Dr. Yanga’s Colleges, Inc.

College of Nursing

U N D IF F ERE N TIA TE D

SCHIZOPHRENIA
A CASE STUDY

Submitted by:
CONESE, Chamel Rafaela M. DILAN, Marites S. GARCIA, Maria Corazon G. GUEVARRA, Michelle DC. JACINTO, Clarissa C. LITIMCO, Rhesa D. MARATAS, Concelia L. NICOLAS, Jose Orlando M. ORTEGA, Raymond M. PALON, Mayrinell Candy R. SALONGA, Irenaly GROUP 2

Submitted to:
Luther Siosana, RN MAN Clinical Instructor 15th of July, 2011

INTRODUCTION
Schizophrenia is a chronic, severe, debilitating mental illness. It is one of the psychotic mental disorders and is characterized by symptoms of thought, behavior, and social problems. Despite its relatively recent history, schizophrenia has been described throughout written history. Ancient Egyptian, Hindu, Chinese, Greek, and Roman writings described symptoms similar to people being possessed by spirits or evil powers. (Medicinenet.com, 2011) Currently, most researchers and clinicians believe it results from a combination of both brain vulnerabilities (either inherited or acquired) and life events. This widely adopted approach is known as the 'stress-vulnerability' model, and much scientific debate now focuses on how much each of these factors contributes to the development and maintenance of schizophrenia. As with most other mental disorders, schizophrenia is not directly passed from one generation to another genetically, and there is no single cause for this illness. Rather, it is the result of a complex group of genetic, psychological, and environmental factors. Schizophrenia is often described in terms of positive and negative symptoms. Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. They can include delusions, disordered thoughts and speech, and tactile, auditory, visual,olfactory and gustatory hallucinations, typically regarded as manifestations of psychosis. Positive symptoms generally respond well to medication. Negative symptoms are deficits of normal emotional responses or of other thought processes, and respond less well to medication. They commonly include blunted affect, alogia, anhedonia, asociality, and avolition. Research suggests that negative symptoms contribute more to poor quality of life, functional disability, and the burden on others than do positive symptoms. As is true with virtually any mental-health diagnosis, there is no one test that definitively indicates that someone has schizophrenia. Therefore, health-care practitioners diagnose this disorder by gathering comprehensive medical, family, and mental-health information. According to the DSM-IV-TR, to be diagnosed with schizophrenia, three diagnostic criteria must be met: First, presence of characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period delusions, hallucinations, disorganized speech, grossly disorganized behavior or catatonic behavior and negative symptoms. Second, Social or occupational dysfunction, and third, Significant duration (continuous signs of the disturbance persist for at least six months.) The primary treatment of schizophrenia is antipsychotic medications, often in combination with psychological and social supports. Hospitalization may occur for severe episodes either voluntarily or (if mental health legislation allows it) involuntarily. The nurses’ role in the treatment of schizophrenia is primarily focused in promoting client’s participation in follow-up care and treatment. Accepting, empathizing and being nonjudgmental of the clients’ sexuality must be done to establish a trusting relationship with the client. Private area should be provided to discuss fears or concerns about sexuality and victimization helps patient to disclose and discuss their feelings. Referrals to outpatient treatment programs or therapy groups might be necessary.

physical examination and research-based evidences. management and causes that will help to minimize the number of Schizophrenia cases. Come up with patient and problem-centered nursing interventions that will address the actual and potential problems of the patient with the use of the information from the data gathered. its prevention. Evaluate the results of the actions done and take note of the need for continuous giving of care. interview with the patient and patient’s significant others. its management and causes.  For the Patient  Help them understand his/her disease. For the Nursing Profession  Enhance the knowledge of the students and to promote proper management of the client concern and through actual application of nursing process. head-to-toe physical examination and related research. . interview. For the Community  Inform the community about the disease process.OBJECTIVES GENERAL OBJECTIVES Conduct a comprehensive case study on Schizophrenia utilizing objective and subjective data gathered through review of patient’s records. SPECIFIC OBJECTIVES   Gather data through review of patient’s record.

