PILAR COLLEGE OF ZAMBOANGA CITY, INC.

R.T. Lim Boulevard, Zamboanga City

Nursing Program

Name: Evangelista, Crystel Jane J.

Clinical Experience: RLE
Clinical Area: Zamboanga City Medical Center
Week: 10
Date: October 20, 21, 22 - 2020
Time: 8am – 8 pm
Preceptors: Romar Filemon A. Lim II, R.N

TPO:
Application of knowledge, skills and attitude through the utilization of nursing process in the
care of patient with maladaptive patterns of behavior with emphasis on health promotion,
prevention, maintenance, curative and rehabilitative health aspects of the health care delivery
system.

EO:
At the end of 18 hours related learning experiences, I shall be able to:
1. Establish and maintain rapport, trust and therapeutic communication with the patient and
others.
2. Gather patient’s data appropriately and completely.
3. Assist patient with tender, love and care, cause no harm to the patient.
4. Assess the patient condition utilizing the mental status examination.
5. Identify health needs/ problem of the patient.
6. Formulate nursing care plan based on the prioritized nursing diagnosis.
7. Implement planned nursing intervention.
8. Monitor and record patient’s vital signs.
9. Provide an art therapy to the patients.
10. Conduct a socialization party for the patients.
11. Document any patient’s data
12. Recognize and respect patient’s confidentiality.
 PATIENT’S PROFILE

Name: Basilio, Juana

Age: 53

Birth date: January 1, 1968

Address: Zamboanga City Medical Center Ward 9

Gender: Female

Civil status: Single

Room: Ward 9

Hospital Number: 793779

Diagnosis: Schizophrenia Multiple episodes in acute episode.

 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
R.T. Lim Boulevard, Zamboanga City
NURSING PROGRAM

Mental Status Examination

Name of Patient: (Initial) Ms. J

I- GENERAL ASSESSMENT AND MOTOR BEHAVIOR

A. APPEARANCE
Hygiene & Grooming: [ / ] Neat [ ] Poor

 The client is wearing a clean gown and shaven.

Dress: [ / ] Appropriate [ ] Sloppy

 The client’s dress is clean and composed.

Eye contact: Decreased
Posture: Slouching throughout the nurse and patient interaction.

B. BEHAVIOR : [ / ] Restless [ ] Agitated [ ] Lethargic

 The patient shows restlessness, rocking repetitively back and forth. All
throughout the nurse and patient interaction she answers questions while
maintaining inconsistent eye contact and often smiles while answering.

C. SPEECH : [ ] Clear [ / ] Mumbled [ ] Rapid [ ] Slow [ / ] Constant

[ ] Silent
Specific: (e.g. client has delusions, confused, withdrawn, or verbose, responses a minimal
yes or no) or no) The client mumbles random words that are not understandable. Client
has delusions and often verbose. Able to response a minimal yes or no. Talks normal in
soft volume with interventions.
 MOOD and AFFECT
A. MOOD: What mood does the client convey? Labile

(Estimate intensity or rate on a scale of 1 to 10) 4

B. AFFECT : [ ] Blunt [ / ] Broad [ ] Flat [ ] Inappropriate [ ] Restricted

II- THOUGHT PROCESS AND THOUGHT CONTENT

[/] Circumstantial thinking [ / ] Delusion [ / ] Flight of ideas [ ] Ideas of reference
[ ] Loose associations [ / ] Tangential thinking [ ] Thought blocking [ ] Thought broadcasting
[ / ] Thought insertion [ ] Thought withdrawal [ / ] Word salad [ ] Confabulation
[ ] Self harm or suicide urges
Describe the characteristics of patient’s responses: The client’s reaction and responses are often
congruent to the mood and client’s response. Thought process is incoherent with delusion about the
past and present situation.

III- SENSORIUM AND COGNITION

A. ORIENTATION: [ ]Oriented to time [ / ] Oriented to person [ ] Oriented to place
B. MEMORY : [ ] Remote memory [ / ] Recent memory
C. CONCENTRATION ABILITY : (Tasks)
Serial sevens: How far does the client go? __________________________________________
Can the client do simple math? When the client was asked what is 1+1, 2+2, and 4+8, the
client answered correctly.
Can the client spell the word backward (e.g. WORLD) After asking the client what is her
favorite word, she said “BEAUTIFUL”, the client refused to spell the word backward. On the
second try, client was able to spell “CAT” backwards.

