I.

INTRODUCTION

A. Overview Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movement, and behavior. It cannot be defined as an illness. Rather, Schizophrenia is thought of a syndrome or disease process with many different varieties and symptoms, much like the varieties of cancer for decades, the public vastly misunderstood Schizophrenia, fearing it as dangerous and uncontrollable and causing wild disturbances and violent outbursts. Only recently has the mental heath industry come to learn and educate the community at large that Schizophrenia has many different symptoms and presentation and is an illness that medication can control. (Videbeck fourth edition, 2008) A particular mental disorder that is very common and dominant, especially in the Philippines, is Schizophrenia. In laypersons term, it is not uncommon to hear the word Schizophrenia defined as split personality. schizophrenia is not characterized b a changing personality; it is characterized by a deteriorating personality. Therefore, this popular notion of a dramatic personality change comes far short of capturing the devastating effect Schizophrenia has on the life a person and the persons family. Simply, Schizophrenia is one of the most profoundly disabling illness, mental or physical, the nurse will ever encounter. (keltner, et al. 1999). Schizophrenia is a psychotic disorder (or a group of disorder) marked by severely impaired thinking, emotion, and behaviors. Schizophrenic patients are typically unable to filter sensory stimuli and may have enchanted perception of sounds, colors, and other feature of their environment. Most Schizophrenics, if untreated, gradually withdraw from intersections with other people, and lose their ability to take care of personal needs and grooming. No laboratory test has been found to be diagnostic of this disorder. Interventions initiated and implemented was upon the cooperation of the patient and significant others. Despite the received wisdom that schizophrenia occurs at similar rates throughout the worlds, its prevalence varies across the world, within countries, and at

the local and neighborhood level. Schizophrenia affects men and women with equal frequency, the disorder often appears earlier in men, usually in late teens or early twenties, than in women, who are generally affected in the twenties to early thirties. In the Philippines alone, out of 86,241,697 population used, the extrapolated prevalence in 697,543-about 5% to 1 % of the population. Schezophrenia still ranks among the top 10 causes of disability in country.

B. Objective and Purpose of the study.

Specifically, this study aims to: 1. Conduct a thorough assessment of the emotional status of the patient. 2. Identify priority nursing problems. 3. Develop nursing care plans to the problems identified. 4. Apply intervention and diversion activities 5. Evaluate the care done and impart health teaching. This study is conducted to provide the nursing studies an opportunity to be exposed and care for a mentally challenged patient. Also, this will enable the students to apply the concepts learned in psychiatric nursing.

C. Scope and Limitation.

The study involves the care of a mentally challenged in Cagayan De Oro City. The client must meet the following criteria: He/ She must have s diagnosed psychosis and must have immediate family available as informant for the study. The study is limited to 5 days of care with each session spanning only two hours. Information about clients history illness will be based only on the interview with the client, clients parent, her relatives and some of her neighbor.

D. Spot Map

SPOT MAP: The point of reference is Liceo de Cagayan University, located in Carmen, Cagayan de Oro City. The patients house is approximately eight kilometers east of the reference. We must take a public utility vehicle from the reference point going to barangay 35 near limketkai mall with a fare of six pesos for students and senior citizen and a seven pesos fare for the regular passengers. The length of time to travel usually takes ten minutes if traffic is moderate rate, but it could also take twenty minutes going to the area if the traffic is very heavy. From the Barangay 35 hall, walk twenty meters straight. Passing a small bridge turn right and the third house from the bridge stand a two story wood house. The patients house is made up of woods near the creek and most of the houses within the area is made up of woods. Bingo is played during their leisure time. The patient sleeps is under the house with her parents and siblings.

E. Patients Profile

Initial name: J R Address:Brgy,35 Limketkai Drive Cagayan de Oro City Date of Birth:July 8, 1991 Age: 19 years old Birthplace: Cagayan de Oro City Civil Status: Single Gender: Female Nationality: Filipino Religion: Roman Catholic Siblings: 1 sister and 2 brothers Children: none Name of Mother: M.R Name of Father: L.R Height: 511 Weight: 44kgs Income: None Date of first Check-up: 2001 Admitting Diagnosis: Schizophrenia Undifferentiated

II.

Anamnesis A. GENOGRAM

*NICOLAS

SOLEDAD

DOMINGA

GREGORIA

ISIDRO

JOLIE

AZON

ALLAN

JOCELYN

MOLY

JANET

ELISA

ROMEA

ISIDRO

MARILOU

HENRY

MARITES

LEMUEL

*JR

JEMUEL

MICHELLE

ALJUN

Informants NAME: Michelle Joy Regalado AGE: 15 years old ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City RELATIONSHIP TO THE PATIENT: Sister LENGTH OF TIME KNOWN TO PATIENT: 15 years APPARENT UNDERSTANDING OF PRESENT ILLNESS Sa akong nabantayan OK ra man siya pag maka inom ug tambal pero kung dili gani mutukar dayon iya sakit, manghilabot sya sa amu ug usahay mukalit ra sya ug hilak ug gusto ran a sya mag-inusara OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT Michelle is a 3rd year High school student at Cagayan de Oro National High School. At first she is very hesitant to answer the question but as we interviewed her, she is very concerned about the condition of her sister. NAME: Jemuel Regalado AGE: 16 years old ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City RELATIONSHIP TO THE PATIENT: Brother LENGTH OF TIME KNOWN TO PATIENT: 16 years APPARENT UNDERSTANDING OF PRESENT ILLNESS Pag maka inom siya sa tambal OK ra sya, normal parehas sa ato pero kung dili gani, mandapat jud siya. Usahay mag hilum-hilum, mag gawas-gawas, mag sulat-sulat ug usahay mag sige ra sya katulog ug magkatawa dayon ug kalit. Gina pang labay pud niya among mga gamit pag dugay siya maka inom ug tambal.

OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT: Jemuel is a third year high school student at Cagayan de Oro National High school. Like his sister, he is also very hesitant to answer the question being asked but he is very accommodating and also he is very concerned about the condition of his sister. NAME: Victoria Martinez AGE: 44 years old ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City RELATIONSHIP TO THE PATIENT: Neighbor LENGTH OF TIME KNOWN TO PATIENT: 12 years APPARENT UNDERSTANDING OF PRESENT ILLNESS: Sa una OK ra man si JR pero nagsugod na adtong gikan dawn a siya sa eskwelahan, kalit-kalit ra man mutukar iya sakit tapos iya gina reklamo iya ulo, sakit daw kayo ug mag sige pud na sya reklamo nga murag ga dug-on daw siya tapos kung feeling daw niya dug-on siya diha na mutukar iyahang sakit. Mag wild na siya, mag lakaw-lakaw pero pagka taud-taud mubalik ra man dayon na siya. OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT Mrs. Victoria Martinez is a housewife and sometimes a part-time sweeper at the Barangay but as of the moment, she gave up her work as a sweeper because she is focusing in taking good care of her grandchildren. Mrs. Victoria Martinez is very nice to us when we had our interview with her. She is very accommodating and like the other neighbors of JR, she is very concerned about the condition of JR. NAME: Marites Regalado AGE: 37 years old ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City RELATIONSHIP TO THE PATIENT: Mother LENGTH OF TIME KNOWN TO PATIENT: 19 years

APPARENT UNDERSTANDING OF PRESENT ILLNESS Sa akong nabantayan sa iya, pag dili gani na siya maka tumar sa tambal, mag lasong gyod na sya pero kung maka tumar gani sa iyang tambal OK ra man dayon siya. OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT Mrs. Marites Regalado is the mother of JR. She is accommodating during the time we interviewed he. She stays at home in the morning and during afternoon, she sells foods in front of Cogon market just to support the needs of her family. She is the one who really takes care of JR because through the entire visits, she was the one who really answers the questions being asked. NAME: Diosdada Calumbay AGE: 74 years old ADDRESS: Brgy. 35, Limketkai Drive, Cagayan de Oro City RELATIONSHIP TO THE PATIENT: Neighbor LENGTH OF TIME KNOWN TO PATIENT: 10 years APPARENT UNDERSTANDING OF PRESENT ILLNESS Sa akong nabantayanka niya, hilumon mana siya. Ga isturyahun pa man gani naku na siya pero sugod anang iyang sakit, naka bantay ko nga mag hilak ra na siya ug kalit. Pag mutukar na kana iyang sakit, mag wild gyod na siya. Ipang labay niya ang mga gamit sa sapa bisan pag linung-ag sa silingan iya gyud ilabay. Mag lakaw-lakaw pud na siya pero pagka taud-taud maka balik ra dayon na siya. OTHER CHARACTERISTIC/ ATTITUDE OF INFORMANT Mrs. Diosdada Calumbay is very accommodating during the interview and like the other neighbors of JR, she is very concerned about JR. Mrs. Calumbay is living with her son and she helps in taking care of her grandchildren.

FAMILY HISTORY
A. MATERNAL AND PATERNAL GRAND LINEAGE

Based on the information handed to us by the clients mother, no one in their family has a disorder like our patient. On the paternal side, the father confirms that his mother has a brother of the same condition as our client. B. FATHER Lemuel is the father of our client and he is the fifth among his siblings. Unfortunately, he was not able to finish his studies. He claimed the he studied until high school but was not able to graduate. His occupation was trisikad driver. c. MOTHER Marites is the mother of JR. she is the youngest among the siblings and like her husband, she was not able to finish her high school. She is the one who really takes care of JR. During afternoon, she sells food at Cogon market just to make a living and support the needs of her family. d. SIBLINGS JR has 3 siblings and all of the three are normal. Sibling rivalry occurs.

D. PERSONAL HISTORY a. Pre-natal The clients mother revealed to us that JR is the eldest in the family. During this time she was able to undergo complete pre-natal check-up. During her pregnancy she suffered emotional stress because during this time, she and her husband were not able to get married. b. Birth JR was delivered full term, through normal spontaneous vaginal delivery at home last July 8, 1991. She weighed 6 lbs.. it was the mananabang who helped her deliver the baby. JR received complete immunization at Carmen Health Center. c. Infancy and Childhood Characteristics