he developed industry as indicated by working along with his stepfather. he was with his stepfather (D. He lost his mind. While on his early 20’s. HISTORY OF PRESENT ILLNESS J. shato.NURSING HISTORY IDENTIFICATION This is the case of J. Magsaysay Sur. Achievement of generativity is not reached as evidenced by being a beggar and consequently by the admission in the institution. Then all he remembered was that he was brought in a van and subsequently to Mariveles Mental Hospital. J. Bansale) whose relationship he explained “Masaya naman kami. had delusions. currently residing at YMCA Compound. During this time. Because of his addiction in playing marbles. In Lawrence Kohlberg’s Stages of Moral Development. . as a child. that time.B was born to a mother (G. Roman Catholic. the client met a person named Bubot he met outside the movie house where his mother was working as a ticket inspector that time. the client is on Level 1 (Pre-conventional) Stage 2 (Instrumental-Relativist Orientation) wherein actions are taken to satisfy one’s needs. he decided to quit studying while on his 1st grade in elementary. The latter was a laundrywoman that time. He became a beggar at YMCA.B’s mother was passive to what his stepfather does. They gambled using their earnings and learned vices like smoking and alcoholism. there came an instance that he hit his mother for he said that he lost himself that time. J. he developed intimacy as indicated by marked good relationship with his best friend. Ayaw ko umalis sa YMCA”. a 38(?) year-old male. DEVELOPMENTAL HISTORY In Erik Erickson’s Psychosocial Theory.B. His stepfather was an alcoholic and was involved in gambling. as the nurse verbalized. hallucinations and wandered. tumbang preso and catching fish on canals.B was reported of being aggressive and seen talking to himself often. says “Nag-iipon ako ng basura. This enabled him to join his father in collecting garbage. okay naman ang pagsasama namin”. This is evidenced by quitting going to school because of his interest in playing marbles. He grew up like any other normal children who were fond of playing marbles. Cabanatuan City endorsed by a DSWD worker to Mariveles Mental Hospital on July 9. CHIEF COMPLAINT “Nagsasalita siya mag-isa at marumi ang katawan”. Pascual) who was separated. JB and Bubot ventured together as salesman of a television accessory. The client. 2003 with the diagnosis of undifferentiated schizophrenia. While growing up. In young adulthood.

Tarlac and the like. Presence of psychiatric or neurological illness among first-degree relatives and history concerning second degree relatives are neither known. HYGIENE Client bathes himself twice a day on a river nearby. EDUCATIONAL HISTORY JB just reached Grade 1. The client states that he also loves going out with his friends and goes on road trips on places like Baguio. Client drinks approximately three and a half (3 ½) glasses of water from nawasa. Voices no dislike and food intolerances. Meals are mainly composed of vegetables.PAST HISTORY MEDICAL HISTORY WITH IMMUNIZATION Client is a smoker and an alcohol drinker. . Can write and express his feelings in Tagalog. Had undergone suturing of the left elbow secondary to fall. According to the client. diabetes mellitus and cancer in his family is not known by the client. His micturition pattern depends upon how much water he drinks. SOCIAL HISTORY PTA. FAMILY HISTORY The presence of hypertension. Client can read in Tagalog. the client works as a construction worker. Client is a 6 pack-year smoker. He has a normal bowel elimination pattern. He used to have friends outside their home and be able to develop a romantic relationship with the opposite sex. he was never been hospitalized nor have experienced any illness except colds which was not given prompt treatment. The client does not know if he has been immunized while he was young. a television accessory salesman and a garbage collector. fish and processed food. The client can write his name. NUTRITIONAL ELIMINATION HISTORY WITH PATTERNS OF The client eats three times a day.

