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A Psychiatric Case Study Presented to the Faculty of the College of Nursing Colegio San Agustin ± Bacolod
In Partial Fulfillment of the Requirements for the course Nursing Care Management 205-B
Kim Arian M. Villanueva
Name of Student _________________________ Date
COLEGIO SAN AGUSTIN-BACOLOD College of Nursing
PSYCHIATRIC NURSING CASE ANALYSIS RECORD (PNCAR)-INITIAL INTRODUCTION (Narrative overview of client¶s diagnosis based on book view) Schizophrenia is a chronic, severe, and disabling mental illness. It affects men and women with equal frequency. It is characterized by deteriorating personality. This disorder is characterized by disturbances in perception, thought process, reality testing, feeling, behavior, attention and motivation. However, altered perception which my client had manifested like hallucination is presented. Hallucinations are probably caused by a hyperdopaminergic state in the limbic area. In the case of my client, hallucination were noted when my client seen talking to himself. Cigarette smoking and schizophrenia people do smoke with schizophrenia probably in the biochemical changes produced by nicotine. Nicotine increases the release of dopamine in the nucleus accumbens ( Addington, 1998). This occurs because nicotinic receptors synapse on dopamine afforests in the reward pathway that is nicotine modulates dopamine release ( Dalack iteal, 1998). Client with schizophrenia smoke so much simply because this makes them feel better. As manifested by my client who smokes every day. Brain injury can be caused by alcohol because it has a toxic effect on the central nervous system (CNS) and can result to changes to metabolism, heart functioning and blood supply. It also interferes with the absorption of vitamin B1 (thiamine), which is an important brain nutrient. It can be associated with poor nutrition; can cause dehydration, which may lead to wastage of brain cells and can lead to falls and accidents that injure the brain.
Source: Keltner, N., Schwecke, L.H., & Bostrom, C. (2007) Psychiatric Nursing 5th pp. 339, 342, 345346,349.
Consider client¶s feeling and emotion professionally. 3. 5.OBJECTIVES Within 72 hours of rendering nursing care at National Center for Mental Health Pavilion 1. 5. ward 6. 3. 4. ATTITUDE: 1. Creatively use of therapeutic communication in interacting with the client. . Formulate appropriate nursing care for the client. 2. Evaluate progress and improvement in client mental status and physiologic functioning. I will be able to: KNOWLEDGE: 1. Provide a therapeutic relationship with client consistently. Maintain confidentiality of the client¶s identity and data gathered. 5. SKILLS: 1. Value each member of the health care team and the time spend. 4. Manifest different Augustinian value imparted by the school. Document every data gathered from the client. 4. Identify the different precipitating and predisposing factor that influenced client¶s illness. 2. 3. 2. Formulate question therapeutically when conducting interview. Accept criticism positively. Obtain relevant data accurately. Identify verbal and non-verbal cues of the client effectively. Determine the client¶s mental disorder accurately.
situation) Not oriented to time.D. Conditions of Admission Check one (1) only: Voluntary (3) Involuntary ( ) Accompanied by (family.CASE ANALYSIS PROPER I. police.N. and person. OPD section) Home Other Significant Information upon Admission Vital signs: Pulse 92 bpm BP 120/70 mmHg Respiration 20 cpm Temperature 36. 2011 4:49 p. (Refer to prescribed format of genogram) . trolley) Ambulatory Admitted from (home.7 ÛC Height 5¶2 Weight 118 Race Filipino Dominant Language Filipino Orientation (person. other) Home Estimated length of stay 2 months Diagnosis: Upon admission Undifferentiated Schizophrenia Current T/C F32. place. Discharge to: (home.sister Route of admission (ambulatory. Ward 6 Date & time of admission: March 5. Tubigan Binan. Contact number 09306288748 Residential address: 179 Brgy. A. other facility. Gender Male Marital status Single Name of significant other J.o. other) Family.m. Age 19 y. Initials of Attending Physician: Dr. place. friend.L. wheelchair. time. cannot follow commands. ADMISSION INFORMATION General Admission Information Client¶s initials C.2 Major Depression Disorder with Psychotic symptoms Chief Complaint/s (as verbalized by clients or significant others/informant) According to significant others: ³nag-uuntog ng ulo sa pader´ ³umiihi na ihi´ ³ayaw uminom ng gamot´ BIOPSYCHOSOCIAL HISTORY ASSESSMENT Predisposing Factors I. facility. Genetic/biologic influences (related to mental and other illnesses) Structural assessment of the family: Use a genogram as applicable: Family of origin/culture extended and present family/significant persons. street. Laguna Pavilion-Unit: Pavilion 1.