ABSTRACT THOUGHT: (Proverbs) [ ] Concrete [ ] Abstract

IV- SENSORY PERCEPTUAL ALTERATIONS

A. HALLUCINATIONS : [ ] Auditory hallucinations [ ] Visual hallucinations
The patient stated that he does not hear any voices nor sees any unusual things.
V- JUDGMENT AND INSIGHT
A. JUDGMENT: [ / ] Good [ ] Poor

B. INSIGHT: [ ] Good (Client realistically assess his or her symptoms)

[ / ] Poor (based on actions, awareness of illness, plans for the future)

VI- SELF CONCEPT

How does the client view himself or herself? When the client was asked how she views himself,
she said she don’t know.
What does the client want to change about himself or herself? When the client was asked what
does she want to change about herself, the client verbalized “Wala man.”.
Personal qualities or attributes: Client did not respond and just smiled.

ROLES AND RELATIONSHIPS

(Current roles, satisfaction with roles, success at roles, significant relationships, support systems)
The client stated that she has a husband who is a soldier and that she visits him sometimes outside
(client did not mentioned the specific place) and that she have 12,000 children and lost count of the
numbers of how many female and male children she have.

VII- PHYSIOLOGIC AND SELF CARE

(Eating habits, sleep patterns. Health problems, compliance with prescribed medications, ability to
perform Activities of Daily Living)
The patient stated that she eats 2 times a day, one for lunch and one for dinner. Client stated she
loves eating Kari-Kari and Beef Soup. She also stated that she sleeps from 9 pm to 11 pm and does
walking outside the room.
 NURSE PATIENT INTERACTION

STUDENT PATIENT NON VERBAL THERAPEUTIC ANALYSIS

NURSE COMMUNICATION COMMUNICATION
Hello po, Ako Hello Nurse, Established eye contact Giving Information Establish
po si Crystel bisaya man. Smiling rapport.
Evangelista,
Student Nurse
po galing sa
Pilar College.
Ano po ba
language niyo?
Tagalog?
Bisaya?
Tausug?

Okay lang Smiling Asking for consent To continue

Ah an aba nah nurse sa labas rapport
interview lang ta nya.
ta ha para
kabalo ta imong
condition,
assessment ra.
Okay lang?

Basilio Juana Smiling Giving information To identify

Unsa man ang Keeping an eye on the client and
ngalan nimo ground obtain
maam? information.

January 1 Smiling Giving information To obtain

Kanus-a man Slouching information.
imo birthday? Rocking back and forth

Keeping an eye on the

Ambot lang Giving broad openings
ground To obtain
Unsa year man Rocking back and forth information.
imo birthday? To obtain trust.

Established eye contact

21 years old Stops rocking back and Giving Information To obtain
Pila na imo man ko. Ay forth information
edad maam? dili, 79.

Blank staring
Talier man ko Giving information To know if
Taga asa ka dira oh patient is
maam? (pointing oriented in
outside place.
skyline)

Blank staring
Giving information
Didto oh sa To obtain
Asa man na gawas information.
talier maam? (pointing the
Naa na ngalan? same
direction)

Established eye contact

Unsa na Points to the MSE Giving information
Ah guide ra sa nurse? To establish
interview. questionnaire rapport.
(pertaining to
MSE
questionnaire)

Keep eye on the

Giving information
ground To obtain
Unsa man (Mumbled
information.
imong relihiyon words)
maam? .
Keeping eye on the Giving information.
ground To obtain
Unsa imong Ambot lang information.
relihiyon
maam?

Established eye contact Broad openings

 Adtu fort To know if
Kabalo ba nimo pilar patient is
asa ka karun? oriented to
place

Established eye contact Encouraging expression

Okay ra man To provide
Kumusta man self-
ka karon maam? expression.
Established eye contact Giving information.
Uhh ambot Scratch head To test
Buti man patient’s
maam. Kabalo cognition.
ba nimo ngano
ka nila gi dala
diri? Giving information.
Stares at the hallway.
Lakaw lakaw
To obtain
Unsa man imo ra diri gawas. information.
gina buhat kung Kita nimo na
naa ka diri si baby girl
ako ga
pakaon niya
Established eye contact. Active listening.
Weather To provide
Ngano man weather lang. self-
ikaw gapa Ako ra man expression.
kaon? Friends mag pa kaon
lang man mo kay dili man
tanan diri? siya mokaon
kung wala
mag subo

Looking at the hallway. Giving information.

Naa, didto sa To obtain

Ana ba maayo battalion information.
man kung ing
ato.
Naa ba ka
asawa maam? Smiling Giving information.

Oo war, To obtain
Asa man na sundalo man information.
siya.
battalion? Unsa Smiling Giving information.
na war? Established eye contact
Ako mag To obtain
bisita sa iya. information.
Gina bisita ka
diri sa imong Smiling Giving information.
asawa maam?
Didto To test
(pointing at psychological
Asa man nimo nurses station state.
gina bisita? direction)
Established eye contact. Broad openings.

