL, Majid M.
SALTAT, Katryn Hazel L.
SAWI, Braille R.

(Date: 28-NOVEMBER-2019)

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

____________________________
Signature of Adviser / Date
 ABSTRACT

TITLE: This case study provides an overall insight on Undifferentiated Schizophrenia

AUTHOR INFORMATION: Jenny Babe Ariola, Sachi Sujit Arora, Abriel Bernabe, Ryan Jake Cajigan,
Shyrlyn Mae Ngayos, Raquel Piluden, Majid Rahhal, Katryn Hazel Saltat, Braille Sawi

BACKGROUND: This case is a classification used when a person exhibits behavior which fit into two or
more of the other types of schizophrenia, including symptoms such as delusions, hallucinations, disorganized
speech, and catatonic behavior.

Why should we care? We care for the reason that we want to increase the knowledge and awareness of each
one about the illness. We care for the reason that we want to get more insights and essential information about
this illness in order for us to disseminate proper practice and awareness to the general public.

CASE DESCRIPTION: We are going to present the case of a 21 year old male who is diagnosed with
Undifferentiated Schizophrenia which is common between the ages of 16-25. A patient with Violent and
hostile behavior and not compliant to medication is the chief complaint.

This case study primarily discusses undifferentiated schizophrenia; what it is, the causes, the signs and
symptoms of it in general, and the specific manifestations we have observed from patient X. The mental status
examination of patient X illustrates the strength of this study as it shows first-hand observations and
assessment done to a patient diagnosed with undifferentiated schizophrenia. Limitations have been set in this
study as it doesn’t include the other types of schizophrenia namely paranoid, catatonic and disorganized. This
case study contains information that could help future researchers about the same topic in order for them to
come up with more and accurate findings regarding undifferentiated schizophrenia, since this type of
schizophrenia is not talked about much.

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 TABLE OF CONTENTS

I.
I. Introduction.................................................................................................................................................３
II. Statement of Objectives..............................................................................................................................３
A. General Objectives..................................................................................................................................３
B. Specific Objectives..................................................................................................................................３
III. Patient’s Profile.......................................................................................................................................３
IV. Chief Complaint......................................................................................................................................３
V. Present History of Illness...........................................................................................................................３
VI. Past History of Illness.............................................................................................................................４
VII. Family Health History............................................................................................................................４
VIII. Developmental History...........................................................................................................................４
IX. Social and Environmental History........................................................................................................４
X. Lifestyle and Health Practices...................................................................................................................５
XI. Health Assessment..................................................................................................................................５
A. General Survey........................................................................................................................................５
B. Head to Toe Assessment.........................................................................................................................６
C. 13 Areas of Assessment..........................................................................................................................７
XII. Diagnostics.................................................................................................................................................9
XIII. Comprehensive Pathophysiology..........................................................................................................12
XIV. Treatment/Management........................................................................................................................13
A. Drugs....................................................................................................................................................13
B. IV Fluids..............................................................................................................................................13
C. Surgery................................................................................................................................................13
XV. Nursing Care Plans.................................................................................................................................15
A. Prioritization of Problems.....................................................................................................................15
a.1. List of Problems..............................................................................................................................15
a.2. Basis for Prioritization........................................................................................................................15
B. Nursing Care Plans.................................................................................................................................16
NCP 1...........................................................................................................................................................16
NCP 2...........................................................................................................................................................16
NCP 3...........................................................................................................................................................16
NCP 4...........................................................................................................................................................16
NCP 5...........................................................................................................................................................16
C. Discharged Plan......................................................................................................................................17
XVI. Learning Insights....................................................................................................................................17
XVII. List of References.....................................................................................................................................18
XVIII. Appendices...............................................................................................................................................19
Appendix A: Approval/ Request Letter........................................................................................................20
Appendix B: Interview Guides......................................................................................................................21
Appendix C: Others........................................................................................................................................22

II. Introduction
Schizophrenia is a chronic, severe, debilitating mental illness characterized by disordered
thoughts, abnormal behaviors, and anti-social behaviors. It is a psychotic disorder, meaning the person
with schizophrenia does not identify with reality at times. There are many types of schizophrenia one is
Undifferentiated-type schizophrenia which is our topic for this case study. Undifferentiated schizophrenia
is a mental illness in which a person has symptoms of schizophrenia that cannot be classified into a
particular type. These other types are paranoid, catatonic, and disorganized schizophrenia. You may be

2
 classified as having undifferentiated schizophrenia if your symptoms are not specific enough to meet the
definition for paranoid, catatonic, or disorganized schizophrenia. It is also the most common form of
schizophrenia because it covers all schizophrenia diagnosis.

Undifferentiated-type schizophrenia is a classification used when a person exhibits behaviors which fit
into two or more of the other types of schizophrenia, including symptoms such as delusions,
hallucinations, disorganized speech or behavior, catatonic behavior.

According to the WHO, Schizophrenia is a chronic and severe mental disorder affecting more than 21
million people worldwide. According to the latest report from Johnson & Johnson's Philippine Health
Information System on mental health conditions (PHIS-MH) with data gathered from 10 government
hospitals and four private hospitals, schizophrenia is the top brain disorder in the Philippines, affecting at
least 42 percent of patients who seek psychological consult.

II. Statement of Objectives

A. General Objectives
This case analysis aims to increase the understanding and knowledge of student nurses on how to care for
patients with Undifferentiated Schizophrenia. It also aids in identifying the primary needs and further health
problems related to this issue, which can support the formulation of an individualized nursing care plan.
B. Specific Objectives

Specifically, this case analysis aims to:

1. Define Undifferentiated Schizophrenia and its effects to the body as a whole;
2. Illustrate the pathophysiology of Undifferentiated Schizophrenia and in relation to
the signs and symptoms specifically observed in the patient;
3. Describe and identify the common signs and symptoms of Undifferentiated
Schizophrenia;
4. Discuss the medical and surgical interventions for the management of
Undifferentiated Schizophrenia;
5. Formulate appropriate nursing care plans suited for the patient based on the
assessment findings;
6. Identify care measures to be given to the patient and family to promote continuity of
care and independence after discharge.

III. Patient’s Profile

Name : Patient X
Ethnic Background : Ilocano
Civil Status : Single
Religion : Roman Catholic
Occupation : DEP

Admitting Diagnosis : Undifferentiated Schizophrenia

Final/Principal Diagnosis:
Date and Time Admitted : October 11, 2019 at 10:00 am

IV. Chief Complaint

Violent and hostile behavior; uncompliant to medications

V. Present History of Illness

The patient was apparently well until fourteen years prior to admission. Patient was constantly bullied
in school which made him aloof from his classmates. This resulted to depression and poor concentration,
which led to the point where the patient had to re-enroll in grade 2 a few times. He denies any family issues or
problems. Interval history revealed persistence of depressive mood, poor concentration, and socially
withdrawn. The patient had no friends and is aloof towards his family members. Patient was unemployed. No
medications and consult was done.
Three years prior to admission, patient started having violent outburst where he punches people who
bully him. He noted relief of depressed mood whenever he fights back with his bullies. Patient also started
having poor sleep, appetite, irritability, and blank stares. He was also becoming physically abusive to his
family and schoolmates. Patient also had poor hygiene. He was also seen talking and laughing at the wall.
Patient was brought to Lorma Hospital for consult where he was given an unrecalled medication, where patient

3
was uncompliant. This did not improve the patient’s condition. There were still violent outbursts of the patient,
hence were brought for another consult at Agoo, where he was given Clozapine 25 mg/tab, but was
uncompliant. Patient was forced to stop schooling due to his violent behavior. He was also caught trying to
poison his family by putting or mixing detergent powder or broken glass or sugar to their food. Not further
consult was done.
Two years prior to admission, patient’s condition and symptoms worsened, hence was given
Fluphenazine 10 ml IM injections, but patient was still uncompliant with the medication.
Interval history then revealed that the patient was put to jail due to drugs; patient was brought to
BGHMC for psychiatric evaluation. Patient was prescribed maintenance medications, but patient was
uncompliant.
One week prior to admission, patient is noted to be awake at night and is seen talking and arguing
with an unseen being. Patient was granted parole by regional trial court, however, the patient’s mother filed a
motion to admit the patient at BGHMC for further treatment because the patient was uncompliant with his
medication, hence the admission.

