Republic of the Philippines CAVITE STATE UNIVERSITY (CvSU) Don Severino de las Alas Campus Indang, Cavite Philippines

COLLEGE OF NURSING In partial fulfilment Of the requirements in NURS 75 (Curative and Rehabilitative Management II)

Presented by: Basa, Leah Cimini, Gio Dimapilis, Joan Dizon, Ria Emelo, Carolline Go, Manuel Jr. Libre, Catherine Ramos, Katrina Rivera, Hadzlyn Rodriguez, Christine Mae Trias, Czarina Vidal, Mariano Jr Group 3 Presented to: Level IV Clinical Instructors

I. Introduction

Human brain is a fascinating control center of human and the human life. It performs so many tasks and functions that enables one to talk, think and respond to internal and external stimuli. The mechanism of its functions has been clearly identified and traced long before. Due to its powerful effect to the human body, any interruptions to its normal activity results to disorders. If happens, the victim becomes unable to express self appropriately, has wrong perceptions of the reality and holds delusional belief; a condition known to be SCHIZOPHRENIA. Schizophrenia, like some other indistinct diseases attacks man in a very soundless, sometimes unknown approach. One cannot say that he/she will be free from the disease on a lifetime. There are so many testimonies from different victims of the disorder throughout the globe. Young, old, men, women, working and non-working are victims. All of them have so many differences, but after the attack of the disease, each one of them is almost alike from one another. They possessed similar signs and symptoms that vary from mild to severe. All of them also wish for something unknown that will help them go back to reality soon enough to escape from the darkness. Schizophrenia affects approximately one percent of the world's population, and onset is most often between 15 and 30 years of age-when society has a maximal investment in a person's development. Therefore, schizophrenia represents a serious problem not only in terms of direct costs and lost productivity but also in terms of lost human potential. Further, patients with schizophrenia utilize a disproportionate share of medical resources. Patients with schizophrenia may constitute as much as 10 percent of the totally and permanently

disabled and a large fraction of the homeless population. For the general physician, the medical care of schizophrenic patients presents a substantial challenge because schizophrenic patients often are unable to supply an accurate medical history and often have difficulty complying with medical treatment for such reasons as homelessness and lack of financial support. Because of suicide and poor access to medical treatment, the mortality of schizophrenic patients is double that of the general population ( The group, not being able to choose which specific mental disorder to present is very enthusiastic and positive that this manuscript together with the simple and actual presentation will shake and awaken variety of one’s emotions. Negative and positive symptoms of the disease that speak how much sufferings the victims of the disease have to endure will be discussed in detailed as well as the different therapeutic ways that student nurses could performed altruistically in order to bring changes and modify behavior of a psychiatric patient thereby facilitating the rehabilitation process.

II. Nursing Assessment

A. Demographic Data

Name of the Patient: Age: Gender: Address: Civil Status: Nationality: Religion: Birthday: Date Admitted: Admitting Diagnosis:
B. Source and Reliability of Information

C.P. 36 years old Male Bagong Pook Ligtong I Rosario Cavite Single Filipino Roman Catholic June 19, 1975 May 2, 2007 Schizophrenia, Undifferentiated t/c Mental Retardation

The primary source of information was the client himself. These and other pertinent data were obtained during our exposure in Cavite Center for Mental Health (CCMH) dated July 23-24, 29-31, and August 5-7 through one-on-one interview and interaction of the client and his student nurse. The group, through the supervision of their clinical instructors and with the CCMH’s staff on duty utilized the client’s chart (secondary

source of data) to validate different findings as well as to gather some necessary information which he cannot directly provide. C. Reasons for Seeking Care The client was brought by his Uncle in Cavite Center for mental health last June 2, 2007 due to frequent episodes of delusions; “I am a 6 year old,” and the client demonstrated inability to recognize the name and how he is related to other members of the family. D. History of Present Illness The client has been admitted five times already in Cavite Center for Mental Health. However, it was not written in the client’s chart what is the reason behind his frequent admission and how old was he during the first admission. It was written in the client’s chart that he has history of smoking cigarettes, drinking liquor, and using prohibited drugs such as “shabu” and marijuana. When he was admitted last June 2, 2007 in CCMH, he denied of having mental illness and claimed that he was normal. Due to his condition, he was put under suicide and escape precautions by the staffs of the institution. At present, the client is taking different medications as follow: Depakote 500mg, OD (once a day); Clozapine 100g, Risperdal oral solution 1cc, BID (twice a day), and Levomepromazine 100mg HS (Hour of sleep-8pm or 9pm).

E. General State of Health The client was diagnosed of having Schizophrenia, Undifferentiated Type with Mental Retardation according to his available chart as well as how we were advised by the staff of the rehabilitation ward. He is being given different medications or drugs as mentioned to manage the disorder. However, different disturbances were still noticeable at him including disturbances in psychomotor, affect, cognition and judgment. (Note: different disturbances showed by the client will be explained further and in detail in the Mental Status Examination). The client has a medium-built body and has a fair brown to white skin complexion. There were some wounds present on the client’s skin and buttocks that resulted from his frequent scratching due to scabies. According to him, he has the skin disease two weeks prior to our interaction with him. The group noticed that when wounds in a certain area dried up, new wounds appear close to the area of previous infestation.