The mother believed that breastfeeding was good for babies but she failed to have exclusive breastfeeding. JR was taken cared by her parents at their home. She suffered cough, colds and fever during childhood. Her mother stated that JR was quiet and shy during childhood. d. Psychosexual Factor JR can indentify her gender as female when asked. e. Play Life During childhood, JR was not able to get along with other because she is shy and quiet. f. School History During her elementary years, she studied and graduated at City Central School, Cagayan de Oro City. During her high school days, she studied at Cagayan se Oro National High school located at Nazareth, Cagayan de Oro city. During her school years, she was observed as silent type of person. According to her mother, she had a good relationship with her classmates as well as with her friends. Most of the time, she wants to be alone rather than talking with her classmates and friends. g. Religious and Social Adaptability JRs family is a Roman Catholic. In the past, they go to church together but as of this time, the family is so busy thats why they only go to church when they have available time. However, JR was not sociable according to her mother. Every time they have visitors, she immediately hides for she is shy and rather wants to be alone. With regards to her relationship with her family, she is very close to her mother. h. Occupational History Our client never experienced working. i. Marital History Our client is still single, she never experienced any relationship towards the opposite sex. j. Onset of Present Illness The onset of JRs present condition started at an early age. His father found out that she didnt eat her food in school during lunch and snack time and also children

according to the father when she was 8 years old he observed that JR was talking to herself and suddenly laugh at herself. Pirmi mi gakasunugan tong una as verbalized by the mother this caused traumatic experience to the patient. When she was 11 years old, she experienced fever for 3 days and was confined for 5 days and after 5 days she was released from the hospital. But she has many complaints about herself thats why her Doctor referred her to Dr. Borromeo, a psychiatrist at Northern Mindanao Medical Center and diagnosed that she had a mental disorder and was given medications by Doctor Go. At present JR was currently taking her medications.

III.

Course in the Hospital A. Mental status Exam DAY 1 DAY 2 Tidy DAY 3 Clean DAY 4 Untidy DAY 5 Clean

A. GENERAL APPEARANCE B. GENERAL POSTURE Posture Activity Facial Expression C. BEHAVIOR D. PATIENT NURSE INTERACTION E. SPEECH Soft Loud

Untidy

Slouch Handwriting Suspicious Negativistic Distant

Slouch Purposeful Happy Friendly

Slouch Purposeful Happy Friendly

Slouch Purposeful Happy Friendly

Slouch Purposeful Happy Friendly

Cooperative Cooperative Cooperative Cooperative

Hesitant Slurred Superiority Humor Frightened F. DOES HIS STYLE AND VOCABULARY CONVEYCoyness Suspiciousness Arrogance Secrecy Superiority Humor Fear G. STREAM OF TALK Spontaneous Deliberate Pressured Blocking H. ORGANIZATION OF TALK Relevant Irrelevant Incoherent Loose Association

/ / / /

/ /

Flight of ideas Tangentiality Circumstantiality Perseveration Clang association Neologism Echolalia Echopraxia I. MOOD AND AFFECT 1. Mood Euthymic Depressed Euphoric 2. Affect Flat Blunt Angry Elated Anxious Fearful 3. Range of Affective expression Consistent Labile Anhedonic / / / / / / / / / / / / / /

Appropriate to the situation and feelings verbalized J. PERCEPTION Hallucination Auditory Visual Olfactory Gustatory Tactile Delusion Grandeur Persecutory Reference Others(specify) Illusion Derealization Depersonalization Identification Thought Broadcasting Dj vu Jamais vu K. ORIENTATION AND MEMORY Identifies date correctly /

yes

yes

yes

yes

yes

Estimated time of the day Knows where she is Knows the examiner Recalls activities done within 24 hours Recalls activities done within 1 week L. Neuro-negative Functioning Sleep and Rest Pattern: Normal Sleeping Early morning Awakening Middle night awakening Hyper insomnia Difficulty of falling asleep Interrupted Others M. Elimination Bowel Bladder N. Abstract Thinking Ability O. Judgment

no yes no yes no

no yes no yes no

no yes no yes no

no yes no yes no

no yes no yes no

1x 4x poor poor

0 7x poor poor

1x 6x poor poor

1x 5x poor poor

1x 6x Poor Poor

Description of MSE First Visit (April 28, 2011) Appearance and Movement During the first day of our visit to J.R, she was untidy, her nails in both feet and hands are dirty and when she went out of the house to meet us she was barefooted. She sits with a slouched back. She displays a suspicious behavior and she keeps on squeezing her hands. Speech The quality of her voice was soft and hesitant when speaking. Her speech was slightly pressured. And she keeps on saying that she doesn't want to be interviewed by students. Emotional State and Reaction The client was anxious during the interview, she kept on saying that students would just visit her and do interviews but did not do her any help for the past few years. Thought Control During the first interview the client was able to recall the activities she has done within 24 hours, she was able to identify the date correctly. She said that her feet and hands are hurting. She could not even estimate the time of the day but she knows where she's at. She could not recall out name but was able to recognize. Neuro-Vegetative functioning The patient said that she was able to sleep normally at night because she was able to take her medicine.

SECOND VISIT (April 29, 2011) Appearance and Movement On the second day of visit we stayed at their neighbor house, J.R appeared tidy. She just took a bath and her clothes are clean.During the interview she was seated 2 feet away from the examiner and she slouch her back. After the interview, she laughed outrageously and when asked what she was laughing about, she did not answer. Speech The client talked vividly in soft and spontaneous speech. The organization of her speech are relevant. Emotional state and Reaction She was very happy during our visit, especially when she received the fruits and bread. And she even told us that she would be happy if we will visit her everyday. Thought Control The client was able to recognize the date but doesn't know the time. She knows that we are at her neighbor's house and she was able to recall the activities she has done for 24 hours. She was still complaining that her feet and hands are hurting. Neuro-Vegetative Function The client said that she was able to sleep normally at night.