VI. Past History of Illness

MEDICAL/SURGICAL: The patient has no known history of hypertension, diabetes mellitus, heart
disease, cerebrovascular disease, seizures, head trauma and loss of consciousness. There was also no history of
any surgical procedures.
PSYCHIATRIC: This is the patient’s first admission, and there were no noted developmental and
behavioral disorders prior to the onset of condition. There was also no known comorbid psychiatric condition.

VII. Family Health History

There is a history of hypertension on the father side. There were no known heredofamilial
diseases on the mother side such as diabetes mellitus, asthma, cancer, heart disease, cerebrovascular disease,
pulmonary tuberculosis, renal problem, thyroid disease, and blood dyscrasia.
VIII. Developmental History
The patient has three siblings. He is a 21-year-old teenager undergoing the process of intimacy vs
isolation which is the sixth stage of Erik Erickson’s Theory of psychosocial. He has verbalized problems with
self-image and isolation. The patient doesn’t have a particular diet, and daily meal consists of meat, fish, rice
and vegetables.
IX. Social and Environmental History
During the interaction with the patient, he verbalizes that he smokes cigarette and drinks alcohol. Due
to peer pressure he was convinced to use drugs. He walked to and from their house to school. The patient
belongs to family of farmers and classified to be of lower class status. Gangsters and drug users are prevalent
in their neighborhood and present along the school premises such his classmates and school mate. He has
difficulty of interacting with others and prefers to stay at home and be alone. He has few friends and mostly
composed of his cousins.

X. Lifestyle and Health Practices

Patient was under the influence of drugs, alcohol, and cigarette smoking. He prefers to eating junk
foods over nutritious foods. They would only seek medical assistance when one of the family members are
extremely sick, and would rather visit quack doctors.

XI. Health Assessment

A. General Survey
The patient was received awake, sitting on bed and mannerism observed like cracking of knuckles and
covering face with both hands.
Patient is calm, anxious, restless and foul smell coming from his mouth is noted. He wears the same
clothes since three days ago, hygiene is fair. Patient is conversant with flight of ideas, oriented to the self and
others around him, disoriented to time but aware on date and is aware that he stays in the psych ward of
BGHMC. He couldn’t keep still, keep on walking around the ward. Losses focus during the conversation.
Patient is an ectomorph. He verbalized that he is 5’5” tall and weighs 55 kilograms. He has a normal
BMI of 19.53.

B. Head to Toe Assessment

1. Head Head is rounded, normocephalic and symmetrical, Good hair
distribution, no deformities, no lesions, no lice however presence of
dandruff noted
2. Eyes Eyebrows: hair is evenly distributed. The patient’s eyebrows are
symmetrical and showed equal movement when asked to raise and
lower them.
Eyelashes: eyelashes are equally distributed and curled slightly
outward.

4
 Eyelids: no presence of discharges noted, no discoloration and lids
close symmetrically with involuntary blinks,
Eyes: bulbar conjunctiva appeared transparent with capillaries
evident. The sclera appeared white. The palpebral conjunctiva
appeared shiny, smooth, and pink. No edema or tearing of the
lacrimal gland. Cornea is transparent, smooth and shiny. Iris is
visible. The pupils are black and equal in size. Pupils are equally
round respond to light accommodation.
3. Ears Hear spoken language correctly, symmetrical ears no gross
deformities, no aural discharge, no tragal deformities, with intact
tympanic membrane. The patient is reactive during the whisper voice
test procedure.
4. Nose and sinuses Nose is patent, septum is located midline, no flaring noted, able to
distinguish the scent of alcohol and perfume, no tenderness on the
frontal and maxillary sinuses.
5. Mouth Complete set of adult teeth, yellowish in color, and no mal aligned
tooth. No dental caries noted. Oral mucosa is dry and pale, no lesions
noted, tonsils are not inflamed, uvula is located midline, no tongue
deviation.
6. Neck No lesions, scars, no neck vein distension, thyroid glands are not
enlarged and moves with deglutition. No tenderness noted and trachea
is in the midline.
7. Chest The chest wall is intact with no tenderness and masses. There’s a full
and symmetric expansion and the thumbs separate 2-3 cm during
deep inspiration when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless respirations.
8. Cardiac Normal rate, regular rhythm, no murmur noted, no visible pulsations
in the precordium, palpable apical pulse.
9. Breast/Chest Skin color is similar with the rest of the body; nipple is dark colored,
no discharges.
10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft,
no direct tenderness or rebound tenderness upon palpation, tympanic,
no organomegaly.
11. Genitals No complaints of dysuria or urinary retention or pain during
urination.
12. Musculoskeletal Muscle strength is 5/5 on both lower and upper extremities.
No visible tremors noted no complaints of pain.
13. Integumentary When skin is pinched it goes to previous state immediately (2
seconds), with brown complexion, tattooes noted on right arm, scars
noted on lower extremities.

C. Mental Status Examination

A. GENERAL APPEARANCE
Patient X is a 21 years old that appeared older than his stated age. He was fairly thin. He’s tall with the
height of 5’6” and weighs 51 kilograms. He was diagnosed of Undifferentiated Schizophrenia.
He greeted me appropriately with a handshake, his palm was notably cold. He nervously and sheepishly
apologized for this. Good skin turgor of 2-3 seconds. His ears are well curved pinna and no deformities or
discharges. His nose is symmetrical with no nasal discharges and nasal septum is in midline and no nasal
fissures. He doesn’t have neck vein engorgement, no masses and no lesions noted. He has clear breath sounds
as I auscultated his back, with symmetrical chest wall expansion, no lesions or deformities, no retractions, and
no lagging. Abdomen is soft, flat, non-distended, and no tenderness. Observed no gross deformities, no edema,
with pinkish nail bed, full and equal pulses, and with good capillary refill of 1-2 seconds noted. He has big scar
on his right lower portion of his leg due to vehicular accident. No skin discoloration however skin is noted to
be dry. He has bracelet on his right arm. Tattoos noted scattered on his right forearm. His nails were
untrimmed and have dirt under. He was dressed appropriately according to his environment however he keeps
on repeating the same set of clothes for 3 days.

B. BEHAVIOR
Patient X was talkative and couldn’t keep still during conversations. Patient X was hyperactive and has
mannerisms like cracking of his knuckles and frequently scratching his head and forearm when asked
questions.
Psychomotor activity noted like he looked agitated. He usually speaks in a normal voice but sometimes
mumbles words that difficult to understand what he was saying and often with racing thoughts, feeling

5
extremely restless and at times impulsive, and he became easily distracted with his surroundings.
Patient X was cooperative and attentive throughout the interview. Sometimes he became sad or angry.

C. SPEECH
Patient X speech noted to have pressured speech because he often rapid but constantly talking and cannot
be interrupted. Observed stereotyping on patient, “minsan kasi may nakikita akong maliwanag, may nakikita
akong maliwanag, liwanag.”

D. MOOD and AFFECT

Patient X described his current mood as anxious and sad as stated “Gusto ko ng umuwi kasi namimiss ko
na mga kaibigan ko at gusto ko ng mag aral ulit.” His affect was full range affect because during conversation
the patient usually laughs without anything funny talked about.

E. THOUGHT PROCESS

THOUGHT CONTENT
“Sir ano pong ginagawa niyo kapag malungkot po kayo?” “Natutulog lang naman ako at minsan
kinakausap ko yung katabi kong pasyente din.” stated by Patient X
Patient X asked me “Ate matutulongan mo ba ako kasi sa tuwing nakakakita ako ng puti nasisilaw ako at
sumasakit yung mata ko” and I replied “Sabihin mo sa doctor lahat ng nararamdaman mo.”
“May naririnig ako minsan na boses na hindi ko maintindihan. Pero sabi ni mama wala naman daw siyang
naririnig.” Auditory Hallucination noted and he usually speaks in a rapid state but sometimes mumbles words
that difficult to understand what he was saying and often with racing thoughts, feeling extremely restless and at
times impulsive, and he became easily distracted with his surroundings.
Patient X was exhibited loosening of associations and flight of ideas; he unpredictably shifted the topic of
conversation from “Kumain na ako kanina ng kanin at gulay” shifted to “Kaaway ko silang lahat pero mahal
ko pa din sila.”