He can remember having three girlfriends who.SEXUAL HISTORY WITH FANTASIES AND DREAMS The client is sexually-active. Client prays. Go to church approximately twice a week. Verbalizes belief in God. Do sexual intercourse during his free time (whenever he doesn’t have work). . VALUES Religious preference is Catholic. JB had sex even if they are not his girlfriend. each he went to the hotel for lovemaking.

answers eagerly) Hair is semi-calbo. Scars unequally distributed on lower extremities. Tanned.) Warm to touch.5C 72bpm 18bpm 100/80mmHg AREA Neurologic FINDINGS July 13. Good skin turgor (3 sec. SIGNIFICANCE An example of psychomotor agitation Hair & Scalp NORMAL Calluses and lichenification are due to manual labor. Fine hair evenly distributed on arms and legs bilaterally. smiles upon seeing the nurse. slightly untidy. Long-length.PHYSICAL ASSESSMENT GENERAL SURVEY Patient received standing. Client is too active (eg. With scar on left elbow (3 inches). Skin Nails NORMAL . Dry and rough. Wears blue shorts and blue t-shirt and does not seem to have clear attention to details. hard. Sitting still with eyes looking away occasionally from the examiner. Dress is appropriate to the weather. VITAL SIGNS Time Temperature Pulse Rate Respiratory Rate Blood Pressure JULY 13. broken and basically immobile. Good capillary refill less than 2 seconds. No clubbing. With calluses on both hands and lichenification on both heels and palms. 2011 (8:45AM) Client appears relaxed. Nail plate firmly attached to the nail bed. Scar on left elbow is due to falls. Dress dry. Dirty. Scalp is dry. 2011 8:45 AM 37. beau lines or splinter hemorrhages. Slightly soiled and wrinkled clothes. Neither tenderness nor masses was found. With white hair unequally distributed. Scars on lower extremity are due to climbing trees. Without presence of edema.

(CN VII) With 1-peso-coin-sized scar on right temple. edema or lesions and freely closeable bilaterally. CN VI) Equal in size. Trachea in midline. Lymph nodes non-palpable. PMI at 5th ICS left midclavicular Scar on left temple is due to being hit by stone. (CN VIII) Color is symmetric with the face. moist and free from exudates. Tongue midline. No nasal flaring. CN IX) Gag and deglutition reflexes intact (CN IX) Client able to stick out his tongue (CN XII) No pulsations visible. Impacted cerumen on both ears negative. NORMAL NORMAL Due to history of smoking and poor hygiene. With fine facial hair. With incomplete number of misaligned discolored teeth. Symmetrically rounded and in midline. asymmetry or inflammation. Eyebrows equally distributed. Hearing aids discharge absent.Head & Neck Eyes Ears Nose Mouth & Throat Cardiac Normocephalic. Face is symmetric with a round appearance. Buccal mucosa and tongue were white and slightly dry. Able to identify taste (CN VII. Nasal septum. Adynamic precordium normal rate. Thyroid non-palpable. Pharynx normally cobblestoned without exudates.and postauricular lymphnodes non-tender. deviation or perforation. Nasolabial folds symmetrical. Client is able to perform the six cardinal points of gaze. Pre. No vibrations are palpated. (CN IV. Lids without ptosis. Visual acuity grossly normal (CN II) PERRLA (CN III). regular rhythm. Nares patent. (-) Romberg test. Gums without hypertrophy. Client is able to clench jaw. No deafness. Slightly dry lips present. External structure without deformity. NORMAL . 2cm apart without protrusion. Client is able to smile and elevate eyebrows. No lesions or ulceration on floor of mouth. (CN V). S1 and S2 heard upon auscultation. Client is able to identify smell of alcohol (CN I) No lesions and ulcerations. Exhibits facial response to touch. midline without bleeding. Without lumps or lesions. and mustache. Due to agitation. uniform convergence. Scar on left submandibular area (1 inch). Neck non-tender. Unpurposive eye movements. Client has beard from the temples to the chin. No tenderness. moderate in size without lesions. Frontal and maxillary sinuses non-tender. Scar on left submantibular area is due to boils. Palpebral and bulbar conjunctiva is clear without lesions noted. No murmur. Nasal mucosa is dark pink. Neck symmetrical without masses. Gums dark and moist without inflammation. scars or pulsations visible. Auricles and mastoid process non-tender. Bruits absent. Eyes are chinky. Irises uniformly black.