Type of neighborhood The client lived in a peaceful environment.´ II. He stressed that he rarely seen disagreement among his neighbors.Family of origin: C. When client asked about problems related mental health. they have three children.A C. D R.N C. D. In her first husband. ³Tahimik lang sa lugar naming.N R. All in all. N. there are 10 members in Mr. N.N R. lahat sila magagaling.´ Their barangay captain according to the client always set to it that rules are properly implemented and makes sure that people living in their place obeys it. R. they have 2 children. In her second husband.N A. he stated. does not have any history of psychological problem. In her third husband. Recently.N Present family (if married): Family History Family members (indicate if mental illness has affected other members from family of origin. D E. N.A G.A L. Minsan lang ako nakakakita nagaaway ang kapitbahay naming kung meron man ay nareresulba ito kaagad.N J. . they got four children. her mother is separated from her third husband.¶s family living in the same house which includes her mother and his 8 siblings. mother married thrice. Family dynamics (describe significant relationships among family members) Family living arrangement Mr. ³wala naman. specify name of disorder) The family of Mr. He verbalized.D H.
Health Care History General health care Regular medical check-up with a general practitioner or specialist (if so. history of heart attacks. near strangulation. Female: Menstrual history Age of menarche________Last menstrual Period______ Regularity and duration of period_________ . G. He verbalized. Cancer (full history.I. N. near drowning. & TB test Mr. details of accidents or periods of unconsciousness for any reasons: blows to the head. Allergies. does not have any problem in the heart and renal except recently he experienced frequent urination and later found out to be urinary tract infection. Diabetes and endocrine disturbances (Thyroid and adrenal function) Mr. treatments. rarely goes to a general practitioner or specialist for health consultation. does not have any neurologic impairment. Lung problems (Condition or event that restricts the flow of air to the lungs for more than 2 minutes or adversely affects oxygen absorption: COPD. seizures. N. ³ hindi talaga ako kumakain ng hipon. fainting. N. He cannot remember the date of his last examination. breast. any metastases: lung.. AGN etc. or resuscitation events) Mr. N.III. does not have diabetes and any endocrine disturbances. doesn¶t have any lung problem but he revealed that he is an active smoker before he was admitted to NCMH. electrical shocks. tract. has allergy to seafood especially to shrimp. N. OTHERS Neurologic impairment (diagnosed brain problem. Nagkakaroon kasi ako ng mga pantal sa buong katawan ko. and outcome) TYPE OF HOSPITALIZATION A. SURGICAL C. why indicated. kidney. high fevers. or hypertension and liver disease) Mr. strokes. results of treatments) Client does not have cancer. MEDICAL WHEN REASONS FOR HOSPITALIZATION TREATMENT/DIAGNOSTIC TEST TAKEN OUTCOME No history of hospitalization B. immunizations. head trauma. dizziness. N. Cardiac /Renal/hepato-problems (Childhood illness such as: rheumatic fever. He usually accompanied by his mother. frequency of visits & date of last examination Mr. He can¶t remember the number of sticks he can have per day but he admitted that he smokes every day. falls and others) Mr. He just added that he usually goes for check-up when he got a flu or fever. Chest x-ray & ECG. headaches. History of Hospitalizations (When.
Before his admission. drowsiness. and caffeine intake) According to Mr. nervousness. although they have a large family size. sexual dysfunction major depression . they can still eat 3 times a day. tremor . ³Ang mga babae kasi maraming arti. appetite. However proper balanced diet was not given much emphasis. is really certain that he is a man. however.Presence of premenstrual syndrome: YES________NO_______ Impact on Lifestyle:______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ____ Concerns about sexuality: Describe feelings about being a man or woman Mr. He is actually glad being a man as he verbalized. somnolence . He also added that he had three girlfriends in the past. anorexia . he was not thin as now however he shared that because of vices he loses weight. sexual problems. cravings. Marami din sila mga pangangailangan kaysa sa mga lalaki. its effects on cognition are mild nausea . insomnia. births. N. body weakness nausea. He has a good appetite to eat food. N. children & their ages.´ To whom is the client more attracted to? (Male or female) He is more attracted to female. diarrhea. insomnia . assess birth control methods used if any) T (Term) P (Preterm) A (Abortion) L (Living Children) Name Age Type of Delivery Use of Family Planning Methods Remarks (TPAL) IV. and sexual side effects. Lifestyle Eating (Unusual or unsupervised diets. Reproductive history (Number of pregnancies. Drug history assessment Use of Prescribed Drugs: Current Name Risperidone Sertrazine Fluoxetine Dosage 2g 50g 2g Prescribed For schizophrenia major depression Results/Effects Constipation. weight changes.