THIRD VISIT (April 30, 2011) Appearance and Movement

On our third visit the client looks clean, she just took a bath. She was very cooperative during the interview. She said that she was happy to see us again. Her hair was well fixed and her finger and toe nails were clean. She sits at a distance with a slouch. Speech Still the client speaks in a soft and deliberate speech. She speaks at a normal pace and answers the questions appropriately. Emotional State and Reaction She was happy and was very cooperative during the whole interview. Thought Control She was able to recall the activities she has done for 24 hours but she was not able to recall the time and date. She knows where she's at but doesn't recall the names of the examiners. Neuro-Vegetative Function The client has a normal sleep pattern.

FOURTH VISIT (May 4, 2011) Appearance and Movement During our fourth visit, the patient was busy watching the television. So we conducted the interview inside their house. She looked very happy and he was well groomed. She was very neat. She slouch her back.

Speech The client speaks in a soft voice and talks spontaneously. The organization of talk is relevant. Emotional state and Reaction She was happy to see us when we arrived at their house. She was calm and she reacts appropriately in every situation especially when she was watching the television. Thought Control Client doesn't show any maladaptive behaviors. The client reacts appropriate to the situation and feelings verbalized. Neuro-Vegetative function The client has normal sleep pattern.

FIFTH VISIT (May 5, 2011) Appearance and Movement During our fourth visit, the client was excited to see us. She looked neat and clean. She was well groomed. She was seated with a slouched back. Speech The client talked deliberately in a soft and she shows no hesitation when speaking. Emotional State and Reaction The client was in very happy and she keeps on smiling. And she portrays comfort and interest during the whole interview.

Thought Control The client knows the date but does not know the time of the day. She was able to recall activities she has done for 24 hours. Neuro-Vegetative Functioning The client has a normal sleep pattern

B. Progress Notes

Day 1: April 28,2011 (Thursday) Specific Objectives: 1. To locate the residence of the client. 2. To establish trust and rapport with the client. 3. To have a verbal contract and consent both client and family. 4. To make an initial assessment. 5. To start the assessment for the mental status of our client. 6. Arrange the date for our next visit On Wednesday, April 28, 2011 the group started LOOKING FOR UOR CLEINT. We were referred by a previous batch that there were psyh client in barangay 35, Limketkai Drive Cagayan de Oro City. So we grabbed the chance and without any hesitation we immediately went to said client. When we arrive at the area, we immediately asked permission in the barangay councils office and were glad that they have allowed us to conduct our study in their barangay,. They referred us to JR who lives near the creek. When we arrived at the client house, the consent was obtained from the mother and the client as they permitted the group to conduct series of interview with them. We cannot disclose the names of the client and her family members for security purposes. We gained the important datas that we needed from the client, her parents, relatives

and neighbour. We gathered the clients profile and some other important information regarding the clients situation. A verbal contact was made about the number of days we were going to conduct the interview, health teaching, nursing intervention and length and time of visit.

DAY 2: April 29, 2011 ( Friday ) , Specific Objectives: 1. Introduced ourselves to our client. 2. Continue establishing rapport to the client. 3. Continue with the mental status exam with the client. 4. Determine the factor that causes the client disorder. 5. Trace the client history 6. Ask the client neighbour for some relevant information. On our second visit, the client was very cooperative during our interview. She was very happy because we brought her a fruits and bread. Our group continued the assessment and traced her family history, The situation that has occurred prior to admission and we even ask the neighbour about fact that may help us on our care study.

DAY 3: April 30, 2011 ( Saturday) Specific Objectives: 1. Asses the client for some changes. 2. Identify more problems of the client. 3. Obtain enough information regarding the client 4. Continue to gather more information from other sources, such as: Neighbors.

On our third visit, the patient has continued to cooperate. We continued the assessment and observe for possible development of her reaction towards us. We continue interviewed the selected neighbours about their reaction and awareness about JGs situation. And we were glad that the neighbors were cooperative and friendly.

DAY 4: May 4, 2011 ( wednesday ) Specific Objective: 1. Re-establish rapport with the clients family. 2. Perform the Mental Status Examination ( MSE) 3. Assess our client in a holistic manner On our fourth visit, we found our patient and family busy watching television. When she saw us, she immediately called her mother and informed her of our arrival. The patient was in a calm and normal mood. She react opportunity to any situation, especially when she was watching the television, she shows appreciation when we gave her a bag of fruits.

DAY 5: MAY 5, 2011 (Thursday ) Specific Objectives: 1. Continue with the final assessment. 2. Continue interviewing the family members with our clinical instructor. 3. WE introduce our CI to our patient. 4. We inform our client that this will be our last visit to her. 5. We gave health teaching to our clients and to her family. On our final visit, we continued the final assessment and continue interviewing the family member and neighbour as well to fill in the lacking information for our clients data. We also imparted important health teaching about proper hygiene, proper nutrition, maintenance of medication regimen, and follow up checkups every month.

We also ended our contract with the patient along with her family that this will be our final visit and final assessment. And we thanked them for their participation to make this care study possible.

IV.