THOUGHT PROCESS
Patient X exhibited loosening of associations and flight of ideas. He goes from one thought to another in
logical sequence but is headed far from the original topic. She unpredictably shifted the topic of conversation
from “May mga kaibigan ako, kilala mo ba si MJ at Nicole.” shifted to “nagcocompose pala ako ng kanta,
gusto mong basahin?”
Patient X was spontaneous during the whole conversation he readily volunteers information without being
asked.
Patient X was easily distracted by the noise and people around him and he stops, pauses, and starts
somewhere else when asking a question “Sino sino po mga kasama niyo sa bahay niyo sir?” “Mama ko, ako, at
yung mga kapatid ko at…” Patient stops when he saw one of the interns. Patient X may appear to forget where
he was in the conversation when he resumes talking.
Patient X noted to have Perseveration, “yung sa sinabi ko kanina ate na nakikita ko na nakakasilaw na
puti, lagi kong nakikita yun.” “Yun kasi ate ang alam kong dahilan kaya ako nagkaganito.” He goes over and
over the same point or idea stated.

MEMORY
Both long – term and short – term memories are assessed.
I assessed his long – term memory by asking “Sir, saan ka nag aral noong elementary ka?” “ahhh sa ano
po…” doesn’t remember most of his childhood memories.
I also assessed his short – term memory by asking “Sir, ano pong kinain niyo kaninang umaga?” “Chicken
adobo po” stated by Patient X. “Sir, anong ginawa niyo kahapon?” “Wala po, nakahiga lang po ako kahapon”
stated by Patient X.

ABILITY TO ABSTRACT AND GENERALIZED

I asked him to tell how two objects are different or alike. I named two items and I asked her how these
differ and how they are similar by giving examples like APPLE and ORANGES, TREES and FLOWERS,
HOUSES and CARS, DOGS and CATS. Patient X can easily differentiate it by stating “Apple at Orange ay
parehas po na prutas pero ang apple po ay kulay red at ang orange po and kulay orange.” “Yung Trees at
flowers naman po ay parehas po silang plants pero yung puno po ay naaakyat at yung flower naman po hindi.”
“Yung House at Cars naman po ay parehas po silang mga bagay po pero yung bahay po tinitirahan po ng tao at
may mga kwarto po di po gaya ng sasakyan ginagamit lang po sa pag byahe.” “Yung Cats and dog’s naman po
parehas po silang mga hayop po pero yung cats po nag mmeow at yung aso naman po ay tumatahol.”

F. INSIGHT
Overall, this client appeared forthright and reliable. He was open about his condition and expressed

6
interest in improving health.
Patient X was aware and understands his illness and need for treatment by stating “may sakit kasi ako kaya
ako nandito pero iniinom ko naman lahat ng gamot ko kasi gusto ko nang lumabas dito.”

G. JUDGEMENT
The patient exhibits good judgment. When given a situation like, “anong gagawin mo sir kapag may nakita
kang nasusunog na bahay at nakita mong may baby sa loob?” The patient answered, “ililigtas ko po yung baby
sa loob, kasi kawawa naman po siya.”

7
XII. Diagnostics
Diagnostic Description of procedure
Procedure and
date done
Complete Blood A complete blood count (CBC) is
Count (CBC) a blood test done to check the
levels of cells in the blood. It
includes numbers and measures of
red blood cells, white blood cells,
and platelets. A CBC may be done
October 11, for many reasons, and is a good
tool for understanding symptoms
2019
as well as trying to figure out a
disease.
REFERENCE:
WebMD
https://www.webmd.com/a-to-z-
guidelines/complete-blood-count
Significance/ Purpose
Significant findings Nursing Implications Nursing Responsibilities
of the procedure
(CBC) blood test is used Hemoglobin The hemoglobin level Dx:
to evaluate overall health of the patient is
and detect a wide range Normal range: normal which  Assessed skin conditions around insertions of pins
and wires.
of disorders, including indicates sufficient
160 g/L  Observed for localized signs of infection at insertion
anemia, infection and supply of o2 in the sites.
leukemia. Result: body.  Noted signs and symptoms of sepsis such as fever,
chills, and diaphoresis.
A complete blood count 147
test measures several
components and features Hematocrit The hematocrit level Tx:
of your blood, including: of the patient is
Normal range: normal which
- Red blood cells, which indicated sufficient
0.37-0.54 L/L  Monitored vital signs
carry oxygen amount of rbc’s in the
 Applied manual pressure and dressings over the
Result: blood. punctured site.
- White blood cells,
 Monitored medication regimen and noted patient’s
which fight infection 0.44
response.
-Hemoglobin, the WBC White blood cell
oxygen-carrying protein counts higher than the Edx:
in red blood cells Normal range: normal range indicates
the patient’s immune
- Hematocrit, the 5.0-10.0
system is activated to
proportion of red blood  Encouraged patient to avoid stress if possible because
Result: combat any infection.
cells to the fluid altered physiologic status influences and changes
component, or plasma, in normal hematologic values.
10.71  Advised to increase fluid and protein intake.
your blood
 Instructed to resume normal activities and diet.
Neutrophil Increased neutrophil
means indicates
8
Normal range: infection or under a lot
of stress.
50-70 %

Result:

80

Lymphocytes Lymphocytes is within

the normal range
Normal range:

20-40 %

Result:

13

Monocytes The monocyte level in

the patient’s blood is
Normal range: normal which
indicates sufficiency
0 – 10 %
to destroy bacteria, but
Result: usually those causing
chronic infections.
6

Eosinophil Eosinophil is within

the normal range
Normal range:

0–7%

Result:

Basophil The basophil level in

9
Normal range: the patient’s blood is
normal which
0 -01 % indicates a role in
allergy reactions
Result:

0.00

RBC Count RBC count in the

patient’s blood is
Normal range: normal which
indicates sufficient
4.04-5.48
supply of oxygen
10^12/L

Result:

4.89

Platelet Count Platelet count is within

the normal range.
Normal range:

150-40010^ 9/L

Result:

363

RBC INDICES RBC indices is within

the normal range
MCV

Normal findings:

80-100fL

10
Result:

98.80 fL

MCH

Normal findings:

27-31pg

Result:

27.31pg

MCHC

Normal findings:

310-360 g/L

Result:

332g/L

RDW-CV

Normal result:

11-16 %

Result:

12.40%

RDW-SD

Normal result:

11
 35-56 fL

Result:

39.00fL

Urinalysis Clinical urine test are various tests It is done to determine PHYSCAL NORMAL Dx:
of urine for diagnostic purposes. A information about EXAMINATION
urinalysis is used to detect and patients general health, Color: DARK YELLOW
manage a wide range of disorders how the other organs are Appearance: TURBID
 Assessed patient’s pattern elimination.
such as Urinary Tract Infection. functioning and other MICROSCOPIC Many mucus threads
 Determined patient’s usual daily fluid intake
October 13, medical conditions. EXAMINTATION may be caused by  Observed for signs of infection.
2019 Pus cells: urinary tract infection
1-2 /hpf (UTI), kidney stones
Red Blood Cells: and ulcerative colitis. Tx:
0-2 /hpf
Yeast Cells:
NONE  Monitored medication regimen.
Bacteria:

12
NONE  Assisted in maintaining acidic environment of the
Epithelial Cells: bladder by use of agents such as vitamin C.
RARE  Provided patient comfort, privacy and safety.
Mucus Threads:
MANY Edx:
Amorphous Materials:
NONE
Glucose:
NEGATIVE  Emphasized the importance of keeping the Perineal
Ketones: area clean.
 Encouraged significant others who participate in
NEGATIVE
routine care to recognize complications necessitating
Urobillinogen medical interventions.
NORMAL  Instructed patient to increase fluid intake
Bilirubin:
NEGATIVE
Erythrocyte:
NEGATIVE
CHEMICAL NORMAL
EXAMINATION
Specific Gravity:
1.019
pH:
6.0
Leukocyte Esterase:
Nitrate:
NEGATIVE
Protein:
NEGATIVE
CRYSTAL NORMAL
Uric Acid:
NONE
Calcium Oxalate:
NONE