Erickson’s Psychosocial Theory of Development The developmental crisis of an individual under this stage is achieving a sense of Intimacy versus Isolation (Young Adult). Furthermore. he/she will be able to possess or demonstrate abstract thinking instead of purely concrete reasoning and responses as well as deductive and inductive reasoning. Jean Piaget’s Cognitive Theory Cognition at this stage falls under The Formal Operational Stage. rules and other universal principles are being followed not just because these are righteous but because of avoiding other people of the society become deprived of what is due to their possession. responsibilities and falls on greater chances of being isolated and avoidant. not only with members of the opposite sex but also with one’s own sex forming long-lasting friendships. Normally. Intimacy is the ability to relate well with other people. When an individual successfully reached this stage.F. C. Developmental History Normal Developmental Stage According to the Client’s Age (36) A. an individual is capable of internalizing actions that are righteous even no one is watching him/her. which is said to be the final form of mental and cognitive maturity. Since an individual needs a strong sense of identity before he/she is able to offer or accept long-lasting friendships. this task grows out earlier in the stage of development. Kohlberg’s Moral Development Post conventional stage or often called as mature form of moral reasoning is the moral developmental stage of the client. Person without a sense of intimacy may have more difficulty accepting frustrations. Analysis of the client’s particular stages and development . B.

B. the client chose to be single. he sometimes disobeys rules inside the ward especially when he feels like he’s not going to benefit from it. and kissing and holding hands of other client while outside the rehabilitation ward. Rejection from friends and to the opposite sex is very painful leading to minimal social contact to total isolation. prejudices against others and relationship during casual interactions as evidenced by frequent verbalization “Wala naming magkakagusto sakin na babae”. according to Erickson resulted when an individual failed to develop trust during infancy or unable to develop a strong sense of identity during the earlier stage of psychosocial development. This shows that the major concern of the client is not to do what is right and what is also good for others.A. This according to Piaget is devastating to an individual because problems will appear very difficult most of the time primarily because of inability to trace and identify causations. he asks cigarette from the other client inside the ward and smokes even if it is not allowed. unable to process successful recall of the past and failure to relate event of the past to the present condition. According to Kohlberg. This. Erickson’s Psychosocial Theory of Development Isolation was developed into the client. He showed negativistic view of self (mutism). this is a sign of a developed nature of self before others which is an end product of unsuccessful triumph against the previous stage: Preconventional. the client demonstrated different cognitive disturbances such as poor reasoning. Because of this kind of view of self. . Jean Piaget’s Cognitive Theory During the student nurse-client interaction. Kohlberg’s Moral Development According to the client. C. Cognitive maturity was not achieved by the client.

some are with pus in it.  The characteristics of the client’s wound signify the infestations of parasitic burrowing . CR= 91bpm BP=110/70mmHg B.4˚C verbalized by the client during our RR= 16cpm interaction. Integument  Fair skin complexion  Skin has of scars from previous wound  Lean body built  Poor eye contact  Slurred Speech and response was good  Oriented to time and place  Client was cooperative during activities “Laging kinakamot. Review of System and Physical Examination Date Performed: July 24.G. 2010 SYSTEM ROS includes PHYSICAL ASSESSMENT history of complaints ROS Findings Significance SYSTEM A. Upon inspection: makati eh”  White complexion which is the same with other body parts  Skin is dry  Scattered wounds on the extremities and buttocks: Erythematous plaques with raised borders. General Health Status Ayos lang sir.” as Temp= 36.  Skin that is dry could be a sign of poor nutrition.

Upon Palpation:  Skin is warm to touch. Trust and rapport must be established first to allay anxiety and for . “linaw sir.  Able to read printed materials slowly but only at specified distance ( not beyond 7 inches apart)  Suborbital hematoma about the size of a Philippine 25centavo coin on the right eye is noted. extremities  Severe itching  Finger nails are not trimmed.  He is bald  The scalp was dry with scars from the previous wounds Upon Palpation:  Head is free from masses or palpable lumps. Head “wala ng buhok. without any abnormal discharges and discoloration noted from the eyes. Presence of scars in the of mites (sarcoptes scabei) that cause lower left eyebrow  Abrasions in both scabies. Upon Inspection: makati rin”  Demonstrates facial symmetry and symmetrical facial movement. C. ayos” Upon inspection:  With poor eye contact  Eyebrows and eyelashes were equally distributed  Eyelids are symmetrical as when open and close. D. Eyes  Has poor eye contact that could be an indication of the client’s inability or failure to develop trust with the student nurses (Peplau’s Interpersonal Process of Communicationclient and nurse are both strangers to each other.  Capillary refill of less than 3 secs.

 Ears recoil and flexible Upon inspection:  Symmetrical and uniform in color  Nasal openings were of equal size  Patent airway and sinuses  Free from nasal discharges the nurse to foster necessary changes.)  Has diminished visual range.  Non-tender palpable mass must be monitored. Nose Sinuses and “Ayos pang-amoy” Upon inspection:  Color of the ears is the same of the facial skin but are positioned a little bit lower when compared to outer canthus of the eyes.  Able to hear sounds in both ears clearly. (It’s one of the many signs and symptoms of Cancer formationCAUTION US).E. Note: the client’s hematoma resulted when he hit the edge of the door of the rest room inside the ward.  The position of the ears as compared to the eyes outer canthus is one of the many manifestations of a congenital defect (Down syndrome).” F. Upon palpation:  He has round. non-tender palpable mass below the left ear. about the size of a M and M chocolate which is differentiated from the left subclavian nodes. . Ears “nakakarinig pareho sir.  Causal factors of hematoma must be identified to intervene properly thus eliminating visual complication in particular.

missing lower incisors as early as 30 years old and tooth decay could be the result of poor oral hygiene. Breast and Axillary  Body odor that is distinct from the breath and the food eaten is a sign of poor or unattended hygiene. I. Upon palpation:  Free from neck tenderness and palpable masses. J.  Axillaries’ hairs are present. “busog sir.  Tonsils are pinkish and not inflamed.  Yellowish teeth and absent lower incisors  decayed upper incisors  Uvula positioned at the midline.  The color of the teeth.  He has non-palpable neck nodes.” as Upon inspection: verbalized by the  With some scratches patient. Neck and inflammation. Upon Inspection:  With the same color with the body  Symmetrical chest and chest movement when breathing. Upon inspection:  Lips are moist.G.  Have body odor.  Able to determine smells of the different foods served appropriately. Upon inspection:  Trachea is located at the midline  Free from stiffness  Shows adequate and smooth neck movement and motion. and scars from healed wounds at the supraumbilical area.  Pinkish nasal mucosal wall. Mouth and Throat H. Abdomen .