Psychodynamics

A1. Tabular Presentation on the Predisposing Factors Factors 1. Predisposing a. Hereditary Present Present in paternal side. Rationale According to Sheila L. Vinebeck, family studies are used to compare whether a trait is more common among firstdegree relatives ( parents, siblings, and children )than among more distant relatives or the general population. Age of onset seems to be an important factors in how well the client fares. Those who develop the illness earlier go worse outcomes than those who develop it later. (Buchaman and Carpenter, 2000) according to Hagop S. Akistol M.D are higher in younger age groups especially in the stage because of having a roe confusion and identity crisis. Sex determines the communitys expectation of a person.

b. age

Onset early manifestation of Schizophrenia.

c. Sex

Increases prevalence of female

A2. Tabular Presentation on the Precipitating Factors Factors 1. Precipitating a. Post-traumatic experience Client According to Shiela L. Videbick, post-traumatic stress disorder is a disturbing pattern of behaviour demonstrated by someone who has experienced a traumatic event such as natural disaster, combat or an assault. The person with PTSD was exposed to an event that posed a threat of death or serious injury and responded with intense fear, helpless, or terror. Peers are a big factor in molding the factors personality. According to Stuart and Sundeem ( 1995 ). Poverty and society could abuse Schizophrenic to cope the insanity of mother world. Present Rationale

b. Environment factor

Client dont heve close friend always stay in the house Client unintentionally skipped meals during days.

c. Skipping of meals

B. Schematic Presentation Biological Factors

Genetics Biochemical

Father

Mother

Increased in serotonin and dopamine

No gender factor

There is history of psychosis in paternal side

Increased vulnerability to develop illness

PSYCHOSOCIAL FACTORS

PRE-NATAL

INFANCY

TOODLER

PRESCHOOLER

SCHOOL

Low economic status Mother experienced stress Complete prenatal

y y

Mixed breastfeed and bottle feed Early weaning Mother is too busy looking for additional income

Minimal interaction with neighbors and frieds

y y

Wants to go to school Aloof

y y y y

y y y

No interest in foods Lack of nourishment No interest to go to school Always wants to stay in the house and want to be alone Start play with imaginary friends Always stay quite Dont have close friends

Mistrust

Shame and Doubt

Guilt

inferiority

SOCIOCULTURAL

Internal

external

Father

Mother

Siblings

y y y y

Surroundings Lack of socialization No known chemical or any substance used Does not engage into drinking alcohol beverages and smoking

Lack of family support

Poor parental role

Non-conducive external environment

Probability of mental illness

Weakened Ego Functioning

Confusion

Low self-esteem

Use defense mechanism -withdrawal

Precipitating Factor: Skipping meals Post-traumatic experience Environmental factor

C.Analogy

Life is like an endless highway. It is full of views on its own way--- the road is a thoroughfare, route, or way between two places. Roads like our journey of life are normally smoothed, paved, or otherwise prepared to allow easy travel, although historically many roads as it is like our lives were simply recognizable routes or left uncared as without any formal construction or maintenance. This is the journey of Gellyn, an introvert teenager from Barangay 35, Cagayan De Oro City. The first two builders, had struggled in gathering the necessary materials for an ideal automobile. Due to very limited resources, lacked of support from the crew and novice builders, the materials acquired for building were substandard. At the very beginning, there was already a problem with regards to the quality of the parts of the automobile. Hence, a weak foundation was molded. In relation with Gellyn, the substandard materials represent the biological factors. Both the grandfather and father had nervous breakdown. In addition, the weak foundation is the imbalance of neurotransmitter dopamine & serotonin. This increases Gellyns vulnerability to mental illness. The builders started to construct the engine of the automobile: the keel but during the process of building conflicts arose. The primary builder seemed not interested and

lacked commitment to his responsibilities. He was impulsive, quick-tempered towards his submissive partner and he even attempted to hit her despite the fact of all of her hardships to make a keel of distinctive attribute that will be the central structural basis of the hull---- a framework for buoyancy. During the conception of Gellyn, the parents had frequent quarrels. The mother suffered from the abuses from his husband the emotional sufferings led to intra psychic trauma. The imperfect engine influenced much the chassis which provides the buoyancy of the automobile. As it is the body of the automobile, chassis is basic and crucial for a car to have a good foundation. Alone the secondary builder made the chassis that would stand still amidst the robust and rough roads. But the builder was unknowledgeable and unskilled to do so, thus a small hole slipped & buoyancy was uncertain. Baby Gellyn was dissatisfied from sucking and feeding as the mother abruptly terminated breastfeeding. The mother still with emotional problems, could not give consistent care to the baby. The inconsistency of care promotes mistrust. For the automobile to move forth, a gasoline is necessary to start the engine. The gasoline must be of its full tank, heated and clutched to start firmly the engine. However the builder was not able to execute such things. Those features were neglected, as a result, the engine overheated. Similarly to a toddler whose toilet training was lax. Consequently, shame and doubt marked instead of autonomy. As the building process continued, disputes between the two builders were clearly inevitable. The unreliability and wrath of the primary builders were unpleasantly evident. For this, some parts of the automobile were enfeebled. The hood itself has no protection from a cold or heated temperature. Its size and shape was disregarded, making the effectiveness of its steering and turning abilities incompetent just before the untamed roughness of the road. This can be compared to a lonesome and shy preschooler who had few playmates. With this, guilt resulted when initiative should have been the product.