etc. & garden chemicals) Mr. he had worked in a construction however it still not enough to provide all their needs. He earns P 2000 a month which can t sustain their daily needs. Other significant environmental factors (describe) Health beliefs and practices (describe) Personal responsibility for health & wellness: Client believes that health is vital and must be given proper attention. Name Dose/Amount Used Reason for Use Results/Effects Use of herbal and/or alternative medicines Mr. N. Occupational hazards (Current/past. Socio-cultural History Financial factors relevant to current adaptation (e. dentures. N. . mercury. Mr. N. risk for falls or skin breakdown) When he was ten years old according to the client. rape or molestation. shared that when he was 16 years old. Noon po ay pinapakain kami ng masustansiyang gulay ni nanay ngunit ditto kinakain ko na lang kung ano man ang inihain para sa amin. ³Ako po ay naliligo araw-araw. cleaning agents. Her mother works as a vendor. insecticides. solvents. work-related accidents. before his admission works as a construction worker. In line with his work are the toxins from the different working material such as cement and paint.Use of Over-the-counter /Non-prescription Drugs Client does not use OTC/ non prescribed drugs. military experiences. Use of assistive devices (Eyeglasses. canes.´ Ritualistic behavior/practices Client doesn¶t have any ritualistic behavior/ practices. hearing aids. loss of income.) Client don¶t use any assistive devices. exposure to violence or abuse. stressful job circumstances) Occupational hazards are the heavy equipments. falling debris such as hallow blocks and the risk for fall. deaf. Client verbalized. poverty or bankruptcy) A financial factor identified to Mr. Injury (Contact sports & sports-related injuries. revealed that his mother used to boil lemon grass every time he got cold and cough. Toxins (Overcome by automobile exhaust or natural gas. paint solvents. is Poverty. & etc.g.) Client don¶t have any impairment/ disability. exposure to lead. missing extremities. N. he was hit by a tricycle resulting to minor injury and abrasions. He added that it soothes his throat. V. chemicals in the workplace: farming pesticides. Impairment/Disability (Blind.
Mr. history of nicotine and caffeine should also be explored since these are aggravating factors of symptoms. he was not interacting to the nurses . ³uminom ako ng lason´. He verbalized. N. N. helping in household chores when 2 months prior to admission. Mr. include development of symptoms from onset & duration until admission. ³ kailangan lang natin manalig sa Diyos upang maunawaan nating mabuti ang nais niyang ipahiwatig sa atin. indicate if there is improvement or deterioration in relation to current episode. client displayed behavioral symptoms talking to self and crying suddenly. he experienced working in a construction to help his mother. job promotion). He was also not helping household chores and prefers to be alone. or intermittent. drinking and using of illegal drugs. when he was still young witnessed how their parents separated. Achievements during school days (curricular & extra-curricular) Mr. Alcohol and Substance Use History Explore possible client use of alcohol and drugs (to ascertain co-morbidity). job loss) or positive (e.´ Because of loss of financial support. he got many medals from different interschool basketball competition. N. History of Psychopathology Information concerning client¶s past psychiatric illness which may be a single event. beliefs & practices (describe) Mr.´ Educational history/background Highest level of education attained Elementary graduate Reasons for dropping out. still it helped them to sustain their daily needs. Mr. Client was apparently along well. is unemployed. appetite.g. History of Present Illness/Current episode or Precipitating Events Describe the situation or events that precipitated this illness/hospitalization which may be negative (e. claimed that he drinks alcohol and smokes every day before his admission at NCMH. He also verbalized. He blamed it to his friends who according to him influenced him in these vices. sexual functioning) should be noted.. Previous jobs work employment: Mr. was a basketball player during his school days. chronic. He also shared that when he was 16 years old. cognitive ability. had worked in a construction when he was 16 years old. Other job interests: Mr. believed that God has a good reason for allowing problems to set in his life. wanted to have any business that could help in financing their daily needs.g. N.. N. At his first week at NCMH. N. He was admitted at NCMH because according to Mr. He also believed that these problems would make him a better person in the future. he needs to quit school when he was in elementary. He shared that he has a lot of friends in their place who according to him introduced him to different vices such as smoking. According to him. N. Though he is not regular. Occupational background Current occupation: Currently. changes in somatic functioning (sleep pattern. N. ³ hindi ako mahal ni tatay« pinapanigan niya parati mga iba kong kapatid. he stressed. transfer or quitting school (if applicable) Client did not proceed to high school due to financial problem. He also admitted that he used drugs like marijuana.Religious/Spiritual values Religious/spiritual values.