13
 Triple Phosphate:
NONE
CAST NORMAL
Fine Granular:
NONE
Course Granular:
NONE
Hyaline:
NONE
Waxy:
NONE
October 15, PHYSCAL NORMAL
2019 EXAMINATION
Color: LIGHT YELLOW
Appearance: CLEAR

MICROSCOPIC  Bacteria may

EXAMINTATION be caused by
Pus cells: possible
0-1 contamination
Red Blood Cells: .
NONE
Yeast Cells:
NONE
Bacteria:
RARE
Epithelial Cells:
NONE
Mucus Threads:
NONE
Amorphous Materials:
NONE
Glucose:

14
NEGATIVE
Ketones:
NEGATIVE
Urobillinogen:
NORMAL
Bilirubin:
NEGATIVE
Erythrocyte:
NEGATIVE
CHEMICAL NORMAL
EXAMINATION
Specific Gravity:
1.005
pH: 7.0
Leukocyte Esterase:
NEGATIVE
Nitrate:
NEGATIVE
Protein:
NEGATIVE
CRYSTAL NORMAL
Uric Acid:
NONE
Calcium Oxalate:
NONE
Triple Phosphate:
NONE
CAST NORMAL
Fine Granular:
NONE
Course Granular:
NONE
Hyaline:

15
NONE
Waxy:
NONE

16
 III. XIII. Comprehensive Pathophysiology
Precipitating Factor/s:
Predisposing factor/s:
-Use of illicit drug
-Familial
-Excessive alcohol intake
-Gender
-Life circumstances
>Common in males
-Childhood experiences

DecreasedDo Increased Decreased Increased Increased

pamine Dopamine Serotonin GABA Glutamate

Loss of balance Mediates Depressed

Inhibits Alertness
Dopamine Mood
Norepinephrine
Level

Inability to focus Anxiety Restlessness

Pleasurable feelings,
Low Energy
addiction

Fatigue Behavior
disturbances
Negative
Feeling Thoughts
Talkative
Anxious
Increase in
Depressed risky behavior
Pressured mood
Speech

Racing Perceptual
Risk for
Thoughts Disturbances
Violence

Psychomotor
agitation Irritability

Anxiety related to
Altered Thought unconscious conflict
Process with reality

Self-care Risk for

Deficit Loneliness

17
IV. XIV. Treatment/Management
A. Drugs
INDICATION /
MECHANISM OF ACTION ADVERSE EFFECT NURSING RESPONSIBILITIES
DRUG NAME CONTRAINDICATION

GENERIC: INDICATIONs: CNS: BEFORE:

DEPHENHYDRAMINE  Antagonizes the effect of  Parkinsonian syndrome  Dizziness, headache, Dx:

histamine H1- receptor specially to counteract drowsiness, paradoxical
BRAND: muscular rigidity and excitation (in children)  Determine why the medication
sites, does not bind to or
CV: was ordered and assess
inactivate histamine. tremor; extrapyramidal
ALLERDRYL symptoms that apply to the
Significant CNS symptoms induced by  Hypotension, palpitations
antipsychotics individual patient.
CLASS: depressant and
GI:  Assessed for any allergies
anticholinergic properties.
 THERAPEUTIC: CONTRAINDICATIONs:  Assessed patient for urinary
Antiparkinson  Anorexia, dry mouth, retention
DOSAGE:  Hypersensitivity; acute constipation, nausea
Therapeutic Effects: attacks of asthma; known Tx:
 50 mg 1 cap OD alcohol intolerance GU:
 Antiparkinson agent  Dysuria, frequency,  Administered medication at the
Use cautiously in: urinary retention right prescribed route and time
 Severe liver disease, Angle- DERM:  . Administered medication with
ROUTE: SOURCE: closure glaucoma; Seizure food
disorders  Photosensitivity
ORAL Davis’ Drug Guide for Nurses  Ensured that patient has fully
14th Edition RESP:
swallowed oral form of
 Chest tightness, thickened
bronchial secretions, medication
www.DrugGuide.com DRUG TO DRUG
INTERACTION: wheezing.
Edx:
 Increased risk of CNS  Advised patient to avoid
depression with other activities while taking the drug
antihistamines, opioid  Instructed patient to move
18
 analgesics and sedatives / slowly to prevent dizziness
hypnotics. Increased
anticholinergic effects with  Instructed patient to notify health
tricyclic antidepressants, care professional if difficulty
quinidine or disopryamide. urination, constipation,
MAO inhibitors intensify confusion, eye pain and rash
and prolong the occur
anticholinergic effects of
DURING:
antihistamines.
Dx:
DRUG TO FOOD
INTERACTION:  Assess for Parkinsonism
 Assess for and report blurred
 Concomitant use of vision.
chamomile and alcohol can  Assess for mental status.
increase the CNS
depression.
Tx:

 Monitored intake and output

ratios
 Monitored for and report
immediately: Mental confusion,
drowsiness, dizziness, agitation,
hematuria, and decrease in
urinary flow.
 Monitored BP and pulse

Edx:

 Instructed patient to change

position slowly to minimize
19
 effects of orthostatic
hypotension.
 Instructed patient to take liquid
form if there is difficulty in
swallowing tablet form
 Advise patient to make position
changes slowly and in stages,
particularly from recumbent to
upright position.

AFTER:

Dx:

 Assessed patient for any other

symptoms such as dizziness to
avoid self-injury.
 Assessed positive (hallucination,
delusions) and negative (social
isolation) symptoms of
schizophrenia.
 Assessed for therapeutic
effectiveness.

Tx:

 Provided comfort measures such

as positioning the patient to help
tolerate drug effects
 Monitored patient for onset of
extrapyramidal side effects
(akathisia—restlessness; dystonia
—muscle spasms and twisting