To set the automobiles course, a hydraulic power steering is essential. It serves as a lever of the steering wheel to maneuver the direction and reach the inaccessible portion of the road. Analogous to an introvert and mediocre pupil the target of the bullies who did not learn to fight back. At this point, inferiority prevailed over industry. Now as the automobile was about to park at the viewing park, the engine was crafted to serve as a propulsion system. This manipulates the powers and the speed of the automobile. During the travel lightning flashed and hit its hood. Moreover thunders roared and storms poured down stronger and stronger which inflicted damages to the automobile. In her adolescent stage, she stopped schooling until grade-6 due to financial constraints and family turmoil. Lightning symbolizes the catastrophic events of her life. The damaged automobile searched for a repair shop to seek for refuge. The engine was opened to be able to be fixed. But unfortunately, the engine gears were affixed loosely to the soft and loose oils, this made the automobile to exhibit radical side-to-side motions. Furthermore, because of the piercing voltage coming from the lightning a fire surged the repair shop and reached the automobile. The automobile did not yield in easily, it struggled for its survival. The Repair Shop signifies her home. Their home was unstable and there was unloving environment between them. The automobilet was wrecked but not beyond repair. The owner exerted efforts to restore what had been damaged. Will the automobile survive and run again? Or will it be brought to ruin? No one can tell. Likewise, the family of Gellyn is making an effort to help her with her illness. Will she survive? Only time can tell. V. Laboratory Exam and results of Psychological Test

Our client has undergone laboratory exam and psychological testing but all the result were lost.

VI.

Diagnosis Schizophrenia, Undifferentiated Type

VII.

Multi-Axial Diagnosis

AXIS 1 Clinical Disorder

Major Psychiatric Disorder y Schizophrenia, undifferentiated y Patient J.R manifested distortion of reality, hallucination and disordered thinking

AXIS 2 Personality Disorder and Mental retardation

The client has a disorganized personality disorder and shows less depressive emotion

AXIS 3 General Medical Condition AXIS 4 Psychosocial and Environment Factors

y y y y

None as observe Patient J.R s family live below poverty line Patient J.R stopped from schooling due to mental illness that she encountered The family cannot avail with the needed health care services due to unaffordable of such Family failed to encourage there reinforce positive behavior and selfesteem

VIII.

Nursing Management

A. Ideal Nursing Management

Nursing Diagnosis: Impaired social interaction related to altered sense or interpretation of reality with difficulty with social skills.

Nursing Management 1. Assess and document past experience and patterns of social activity alteration
y

Rationale For Previous level of functioning and types of activities enjoyed are identified

2. Assess current strengths and problem area regarding social interactions

For Areas of strength to reinforce and build upon are identified as well as problem areas that can be improved

3. Identify with the patient. goal for increase social interaction

For Compliance is increased when that patient is part of the decision making process.

4. Support and reinforce efforts and success in social interaction

To positive reinforcement, even for slight movement toward the expected behavior change, is very reinforcing and encouraging when patients are trying to master a new behavior.

5. Teach essential components of appropriate social interaction. Begin with simple steps of social interaction, such as making eye contact during conversation, productive patterns of speech

To address gaps in knowledge of social skills

6. Provide emotion support as patient tries to reach goals

To have low self esteem and may be discouraged by their own performance or the reactions of others to their efforts to socialize and communicate. Empathetic listening and support can enhance verbalization without criticism while listening a new behavior.

7. Provide a group situation to improve social skills

To provide an opportunity to practice skills for social interaction in a less threatening and more supportive environment

8. Evaluate the care plan as needed, and at regular intervals, to ensure that the direction and method of treatment is appropriate

To ensure that the goals are neither too advanced nor too basic for patient's needed and that the opportunities for skills development match the need symptom

Nursing Diagnosis: Anxiety related to maladaptive reaction to an identifiable stress stressor. Nursing Management 1. Assess level of anxiety; provide supportive nurse patient relationship and opportunities for ventilation regarding feelings of anxiety and their etiology. Provide opportunities for patient to learn to master feelings through
y

Rationale Supportive nurse patient relationship will assist the patient exploring the root causes of his or her anxieties, and once this is done, the patient will have the strength and courage to learn to master

regular counseling or therapy sessions; daily journal keeping; development of appropriate release activities such as physical exercise, yoga, relaxation training, medication, art work, and volunteer work 2. Assess appetite and weight loos or gain assist patient in meal planning and counseling
y

these feelings

Assess appetite disturbance can lead to making the patient fell worse and also negatively alter his or her self-concept. Nutritional counseling and assistance with meal planning often including vitamin supplementation, is necessary to assist the patient in regaining a state of wellness

3. Assess sleep patterns and assist the patient in reestablishing her normal sleep pattern

Sleep pattern disturbance such as difficulty falling asleep, midnight awakening impact negatively on one's overall wellness and need to be attended to in order to assist the patient in regaining an overall state of wellness

Nursing Diagnosis: Post-trauma response related to past history of physical and emotional

Nursing Management 1. Assess the nature of the past y

Rationale This allows for individualized care based upon the most dysfunctional symptoms

2. Determine the response to the event both currently and in the past 3. Assess whether there is any current contact with the perpetrator and the nature of the relationship 4. Ascertain the coping mechanisms used to deal with the memories of trauma 5. Remind that flashbacks may be memories of emotions as well of physical acts 6. Provide the opportunity to relate the story of the abuse, including the emotions as well as physical acts 7. Provide opportunity to relate the story of the abuse, including the emotions involved. Assure that the therapy happens in a safe, structured setting and that the patient has social or emotional support after the session 8. Continually check for safety for issues 9. Reorient to place, person, and time at end of session 10. Provide emotional support on the unit if life review work is being done in individual or group therapy 11. Evaluate extent of intrusion thoughts about event into daily life