Usual bowel pattern _every other day_ Constipation _3__ Diarrhea ___ Type of self-care assistance provided for either of these problems: Client usually increases his fluid intake to relieve him from constipation. he experienced burning sensation that was relieved by medication prescribed by his physician. No discharges noted. Problem with: Indigestion/Heartburn Client doesn¶t experiences indigestion/ heartburn (If yes. Ears: Pain ___ Drainage ___ Hearing Difficulty ___ Hearing Aid ___ Tinnitus___ Nose: (discharge) present of black heads noted. Frequency ______________ Urinary hesitancy _____ Nocturia _____ Pain/burning Currently client doesn¶t experience pain upon urination but he had shared that a few days after his admission. Dentures: Upper: _ (--) _ Lower _ (--) __ Problem with chewing/swallowing Client doesn¶t have problems with chewing/swallowing. Swelling not noted Discharge not noted Lumps not noted Dimpling not noted Practice self -breast examination? Client doesn¶t practice breast self examination. PHYSICAL ASSESSMENT Review of Physiological systems.even to his sister who admitted him at that place. His blood pressure is within the normal range. relieved by) ______________ Nausea/Vomiting Client experienced nausea and vomiting that can be attributed to current medication usage (If yes.__ Incontinence Client doesn¶t experience urinary incontinence. Frequency_________________________ Cardiovascular status: Blood Pressure (usual) 120/70mmHg Pulse (usual) 87 bpm History of: (Check all that apply) Hypertension ___ Palpitations ___ Heart Murmur ___ Chest Pains ______________________ Shortness of breath ____ Pain in legs___ Phlebitis ___ Ankle/leg edema______________ Numbness/Tingling in extremities ________________Varicose veins________________ Other significant observations Client doesn¶t have any cardiovascular problem. After 1 month. Eyes: Glasses ___ Contacts ___ Swelling ___ Discharge ___ Itching ___ Blurring ___ Double Vision ___ Other observations: Eyes are symmetrical. Presence of dirt was noted. Indicate with a (3) mark OR give a specific description. relieved by) _____________ ___________________________________________________________________________ Loss of appetite __Client doesn¶t experiences loss of appetite___ (Measures taken) _______________ _ History of Ulcers Client doesn¶t have any history of ulcers. Genitourinary/Reproductive status: Usual voiding pattern __5x a day approximately 12o cc of urine. Mouth: (lesions) lesions not observed Neck: (lumps) no lumps palpated Respiration: Normal 3Labored _______ Rate ___18cpm___ Rhythm __regular____ Breast: Pain/Tenderness Client doesn¶t feel any pain or tenderness in his breast. Gastrointestinal status: Usual diet pattern: Client doesn¶t have any diet pattern. He just eats what had prepared for them. he recovered and is now interacting with nurses until now. . Skin: Warm __3___ Dry ___3__ Moist _____ Cool _____ Clammy_____ Pink _____ Cyanotic _____ Poor turgor _____ Edematous _____ Evidence of Rash __3___ Bruising _____ Needle Tracks _____ Hair and scalp: Hirsutism _____ Loss of hair _____ Nails: (condition) Nails were not neatly trimmed. He also doesn¶t any history of hypertension. Food allergies: Client have allergy on sea foods especially shrimp.