K. Upon Palpation:  Free from palpable subcutaneous emphysema Upon percussion:  Resonant sound is produced. Upon Auscultation:  6x/min bowel sounds heard over the lower epigastric area.  Symmetrical and synchronized chest retraction and expansion.  Free from palpable pulsations.  Bronchovesicular sounds heard between  . Upon Auscultation:  Vesicular sounds heard over the lower lobes of both lungs. “Hindi naman ako Upon Inspection: hirap huminga. Respiratory Color is the same with that of the skin. Upon Percussion:  All quadrants of the abdomen have tympanic sounds. Upon Palpation:  Free from tenderness and abdominal rigidity.  Free from wheezes or stridor.  Symmetrical and free from bulges. free from obstructions.” As  RR=16cpm verbalized by the  Airway is patent and patient.

regular  Skin is warm-to-touch.kulang Upon Inspection: Musculoskeletal tulog” as verbalized  Demonstrate poor by the client.  Fine to coarse tremors of the hands and feet more evident at the left . “pagod sir. Upon Inspection:  Free from jugular vein distension. Urinary “umiihi umiinom” painless not physically assessed. posterior tibialis and dorsalis pedis arteries. musculoskeletal coordination.the scapula and lateral sterna border. Upon auscultation:  S1 (lub) and S2 (dab) sounds are heard over the Point of Maximum Impulse (PMI). (not examined) tremors and some other psychomotor disturbances are some of the many side effects of psychotics and other  Coarse O. Upon Percussion:  Dullness is heard when percussed at the midclavicular line. temporal. Cardiovascular No subjective cues. L. Reproductive No verbal cues  Genitalia M.  Palpable radial. kapag Upon inspection:  Voids yellowish urine of approximately 80cc after the therapy.  Bp=110/70 mmHg Upon Palpation:  PR = 91 bpm.  Verbalizes urination. N.

these areas client is walking and sitting. Schizophrenia place and person. appropriately. of the brain together with the neurological imbalances are damaged. walk slowly. tremors stimuli. The client can and interpretation also show purposeful control of of the different the extremities and body sensations and movements. . but has difficulty running and jumping. Is conscious primarily affects and can able to respond the frontal. For of the left hand and feet are schizophrenic visible particularly when the client.Brief Neurologic Examination “Christopher pangalan ko” “Taga-cavsu kayo” “Si Mam Eder ung babae at Sir Rolly ung lalake na nurse” “Soscialization lagi sa huling araw” extremities. heat and cold as movement and well as the different smells and control.  Demonstrates kyphotic posture. These all result to different positive and negative symptoms of the disease that are most of the time tremendous and life-threatening to its victim. The client is oriented to time. However. speech and tastes of the food served language. memory. drugs prescribed to  Weak appearance of manage schizophrenia. He has a slurring of hippocampus speech and demonstrates region of the brain echolalia but not all the time. musculoskeletal. that are respectively He can perceive and process responsible for fine different stimuli and sensations and gross muscle such as pain. although delayed for temporal and sometimes.  Is Able to stand. sit.

The patient repeatedly holds his head with two hands then looks upward and downward particularly when not doing anything. It takes a while for him to walk from the chair going close to the board when asked to read. General Appearance and motor behavior T U R B A N C E The patient speaks in a slow manner with slurring and shows disorganization of thoughts/topics and ideas sometimes. The patient refused to talk about making his own family because according to him. e.The patient was telling . He has fine to course tremors of the extremities more evident at the left extremities especially when walking and sitting on a chair. weak. Automatisms. B. He always give five and wave his hand whenever he sees familiar persons or faces. there will be no woman fit for her. wears appropriate dress which is the yellow clothes. stands in kyphotic posture. D I S A.. Flight of ideas.The patient has a consistent overall slowed movement. to student nurses. Mental Status Examination The patient takes a bath every day.This is the extreme form of negativism.H.g. with poor eye contact. Communication Mutism. Psychomotor Retardation.

C. E.The patient takes a few seconds before answering some questions for about 35-45 seconds and sometimes the question should be asked twice so that he can understand what you are trying to say. Blocking.There were times in our conversations that the patients abruptly stop talking or sharing his thoughts. Looseness of associations.g. He was telling that it was his car then suddenly he heard the sound of helicopter passing the area and he said that Robin Padilla was inside the helicopter.The patient has difficulty in speaking. Latency of response. This made other client told “Traffic!” Echolalia.the client suddenly talks about Ligtong Highschool when talking about the jeepney and helicopter..D I S T U R B A N C E something about the car seen in front of us. He . Perception. He talked in depth and the words are not pronounced the way it should be and incomprehensible sometimes. Thought The way of thinking was far from his age. Student nurse: “Exercise po tayo” Perea: “Exercise po tayo Student nurse: “Tayo na po tayo” Perea: “Tayo na po tayo” Slurred of Speech.He will be saying exactly the same answer of other client on certain topic.