20

MECHANISM OF ACTION
DRUG NAME
GENERIC:
HALOPERIDOL  Alters the effect of
dopamine in the CNS. Also
BRAND:
has anti cholinergic and
alpha-adrenergic blocking
motions; or pseudo parkinsonism
—mask-like face, rigidity,
tremors, drooling, shuffling gait,
dysphagia). Report these
symptoms; reduction of dose or
discontinuation may be
necessary.
 Monitor patient for sign and
symptoms of adverse reaction.
Edx:
 Advised patient to comply on her
treatments and regimens.
 Instructed patient to change
position slowly to minimize
effects of orthostatic
hypotension.
 Instructed the patient to avoid
alcohol intake.
INDICATION /
ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
INDICATIONs: CNS: BEFORE:
 Acute and chronic  Seizures, extrapyramidal Dx:
psychotic disorders symptoms
including: schizophrenia  Assessed mental status (orientation,
who require long-term EENT: mood, behavior) prior to and
21
HALDOL activity. parenteral antipsychotic
therapy. Also useful in
CLASS: managing aggressive or
agitated patients.
 THERAPEUTIC: Therapeutic Effects: Tourette’s syndrome.
Antipsychotics Severe behavioral
 Diminished signs and
PHARMACOLOGIC: problems in children
Butyrophenones symptoms of psychoses. which may be
DOSAGE: Improved behavior in accompanied by:
unprovoked, combative,
children in children with
 adult:PO 0.2–5 mg explosive hyper
Tourette’s syndrome or excitability, hyperactivity,
b.i.d. or t.i.d.
other behavioral problems. accompanied by conduct
 IM 2–5 mg repeated disorders. Considered
second line treatment after
q4h prn
SOURCE: failure with atypical
ROUTE: antipsychotic.
Davis’ Drug Guide for Nurses 14th  Unlabeled use: nausea
ORAL Edition and vomiting from surgery
of chemotherapy.
www.DrugGuide.com
INTRAMUSCULAR
CONTRAINDICATIONs:
 Hypersensitivity, angle-
closure glaucoma; bone
marrow depression; CNS
depression; parkinsonism;
severe liver or
cardiovascular disease.
Use cautiously in:
 Debilitated patients,
Cardiac disease; diabetes;
respiratory insufficiency;
prostatic hyperplasia; CNS
 Pharyngitis, rhinitis, visual
disturbances
CV:
 Arrhythmias, orthostatic
hypotension, tachycardia
GI:
 Constipation, diarrhea, dry
mouth, nausea, weight
gain, abdominal pain,
anorexia, dyspepsia,
polydipsia, increased
salivation, vomiting,
weight loss.
GU:
 Decreased libido, difficulty
urinating, polyuria,
priapism.
DERM:
 Itching, skin rash, dry skin,
increased pigmentation,
sweating, photosensitivity,
seborrhea.
RESP:
 Cough, dyspnea.
ENDO:
 Dyslipidemia,
galactorrhea,
hyperglycemia.
periodically during therapy
 Assessed positive (hallucination,
delusions) and negative (social
isolation) symptoms of
schizophrenia.
 Assessed weight and BMI initially
and throughout therapy.
Tx:
 Provided safety measures (e.g.
adequate lighting, raised side
rails, etc.) to prevent injuries
 Closely monitoring of patient for
suicidal tendencies, particularly
when therapy starts and dosage
changes, because depression may
worsen
 Monitor for parkinsonism and
tardive dyskinesia.
Edx:
 Advise patient to verbalize feelings
and concerns.
 Encouraged the patient to eat before
taking the medications.
 Instructed patient no to take more
than your prescribed dosage.
22
 tumors; intestinal
obstruction; seizures.
DRUG TO DRUG
INTERACTION:
 Increased anticholinergic
effects with drugs having
anticholinergic properties,
antihistamines,
antidepressants, atropine,
phenothiazine, quinidine,
and disopyramide.
Increased CNS depression
with other CNS
depressants including
antihistamines, opioid
analgesics, and
sedative/hypnotics.
Concurrent use of
epinephrine may result in
severe hypotension and
tachycardia. May decrease
therapeutic effects of
levodopa. Acute
encephalopatic syndrome
may occur when used with
lithium.
DRUG TO FOOD
INTERACTION:
 Concomitant use of
DURING:
Dx:
HEMAT:
 Observed patient carefully when
 Agranulocytosis, administering medication, to ensure
leukopenia, neutropenia. medication is actually taken and not
hoarded
MS:  Observed Rights to patient, drug,
time, route and dose.
 Arthralgia, back pain
 Observed patient when
administering medication to ensure
medication is swallowed and not
hoarded or cheeked.
Tx:
 Provided comfort measures such
as positioning the patient to help
tolerate drug effects
 Ensured that patient has fully
swallowed oral form of medication
 Monitor for therapeutic
effectiveness. Because of long half-
life, therapeutic effects are slow to
develop in early therapy or when
established dosing regimen is
changed.
Edx:
23
  Advise patient to verbalize feelings
chamomile and alcohol can and concerns.
increase the CNS  Urged patient to avoid performing
depression. dangerous activities until drug’s
CNS effects are known.
 Instructed the patient to report any
untoward signs and symptoms
observed.

AFTER:

Dx:

 Assessed patient for any other

symptoms such as dizziness to avoid
self-injury.
 Assessed positive (hallucination,
delusions) and negative (social
isolation) symptoms of
schizophrenia.
 Observe patients closely for rapid
mood shift to depression when
haloperidol is used to control mania
or cyclic disorders. Depression may
represent a drug adverse effect or

24
 reversion from a manic state

Tx:

 Closely monitored patient for

suicidal tendencies, particularly
when therapy starts and dosage
changes, because depression may
worsen
 Provided comfort measures such
as positioning the patient to help
tolerate drug effects
 Monitor patient for sign and
symptoms of adverse reaction.

Edx:

 Instructed patient to change

position slowly to minimize
effects of orthostatic
hypotension.
 Instructed patient to take liquid
form if there is difficulty in
swallowing tablet form
 Advised patient to comply on
her treatments and regimens

DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES

CONTRAINDICATION

25
GENERIC: INDICATIONs: CNS:

RISPERIDONE  May act by antagonizing  Schizophrenia in adults.  akathisia, somnolence, BEFORE:

dopamine and serotonin in Short-term treatment of dystonia, headache,
BRAND: acute manic or mixed insomnia, agitation, Dx:
the CNS.
episodes associated with
RISPERDAL anxiety, pain,  Assessed for allergy to
Bipolar I Disorder (oral
RISPEDAL CONSTA only), can be used with parkinsonism, neuroleptic risperidone, lactation, CV
RISPERDAL M-TAB lithium or valproate (adults malignant syndrome, disease, pregnancy, renal of
Therapeutic Effects:
only. suicide attempt, dizziness, hepatic impairment, hypotension.
CLASS: fever, hallucination, mania,
 Decreased symptoms of  Observed Rights to patient, drug,
psychoses, bipolar mania, impaired concentration. time, route and dose.
THERAPEUTIC: CONTRAINDICATIONs:
Antipsychotics, mood or autism.  Assessed weight and BMI
CV:
stabilizers,  Hypersensitivity initially and throughout therapy.
 PHARMACOLOGIC:  tachycardia, chest pain,
Benzisoxazoles Use cautiously in: Tx:
orthostatic hypotension,
DOSAGE: SOURCE:  Debilitated patients,
peripheral edema, syncope,  Monitor closely for notable
patients with renal or
 Schizophrenia: 1 mg PO BID Davis’ Drug Guide for Nurses 14th hypertension. changes in behavior that could
hepatic impairment (initial
the gradually increase with Edition indicate the emergence or
dose reduction EENT:
daily dosage increments of 1 worsening of suicidal thoughts or
mg BID on the second and www.DrugGuide.com recommended); underlying
cardiovascular diseases;  rhinitis, sinusitis, behavior or depression,
third days to a target dose of 3
mg PO BID by the third day history of seizures; history pharyngitis, abnormal especially during early therapy.
 Bipolar Mania: 2-3 mg/ day; of suicide attempt or drug vision, ear disorder Restrict amount of drug available
range 1-6 mg/ day. abuse; diabetes or risk to patient.
GI:  Monitor BP (sitting, standing,
factors for diabetes (may
worsen glucose control); lying down) and pulse before and
ROUTE:  constipation, nausea, frequently during initial dose
patients at risk of vomiting, dyspepsia,
aspiration. titration. May cause prolonged
ORAL abdominal pain, dry QT interval, tachycardia, and
DRUG TO DRUG mouth, increase saliva. orthostatic hypotension. If
INTERACTION: hypotension occurs, dose may

26
  Increased therapeutic and
toxic effects with
clozapine.
 Decreased therapeutic
effect with carbamazepine.
OTHER:
 Decreased effectiveness of
levodopa.
DRUG TO FOOD
INTERACTION:
 Concomitant use of
chamomile and alcohol can
increase the CNS
depression.
RESP:
 Rhinitis, coughing,
sinusitis, pharyngitis,
dyspnea
 Chest pain, arthralgia, back
pain, neuroleptic malignant
syndrome, diabetes
mellitus, hyper glycaemia
need to be decreased.
 Closely monitored patient for
suicidal tendencies, particularly
when therapy starts and dosage
changes, because depression may
worsen
Edx:
 instructed the patient to keep the
tablet in its blister pack until you
are ready to take it.
 Instructed the patient to have
meals before taking in the
medication.
 Instruct the patient for onset of
extrapyramidal symptoms.
DURING
Dx:
 Observed patient when
administering medication to
ensure medication is swallowed
and not hoarded or cheeked.
 Assessed patient’s mental status
(orientation, mood, behavior) and
mood before and periodically
during therapy.
 Assessed positive (hallucination,
27
 delusions) and negative (social
isolation) symptoms of
schizophrenia.