Requires assistance with: Mobility (--) Feeding (--) _____ Dressing (--) _____ Hygiene (--) Toileting (--) Other (--) _____ Refusal to eat ___none___ Reason __________________________________________ Statement describing personal hygiene and general appearance: . Very low concentration reveals dilute urine. while high value signifies dehydration. Skeletal Deformities (describe. frequency.015 Protein: + 1. turbid or strong urine odors are signs of urine tract infections. Coordination (describe limitations. urine protein is present in a very less amount and is rarely detected.1 Activity/rest patterns Exercise (type. if applicable) Client can perform fully the degree of range of motion. For a healthy person. he sometimes mingle with the other patient. etc. Patterns of awaking during the night: Client doesn¶t experience any disruption in his sleeping time.) Client doesn¶t use any sleeping aids Insomnia _-Hypersomnia --___ Reversal of sleep pattern Client doesn¶t experience reversal of sleep pattern. Pain (describe) Client did not feel any musculoskeletal pain. Personal hygiene/activities of daily living (ADL): Patterns of self-care: Independent Client performs his activities of daily living independently. Nausea and vomiting Altered laboratory test values and possible significance (If applicable) Altered laboratory test value Normal Value Significance Urinalysis: Date (3-6-11) Near transparent or yellowish Transparency: Slightly Turbid Clear colored urine signifies normal conditions. Negative test result reveals less chances of infection. He usually sleeps at night and during the day. listening to music Pattern of sleep: Number of hours per night: 6hrs Use of sleeping aids (music. Presence of protein in very low concentration. Higher protein levels than this is a sign of proteinuria. Leisure activities: sleeping. He doesn¶t seek help from other people in doing his daily activities. Specific Gravity: 1. duration) Client involved himself in exercises such walking every early in the morning. While cloudy. say 10 mg/100 ml or 150 mg/day is normal.010 -- WBC: 14-19/ hpf 0. if applicable) kyphotic spine Medication side effects (What symptom(s) is/are the client experiencing that may be attributed to current medication usage? Dizziness. Feel rested upon awaking? The client feel rested upon awakening and ready to face another day. a positive result is a warning sign for elevated production of WBCs and urinary tract infections. if applicable) Client¶s movements are coordinated with each other.Any Genital lesions: Not able to observed Discharge_________________________ Odor _______________________________ Musculoskeletal status: Weaknesses (--) _ Tremors (--) Describe ________________________ Degree of range of motion (describe limitations.
Her general appearance is neat and clean except for her hair which has dandruff. Speech Impediment (Describe if applicable Mr. He answers questions appropriately.The client did his personal hygiene. homicidal or suicidal thinking. He has good eye contact while talking to me. N. Speech Clear Loose association Rumination Speech logorrhea Coherent Flight of ideas Tangential Slurred Speech Aphasic Circumstantial Incoherent Perseveration Slow Neologisms Verbigeration Impoverished Describe the speech pattern Mr.Recent: Loss Intact Suicidal Memory ± Remote: Loss Intact Describe and support the underlined thought content Mr. Other observations Thought Content Delusional Suspicious Obsessive Homicidal Memory . He was always constant to his answers especially when you try to clarify the content of what he had said. MENTAL STATUS EXAMINATION Underline as many criteria under each category as applicable to the client General Appearance Uncooperative Cooperative Unkempt Well-groomed Older looking than age Tense posture Bored Angry heavily made-up Younger looking than age Relaxed Underweight Overweight Bizarre behavior observed (Describe postures or psychomotor activity) Mr. the client smiles. He doesn¶t have any problem like delusional. He usually slouches when walking. He doesn¶t have any speech impediment. Emotions: Mood/Affect Happy Euphoric Depressed Sad Apathy Anxious Flat Frightened Blunted Angry Inappropriate Elated Labile Congruity of mood/affect (Describe how manifested) Client¶s mood/affect is appropriate to an event just like when an event have a happy theme. N memory from his past up to the present is still intact. speaks clear and comprehensible. has no speech impediments. II. N. Other pertinent physical assessment not previously mentioned: no other pertinent data not mentioned. have a kyphotic posture. Thought Process Clear Logical Illogical Blocking Rapid flow of thought Concrete thought process Easy to follow Relevant Confused Loose association Circumstantial Capable of abstract thought Describe and support the underlined thought process . N.