He believes that they have mazda3. he remained serious and was not even smiling. trees. . He believes that he is already 40 years old wherein he is only 36 year old upon verification to his chart. He thinks and talks about simple things like car. He was unpredictable. He insisted that Ligtong high school is located in Tagaytay City. clouds. mountains. etc. It shows that he was not interested on whatever’s happening in the environment but claimed that he’s enjoying it and was happy.the patient most of the time had flat affect. From being serious to funny then serious again. Preoccupations. Blunted affect. house.This means that a person displaying one type of expression. Even though he was telling that he was happy. sun.The false belief that cannot be corrected by logic. D. The patient always in serious expressing his thoughts and emotions. Labile mood. the patient kept saying he wanted to go home because he missed every member of his family.this means that recurrent thought or center of particular idea or thought with an intense emotional component..The patient rapidly changes moods. Mood and Affect D I S T U Restricted affect. In every interaction. Upon admission he was claiming that he was a 6 years old boy. Delusions. Mood and the affect are unpredictable.Process and content D I S T U R B A N C E thinks concretely with inability to demonstrate abstract thinking and reasoning. rains.

Sensorium and intellectual Process D I S T U R B A N C E . Memory impairment. Alterations in orientation.R B A N C E Apathy. The patient was orientated to time. Intellectual functioning. Attention was poor because of the different factors including the environmental factor. He was asked about the things they have done for that day and he replied.the person cannot identify the woman who visited him a few months ago if that was his mother or his auntie. The abstract thinking ability was poor and almost absent.Majority of our planned activities was full of fun. He’s concentration and focus can be easily distracted by nuisance and other stimuli. We don’t initiated drawing that day. Some person’s outside the institutions like his friends before are unrecognizable. The patient seemed to have lack of interest in the activities especially when we had the recreational therapy that includes different plays. “nagdrawing po”.This means the inability to use abstract thinking and utilizing concrete thinkingliteral E. He’s short term and long term memories are impaired. He only joined once and he easily gets tired. Disturbances in retention and attentionRetention have something to do with the memory of the patient on how he remembers things well that happen in the past. place and person that he’s having a regular interaction.The patient was asked in the ward after having an activity. knowledge and most importantly they were therapeutic.

G.The patient was not able to identify strengths and weaknesses that may affect the response of treatment. Insight is the ability to understand the true nature of one’s situation and accept some personal responsibility for that situation. Judgment refers to the ability to interpret one’s environment and situation correctly and to adapt one’s decisions and behaviors accordingly. The patient displayed bizarre behaviors such as not wearing shorts sometimes when inside the ward. . D I S T F. Judgment and Insight U R B A N C E The patient sense himself as a bad and useless person. kissing other client and masturbating.translations/interpretation. Superficial reasoning is manifested by the client. He didn’t have understanding of his disease and it’s management. Self-concept The patient has weak ego and sometimes hopeless about achieving his dreams in life because for him. Poor insight. it will take more time before he finally go home. no causations and cause and effect being used about the topic. The house is just a house and the sun is a sun.

Roles and Relationships The patient did not participate in our activities for two days and stayed inside the ward instead. . Sometimes he wanted to go back in the ward even the activity was not yet done and claiming that he’s having a headache. H.The patient has difficulty in maintaining relationship.

There was an obvious sadness in his face. He displayed poor eye contact and most of the time answered questions in short statements. The client has history of substance abuse such as smoking cigarettes. He seemed not to be in good condition. alcoholic beverages and marijuana.I. He is under the rehabilitative phase of treatment in the ward and verbalized willingness to be discharged soon enough to visit and be with his family. Functional Assessment Health Perception The patient was asked about his present condition and he answered. Nutritional and Metabolic Pattern . “Ayos lang po sir”.

He said it is usually well formed and with foul odor. Activity-exercise pattern The different exercises that are initiated by the group are considered to be his form of exercise. Elimination Pattern The client has no difficulty voiding and defecating every day. Due to fear and to avoid food-drug interaction.The client’s daily food intake is regulated by the staff of the rehabilitation ward. He had fine to course tremors of the extremities that contribute to movement difficulties. chocolates and other ingredients that might bring adverse effect. It was noted that the client had difficulty performing the portrayed steps of exercises done by the students but he was trying his best to follow and participate. Voiding according to him usually follows after drinking water or juice or approximately 40-50cc per hour. He too has no reported signs of food and drug allergies. foods to be served to him and to other clients need to free from cheese. He eats what the rest of the clients inside the ward eat. Defecation of the client takes place one to two times per day. Sleep-Rest Pattern . He said he’s not choosing food to eat and verbalized that the food that we served were all good and delicious. It is already a regular session to start the activity for the day. He’s upper central incisors are decayed while the lower incisors were missing already.

Usual sleeping hours of the client ranges from 6-8 hours every night. He didn’t answer when asked about his family and other relatives.Relationship Pattern The client usually isolates himself from other client inside the ward. He also added that he can never have his own family because no woman would have the courage to love someone like him. Coping and Stress Management Pattern The client watches television and sleeps when feeling tired or feeling alone and sad. He often shared about going home again but said that it is a dream. At day time. According to him.The patient had no sleeping difficulty. he’s get used to sleeping at day time. The patient had never been discharged since his admission last 2007. He only talks when somebody initiated the conversation first but with problems maintaining good and long interaction. He wakes up 4am every morning to comply with the institutional policy. if he is not doing anything or no student nurses to attend them and bring them outside. Role. Personal Habits . he takes some naps or watches television which is located at the wall of the ward lobby. Self esteem The patient showed low self-esteem. He greeted those persons that are familiar to him by waving his hands.

Environmental hazards The client is staying inside the rehabilitation ward together with other clients. He takes a bath. Problem Date identified Date Resolved . eats regular meals and participates in some activities outside when asked to do so such as sweeping dry leaves with the supervision of the staff on duty. brushes his teeth. Students and visitors are also being informed and advised about things that might threaten their safety. Sharps and other hazardous objects and materials are not being kept and allowed inside the ward. The rehabilitation ward is still spacious and good to accommodate the number of clients they cater at that time. Problem List Problem No.He said that he is just following the routine activities in the area starting from the morning until the time of sleeping. The ward has wide windows and doors that allow direct visualization and monitoring of the clients inside by the nurse on duty. III.