Oo naa To obtain
12,000 information.
Naa mo anak
maam?
Looking down Labile
Scratching head
Ambot dili ko To test
kabalo psychological
Pila man bayi state.
ug laki? Giving information.
Looking at the hallway

10 gabii To test if
patient is
Kabalo ba nimo Broad openings. oriented to
unsa oras na Looking at the hallway.
time.
karun?
To test
2, 4, 10. patient’s
Mangutana lang cognition.
ko ha unsa ang
1+1

2+2 Smiling Giving information.

4+8
Beautiful To further test
Smiling Giving information. cognition.
Unsa imong Maintaining eye contact
favourite word?
Ah
Murag ikaw To further test
lang maam cognition.
haha, sige daw Smiling Giving information.
spell “beautiful” Looking at the MSE
backwards questionnaire To further test
CAT, TAC cognition.

Okay ra ani na
lang “CAT” Giving information.
backwards Blank staring

To test
Wala man, sa patient’s
una naa karon sensory
Very good. wala na man. perceptual
Karun, naa ba alterations.
ka unsa Giving information.
ginadungug o
Establishing eye contact
naa ba ka
makita lain?
To obtain
Gi lubid man information.
na akong
Buti man na. silingan
Encouraging expression
Ngano man na Maintaining eye contact
imong kamut Smiling
maam?
To allow
Wala man patient to self-
express
Ah sige sige. Encouraging expression
Mangutana lang Maintaining eye contact
ko kung paunsa
nimo makita To allow
imong sarili? Ah akong patient to self-
kamot gi express
Giving information
kulam ni
Unsa imong Grace. Looking inside Ward 9
mga gusto room
palitan sa imong To obtain
sarili? Gi kulam pud further
niya si ano information.
wala tu sakit,
Kinsan man na selos man si
si Grace? Grace gi Giving information
butang niya Looking inside Ward 9
sakit. room
To obtain
Naas a loob si Encouraging expression further
 Grace. (Ward Establishing eye contact information.
9 room) Smiling
Kinsa mana si
Grace maam? To continue
Okay ra man, rapport.
weather
weather lang. Giving information
Paunsa man ang Looking at the hallway
relationship
ninyo lahat diri?
Pati kay Grace? To obtain
Friends ramo? Galakaw information.
lakaw ko diri.
Giving information
Gina palakaw
Ah sige sige. man kame Establishing eye contact
Ani oh, ga nila, nurse.
exercise ka
maam? To obtain
Uhm mga 9 further
kabar mu information.
Giving information
mata 10, ay Smiling
Maayo man naa 11.
mo exercise.
Ano oras man Giving information To test
ka matulog Looking at the hallway
Oo. patient’s
maam ug mu
cognition.
mata?
To obtain
So bale 2 hours
Naa man mu Giving information information.
lang imong
tulog? shagit pag Smiling
gabii diri.
Ngano man 2 To obtain
hours lang? further
Giving information
Ngano man ka information.
magising sa Human na Maintaining eye contact
gabi? man.
To obtain
Giving information further
Nikaon na ka Playing with hands information.
Isa sa umaga,
karun adlaw
isa gabii.
maam?
Encouraging expression
Paunsa man diri Lunch, Rocking back and forth To obtain
ang oras para pananghalian. Smiling further
mukaon? information.

Unsa na lunch Nah! Katong Encouraging expression To allow self-

or breakfast? Maintaining eye contact
 Kari-Kari ug Smiling expression.
Baka katong
Ah okok. Unsa sabaw. Giving information
man imong Smiling
favourite na Oo, sarap to. To continue
ulam maam? rapport

Gigutom man Expressing gratitude

ko sarap siguro Tapos na Smiling To give signal
to haha. nurse? Maintaining eye contact that interview
is already
Nah okay ra ta done.
maam tapos na
ang interview Salamat To express
nurse. gratitude.

Tapos na,
salamat maam
pasok na ka ulit.

ANATOMY AND PHYSIOLOGY

The brain, a miraculous three-pound organ, is responsible for all bodily processes, interprets data
from the outside world, and embodies the mind and soul. The brain controls a wide range of
functions, including memory, creativity, emotion, and intelligence. The brain is made up of the
cerebrum, cerebellum, and brainstem and is protected inside the skull.

Our five senses—sight, smell, touch, taste, and hearing—all convey information to the brain,
frequently several at once. It puts the signals together in a way that makes sense to us and can
help us remember that information. The brain regulates various bodily functions, including our
thinking, speech, memory, and arm and leg movement.

The brain and spinal cord make up the central nervous system (CNS). The cranial nerves that
branch from the brain and the spinal nerves that emerge from the spinal cord make up the
peripheral nervous system (PNS).