An atmosphere helps correct distortions and misperceptions of the environment Non- reality based thinking may increase when anxiety level increases Concerns or fear may be expressed as safety Distortions in thinking may place patients risk for injury to harm themselves or others Technique such as humming, using radio, or telling the voices to go away can be used for symptom To relate details of the event and the emotions of the event and the emotions involved in a supportive environment

Whether the patient is becoming overwhelmed is elevated Disorientation may occur when relating intensely emotionally charged events from the past Continued safety during hospitalization and between sessions is ensured The effectiveness of the intervention is evaluated

Nursing Diagnosis: Self care deficit related to perceptual or cognitive impairment

Nursing Management 1. Assess and document current level of functioning and possible reasons for the deficits y

Rationale For a foundation of capabilities is established and problem areas identified which may include skill deficits as well as the etiology of the behaviour

2. Individualize a care plan to support current level of functioning and increase independence in completing the bathing or hygiene regimen

Bathing and hygiene levels are maintained while promoting increasing independence for self care. This may start with physical assistance and move to minimal or absent verbal prompting

3. Teach about social and health benefits or bathing and hygiene

An opportunity is provided to reinforce the care plan and address any unique concerns

Nursing Diagnosis: Dressing or Grooming Self care deficit related to cognitive or perceptual impairment

Nursing Management 1. Assess and document the patients current strengths and deficits in areas y

Rationale For a foundation of capabilities is established and problem areas identified which may include skill deficits as well as the etiology of the behaviour

2. Assess any special meanings that dressing or grooming in a circular manner

It is important to know any special meanings attached to dressings or grooming behaviour that is

problematic 3. Assure easy access to clothing, toilet mirror other dressing and grooming needs y Patients with thought disorders can be easily overwhelmed if preparatory activity is too complex, they also need sufficient time to complete the activity at their own pace 4. Proved support needed to complete grooming or hygiene activity y Physical assistance may be required when first admitted or when more psychotic. Verbally direction should be clear, concise, simple and repeated often 5. Establish a group specifically to address dressing/grooming deficits. This is to decreases the intensity of one interaction ,which may be uncomfortable and provides a supportive group of peers to enhance both socialization opportunities and learning. 6.Indicate about appropriate dress for further conditions. Patients may be less sensitive to temperature changes because of their illness and the effects of medication and may be at risk for heat or cold injury. Nursing Diagnosis: Self care deficit related to disorganized thought and responses the limit the ability to follow through with activities that involve steps

Nursing Management 1. keep messages short and simple; redirect and refocus when confusion increases

Rationale Brief and clear communication simplifies messages received when there is difficulty in interpreting verbal and non-verbal information.

2. Orient to the environment through signs, Appropriate communication assists in interactions with family, objects or other interactive group. 3. Provide consistency in schedule bathing and activities. 4. Provide adequate nutrition and rest periods and periodic checks of change in bowel or bladder elimination. 5.Administer medications as prescribed for agitation and depression 6. Assess risk factors for falls or harming others due to loss of functioning; environmental controls. maintaining orientation and reduces loss of ability to take ction in life skills. Consistent routines promote further orientation to time and place. Due to loss of ability to process environment and own physical cues, the patient needs assistance in the basic activities of daily living. Medication can assist in regaining control of impulses, reduce agitation from psychosis, and treat depression. Safety precautions assist staff and patient to maintain safe environment yet supports maximum level of independence.

Nursing Diagnosis: Sleep pattern disturbance related to disruption in brain center which controls wakefulness and circadian rhythm.

Nursing Management 1. Document sudden problems with restlessness and difficulty sleeping during the night or wandering which are changes from usual sleep cycles. 2. Assees for hallucination which contribute to difficulty of sleep.

Rationale Onset is sudden; often the night sees first signs, via alterations in sleep cycle.

Environmental, even familiar objects, my be misinterpreted at night because low lighting can cause shadows.

3. Discourage naps during the day

To promote a regular sleep cycle during the night.

4. Ask family about bedtime routine and maintain as close s possible.

Familiar routine can be both reassuring and orienting as to the time of day.

Nursing Diagnosis: Ineffective individual coping related to poor cognitive skills.

Nursing Management 1. assess and document current coping mechanism

Rationale Strengths and problem areas are identified and staff allowed to set realistic and staff allowed to set realistic expectation for behaviour

2. Patient identifies high-risk situations and When situation that may precipitate an develops alternate ways. increase in symptoms are identified strategies to avoid or decrease the stimulus or resulting anxiety may developed 3. Teach steps in problem solving process A step by step structure is helpful for people whose thoughts are disorganized 4. Provide practise situation to use problem solving skills Using skills in field test situation helps build confidence and provide opportunities to generalize the use of the skills. Nursing Diagnosis: Altered thought processes related to vulnerability to increased stress levels.