Actual Active /Problems Risk or Potential Problem .

Observed for behavioral responses like hallucination.DISTURBED SENSORY PERCEPTION. Auditory related to biochemical imbalances specifically increased dopamine levels Background Knowledge Patients with disturbed sensory perception experiences changes in the amount or patterning of incoming stimuli accompanied by a diminished. . withdrawal.” as verbalized by the patient. GOAL MET Patient was freed from injury and was kept safe. confusion/ disorientation. the patient will regain normal level of cognition and maintain reality orientation. To assess degree of sensory impairment. inappropriate affect. AUDITORY Cues/Data Nursing Diagnosis Disturbed sensory perception. Goal Short Term After two hours of nursing intervention. He was able to recognize presence of sensory impairment. Established rapport. Reoriented the patient to Objective:  Poor concentration  Altered communication pattern (confabulations)  Hallucinations  Labile mood - - Probing may increase suspicion and interferes with good nursepatient relationship. delusions. To build trust and facilitate expression of thoughts and feelings. distorted or impaired response to such stimuli. Encouraged patient to talk about his feelings and perceptions in a therapeutic manner. the client will be able to recognize and correct false belief w Long Term After weeks of nursing intervention. Intervention Rationale Evaluation Subjective: “Yan ung naririnig ko na kotse kagabi kaya hindi ako makatulog. exaggerated.

quiet and calm environment. To avoid injuries and over stimulation that my trigger increase anxiety level and aggressive behavior. Scheduled structured Provides stimulation without undue . Provided safe. - Involved patient in different treatment modalities such as music therapy and remotivation therapy. place.- person. Provides sensory stimulation and will reorient patient to reality. Provided strict supervision. - To promote normalization of response to stimuli. time and events as necessary.

activity and rest periods with clear. Clear and consistent limits provide a secure structure for the patient. - Enhances commitment and continuation of plan. fatigue. - Presented reality concisely and will reinforce delusion (Videbeck). optimizing outcomes. Interacting with reality is therapeutic to the patient. simple directions/ rules and simple sentences. - Provided explanations of and planned care . Never accept the hallucinations as reality.

with the client. .

Noted orientation to time. current level of functioning and effect of the delusional thoughts to his life. . Objective:  Delusional thinking  Non reality based thinking  Short attention span  Distractibility  Impaired judgment To determine the patient’s ability to participate in planning care. Intervention Rationale Evaluation Subjective: “Meron kaming mga kotse at helicopter ang driver si robin. Established rapport. the patient will regain his normal and usual orientation to reality. Assessed the patient’s attention span and ability to make decisions or problem solve. Assessed the patient’s thoughts process. Background Knowledge One of the many symptoms of schizophreni a.” as verbalized by the patient. Delusion which is a false and fixed belief that cannot be corrected by logical reasoning. insight and judgment. To evaluate the extent of thought process disturbance GOAL MET. To build trust and facilitate expression of thoughts and feelings. Long Term After 4 months of nursing intervention with proper medical management. place. undifferentiat ed type is the pronounced delusions. client might experienced anxiety and Goal Short Term Within the shift the patient will respond to realitybased interactions initiated by the student nurse appropriatel y. distractibility and impaired judgement secondary to schizophrenia undifferentiated type. Assessed the client’s condition including nature of the problem. When confronted and corrected.DISTURBED THOUGHT PROCESS Cues/Data Nursing Diagnosis Disturbed thought process related to increased dopamine levels as evidenced by delusional thoughts. The patient was able to interact with the student nurse and expressed his thoughts and feelings with no inhibitions. person.

Some client when overwhelmed experience thought disturbances. they are very sensitive attention seeker and needs to be attended to . pleasant. simple directions/ rules and simple sentences. Scheduled structured activity and rest periods with clear. To recognize the client’s perceptions and understand the patient’s feelings.might withdraw self from the previously established relationship between the nurses. calm manner. Listened to the patient with regard and sincerity. To inhibit stimulation of the client that will improve escalate his delusions. quiet environment and approached the client in a slow. Established alternate means of self expression such as writing and drawing. Provides stimulation without undue fatigue. According to Videbeck. Maintained a safe. Listening conveys to the client that he is worthwhile as a person and worth talking to.

self integrity and worth are preserved and increased. Showed empathy regarding the patient’s feelings. Empathy conveys caring. . It is a strategy in order to determine the falseness or truthfulness of what he said in order to correct in a nonthreatening manner. interest and acceptance. When this type of client perceives that someone is willing to listen and help them when in need.facilitate or foster necessary changes. reassured patient of presence and acceptance. Exploring the content of the client delusion does not reinforce his false belief. Some therapies are facilitated to serve Explore the content of the client’s delusional thought and presented reality concisely and briefly.

.coping mechanisms.Emphasized the importance of cooperation with therapeutic regimen such as small group therapy and Remotivational therapy. through which the client will be able to deal little by little the different events of the past and present helping them instil positive self. as catharsis.