logical. doesn¶t show any perceptual disturbances. N. He could able to tell about the recent activities and people who conduct such activity. N.lethargic ___________ Stuporous _________ Responds to external stimuli________ Memory Remote His memory about his past is still intact. Insight Client¶s perception of illness and expectations of hospitalizations. N. He knows his present situation. He could still remember the time when his parents separated. memory about recent happenings is still intact. is oriented to time. this question. Knowledge and Judgment Describe client¶s answer to a hypothetical question (What will you do if you find a fifty peso bill while going around SM?) When I asked Mr. Person: Y N c. Oriented to a. He is always willing to express his thoughts and feelings. N. alert and awake___3___ Drowsy. N. how their family became affected by that separation. he can now understand his situation with no regrets. . Time: Y N b.confused. or inhibit the expression of behaviors and feelings Every time I asked Mr. He could still keep in mind. Recent Mr. relevant and easy to follow. person and place. once shared that he had experienced some episodes of auditory hallucinations before he was admitted. N. Situation: Y N Describe other significant observations Mr. regarding sensitive. Cognition and Sensorium Level of consciousness Conscious. he answered me that he will return the money to the rightful owner. His answer was based on his idealistic view that a person must return anything that does not belong to him. or circumtiality upon giving that information. Although Mr. coherent. Impulse Control Describe client¶s ability to delay. he now verbalized that he no longer hear those voices. modulate. Perceptual Disturbances Illusions Hallucinations Depersonalization Derealization Describe and support the underlined thought process Mr. I could observe that he knows how to control his feelings. He doesn¶t show looseness of association.All information coming from the mouth of the client is clear. Focus/Concentration Client can easily be distracted by some external stimuli such as noise and people playing basketball. Place: Y N d. He sees things as it is. Orientation Encircle Y or N (Yes or No). Client has a good insight regarding his present situation and he knows what had brought him to NCMH.
Superego identity is the accrued confidence that the outer sameness and continuity prepared in the future are matched by the sameness and continuity of one's meaning for oneself. N. because they are reminders of the feelings for the parents and the trauma that resulted from all that. The ability to settle on a school or occupational identity is pleasant. Erickson¶s.III. This begins at puberty involves the development of the genitals. those feelings for the opposite sex are a source of anxiety. However. and (3) the not-me. IV. adolescent is concerned most with how they appear to others. He was confused by the different changes he newly met. 14-24 years old. Erikson stressed that in this stage. He coped with it negatively by drinking and smoking. had faced different stressors in life which he did not cope well and had hindered him to achieve the sense of identity. which grows from experiences of punishment and disapproval. On the Sullivan¶s Interpersonal theory. when a person can freely experiment and explore²what may emerge is a firm sense of identity. While on the Freud¶s Psychosexual Development. as evidenced in the promise of a career. There were no any psychological tests that were reflected on the chart of the client. which results from experiences with reward and approval. the child develops a sense of sexual identity. The µMe¶ personification which usually observed during infancy children acquire three ³me´ personifications: (1) the bad-me. PSYCHOLOGICAL TESTS Document results of psychological tests that were administered to the client (If any). the client is in the genital stage. which allows a person to dissociate or selectively not attend to the experiences related to anxiety. The problem of adolescence is one of role confusion²a reluctance to commit which may haunt a person into his mature years. Sullivan believed that people acquire certain images of self and others throughout the developmental stages and he referred to these subjective perceptions as personifications. COPING AND ADAPTATION RESPONSES Current resources Growth and stages of development (Based on Freud¶s. (2) the good-me. and libido which begins to be used in its sexual role. The psychosocial crisis in this stage is the identity VS role confusion. an emotional and deep awareness of who he or she is. the client belongs to the stage of adolescents. On Freud¶s Psychosexual theory he had reached the . Late adolescence is characterized by a stable pattern of sexual activity and the growth of the syntaxic (Experiences that can be accurately communicated to others) mode. is in the late adolescence stage. as young people learn how to live in the adult world. Mr. Late adolescence may start at any time after about age 16. a psychological moratorium. but psychologically. In later stages of Adolescence. Sullivan¶s Theorieswhichever is/are applicable) Theoretical explanation Based on the Erickson¶s Psychosocial Development. Actual behavior Mr. N. it begins when a person is able to feel both intimacy and lust toward the same person. Given the right conditions²and Erikson believes these are essentially having enough space and time.