Pinag- . Sunken umbilicus. Hair is black with unequally distributed white hair. rubbing the chin. Wears blue shorts and blue t-shirt and does not seem to have clear attention to details. Dress is appropriate to the weather. No tenderness. Sitting still with eyes looking away occasionally from the examiner. and rubbing the scalp) MOOD AND AFFECT Mood is happy. pulsation or peristalsis noted. Good ROM without tenderness in the upper and lower extremities. (-) Psoas sign (-) Murphy’s sign (-) Rovsing’s sign. Spasticity. Client’s posture while sitting is slouched. rigidity and flaccidity absent. Gestures and facial expressions are appropriate to what the client is saying with different hand movements especially when thinking (interlacing fingers. Toenails untrimmed. Affect is blunted (with few observable facial expressions). No tenderness. “Karamihan sa mga binibigyan nila (nurses) ng gamut ay namamatay. Client feels all-knowing as reflected by the statement. Fremitus is symmetric. as evidenced by smiling while having blank eyes. Client able to shrug shoulder against resistance (CN XI) NORMAL Abdomen NORMAL Musculoskeletal NORMAL MENTAL STATUS EXAM APPEARANCE AND BEHAVIOR Client appears active (participates eagerly on activities). No effusion. Gait is unsteady (walks like he has unequal leg length). unlabored and regular Rounded. lesions. (-) Balloning. No adventitious sound noted. No edema and joint swelling. Respirations even.Thorax and Lungs line. Client’s posture upon standing is upright. “Na-enjoy ko ang ginawa natin (therapy)”. Anhedonia is absent as evidenced by the statement. at times. Affect is inconsistent with mood. striae. Umbilicus in midline without discharge. Neither hepatomegaly nor splenomegaly. Bowel sounds of 12/min during auscultation. symmetrical without masses. Muscle strength 5/5 all throughout. Without pulsations or lesions. Presence of hair without bruises was also noted. Slightly soiled and wrinkled clothes. (-) Ballottement. Affect is congruent with thought content as evidenced by the client saying “Masaya kami ng girlfriend ko” in a happy intonation while smiling.

Unable to perform backward 100. kung matinik ay malalim. Tones and pitch of voice appropriate to statements. person and place. depersonalization.” . Speech is slurred. kung may tsinelas ka e hindi. INSIGHT Insists that he is not mentally-ill. Client exhibits thought blocking as evidenced by abrupt cessation of speech. Hallucinations. compulsions.” Writes name and draws/copies simple figures.eeksperimentuhan niyo kami. Volume is loud.’’ Short-term memory intact as evidenced by being able to recall the three objects shown and named earlier. parang ang mga tao yan na masaya sa bahay. suicidal thought are not present. Parang mga tao yan masaya sa bahay. He also exhibits circumstantiality as evidenced by the statement “Masaya ang mga ibon pag nakakakain ng mga prutas. Words are common. JB answered “Ipagtatanung-tanong ko at kung walang may alam e itatago ko na lang. delusions. SENSORIUM Oriented to time. Unable to interpret the proverb “Ang naglalakad ng matulin. Speech rate is fast. phobias. instead he says he is normal (a man picking up garbage) JUDGMENT When asked “Ano ang gagawin mo pag nakapulot ka ng wallet na may pera”.” SPEECH Client converses in Filipino. Can perform serial 7’s up to 42. Remote memory is intact as evidenced by being able to recall how he was brought to the institution. obsessions.” He exhibits alogia (lack of substance in what the client says) as evidenced by saying “Ewan ko” usually. Blocking of thoughts evidenced by hesitant speech. THINKING Thoughts illogical and disorganized as evidenced by circumstantiality. illusions. Client is alert.” His interpretation is “Kung wala kang tsinelas syempre matitinik ka. Tuwing alas-tres ginigising ako ng paghuni ng ibon. Recent memory is intact as evidenced by being able to recall his activities three days ago. Able to tell the similarities between a cat and a dog. Answers questions with hesitations.