Intervention Rationale Evaluation Subjective: “Ayoko na” stated by the patient when he was told to lengthen the duration of brushing his teeth Self-care deficit: Hygiene related to cognitive impairment as manifested by body odor. Determined the individual strengths and skills of the patient in performing self care. Serve as baseline data. Self-care deficit is typical expectation for client with schizophrenia of any type. According to Lippincott’s Nursing Review for NCLEX. 3-5 seconds duration of brushing his teeth To be able to build therapeutic relationship with the patient that will serve as a ground for instilling changes as planned. dental Objective: carries and has body odor severe itching of skin 2˚ to (+) dental carries Schizophreni a. To promote good hygiene and physical comfort Assessed the client’s condition tracing the underlying reason of self-care deficit. the client initiated brushing his teeth and verbalizes that he’ll take a bath every day. To find out the degree of impairment and the intervention needed. After two hours of nursing intervention. severe itching undifferentiat of skin ed type. Established rapport with the patient. . selfdirected activities that used to be attended by the client seemed to be overwhelmin g to them. After two hours of nursing intervention. the client will be able to perform some if not all of the different activities of daily living directed to maintain good personal hygiene such as brushing of teeth and taking regular bath.SELF CARE DEFICIT Cues/Data Nursing Diagnosis Background Knowledge Goal Short Term Long Term GOAL MET.

To correct patient’s way of performing selfcare while promoting selfcare independence. optimizing outcomes and supporting health promotion.To enhance commitment to plan.To schedule activities conforming t . They . ..

perception or insight of the client about the problem will provide the nurse an idea on which to start or give emphasis first. In a manner that will not challenge the client. Encouraged the client verbalization and perception about hygiene and the different activities to maintain good hygiene. .eventually lose the initiative to perform different activities of daily living such as brushing the teeth. To facilitate and help the client perform necessary activities to maintain good oral hygiene. Setting contract is therapeutic and enhances the client’s eventual taking Set contract with the client that before each interaction with the student nurse. It is therefore the responsibility of the nurse or the caregiver to assist the client little by little in the performance of daily living to facilitate independence as soon as Assisted the client in performing self-care activities such as in brushing his teeth. changing clothing and even putting on their slippers.

Most often than not. structured activity and tasks must be planned to cope the client’s situation. Client who loses the initiative of doing self-care also loses the sound judgment of its importance. If necessary. Emphasized the importance of good oral and personal hygiene. when client recognized and perceived the . he should have taken a bath before going out and will brush his teeth before the activity starts. Skinner’s operant conditioning Theory states that the behavior that is rewarded and accepted. starting the next day. clearly understood by the client is the behavior that is continued.possible to avoid total dependence of the client. independence in performing selfcare.

.benefits of doing such. instruction and fostering changes take place in abit.

kati…. The epidermal and dermal layer of the Goal Short Term After 2 hours of nursing intervention.IMPAIRED SKIN INTEGRITY Cues/Data Nursing Diagnosis Impaired skin integrity related to mechanical factor/press ure as evidenced by the presence of the distributed/s caterred wounds and scratches secondary to parasitic infestation (sarcoptes scabei). characteristics of wounds and scratches as well as the different areas that are affected. the client will be able to recognize. depth. the client will be able to regain the normal and usual skin integrity. . Long Term After one month of nursing intervention. Malnutrition may contribute in delayed healing of tissue. The client cannot control himself from scratching the wounds and skin especially when itchy. This was brought by the infestations of the parasitic mites that the other client in the rehabilitation ward also acquired. Objective: (+) rashes that progresses throughout the extremities and buttock (+) abrasions and lesions in both extremities scars from previous Noted skin color. understand and participate with the different necessary activities or preventive measures in order to preserve skin integrity. Intervention Rationale Evaluation Subjective: “Kati… Sir. Assessed patient’s condition. To identify the degree of skin damage and for future comparisons. Goal Unmet. odor and discharges. Background Knowledge The client’s impaired skin integrity is due to frequent scratching due to itchiness. Determined nutritional status. width. texture characteristics of lesions including color changes.” as verbalized by the patient. To determine the degree of the problem.

.Itching can be a side effect of psychotropic drugs. .inflict injury and ability to perform selfcare skills.To identify areas to be addressed in teaching plan and potential referral needs.To identify risk for self. . .

To identify the amount and the type of teaching approach necessary to address the problem. Applied povidoneiodine on wounds and covered them with sterile gauze. Inspected the client’s skin and wounds every day before and after interaction. To prevent complications of the wounds. To monitor healing progress as well as id complication exist. To prevent damage to the skin when itchiness is felt. Cut/trimmed the client’s nails into short. Ascertain attitudes of an individual about the wounds and scratches that he has.wound skin warm to touch skin are damaged which loses the integrity of the skin to protect the inner layer from mechanical or chemical attack. .

rub or scratch the wounds by bare hands especially if hands are not washed with soap and water before doing so.Informed the client about the importance of good personal hygiene in facilitating wound healing. To instil the client’s responsibility in preventing wound complication thus facilitating faster healing of the wounds. Advised the client not to touch. . To prevent wound contamination.

. Goal Met: The client was able to join group activities during the socialization day.”as verbalized by the patient. Spent time with the client. Intervention Rationale Evaluation Subjective: “Hindi labas sir sakit ulo. acceptance. Develop a therapeutic nurseclient relationship through frequent. Long Term After three weeks of nursing intervention. Show unconditional positive regard.Impaired Social Interaction Cues/Data Nursing Diagnosis Impaired social interaction r/t disturbed thought process as evidenced by withdrawn behavior and flat facial expression secondary to the presence of the disease: Schizophrenia. brief contacts and an accepting attitude. and conveyance of positive regard enhance the client's feelings of selfworth. Avoids talking to other client inside the ward. He used to be an active participant of the different activities and claimed to be having a headache to be excused from the group going out. the client will be able to maintain trusting relationship with others and will be utilize effectively the different social support system available in order to avoid future isolation and social withdrawal.patient did not attend the program twice. Sits on bed while staring on his palms. Background Knowledge Client when cannot tolerate the external and internal stimuli chooses to stay alone and inhibits social interaction. Has withdrawn behavior. This may mean just sitting in silence for a while.Nurse’s presence may help improve client's perception of self as a worthwhile person. Videbeck Goal Short Term After the shift. the patient will develop trusting relationship with nurse and will demonstrate willingness and desire to socialize with others. Presence. Undifferentiate d type. To determine the causative factors of the client’s withdrawn behavior. Objective: . Assessed the client’s condition by asking the nurse on duty.