He always has the feeling that other would as well neglect him. all the finances were turned on to his sister. verbalized that he just accepted his destiny or fate. Maladaptive. friends were not able to visit him. opportunities. As a result. This was because of his past experiences with his father wherein he can¶t find love from him. assistance from relatives His mother worked as a vendor before she became ill. or Dysfunctional Mark with a (3) and Identify: (may be several) Pattern of Coping with Stress ____ Fight or flight 3 Dependence on other¶s decision 3 Acceptance of fate or destiny ____ Use of physical illness 3____ Blaming others/self 3 Use of problem-solving coping skills Classification ________________ Maladaptive Adaptive _________________ Maladaptive Adaptive B. N. He searched for work to help his mother. N. He would always relate this experience with his relationships with other people. relationships. After he became. community) . he would often hide his feelings and emotions within himself which is a negative way of coping to stress. he said that he could still feel their love and care. Consider the following elements: How does the client solve his/her problems? Classify each into Adaptive. He further stressed that his father always gives good complements to his other siblings and when it comes to him all his achievements were neglected. Based on the Sullivan¶s Interpersonal Theory. He found a work in a construction with his uncle. Previous patterns of coping with grief and stress Significant losses / changes /grief responses. Support systems (before and during admission) Family All his family members gives him support and encouragement until now. job. All the finances before were supported by his mother and his sister who worked as a seamstress. Mr. It was further worsen when they were forced to quit school because their mother can¶t pay all their school fees. (Generally. N. Economic security (sources of family income. his support systems were his friends. especially inside the Pavilion 1. He shared that he was upset during those time especially when he witness his mother depression. A. Situations where and how patterns of coping were applied Mr. how does the client respond to loss of significant persons. the nurse and the attendant. & etc?) He was greatly affected when h is father live them. Palliative. Friends Although Mr.final stage which is genital wherein before he had involved himself to have true intimacy but because of uncontrollable circumstances that feeling was vanished. Community: On the community. Role contributions and responsibility for others (family. acquired the bad-me personification.
He would always stress that he find peace in silence. Just take for example his experience when his parents separated. he usually focused on the intellectual aspects to avoid unacceptable emotions (intellectualization). N. He had also added during our conversation that he never felt love from his father and he associated this with a logical reason rather with the real reason (rationalization). Kaya nga wala akong makitang regular na trabaho. He sometimes blamed himself for their misfortune (Introjection). he once verbalized. Characteristics that the client would want to change about self . During our interaction. N. level of anxiety when it comes to mild are calm and cooperative. Level of self-esteem: (Underline one) LOW MODERATE HIGH Characteristics that the client likes about self According to Mr. Ego defense mechanism (Underline as many as applicable) Projection Intellectualization Reaction formation Compensation Conversion Substitution Suppression Denial Fantasy Symbolization Denial Isolation Undoing Rationalization Religiosity Introjection Fixation Splitting (Dissociation) Displacement Repression Sublimation Regression Identification Describe how the identified responses are used by the client When Mr. Level of anxiety (Underline particular level and the behaviors that apply to it) MILD MODERATE SEVERE PANIC Perceives environment correctly Unable to concentrate Confused Depersonalization Excessive hyperactivity Calm Friendly Passive Alert Impaired attention ³Jittery´ Cooperative Hypervigilant Tremors Rapid speech Withdrawn Disoriented Fearful Hyperventilating Misinterpreting the environment (hallucinations/delusions) Obsessions Compulsions Somatic complaints Other behaviors (Describe) Mr. He would always keep in mind what his elder sister told him that he must always stay away from conflicts. opened up about his experiences that cause his anxiety. he told me nothing instead he gives more emphasis on things he done to help his family to survive. 2. When I asked him of his feelings during those times. he worked in a construction.´ 3. Psychosocial responses 1. he likes his being simple and silent type. He perceives his environment correctly. He further said that he would always keep himself distant from other client to avoid any conflicts to form. He doesn t suspect me even in our first day of interaction. N. Adaptation responses A. ³Ako kasi hindi nakapagtapos. He was calm and he doesn t easily escalate. it was evidenced by the client s cooperation during our activity and interaction however he can easily be distracted. He verbalized that he gives all what he earned to support all their daily needs.Before he was admitted at NCMH.