Brain
The brain is composed of the cerebrum, cerebellum, and brainstem
  Cerebrum: is the largest part of the brain and is composed of right and left hemispheres.
It performs higher functions like interpreting touch, vision and hearing, as well as speech,
reasoning, emotions, learning, and fine control of movement.

 Cerebellum: is located under the cerebrum. Its function is to coordinate muscle

movements, maintain posture, and balance.

 Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the spinal
cord. It performs many automatic functions such as breathing, heart rate, body
temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and
swallowing.

Right brain – left brain

The right and left hemispheres of the cerebrum are separated, and they are connected by a bundle
of fibers known as the corpus callosum that carries messages from one side to the other. Each
hemisphere is in charge of the body's opposite side. Your left arm or leg could become weak or
paralyzed if a stroke hits the right side of your brain.
Lobes of the brain
The different fissures between the cerebral hemispheres split the brain into lobes. There are four
lobes in each hemisphere: frontal, temporal, parietal, and occipital (Fig. 3). Again, there are
regions in each lobe that have very particular activities. It's crucial to realize that the brain's
different lobes work together to accomplish tasks. The connections between the right and left
hemispheres of the brain, as well as between its lobes, are extremely intricate..

Frontal lobe

 Personality, behavior, emotions

 Judgment, planning, problem solving
 Speech: speaking and writing (Broca’s area)
 Body movement (motor strip)
 Intelligence, concentration, self awareness

Parietal lobe

 Interprets language, words

 Sense of touch, pain, temperature (sensory strip)
 Interprets signals from vision, hearing, motor, sensory and memory
 Spatial and visual perception

Occipital lobe

 Interprets vision (color, light, movement)

Temporal lobe

 Understanding language (Wernicke’s area)

 Memory
 Hearing
 Sequencing and organization
 ANALYSIS

 Schizophrenia is a severe mental illness in which reality is perceived by

sufferers strangely. Schizophrenia may include hallucinations, delusions,
and severely irrational thinking and behavior, which can make it difficult to
go about daily activities and be incapacitating. Schizophrenia patients
require ongoing care. Significant distress and impairment in personal,
family, social, academic, occupational, and other significant areas of life are
typically linked to schizophrenia. Schizophrenia patients have a two to three
times higher risk of dying young than the general population.


 Additionally, those who have schizophrenia need ongoing care. However,

the sooner they receive treatment, the greater their prospects are for recovery
and a higher quality of life. The signs of schizophrenia can be controlled
with medication and counseling.

PATHOPHYSIOLOGY

Schizophrenia is frequently misunderstood, despite the fact that it is one of the most prevalent
psychiatric conditions. Here is a description and definition of it.

 Schizophrenia is a serious mental disorder in which people interpret reality abnormally.
Schizophrenia may result in some combination of hallucinations, delusions, and
extremely disordered thinking and behavior that impairs daily functioning, and can be
disabling. People with schizophrenia require lifelong treatment.
Schizoaffective Disorder

People with schizoaffective disorder experience symptoms a major mood episode of depression
or bipolar disorder (major depression or mania) at the same time as symptoms of schizophrenia
(delusions, hallucinations, disorganized speech, grossly disorganized behavior, or negative
symptoms). Symptoms of a major mood episode must be present for the majority of the duration
of the active illness and there must be a period of at least two weeks when delusions or
hallucinations are present in the absence of a mood episode.

Signs and Symptoms

When the disease is active, it can be characterized by episodes in which the person is unable to
distinguish between real and unreal xperiences. As with any illness, the severity, duration and
frequency of symptoms can vary; however, in persons with schizophrenia, the incidence of
severe psychotic symptoms often decreases as the person becomes older. Not taking medications
as prescribed, the use of alcohol or illicit drugs, and stressful situations tend to increase
symptoms. Symptoms fall into three major categories:

 Positive symptoms: (those abnormally present) Hallucinations, such as hearing voices or

seeing things that do not exist, paranoia and exaggerated or distorted perceptions, beliefs
and behaviors.
 Negative symptoms: (those abnormally absent) A loss or a decrease in the ability to
initiate plans, speak, express emotion or find pleasure.
 Disorganized symptoms: Confused and disordered thinking and speech, trouble with
logical thinking and sometimes bizarre behavior or abnormal movements.

Cognition is another area of functioning that is affected in schizophrenia leading to problems

with attention, concentration and memory, and to declining educational performance.

Symptoms of schizophrenia usually first appear in early adulthood and must persist for at least
six months for a diagnosis to be made. Men often experience initial symptoms in their late teens
or early 20s while women tend to show first signs of the illness in their 20s and early 30s. More
subtle signs may be present earlier, including troubled relationships, poor school performance
and reduced motivation.