rules and limitations of the relationship with the client to establish a therapeutic environment Establish an agreement or contract which includes meeting time and place. be consistent. Adjust client in dealing with physical and emotional dimensions. all to establish trust and rapport. feelings. it is also ideal to have the same nurse to attend to the client all throughout. Provide information about condition. beliefs. . fears and feelings that could have an impact on interaction and relationship with the client. and healthy relationships. Examine values. Discuss about setting limits on how much information the client discloses on group setting. It is ideal to have a male nurse for a male psychiatric client. TERMINATION PHASE  Guide the client in their own identification of the specific changes in thoughts. effective communication. Perform self-exploration to analyze personal/professional strengths and limitations. prognosis and treatment needs of the client. goal. Private area should be provided to discuss fears or concerns and helps client to disclose and discuss their feelings. and behaviors that have occurred.NURSING INTERVENTIONS PRE-ORIENTATION PHASE   Prior to the actual meeting. Accept. length of meeting time. and a female nurse to a female client. attitudes. empathize and be nonjudgmental of the client. ORIENTATION PHASE     Define roles. frequency of meetings. WORKING PHASE        Provide client with interactions/experiences that will help to uplift self-esteem and develop sense of personal power. review the client’s record and other sources of pertinent information to have background information of the client’s condition. Provide clarification and education that might be needed about functioning. confidentiality and its limits. To establish trust. show congruence in verbal and non-verbal communication. Provide different therapies to facilitate holistic development.

   Encourage clients to form relationship with future counselors. Discuss the clients reaction to the relationship regardless of the length. and new fiends by pointing out benefits from the nurse-patient relationship. foster treatment compliance and promote continued growth. frequency and intensity of the relationship. Finalize referrals to appropriate resources which provides support. .

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Gusto ko na umuwi sa amin. hindi mo kailangang magsalita pwera na lang kung gusto mong makipag-usap. MAKING OBSERVATION Verbalizing what is observed in the client for validation and to encourage discussion. The nurse had self-awareness activity. OFFERING SELF Making self available and showing interest and concern. WORKING PHASE Mukhang masaya ka ngayon Junjun? Jun-jun (client) gestures opening of mouth and smile. Andito ako ngayon para tulungan kang makagawa ng hakbang para masolusyonan ang kalagayan mo. Cabanatuan City. “Magandang umaga Mang Jun-jun”. Kamusta ka ngayon? may gusto ka bang sabihin o ikwento sa amin? “ok lang. namamasyal sa park. Ako si Icor at siya naman si Talit. pumunta kami sa QUESTIONING Paano ba ang naging relasyon mo sa pamilya mo nung nasa inyo ka pa? QUESTIONING .yung pamilya ko gusto ko na sila makita. ORIENTATION PHASE “Magandang hapon. kumakain kami sa jollibee. “nagsasalita mag-isa” to name a few. Kami ang mga nurses mo ngayon at sa mga susunod pang pagkikita natin. Client is endorsed by a DSWD worker. “mahaba ang kuko at balbas”. Using open-ended questions to achieve relevance and depth in discussion.THERAPEUTIC COMMUNICATION NURSE CLIENT THERAPEUTIC COMMUNICATION TECHNIQUE ANALYSIS PRE-ORIENTATION PHASE Assigned client is a 38(?)-year old male with undifferentiated schizophrenia from YMCA Compound Magsaysay Sur. “may mga dalang basura”.nanunuod kame ng sine. Using open-ended questions to achieve relevance and depth discussion. Admission complaints include ”madumi ang katawan”.” Client nods. “ok naman Masaya naman. Sasamahan muna kita dito. Maaari ko po bang malaman ang pangalan niyo? “Ako si Jun-jun Bansales” QUESTIONING Using open-ended questions to achieve relevance and depth discussion.