groomed except for the dandruff on his hair. Physiologic responses Psychosomatic manifestation Describe any somatic complaint that may be stress-related. relieved by/worsened by use of prescribed/over-the counter drugs) Client once complained discomfort in sleeping due to an abscess in his back. was now on the stage of acceptance. etc.If there is a thing that he want to change in his self. Formulate Discharge Plan (Use separate sheet) VI. e. He opened up that he has fear of being ignored. intensity. headache. 7-10. It was relieved by the use of medication prescribed by the doctor. N. ANGER BARGAINING DEPRESSION ACCEPTANCE DENIAL Describe client¶s behaviors that are associated with this stage of grieving in response to loss or change Mr. 4-6. This was evidenced based on the client¶s verbalization that he understand and accept whatever life he has right now and whatever past he had gone through. Nursing Diagnosis Actual Nursing Problem Impaired social interaction r/t low self-esteem secondary to undifferentiated schizophrenia Potential Problem _________________________________________________________________________ _________________________________________________________________________ B. mild. pain: chest pain. it is not painful. According to client. Formulate Nursing Care Plan (from the identified nursing diagnosis. Stage and manifestation of grief over life changes (impaired psychosocial functioning) Underline one (1) only. had a good eye contact while we were having our interaction. moderate. Objective assessment of self-esteem Eye contact Mr. (onset. please use separate sheet) C. location. B. He opened up information without any hesitation. N. EVALUATION OF PSYCHOTHERAPEUTIC AND OTHER INTERVENTION Evaluation of NPR . severe). General Appearance Mr. N. that is his being introvert. quality. was neat and well. V..g. scale of 1-10: 1-3. other anatomical pain or discomfort. He was cooperative during our interaction. DIAGNOSES AND INTERVENTIONS Integrating Nursing Diagnosis and Interventions with DSM-IV-TR Diagnosis A. origin. Participation in group activities and interaction with others (in general) Client participates in group activities however most of the time he would just keep himself in silence. 4.
He verbalized that he was happy because whenever a dance steps were introduced to him. was cooperative. was also participative. Mr. and a house which symbolizes the place where he came from.PM was able to follow all the instructions without any complains. Calisthenics During our calisthenics. N. My interpretation for this is that Mr. N. M. References: (Use APA format) Keltner (2007). was able to follow the steps given by our group mates. (2004) Nurse s Pocket Guide. Psychiatric nursing 6th ed. N. N. He was able to identify the different parts of newspaper. Dance Therapy Mr. & Murr.. was able to express his creativity through applying water color and joining pieces of materials given to them. he could exercise her body and could make him body active and alert. N. he stated that it just came up into his mind. 9th ed. Newspaper Reading During our newspaper reading.I was glad that I had gained Mr. N. really missed his family as well as his place. Doenges. N. he formed a cart with trees surrounding it. A. Mr. was able to follow instructions in our food preparation. M. Moorhouse. Community Singing He was also able to participate during the community singing by joining the group in singing. He verbalized that he really likes the drawing that we had shown to them because it resembles the place where he came from. . Other Activities Food Preparation Mr. he draws mountain. sunrise. On the mellow music. He was able to express his feelings and insights regarding the poem. He did his best up to his optimum level of functioning. He was also able to express what work he wants to engage if ever he will be discharge. F. He verbalized that he was glad that he had made a sandwich with a different taste. trust. Though he sometimes kept himself in silence during group activities but when our conversation begins. He also draws lines which form a person which is actually him. Occupational Therapy In arts and craft. He opened up much information without any hesitation. During our conversation he verbalized that he like our community singing because we didn¶t just introduce a song but with actions. N. Remotivation Therapy During the remotivation therapy Mr. On the fast music. he involves himself well. The steps were familiar to him. He was also able to express his thought regarding the article that we read during our conversation. Responses of Clients to Different Therapeutic Activities Music and Art Therapy through Art Appreciation Mr. During his explanation. was cooperative during the music and art therapy. Mr. during the dance therapy. he admitted that he had hard time in assembling the said materials however he was glad after he had done and seen his work. During our conversation. Play Activities We were not able to have play activities because of some unexpected events..
M.. & Murr. (2006) Nursing Care Plans 7th ed. A. . F.. Moorhouse.Doenges. M.
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