Republic of The Philippines

Tarlac State University

College of Science
Department of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City
___________________________________________________________________________

PSYCHIATRIC CLINICAL CASE ANALYSIS

(NCM 117 LABORATORY)

Submitted by:

Bergonio, Angel Marie

Hatiya, Rhoda S.
Melendez, Aleckza Jade S.
Santos, John Radley S.

BSN 4-2 (Group 5)

Submitted to:
Princess Liahona G. Pascua RN, MSN

Clinical Instructor
CASE SCENARIO

Hello! Here is your group case scenario. A young man a few months short of
his 18th birthday is presented to his general practitioner (GP) in a state of
agitation. Although his parents are worried about him, he does not really
think there is a problem. He is hearing voices and these cause him some
anxiety. The voices sometimes give a running commentary of what is
happening. He denies any substance misuse. He attended Child and
Adolescent Mental Health Services (CAMHS) about 12 months ago when he
had lost interest in his previous activities and had become increasingly
withdrawn although no low mood was reported. He was lost to follow-up
when his family sent him to live with some relatives in the hope that a new
environment might improve the situation. He has recently returned home but
the situation is worsening rather than improving.
 TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

PSYCHIATRIC CLINICAL CASE ANALYSIS

Name of Patient Patient X Age: 17 Gender: M

Address Date Admitted 10-26-2021
Diagnosis Undifferentiated Schizophrenia

NURSING HISTORY

Past: About a year ago, patient was said to have loss interest in his usual activities that he does
and had low mood at the same time became withdrawn. Aside from that he had no known use
of any medication nor has been injured and has not been hospitalized from any injury. Also,
patient has no known allergic reaction to any medications.

Present: The patient states he’s been hearing voices which has caused him to have anxiety. He
is currently in a not so good situation, as to his condition– he is becoming worse rather than
improving.
MENTAL STATUS EXAMINATION (Separate page)

PSYCHOPATHOLOGY (Book –based and Patient-based)

DRUG STUDY (1 drug study per group. Please coordinate with other groups so as not to
repeat the medications used)

NURSING AND MEDICAL MANAGEMENT (including 1 NCP)

Name of Student
Bergonio, Angel Marie
 Hatiya, Rhoda S.
Melendez, Aleckza Jade S.
Santos, John Radley S.

BSN 4-2 (Group 5)

Date Submitted 10-26-2021 C.I.’s Signature

 Mental Status Examination No. 1

Date: October 26, 2021 Day: __________

Note: Put a check mark in the appropriate box of significant observed descriptor/s.

1. General Description
1.1. Appearance
Descriptors Yes No Remarks
Congruent apparent age      
Appropriate dressing    
Clean / Hygienic    
Good posture    
Good gait      
Appropriate facial expression    
With eye contact    
With pupil dilatation      
With pupil constriction      
Normal state of health & nutrition      
1.2. Speech
Descriptors Yes No Remarks
Rapid speech      
Slow speech      
Loud volume    
Soft volume      
  Patient cannot
express himself
Minimal speech   easily
Pressured speech    
Stuttering      
Slurring of words      
Unusual accents      
1.3. Motor Activity
Descriptors Yes No Remarks
Lethargic      
   Appears
Tensed   nervous/anxious.
Restless      
Agitated     Patient seems
worried about
something and
doesn’t feel right
 about it.
With observed tics      
Grimaces      
Tremors    
Compulsive    

1.4. Interaction During Interview

Descriptors Yes No Remarks
Hostile      
Uncooperative      
Irritable      
Guarded      
 
Apathetic    
Defensive    
Suspicious      
Seductive      

2. Emotional State
2.1. Mood
Descriptors Yes No Remarks
Sad      
Fearful    
Hopeless    
Euphoric      
Anxious  
Patient is anxious
by the voices he
  has been hearing
Happy      

2.2. Affect
Descriptors Yes No Remarks
Congruent / Appropriate      
Flat      
Labile      

3. Experiences
3.1. Perceptions
Descriptors Yes No Remarks
Hallucinations: Auditory     Patient has been
bothered by the
voices he is
hearing that are
 giving commentary
of what is
happening
Visual      
Tactile      
Gustatory      
Olfactory      
Illusions      

4. Thinking
4.1. Thought content
Descriptors Yes No Remarks
Delusion: Religious      
Somatic      
Grandiose      
Paranoid      
Thought broadcasting      
Thought insertion      
Depersonalization      
Hypochondriasis      
Ideas of reference      
Magical thinking      
Nihilistic ideas      
Obsession      
Phobia    
4.2. Thought process
Descriptors Yes No Remarks
Circumstantial      
Flight of ideas      
Loose associations      
Neologisms      
Perseveration      
Tangential      
Thought blocking      
Word salad      

5. Sensorium and Cognition

5.1. Level of consciousness
Descriptors Yes No Remarks
Confused      
Sedated      
Stuporous      
Oriented to: Time      
Place      
 Person      
5.2. Memory
Descriptors Yes No Remarks
Intact remote memory      
Intact recent memory      
Intact immediate memory      

5.3. Level of concentration and calculation

Descriptors Yes No Remarks
  Was bothered by
the voices he is
Easily distracted   hearing
With difficulty in simple math      
5.4. Information and Intelligence
Descriptors Yes No Remarks
With learning disability      
With learning difficulty      
Able to interpret simple proverb      
5.5. Judgment
Descriptors Yes No Remarks
Appropriate judgment      
  Patient was not
able to continue on
his follow up
check-ups after he
moved to a new
With good relationship to others   environment
5.6. Insight
Descriptors Yes No Remarks
Accepts presence of problem    
Blames the problem on others      