. decision without verbal or any form of punishments.identifies this one as a form of client’s strategy in order to give time for self to manage internal or external feeling of isolation Encouraged attendance in group activities paying particular concern on the different benefits those activities will give him. Client’s when able to verbalize concerns find peace Encouraged the client’s verbalization in mind and hearts. This will also of feelings about avoiding interactions provide the nurse and being withdrawn the basis of health teaching or in sometimes. instilling positive coping behaviors if needed. To enhance interest of the client in participating with the different activities. Acknowledge that his or her absence Acknowledged was noticed may client's absence from reinforce the any group activities client's feelings of and respect his self-worth.

Midbrain and the hindbrain together make up the brainstem. The metencephalon contains structures such as the pons and cerebellum. and directing sensory information throughout the body. interpreting. and the hindbrain.IV. and the conduction of sensory information. The Brain Structures A. Brain Divisions A. Basal Ganglia  Involved in cognition and voluntary movement  Diseases related to damages of this area are Parkinson's and Huntington's . b. producing and understanding language. the midbrain. and digestion. heart rate. Anatomy and Physiology THE ANATOMY AND PHYSIOLOGY OF THE HUMAN BRAIN The anatomy of the brain is complex due its intricate structure and function. the cerebral cortex. B. relaying sensory information. The myelencephalon is composed of the medulla oblongata which is responsible for controlling such autonomic functions as breathing. and controlling autonomic functions. perceiving. Most of the actual information processing in the brain takes place in the cerebral cortex. Forebrain is responsible for a variety of functions including receiving and processing sensory information. movement coordination. They are the forebrain. and controlling motor function. These regions assist in maintaining balance and equilibrium. Diencephalon = contains structures such as the thalamus and hypothalamus which are responsible for such functions as motor control. thinking. This region of the brain is involved in auditory and visual responses as well as motor function. The hindbrain extends from the spinal cord and is composed of the metencephalon and myelencephalon. This amazing organ acts as a control center by receiving. There are three major divisions of the brain. The midbrain is the portion of the brainstem that connects the hindbrain and the forebrain. telencephalon = contains the largest part of the brain. Two major divisions of forebrain: a.

receives and processes sensory information Temporal Lobes - involved with emotional responses. and planning  Occipital Lobes-involved with vision and color recognition  Parietal Lobes . and speech H. Cerebrum  Largest portion of the brain  Consists of folded bulges called gyri that create deep furrows I. problem solving.5mm to 5mm) of the cerebrum  Receives and processes sensory information  Divided into cerebral cortex lobes G. Cerebral Cortex Lobes  Frontal Lobes -involved with decision-making. Corpus Callosum  Thick band of fibers that connects the left and right brain hemispheres . medulla oblongata. and the pons. Brainstem  Relays information between the peripheral nerves and spinal cord to the upper parts of the brain  Consists of the midbrain. Broca's Area  Speech production  Understanding language D. Cerebral Cortex  Outer portion (1. memory. Central Sulcus (Fissure of Rolando)  Deep grove that separates the parietal and frontal lobes E. Cerebellum  Controls movement coordination  Maintains balance and equilibrium F.B. C.

J. fibrous band of nerve fibers that connect the hippocampus to the hypothalamus  Hippocampus . hormonal secretions.directs a multitude of important functions such as body arching.involved in emotional responses. Olfactory Bulb  Bulb-shaped end of the olfactory lobe  Involved in the sense of smell N. Pituitary Gland  Endocrine gland involved in homeostasis  Regulates other endocrine glands P. and memory  Cingulate Gyrus .mass of grey matter cells that relay sensory signals to and from the spinal cord and the cerebrum K. Meninges  Membranes that cover and protect the brain and spinal cord M.a fold in the brain involved with sensory input concerning emotions and the regulation of aggressive behavior  Fornix . Medulla Oblongata  Lower part of the brainstem that helps to control autonomic functions L. Limbic System Structures  Amygdala . Pineal Gland  Endocrine gland involved in biological rhythms  Secretes the hormone melatonin O.receives sensory information from the olfactory bulb and is involved in the identification of odors  Thalamus . hunger.sends memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieves them when necessary  Hypothalamus . Reticular Formation . and homeostasis  Olfactory Cortex . Pons  Relays sensory information between the cerebrum and cerebellum Q.

and the cerebellum Lateral Ventricle .canal that runs between the pons. Wernicke's Area  Region of the brain where spoken language is understood .largest of the ventricles and located in both brain hemispheres Third Ventricle .provides a pathway for cerebrospinal fluid to flow S.produces cerebrospinal fluid Fourth Ventricle . Nerve fibers located inside the brainstem  Regulates awareness and sleep R. medulla oblongata. Substantia Nigra  Helps to control voluntary movement and regualtes mood.canal that is located between the third ventricle and the fourth     ventricle Choroid Plexus .  Aqueduct of Sylvius .