Tx:

 For orally disintegrating tablets,

open blister pack by pealing back
foil to expose tablet; do not try to
push tablet through foil. Use dry
hands to remove tablet from
blister and immediately place
entire tablet on tongue. Tablets
disintegrate in mouth within
seconds and can be swallowed
with or without liquid.
 Monitored BP (sitting, standing,
lying down) and pulse before and
frequently during initial dose
Monitor for symptoms of
hyperglycemia polydipsia,
polyuria, polyphagia, weakness)
periodically during therapy.
 Checked if the medication was
swallowed by the patient.

EDX:

 Advised patient to avoid

performing dangerous activities
until drug’s CNS effects are

28
 known.
 Instructed the patient not attempt
to split or chew tablet. Do not try
to store tablets once removed
from blister.
 Instructed patient to change
position slowly to minimize
effects of orthostatic
hypotension.

AFTER:

DX:

 Assessed patient for any other

symptoms such as dizziness to
avoid self-injury.
 Assess fluid intake and bowel
function.
 Assessed for therapeutic
effectiveness.

TX:

 Closely monitored patient for

suicidal tendencies, particularly
when therapy starts and dosage
changes, because depression may
worsen
 Monitored patient for onset of
extrapyramidal side effects
(akathisia—restlessness; dystonia
29
 —muscle spasms and twisting
motions; or pseudo parkinsonism
—mask-like face, rigidity,
tremors, drooling, shuffling gait,
dysphagia). Report these
symptoms; reduction of dose or
discontinuation may be necessary
 Provided comfort measures such
as positioning the patient to help
tolerate drug effects

EDX:

 Instructed the patient to take

missed doses as soon as
remembered with remaining
doses evenly spaced throughout
the day.
 Advised patient to comply on her
treatments and regimens.
 Instructed the patient to avoid
alcohol intake.

30
V. XV. Nursing Care Plans

A. Prioritization of Problems
NURSING DIAGNOSES JUSTIFICATION
We have chosen this diagnosis as our top priority since it
1. Altered Thought Process r/t describes the state of having an altered perception and
Psychological conflicts as manifested cognition that interferes with daily living. In people with
by cognitive deficits, hallucinations, diagnosed with schizophrenia, this is usually the common
and distractibility. problem which needs to be emphasized as it greatly
affects the way a person acts, thinks, and feels.
2. Anxiety R/T Unconscious Conflicts We have chosen this diagnosis as our second priority since it is
W/ Reality as evidenced by restlessness common in schizophrenic patients, however not as common as
and frequent pacing the first priority. Anxiety must be prioritized, because it affects
both the way a person feels emotionally as well as physically.
And according to Peplau’s Therapeutic Communication model,
this can be solved by the use of therapeutic communication.
3. Self-care Deficit R/T regression and We have chosen this diagnosis as our third priority, since it
cognitive impairment as manifested by mostly concentrates on the physical being of a person.
difficulty carrying out tasks associated Dorothea Orem's Self-Care Deficit Theory focuses on each
with hygiene, dressing, and grooming “individual's ability to perform self-care, defined as 'the
practice of activities that individuals initiate and perform on
their own behalf in maintaining life, health, and well-being.
Self-care is also vital and can help in the quick recovery of a
person.
4. Risk for violence: Directed to others We have chosen this as our fourth priority, since it is only a
r/t altered thought process as evidenced risk. If a patient’s disturbed thought process will be treated, the
by impatience and angry responses risk for violence would most probably be gone. However, it is
toward others. still a priority since it can bring danger to both patient and
people around him/her.
5. Risk for loneliness r/t decreased We have chosen this as our fifth priority, since it is only a risk.
exposure to events in the outside world Loneliness affects a person emotionally, and could later affect
as manifested by frequent complaints of him/her mentally and physically.
boredom

31
B. Nursing Care Plans

1. NCP 1: Altered Thought Process r/t Psychological conflicts as manifested by cognitive deficits, hallucinations, and distractibility.
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
S> “May mga kaibigan Cognitive processes include STO> Within 4 hours of DX: ST>
ako, kilala mo ba si MJ at those mental processes by Nursing Intervention the pt. - Assessed patient’s behavior and - Age, gender, cultural, and personal Goal met: Within 4 hours of
Nicole?” immediately which knowledge is acquired. will be: social interactions for appropriateness. norms may influence an individual’s nursing interventions,
followed by “Nag These mental processes -Oriented to time and place behavior. It may be helpful to use patient was able to be
compose pala ako ng include reality orientation, without being confused considerations of safety when evaluating oriented to time and place
kanta, gusto mong comprehension, awareness, -Able to understand and an individual’s behavior. without being confused as
basahin?” as verbalized and judgment. A disruption in remember the health teachings evidenced by answering
by the patient. these mental processes may rendered correctly when asked
lead to inaccurate - Evaluated the patient’s ability and -The patient’s ability and/or willingness separately by 2 student
“Minsan may naririnig interpretations of the willingness to respond to verbal to respond to verbal direction and/or nurses.
ako, bumubulong sila sa environment and may result in direction and limits. limits may vary with patient’s mood, -Patient was able to
akin” as verbalized by the an inability to evaluate reality perceptions, degree of reality orientation, understand the health
patient. accurately. Alterations in and environmental stressors. teachings rendered by the
thought processes are not student nurse as evidenced
limited to any one age group, by repeating what have been
O> -Disorientation to gender, or clinical problem. -Confusion, disorientation, impaired taught.
time -Observed for statements reflecting a judgment, suspiciousness, and loss of
-Observed frequent flight LTO> Within 48 hours of desire or fantasy to inflict harm on self social inhibitions all may result in LT> Goal partially met:
of ideas Nursing Intervention, the pt. or others. socially inappropriate and/or harmful Within 48 hours of nursing
-Observed irritability and will be able to: behavior to self or others. interventions, patient was
impatience when unable - Participate in unit activities. able to participate in their
to answer questions asked -Communicate well with OT activites, however, still
-Observed frequently lessened frequency of flight of - Develop trust between patient and had flight of ideas when
asking his mother about ideas. TX: nurse to improve effectiveness of spoken to.
specific dates and events - Provide encouragement in a non- interventions and cooperation.
that took place before his judgemental, compassionate way,
admission. understanding that symptoms are real
-Inability to determine if a to patient - If reorienting is initially ineffective,
behavior is performed avoid persistent attempts or arguing as it
- Avoided arguing with a patient can agitate the patient or cause feelings
NURSING DIAGNOSIS: regarding delusions or hallucinations of isolation.
Altered Thought Process Never confirm a delusion or

32
 hallucination (“I see Jesus, too!”) – this
can exacerbate agitation or confusion.

- Reorienting helps patient to

differentiate between reality and
hallucination, time, and place.
-Reoriented patient as necessary

-Help redirect patient to acceptable

EDX
- Encourage reality-based activities
such as listening to music or reading
books
- Encourage patient to communicate
thoughts and feelings.
activities and behaviors and reduce the
risk for distractions and flight of ideas.
- Helps understand and anticipate
behaviors and help identify stressors
such as fear or helplessness. Reduce
anxiety.
 -This is to maximize level of function

-Encouraged patient to participate in

resocialization activities/groups when
available.