Descriptive Analysis

According to the mental status examination result of Patient X, his appearance

is normal. He happens to have minimal speech as he was not table to express
himself that much. He appeared tensed at the same time agitated– it was
mentioned earlier that he was hearing voices or is having an auditory
hallucination that is why he gets distracted easily. It was also stated that he
was not able to continue his follow ups after he moved to a new environment
and this is being interpreted as not having good relationship with others – as to
his case becoming more worse than improving. Moreover, all other findings in
the assessment were in normal condition.
 DRUG STUDY

NAME OF ROUTE & INDICATION MECHANISM OF CONTRAINDICATIO SIDE EFFECTS NURSING

DRUG DOSAGE ACTION N RESPONSIBILITY
Generic Priority: Monitor
name: 5– 10 Schizophrenia. Acute Antagonizes - Contraindicated  NEUROLEPTI closely for notable
Olanzapine mg/day therapy of manic or dopamine and in: C changes in behavior
initially mixed episodes serotonin type 2 Hypersensitivity; MALIGNANT that could indicate
associated with in the CNS. Also Lactation: SYNDROME, the emergence or
Brand name: IM bipolar I disorder (as has Discontinue drug  SEIZURES, worsening of
Zyprexa monotherapy [adults anticholinergic, or bottle feed;  SUICIDAL suicidal thoughts or
and adolescents] or antihistaminic, Phenylketonuria THOUGHTS, behavior or
with lithium or and anti– alpha1- (orally  agitation depression.
Drug class: valproate [adults adrenergic disintegrating  delirium - Monitor BP
Antipsychoti only]). Maintenance effects. tablets contain  dizziness (sitting,
c therapy of bipolar I aspartame). standing,
 headache
disorder. Acute Therapeutic lying), ECG,
 restlessness
agitation due to Effects: pulse, and
schizophrenia or Decreased  sedation respiratory
bipolar I mania (IM). manifestations of  weakness rate before
Depressive episodes psychoses.  dystonia and
associated with  insomnia frequently
bipolar I disorder  mood changes during dose
(when used with  personality adjustment.
fluoxetine). disorder - Observe
Treatment-resistant  speech patient
depression (when impairment carefully
used with fluoxetine). tardive dyskinesia when
administering
medication to
ensure that
medication is
taken and not
 hoarded or
cheeked.
Monitor CBC
frequently during
initial mo of therapy
in patients with pre-
existing or history of
low WBC. May
cause leukopenia,
neutropenia, or
agranulocytosis.
Discontinue therapy
if this occurs.

NURSING AND MEDICAL MANAGEMENT

Cognitive-Behavior Therapy CBT places an emphasis on helping individuals

learn to be their own therapists. Through exercises
in the session as well as “homework” exercises
outside of sessions, patients/clients are helped to
develop coping skills, whereby they can learn to
change their own thinking, problematic emotions,
and behavior.
Antipsychotics drugs Antipsychotic medications work by altering brain
chemistry to help reduce psychotic symptoms like
hallucinations, delusions and disordered thinking.
They can also help prevent those symptoms from
returning.
 PSYCHIATRIC NURSING CARE PLAN

Date: October 26, 2021

Psychodynamics & Nursing

Assessment Goal and Objectives Rationale
Theory Interventions
Subjective: Freud originally held After 1 week of nursing Independent:
“I just want to be that the narcissism of interventions, the patient - Establish a - Trust and rapport are
alone” as verbalized schizophrenic patients abled to Therapeutic important with the
by the patient. prevented them from - use appropriate Relationship patient relationship,
being able usefully to skills to initiate and with the it will help build a
Objective: relate to the analyst maintain an Patient therapeutic nurse-
- Hallucination and so develop the interaction. client relationship
- Shows no therapeutic
interest relationship of - Maintain a - To keep patient safe.
transference with him Safe
Nursing Diagnosis: or her. For this reason, Environment
- Impaired Freud believed that
Social schizophrenic patients - Let the patient - To set behavioral
Interaction could not be treated know what limits
related to with psychoanalysis. behaviors are
Impaired acceptable, and
thought which are not
processes.
- Assist the - To reduce anxiety
patient to
explore
breathing and
relaxation
techniques

- To assist patients to
 - Encourage the work through their
Patient to Use perceptions,
a Journal responses, and
emotions

- This assists patients

- Encourage to cope with their
client to emotions and limit
discuss his or behaviors that result
her feelings in ineffective
coping.
- Involve client - By practicing these
in role playing new behaviors, it
new ways to enables the patient to
deal with become free and
identified comfortable with
behaviors or them in a safe
situations. situation or
environment.

- Encourage the - to help the patient in

patient’s overcoming the
engagement in sense of isolation in
physical and impaired social
social interaction with
activities. individuals of
various age groups
Dependent:
- Administer - To prevent anxiety
anti-
depressants or
anti-anxiety as
needed.
Collaborative:
- Encourage the - To build rapport and
patient to form therapeutic
participate in relationships
the goal. They
should be
allowed to
make choices
and maintain
independency,
as long as it is
within the
limits set