V. Psychopathology .


VI. Psychopharmacology .

renal or Unlabeled uses: hepatic impairment. P. photosensitivity GI: Nausea. pregnancy. weight. dry mouth. arrhythmias Dermatologic: Rash. orange juice. and increasing dosage. headache. neuroleptic malignant syndrome. especially Other: Chest pain. fever. tardive dyskinesias CV: Orthostatic hypotension. increased saliva Assessment History: Allergy to risperidone. CNS agent. Presentation: Oral solution Treatment schizophrenia of Contraindicated with hypersensitivity to risperidone. dry skin. Do not mix with . or low-fat Adverse effects in Italic milk. coffee. and atypical alpha-adrenergic blocking activity Dose: may contribute to some of its 1 cc therapeutic and Frequency: BID adverse actions. Responsibilities pharyngitis. dyspnea Maintain seizure precautions. sinusitis. somnolence. Bipolar disorder. seborrhea. constipation. back pain. CV disease. antihistaminic. BP. hypotension Physical: Temp. hypotension. dizziness. renal or hepatic impairment. anxiety. agitation. orthostatic BP. when initiating therapy arthralgia.DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATIO N ADVERSE EFFECTS NURSING RESPONSIBILITIES Generic Name: Mechanism of action not fully understood: Risperidone Blocks dopamine serotonin Brand Name: and receptors in the Risperdal brain. R. liver and kidney function tests Respiratory: Rhinitis. antipsychotic. CBC. reflexes. aggression. lactation. lactation. vomiting. abdominal discomfort. Nursing coughing. anticholinergic. urinalysis. pregnancy. normal output. liver evaluation. treatment of patients with dementia-related psychotic symptoms CNS: Insomnia. orientation. adventitious sounds. bowel sounds. Delaying relapse in long-term treatment of Use cautiously with schizophrenia cardiovascular disease. depresses the Classification: RAS. diabetes Mix oral solution with mellitus 3–4 oz of water.

Assess for EPS. particularly in initiation of therapy. cycle disorder and notably absence and myoclonic seizures. urea generalized seizures. . For the prophylaxis of migraine. increased plasma prolactin levels and if EPS occur. Assess for pain. Also used to treat acute manic phase of bipolar disorders. The most frequent adverse Assess for effects are GI disturbances. GI Assess for changes in bowel. complaints. which decreases seizure activity. Treatment of primary Hepatic dysfunction. Instruct the patient to inform physician of transient intestinal cramps.DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATIO N ADVERSE REACTION NURSING RESPONSIBILITIES Generic Name: Divalproex Sodium Brand Name: Depakote ER Classification: Anti-convulsant Dose: 500 mg Presentation: Tablet Increases level of gamma/amino butyric in brain. and also for partial seizures.

Contraindicated with allergy to clozapine. narrowangle glaucoma. malignant Assessment . CBC. narrowhypotension. seizures. D3 and D5 receptors but has high affinity for the D4 receptor. pregnancy GI: Nausea. liver evaluation. ophthalmologic exam. myeloproliferative disorders. bowel sounds. orthostatic BP. dizziness. comatose states. orientation. hypertension lactation. myeloproliferative disorders. comatose states. sounds. severe CNS depression. abdominal Physical: T. P. GU: Urinary abnormalities intraocular pressure. Management of severely ill schizophrenics who are unresponsive to standard antipsychotic drugs. CNS: sedation. R. dry mouth reflexes. discomfort. salivation. D2. prostate enlargement. Hematologic: Leukopenia. agranulocytopenia normal output. Reduction of the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. severe CNS depression. increased sweating.DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATIO N ADVERSE REACTION NURSING RESPONSIBILITIES Generic Name: clozapine Brand Name: Clozaril Classification: Antipsychotic s Dose: 100 mg Frequency: Presentation: Tablet Clozapine has relatively weak dopamine receptorblocking activity at D1. disease. restlessness. headache. disturbed nightmares. EEG Nursing Responsibilisties: Drowsiness. weight. history of clozapine-induced agranulocytosis or severe granulocytopenia. palpation. syncope. sleep. history of seizure disorders. urinalysis. lactation. angle glaucoma. history of clozapine-induced agranulocytosis or severe granulocytopenia. constipation. liver and kidney function tests. • Use cautiously with CV disease. weight gain. αadrenergic histamine H1 and cholinergic receptors. It has also blocking effects on serotonin. adventitious granulocytopenia. CV prostate CV: Tachycardia. pregnancy. tardive neuroleptic syndrome History: Allergy to clozapine. normal urine rash output. ECG changes. BP. prostate Other: Fever. enlargement. history of seizure disorders. vomiting. agitation. dyskinesia. tremor. ECG.

tachycardia. seizure. jaundice. Assess the client for history of drug allergies. Inform the client of side effects and encourage to report problems instead of discontinuing medication Teach client methods of managing or avoiding unpleasant side effects and maintaining medication regimen for: Dry mouth – sugar-free fluids and sugar-free hard candy. cardiac problems and other drugs prescribed.DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATIO N ADVERSE REACTION NURSING RESPONSIBILITIES Generic Name: levomepromazi ne Brand Name: Nozinan Classification: Antipsychotics Dose: 100 mg Frequency: HS Presentation: Tablet Levomepromazin Schizophrenia e is a phenothiazine with CNS depressant. QT prolongation. changes in libido. Comatose state Severe CNS depression Pheochromocytoma Blood dyscrasia. αadrenergicblocking. ileus. constipation. headache. photosensitivity. incontinence. Hypotension. increase water and bulkforming foods. priapism. stool softener permissible but avoid laxatives photosensitivity–use sunscreen . polyuria. wt gain. nausea. orthostatic hypotension. urinary retention. neuroleptic malignant syndrome. It acts by blocking dopamine receptors in the mesolimbic dopaminergic system. dizziness. ejaculatory disorders. orthostatic hypotension. interference with temperature regulation. gynaecomastia. Severe constipation – exercise. Client should avoid calorieladen beverages and candy Potentially Fatal: Arrhythmias. irregular menstruation. rash. antihistaminic and analgesic activity. antimuscarinic. extrapyramidal effects. blood dyscrasias. vomiting. hepatotoxicity. drowsiness.


Progress Notes .VII.

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