NCP 2: Anxiety R/T Unconscious Conflicts W/ Reality as evidenced by restlessness and frequent pacing
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
S> Anxiety is defined as Vague STO: DX: STO> Goal partially met:
“Saan na si mama?Ang uneasy feeling of discomfort Within 8 hours of nursing -Assessed patient’s level of anxiety -To serve as a baseline data to Within 8 hours of nursing
tagal naman niya.” ; or dread accompanied by an interventions, the patient will compare subsequent assessment. interventions, the patient
“Hindi ako mapakali autonomic response (the be able to: -Determined how patient copes with was able to identify
kung wala si mama eh.” source often nonspecific or anxiety -The assessment helps determine the strategies to reduce
As verbalized by the unknown to the individual); - Identify strategies to reduce effectiveness of coping strategies anxiety such as deep-
patient. a feeling of apprehension anxiety currently used by the patient. breathing exercises.
caused by anticipation of However, the patient was
O> danger. It is an alerting -Patient has posture, facial still slumping while sitting,
33
 -Observed pacing from signal that warns of expressions, gestures, and -Assessed physical reactions to -Anxiety also plays a role in looking preoccupied by
the bedroom to the impending danger and activity levels that reflect anxiety somatoform disorders, which are thoughts.
window rails enables the individual to decreased distress characterized by physical symptoms
-Observed frequently take measures to deal with such as pain, nausea, weakness, or
rubbing palms together the threat. dizziness, that have no apparent
-Noted restlessness when physical cause. LTO> Goal unmet:
s/o is not around LTO: Within 48 hours of
Within 48 hours of nursing TX: nursing interventions,
Diagnosis: interventions the patient will -Maintained a calm manner while -The healthcare provider can transmit patient still had difficulty
Anxiety r/t Unconscious be able to: interacting with patient. his/her own anxiety to the in concentrating, and
Conflicts With Reality hypersensitive patient. The patient’s would frequently complain
- Demonstrate improved feeling of stability increases in a calm about his thoughts and
concentration and accuracy and nonthreatening atmosphere. worries.
of thoughts.
-Using anxiety-reduction strategies
-Demonstrate ability to -Assisted the patient in developing enhances patient’s sense of personal
reassure self anxiety-reducing sills such as mastery and confidence.
relaxation, deep-breathing, positive
visualization, and reassuring self- -Learning to identify a problem and
statements. evaluate alternatives to resolve it helps
-Assisted patient in developing patients to cope.
problem-solving abilities.
Emphasized the logical strategies
patient can use when experiencing
anxious feelings.
-The presence of significant others
EDX: reinforces feelings of security for the
-Encouraged patient to seek patient.
assistance from an understanding
significant other or from the health
care provider when anxious feelings
become difficult
-If patient and family can identify
-Educated patient and significant anxious response, they can intervene
other about the symptoms of anxiety earlier than otherwise.

-Taught client to identify and use -Early interruption of the anxious

34
 distraction or diversion tactics when response prevents escalation
possible.

NCP 3: Self-care Deficit R/T regression and cognitive impairment as manifested by difficulty carrying out tasks associated with hygiene, dressing, and grooming
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
S> Self-care deficit is an STO: DX: STO> Goal Unmet:
“Hindi ako naliligo kasi impaired ability to perform Within 8 hours of nursing Within 8 hours of nursing
ang ginaw ditto, or complete abilities of daily interventions, the patient will - Assessed ability to carry out ADLs -This determines the aspects of self- interventions, the patient
malamig pa ang tubig.” living for oneself such as be able to: such as feeding, dressing, grooming, care that are problematic to the was not able to maintain
As verbalized by the feeding, dressing, bathing, -Maintain proper grooming and bathing on a regular basis. patient. The patient may only require proper grooming as he
patient. and toileting. Self-Care as evidenced by clean assistance with some self-care didn’t take a bath for two
“Apat na araw na siyang Deficit is the inability of an fingernails, fixed hair, change measures. days, and hasn’t changed
di naliligo kasi nilalamigindividual to perform self- of clothing, and absence of - Assessed specific cause of each his clothing.
daw siya parati.” As care. The deficit may be the foul odor. deficits such as weakness, visual -Different etiological factors may
verbalized by the effect of temporary problems, and cognitive impairment. require more specific interventions to
mother. limitations, such as those enable self-care.
one might experience while - Identified preferences for food,
O> recovering from surgery, or LTO: personal care items, and other things LTO>Goal Unmet:
-Poor grooming the result of gradual Within 72 hours of nursing such as clothing. -These support patient’s individual Within 72 hours of
observed as shown by deterioration that erodes the interventions, the patient will and personal preferences. nursing interventions, the
dirty and untrimmed individual’s ability or be able to: TX: patient still would not do
nails, unpleasant mouth willingness to perform the -Perform ADLs without being -Provided positive reinforcement for ADLs and follow his
odor, messy hair, and activities required to care reminded by significant all activities attempted bathing routine until his
unpleasant smelling for himself or herself. Also, others or the staffs. -This provides the patient with an mother forces him to.

35
 clothes. patients who are suffering -Maintain a permanent -Planned activities to prevent fatigue external source of positive
-Observed to be wearing from depression may not routine for bathing and other during bathing reinforcement
the same set of clothes have the interest to engage self-care activities such as
for 2 days. in self-care activities. fixing hair and brushing -Energy conservation increases
-Noted scratching scalp teeth. -Used consistent routines and activity tolerance and promotes self-
repeatedly. allowed adequate time for the care
patient to complete tasks
Diagnosis: -This helps the patient organize and
Self-care deficit related carry out self-care skills
to psychological EDX:
dysfunction as -Instructed patient to select bath
time when he is rested and
manifested by poor
unhurried
hygiene and poor -Hurrying may result in accidents and
grooming -Emphasized the importance of the energy required for these activities
taking a bath and changing clothes may be substantial
daily
-Taking a bath and changing clothes
daily are important to keep oneself
-Emphasized the importance of clean, odorless, and less susceptible to
keeping nails trimmed and clean infections.

-Keeping nails trimmed is important

in order for the patient to avoid
inflicting pain to others or self by
scratching, and keeping nails clean are
important to avoid the collection of
dirt under them, which contains
bacteria.

36
NCP 4: Risk for violence: Directed to others r/t altered thought process as evidenced by impatience and angry responses toward others.
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
Violence is defined by the STO> Within 8 hrs. of Nursing DX: Goal fully met if:
O> World Health Organization in Intervention the pt. will be able -Ascertained client’s perception of -May indicate possibility of loss of Patient refrains from being
- Observed irritability and the WRVH as “the intentional to: self/situation. control and intervention at this point can irritated when ideas or
impatience when unable use of physical force or - Divert attention prevent a blow-up. wishes are being refuted.
to answer questions asked power, threatened or actual,
-Periods of sadness against oneself, another -Observed for early cues of -People who grow up in homes where
-Angry response when person, or against a group or distress/increasing anxiety such as violence us accepted tend to grow up to
ideas are refuted community that either results irritability, lack of cooperation, use violence as a means of solving Goal unmet if:
-Observed frequent in or has a high likelihood of demanding behavior, body problems. Patient denies
cracking of knuckles resulting in injury, death, LTO> Within 72 hours of posture/expression. acknowledging realities of
-Observed frequent psychological harm, Nursing Intervention, the pt. the situation, and is unable
pacing back and forth maldevelopment or will be able to: -Assessed client coping behaviors to verbalize understanding
inside the ward. deprivation”. Dopamine and already present. -Facilitates early intervention and assists of why the behavior occurs.
serotonin accumulate in -Acknowledge realities of the client to manage situation independently Also if patient doesn’t
neurons, which have been situation; acknowledge why if possible. demonstrate self-control
NURSING DIAGNOSIS: correlated with extreme behavior TX: with decreased
Risk for violence: aggressive behaviors. -Verbalize understanding of -Helped client express feelings of hyperactivity.
Directed to others r/t why behavior occurs anger -Motivating the client to tell the cause of
altered thought process -Demonstrate self-control with resentment or annoyance helps in
decreased hyperactivity as calming the patient down and knowing
evidenced by relaxed posture the reason for the behavior.
and non-violent behavior.
-Removed any objects that could harm -If the patient is in a state of agitated,
the environment around the patients confused, patients will not use these
objects to harm themselves or others.

37
 -Kept the patient’s environment at low -Anxiety levels will increase in an
stimulus levels such as providing low environment full of stimulus. Existing
lighting, and low noise level. individuals may be perceived as a threat
because of suspicious, and eventually
make the patient agitation.

EDX:

-Provided health education to s/o on -Providing health education to s/o will

understanding the signs and symptoms help in making them aware of what to
of violent behavior/occurrence of observe if the patient starts being violent,
violent behavior. for them to be able to know what to do.

-Explained how to care for patients -Explaining how to care for patients with
with violent behavior to s/o violent behavior is important in order to
promote safety for the client and people
around him.

-Emphasized the importance of -Relaxation techniques help in diverting

relaxation techniques like deep- the patient’s attention, and avoiding the
breathing exercise. chances of being violent.