specific factual information the client may or may not request.” PLANNING AND SUMMARIZING Yung tatay ko naninigarilyo tapos palaging umiinom.” FOCUSING “Hindi mo ba sinubukan itanong sa nanay mo kung ano ang naging dahilan ng paghihiwalay nila?” Ngayon ay napag-usapan natin ang mga bagay tungkol sa inyong pamilya. Providing a view of the meaning or importance of something Stating main points of discussion to clarify relevant points.” “Dati ayoko tigilan dahil napapagaan nito ang pakiramdam ko e.tagaytay. Pumupunta ako duon kapag pasko o fiesta.” Tapos? Kasi sa Nueva Ecija Nakatira Yung tatay ko. “Kanina sinabi mo sa amin na tinutulungan mo sa construction ang tatay mo.Hindi ko na tinanong. at sa nueva ecija…….” QUESTIONING “Oo. Use to review a health teaching session. step-father ko lang siya. may mga bisyo ka ba dati?” “Naninigarilyo ako at saka umiinom ng alak. ibig sabihin ba nito ay pumupunta ka pa sa Nueva Ecija?” “Ang ibig sabihin nito ay step father mo ang asawa ng nanay mo ngayon?” FOCUSING Pursuing a topic until its meaning or importance is clear. Providing a view of the meaning or importance of something. Kasi naghiwalay yung nanay at tatay ko nung pinagbubuntis pa lang niya ako.baguio.” CLARIFICATION It helps the client to articulate thoughts.” SEEKING INFORMATION “Ikaw ba Mang Junjun. May naalala ka bang nagyari sa iyo?” “Hindi. Kahapon. Kapag may oras. ayos lang.Umaasa ako na bukas ay magiging produktibo rin ang ating pag-uusap. ibinilin namin na alalahanin niyo ang mga nagyari sa buhay at pamilya mo. Pero ngayon makakatulong kung magbabago na ako para makauwi na ako. ayos lang. nagsusugal lalo pag wala siyang ginagawa o walang trabaho. walang kontruksyon. Using open-ended questions to achieve relevance and depth discussion Stating main points of discussion to clarify relevant points. “Oo.” FOCUSING Providing in a simple and direct manner. feeling and ideas clearly. “May ginawa po ba kayong paraan upang matigil ang inyong paninigarilyo at pag-inom ng alak?” QUESTIONING “Sa sinabi mo ay mukhang naliwanagan ka na sa mga tamang VERBALIZING THE IMPLIED Asking client is to elaborate ideas or feelings to foster description. ano ang naging dahilan ng paghihiwalay ng nanay at tatay mo?” “Hindi ko alam kasi buntis palang nanay ko nung naghiwalay sila.” GENERAL LEADS . Use to review a health teaching session “Sa palagay mo.” “Oo. “Hindi. . Asking for relationship among events.

SUMMARIZING Stating main points of discussion to clarify relevant points. Mag-iingat ka palagi at patuloy na magtiwala sa ating Panginoon. Use to review a health teaching session . Ipagpatuloy mo lamang ang iyong magandang adhikain upang tuluyan mo nang makita aang iyong pamilya.bagay na maari mong gawin.” Client smiles. Tama ba ang pagkakaintindi ko?” TERMINATION PHASE “Sa ating pagsasama sa konting sandali ay nakita ko ang determinasyon mong magbago para muling makita ang iyong pamilya at makapagsimula muli ng panibagong buhay.

as client verbalized. optimizing outcomes.  To recognize that today’s success is as important as any long-term goal. emotional and intellectual RATIONALE  This helps in determining the ability of individual to participate in own care  Personal care assistance is part of nursing care and should not be neglected while promoting self-care independence. Facilitate practice and promotion of short-term goal setting and achievement Facilitate accessibility of grooming equipment within easy reach Facilitate assistance of the client to become aware of the responsibilities in healthcare and to assess with them their strengths Physical.    Grooming selfcare deficit related to thought disturbance as evidenced by inability to maintain appearance at satisfactory level.  pungent odor  soiled clothing  untrimmed fingernails  visible dental plaques  unshaved facial hair  Short-term Goal  Partiallycompensatory  After 15 minutes of NI.NURSING CARE PLANS ASSESSMENT PLANNING S  “Hindi pa ako naliligo”.  This enhances commitment to plan. and health promotion. DIAGNOSIS   .  Avoids frustrations on performing personal care  Promotes reinforcement EVALUATION Client’s condition improved. Facilitate on performance/ assistance with meeting client’s needs when he is unable to meet own needs Facilitate promoting client’s participation in problem identification and desired goals and decision making. the client will be able to perform grooming activities for oneself.  O INTERVENTION Facilitate determination of factors such as language barriers and existing medical conditions.

