Name: Gacila, Mark Calvin M.

Age: 44 yrs old

Address: 197 D. Marular A, Caloocan City
Religion: Catholic
Son: Matthew Garcila 21 yrs old studying BSN.
Uncle: the one who bring him in CHS Gerson Mendoza

Occupational History: Computer Software Design and programming at AMA

Worked in 2yrs at Makati SM
Marital History: The client stated “Nabuntis ko kaya pinakasalan ko” and added “pinikot lang
ako non”. He also said “hindi ko na alam kung nasaan siya ngayon pero alam ko na may iba na
siyang pamilya bago ako mapasok sa ganitong institusyon”.

Admitted to first SUNSHINE Institution since October 2016

And transferred to CHS August 2018

CHIEF COMPLAINT:
Non Compliance to meds
Verbally Assertive

DIAGNOSIS
Schizophrenia, multiple episodes in partial remission.
Multiple episodes: Symptoms experienced by the client. Mood swings
Partial Remission: Symptoms of major depression in abusive of drugs. The client stated
“nagsimula akong gumamit ng drugs noong umalis ako sa una kong trabaho dahil sa pressure
at hirap ng trabaho, nagtry ako mag apply sa iba pero nireject ako ng nireject ng paulit ulit,
tapos ayon nadepress nako ng tuloy tulo”

TEST EXAM:
X-Ray: Lungs is clear
Heart is normal
Diaphragm costophrenic sulci and thorax are intact
Note: a chest radiograph sign usually indicative of a small pleural effusion. a buildup of fluid
between the layers of tissue that line the lungs and chest cavity.

MEDICATIONS:
Clozapine 100mg per tab——— intake 1 tab before bedtime
Atypical antipsychotic medication for treatment-resistant schizophrenia
Levomepromazine 100mg per tab——— intake 1/4 tab before bedtime
is a neuroleptic agent (an antipsychotic) which is commonly used to relieve nausea and
vomiting in palliative care settings.
Drugs used to treat nausea and vomiting are known as antiemetics.
Fluphenazine 25mg/ml ————- 1 ml through IM every 4 weeks
is a typical antipsychotic used for the symptomatic management of psychosis in patients
with schizophrenia.
Escitalopram: 10mg per 1tab———- 1 tab daily
medicine to treat depression and anxiety - NHS.

SLEEP PATTERN
6:00am gising
6:30 am VS
7:00 am morning exercise
7:30 am breakfast
8:00 am Medications
9:00 am Bath time
After bath time SNACKS
1-3:00pm siesta time
8:00pm medications
9-10:00 night night

NURSING PROGRAM REPORT

BP taken
Participated in morning exercise
NPI done
Medications given and recorded
reality and re-orientation done
Calm and manageable
Personal and hygiene done
Participated in all activities during grand socialization
Observed

NURSING INTERVENTION
❤️Start Milieu Therapy
❤️Continuous intake of medications
❤️Treatment Adherence——————Management of Schizophrenia requiring regular
medication intake and regular follow-up consultations. Medications and proper family support
are necessary to control symptoms of his conditions.