NCP5: Risk for loneliness r/t decreased exposure to events in the outside world as manifested by frequent complaints of boredom
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation
38
 O> Loneliness is a subjective
-Noted blank stares state that exists whenever a STO: DX: STO:
-Not participating in client says it Within 8 hours of nursing -Assessed mental health status and -To obtain a comprehensive cross- Goal met if patient
diversional activities does and perceives it as interventions, the patient will orientation sectional description of the patient’s enumerates ways on how
noted imposed by others. Social be able to: mental health state to distract self from feeling
-Observed frequently isolation is not the -Enumerate ways on how to lonely such as trying to
complaints about voluntary solitude necessary distract self from feeling communicate with others
boredom for personal renewal, nor is lonely -Assessed verbal and non-verbal -To alleviate emotional state such as or reading pocketbooks.
-Observed slumping it the creative -Decrease frequency of patient communication needs fear and confusion in order to -Goal met if patient
while sitting down aloneness of the artist or the complaining about wanting to overcome the barrier to effective seldomly talks about
-Noted frequently aloneness—and possible go home communication wanting to go home.
sighing suffering— - Assessed the coping mechanisms
-Noted frequently a client may experience from LTO: and methods of dealing with the -Assessing reveals successful
complaining of wanting seeking individualism and Within 72 hours of nursing problems of life previously techniques that can be used in the LTO:
to go home independence interventions, the patient will current situation. Goal unmet if patient
(e.g., moving to a new city, be able to: TX: doesn’t join group
Nursing Diagnosis: going away to college). -Show no experience of -Established therapeutic diversional activities, and
Risk for loneliness r/t isolation and loneliness as relationship and spent time with the doesn’t interact much with
decreased exposure to evidenced by participating in patient. -Being truly present was listed as one other patients as
events in the outside OT activities and interacting behavior that demonstrated caring evidenced by preferring to
world well with other patients -Explored ways to increase the stay in bed instead of
client’s support system and -Satisfaction with support networks mingling.
participation in groups. and personal involvement in groups
demonstrated significantly lower
scores of loneliness

-Determined the presence and level -Indicators of despair and suicide may

of risk for suicidal thoughts. be present. When the signal is
recognized, the clients are usually
willing to express their thoughts and
feeling of alienation and despair.

-Some clients withdraw because of the

EDX: tumultuous feelings of not being heard
-Encouraged contact with family by their family. Contact promote a
and friends. sense of support, concern,
39
 involvement, and understanding.
Supporting a loved one when they
learned of the diagnosis is useful and
can provide long-term optimism.

-It is important to recognize that the

positive relevance of social
relationships is related to the content
-Encouraged the client to be and quality relationship.
involved in meaningful social
relationship that are characteristics
of both giving and receiving

-This would help in making the patient

-Encouraged patient to talk about feel less vulnerable, and would help in
feelings of loneliness and their making future care plans.
causes.

40
 C. Discharged Plan
Health Teaching
Diet/Nutrition 1. Instructed not to use alcohol or illegal drugs because it
interacts with medicine used to treat schizophrenia.
2. Encourage patient to increase fluid intake per day to
maintain hydration and promote proper regulation of
the body process.
3. Emphasized the importance of taking high protein and
carbohydrate diet including foods rich in vitamin C to
promote well balanced diet.
Hygiene 1. Emphasized the importance of proper hygiene like
taking a bath every day and to do proper hand hygiene
and oral hygiene.
2. Instructed patient to always trim hand and toe nails to
prevent bacterial growth.

Activity 1. Advised to get plenty of rest to maintain progress.

2. Encouraged the patient to do exercises of daily living
as long as he is capable.

Medication 1. Advised to take medications in a prescribed dose.

Make sure to continue drug intake in the prescribed
length of time. Inform healthcare provider or
psychiatrist if in doubt or questions about the
medications.
2. Instructed and encouraged significant others to
monitor patient’s ability to take medications strictly
following right dose and route.
3. Emphasized importance of compliance to treatment
regimen.
4. Instructed on dose, frequency and time of
administration of medication.

Other Follow up care:

1. Advised the patient to return for follow up check up
on the stipulated date at the outpatient department.
2. Encouraged patient to attend counseling sessions and
don’t just stop attending.
3. Instructed to come back to the same institution for
follow up checkup as ordered.

XVI. Learning Insights

A. ARIOLA, Jenny
I have learned all about unspecified schizophrenia, something new to me. I have also
realized the importance of time management in making this case.
B. ARORA, Sachi

41
 This is a very interesting case. This is also my first time handling a psychiatric case. I
have realized the importance of teamwork and cooperation in making this case.
C. BERNABE, Abriel
I believe that everything can be done easily if everyone would contribute in making
the case.
D. CAJIGAN, Ryan
Psych ward is my favorite. It’s nice handling a psychiatric case. It was stressful
making this case, but worth it.
E. NGAYOS, Shyrlyn
I have learned many things about this case, and it makes me want to study more
about it. That’s how interesting it is.
F. PILUDEN, Raquel
I was able to handle this case firsthandedly, and I’m glad I’m able to justify what I
have done to help him.
G. RAHHAL, Majid
I have learnt how a small contribution could make a lot of difference in finishing a
case.
H. SALTAT, Katryn
I have learnt new things I’ve never known before. I also realized how important
groupwork is in achieving this case.
I. SAWI, BRAILLE
I’m glad to be part of this case study. I’ve learned a lot, and would like to know more
about it hopefully in the near future.

XVII. List of References

Biederman J, Petty C, Faraone SV, et al. Moderating effects of major depression on patterns of
comorbidity in patients with panic disorder. Psychiatry Research. 2004;126:143–149. [PubMed]

Blake DD, Weathers FW, Nagy LM, et al. The development of a clinician-administered PTSD
scale. Journal of Traumatic Stress. 1995;8:75–90. [PubMed]

Boyd, M.A. (2018). Psychiatric Nursing: Contemporary Practice. (6th ed.). Philadelphia: Wolters
Kluwer.

Cougle JR, Keough ME, Riccardi CJ, et al. Anxiety disorders and suicidality in the National
Comorbidity Survey-replication. Journal of Psychiatric Research. 2009;43:825–829. [PubMed]

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Craven MA, Bland R. Better practices in collaborative mental health care: an analysis of the evidence
base. The Canadian Journal of Psychiatry. 2006;51(Suppl. 1):7S–72S. [PubMed]

Creamer M, Burgess P, McFarlane AC. Post-traumatic stress disorder: findings from the Australian
National Survey of Mental Health and Well-being. Psychological Medicine. 2001;31:1237–
1247. [PubMed]

CSIP Choice and Access Team. Improving Access to Psychological Therapies: Positive Practice
Guide. London: Department of Health; 2007.

Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based Practice. (7th
ed.). Philadelphia: F.A. Davis Co.

Giger, J.N. (2017). Transcultural Nursing: Assessment & Intervention. (7th ed.). Missouri: Elsevier.

NICE. Alcohol-use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and

Alcohol Dependence. 2011. NICE Clinical Guideline 115. Available at: www.nice.org.uk/CG115.
[NICE guideline] [PubMed]

NICE. Depression in Adults with a Chronic Physical Health Problem: Treatment and

Management. 2009. NICE Clinical Guideline 91. Available at: www.nice.org.uk/CG91 [NICE
guideline] [PubMed]

NICE. Generalised Anxiety Disorder and Panic Disorder (With or Without Agoraphobia) in Adults:
Management in Primary, Secondary and Community Care. 2011. NICE Clinical Guideline 113.
Available at: www.nice.org.uk/CG113 [NICE guideline]

NICE. The Guidelines Manual. London: NICE; 2009.

NICE. Medicines Adherence: Involving Patients in Decisions about Prescribed Medicines and

Supporting Adherence. 2009. NICE Clinical Guideline 76. Available at: www.nice.org.uk/CG76.
[PubMed]

Townsend, M.C. & Morgan, K.I. (2017).

Townsend, M.C. (2015). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based

Practice. (8th ed.). Philadelphia: F.A. Davis Co.

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XVIII. Appendices

44
B. Appendix A
Approval/Request Letter

45
C. Appendix B
Interview Guides

46
D. Appendix C
Others (just specify)

47