DIAGNOSIS . preferably at client’s eye level. INTERVENTION  Focus on keeping communication simple.    Impaired verbal communication related to thought disturbances as evidenced by circumstantiality. the client will be able to express himself clearly. as client verbalized. This will help to gather thorough history of the patient and to understand clearly the client’s statemements .      tangentiality circumstanciality flight of ideas loose association active (answers eagelry)  Short-term Goal  Partiallycompensatory  After 15 minutes of NI. This will help to maintain his focus on your conversation. honest statements.  RATIONALE This will help the client to understand easily and to communicate effectively.  Facilitate maintaining eye contact.ASSESSMENT PLANNING S O  Day 1: “Nakahiga ako tapos bigla nagdilim mata ko at nasampal nanay ko”. Facilitate responding with simple straightforward.  Day 2: “Nakaupo ako tapos nagbabalat ng buto ng acacia at nagdilim paningin ko tapos nasamapal ko nanay ko”. EVALUATION Client’s condition improved. as client verbalized. speaking in short sentences using appropriate words.

RATIONALE  For early recognition of changes promotes proactive modifications to plan of care. DIAGNOSIS .  To maintain gains and continue progress if able. kung may tsinelas ka e hindi”.  Depend on administering anti-psychotic drugs (e.  Thoughts are illogical and disorganized  Answers questions with hesitations  Thought blocking as evidenced by abrupt cessation of speech PLANNING  Short-term goal  Partially compensato ry  After 15 minutes of NI the client may be able to demonstrat e behavior changes to prevent changes in mentation. EVALUATION Client`s condition improved.  Altered attention span  Decreased ability to use abstract reasoning or conceptualize . as client verbalized after being asked to interpret the proverb. kung matinik ay malalim”.ASSESSMENT S  “Kung wala kang tsinelas syempre matitinik ka.  To treat condition pharmacologic ally.  Facilitate in scheduling structured activity and rest periods.g haloperidol).  Facilitate assistance ibn identifying ongoing treatment needs/rehabilita tion program for the individual. O DISTURBED THOUGTH PROCESSES related to mental disorder. “Ang naglalakad ng matulin.  To provide stimulation while reducing fatigue. INTERVENTION  Focus on performing periodic neurological/be havioral assessment as indicated and compare with baseline.

 This was determining violent intent. DIAGNOSIS RISK FOR OTHER DIRECTED VIOLENCE RELATED TO MANIPULATIVE BEHAVIOR  This prevents the becoming of the unnecessary attempt. .  Provide an opportunity for client to look at reality of choices and potential outcomes.  Depend on determining the availability of homicidal means.ASSESSMENT PLANNING  Short. INTERVENTION  Facilitate observation and listening for early cues of distress.  Facilitate discussion of consequences of actions if they were to follow through on intent. RATIONALE EVALUATION  These cues Client’s may indicate condition possibility of improved loss of control and intervention at this point can prevent a blow up.term goal  Partially compensatory  After 15 minutes of nursing interventions. the patient may be able to demonstrate submissive behavior as evidence by appropriately controlled behavior.  Depend on maintaining straight forward communication .  Facilitate directly asking the person if he is thinking of acting his thought or feelings.  This avoids reinforcing manipulative behavior.

Encouraged the client to join groups dealing with self – esteem. Reinforced to client that administering medications without doctor’s prescription would result to serious complications. meticulous hand washing and oral hygiene. high protein. explained that when the client manifests adverse effects or requires medication. Provided clear. Instructed client on how to recognize and when and where to report signs and symptoms related to drug toxicity. high carbohydrate diet. tours and painting. walking. simple and understandable factual information to the client regarding the rehabilitation program. Free of weapon) Provided clear. assertiveness. Reiterated the importance of a clean and safe environment (eg. Facilitated identification and utilization of effective coping strategies. simple. client-appropriate dose. Reinforced the need and importance of regular multivitamins. . it is best to seek professional help immediately. Discussed arrangement of non-threatening activities that involved patients in doing something *eg. indication. and understandable explanation on each medication’s name.   E T H     O D S     Emphasized the need for a well-balanced diet and initially a high calorie. and adverse effects. Emphasized to the client the importance of personal hygiene such as bathing. side.HEALTH TEACHINGS M   Instructed the client to comply with the medication regime. social and relationship skills and stress management.

O ➢ Altered attention span ➢ Decreased ability to use abstract reasoning or conceptuali ze. ➢ Thoughts are illogical and disorganize d ➢ Answers questions with hesitations ➢ Thought blocking as evidenced by abrupt PLANNING ➢ Shortterm goal ➢ Partially compensa tory ➢ After 15 minutes of NI the client may be able to demonstr ate behavior changes to prevent changes in mentation . INTERVENTION ➢ Focus on performing periodic neurological/b ehavioral assessment as indicated and compare with baseline. as client verbalized after being asked to interpret the proverb. ➢ Depend on administering anti-psychotic drugs (e. kung matinik ay malalim”. RATIONALE ➢ For early recognition of changes promotes proactive modifications to plan of care. .ASSESSMENT S ➢ “Kung wala kang tsinelas syempre matitinik ka. ➢ To maintain gains and continue progress if able. ➢ Facilitate assistance ibn identifying ongoing treatment needs/rehabili tation program for the individual. “Ang naglalakad ng matulin. ➢ To provide stimulation while reducing fatigue. kung may tsinelas ka e hindi”.g haloperidol). ➢ Facilitate in scheduling structured activity and rest periods. EVALUATIO N Client`s condition improved. ➢ To treat condition pharmacolog ically.

➢ Facilitate directly asking the person if he is thinking of acting his thought or feelings.term goal ➢ Partially compensato ry INTERVENTION ➢ Facilitate observation and listening for early cues of distress. RATIONALE ➢ These cues may indicate possibility of loss of control and intervention at this point can prevent a blow up.cessation of speech DIAGNOSIS DISTURBED THOUGTH PROCESSES related to mental disorder. EVALUATION Client’s condition improved ➢ After 15 minutes of nursing intervention s. the patient may be able to demonstrat e submissive behavior as evidence by appropriatel y controlled behavior. ➢ Depend on determining the availability of ➢ This prevents the becoming of the unnecessary attempt. ➢ This was determining violent intent. . ASSESSMENT PLANNING ➢ Short.

. ➢ Depend on maintaining straight forward communicati on.homicidal means. ➢ This avoids reinforcing manipulativ e behavior. DIAGNOSIS RISK FOR OTHER DIRECTED VIOLENCE RELATED TO MANIPULATIVE BEHAVIOR ➢ Provide an opportunity for client to look at reality of choices and potential outcomes. ➢ Facilitate discussion of consequence s of actions if they were to follow through on intent.

explained that when the client manifests adverse effects or requires medication. • • • Reinforced the need and importance of regular multivitamins. and understandable explanation on each medication’s name. O D • Emphasized the need for a well-balanced diet and initially a high calorie. Provided clear. S Facilitated identification and utilization of effective coping strategies. • Reinforced to client that administering medications without doctor’s prescription would result to serious complications. high carbohydrate diet. indication. tours and painting. it is best to seek professional help immediately.HEALTH TEACHINGS M • • Instructed the client to comply with the medication regime. meticulous hand washing and oral hygiene. Encouraged the client to join groups dealing with self – . Free of weapon) • Provided clear. high protein. E T H • Reiterated the importance of a clean and safe environment (eg. walking. simple. • Emphasized to the client the importance of personal hygiene such as bathing. side. • Discussed arrangement of non-threatening activities that involved patients in doing something *eg. • Instructed client on how to recognize and when and where to report signs and symptoms related to drug toxicity. and adverse effects. simple and understandable factual information to the client regarding the rehabilitation program. client-appropriate dose.

social and relationship skills and stress management. .esteem. assertiveness.