Nursing Management 1. Assess and document mental status and identify how symptoms interfere with y

Rationale This allows for individualized care based upon the most dysfunctional

daily functioning 2. Provide a reality oriented milieu y

symptoms An atmosphere helps correct distortions and misperceptions of the environment

3. Be attentive to the themes from hallucinations 4. Be attentive to the themes from hallucinations, distortions 5. Provide a safe environment and other cognitive

Non-reality increase increase

based when

thinking anxiety

may level

Concerns or fear may be expressed as safety Distortions in thinking may place patients risk for injury to harm themselves or others

6. Teach how to cope with distressing hallucinations

Technique such as humming, using radio, or telling the voices to go away.

dili ko ganahan naa lain tao as verbalized by the patient y y y y y Expressed feeling of aloneness Insecurity in public Inappropriate or immature interest in activities Lack of family support, social groups and friends Lack of purpose in life

A P

Impaired social interaction related to altered sense or interpretation of reality or difficulty with social skills. Short term: At the end of 15 minutes of nursing intervention, the patient will be able to verbalized willingness to engage in social interactions. Long term: At the end of 4 days, the client will be able to indulge in activities with others in the environment.

1. Encouraged the client to engage in social activities that were within the clients physical capabilities and tolerance level. I 2. Intervened with the client demonstration hallucination and impaired verbal communication such as engaging the client in brief, clam social contacts throughout the day. 3. Spent brief intervals with the client each day, engaging in meaningful, non-challenging interactions. 4. Helped the client compare the difference between social isolation and desire for solitude or privacy. 5. Provided the client with progressive activities according to level of tolerance and cognitive and effective functioning such as simple group activities. E The goal was partially met since the client was able to have an improved reality orientation but still manifests visual hallucinations and was not able to exhibit logical organization of thoughts. S y y O y y y A Anxious Depressed Frequent urination Dysfunctional eating pattern Restlessness

Anxiety related to maladaptive reaction to a identifiable stressor Short term: The patient will be able to recognize and handle feelings of anxiety appropriately.

Long term: The patient will be able to manage anxietyprovoking situations and develop coping skills. 1. Assisted client to recognize own anxiety

2. Promoted insight into anxiety and related factors. I 3. Provided opportunity for learning new, adaptive coping responses. 4. Involved client and family in educational or support activities. The goal was partially met since the client was able to identify E resources yet it is not used effectively.

S y O y y y y A Discomfort Unpleasant odor Unfixed hair Dry skin Dirty nails Self care deficit related to perceptual or cognitive impairement Short term: At the end of 15 minutes the patient will be able to P safely perform to maximum ability self care activities. Long term: At the end of 5 days, the patient will be able to identify resources which are useful in optimizing autonomy and independence. 1. Established rapport on the patient. 2. guided and supported the patient and let her performed the I procedure. 3. Used consistent routines and allow adequate time for patient to complete tasks. 4. Provided privacy. 5. Provided positive reinforcement for all activities attempted. E The goal was partially met since the patient was albe to

perform self care activities.

S y O y y A Denial Depression Verbalizing inaccurate information Knowledge deficit related to present health condition. Short term: At the end of 15 minutes the patient will be able to P demonstrate motivation to learn. Long term: At the end of 5 days patient will be able to identify perceive learning needs. 1. Provided physical comfort for the learner. 2. Provided an atmosphere of respect, openness, trust and I collaboration. 3. Allowed for and support self-directed, self-designed learning. 4. Assisted the learner in integrating information into daily life. 5. Encouraged questioning. E The goal was partially met since the client was able to verbalized understanding of learning.

IX.

Medical Management DRUG STUDY

Name: JR Generic Name: Akineton Brand Name: Biperiden Date Ordered: December 08,2010 Classification: Antiparkinsonian Dose/ Frequency/ Route: 2 mg/qd Mechanism of Action Acts as Specific Indication an Adjunctive therapy Hyper with of abstruction, of narrow-angle glaucoma, obstruction, prostatic hypertrophy. that genitourinary(GU) Contraindication Side Effects/ Nursing Precaution y Monitor bowel function and institute a bowel program. y Ensure that the pts voids before taking the drug. y Establish safety measures if CNS or vision

Toxic Effects sensitivity CNS; GI confusion, memory loss, nervousness, light headedness, vision, mydriasis, GI: dry mouth, constipation GU: flushing, decreased sweating. urinary retention, and EEFT: blurred

anticholinergic,

of to drugs in those disorientation,

principally in the parkinsonism, CNS, returning relief balance to the symptoms basal gangliaand reducing severity rigidity, akinesia, tremors, peripheral anticholinergic effects help to reduce droolingand other secondary and disorders the accompany of phenothiazine theraphy.

extrapyramidal

effects parkinsonian

of

changes occur.

Generic Name: Carbamazepine Brand Name: Carbatrol Date ordered: December 8, 2010 Classification: Antiepileptic Dose/ Frequency/ Route: 100mg od Mechanism Action Inhibits polysynaptic responses and blocks posttitanic potentiation, mechanism of action is not understood, related to the tricyclic antidepressant. of Specific Indication Treatment seizure disorders, including partial seizures with complex patterns, tonic-clonic seizures. Contraindication Side Effects/ Nursing Precaution y Administer the drug with food. y Monitor CBC CV before and periodically during therapy. y Discontinue if skin rsh, bone marrow suppression and personality changes occur. Toxic Effects Hypersensitivity to Drowsiness, bone depression severe dysfunction. marrow dizziness, and nausea, hepatic vomiting, hepatitis, hematological disorder. complication,

of refractory drugs in those with ataxia,

Generic Name: Haloperidol Brand Name: Haldol Date ordered: December 8, 2010 Classification: Anti psychotic Dose/ Frequency/ Route: 50 mg BID Mechanism of Specific Action Blocks synaptic dopamine receptors the parts in brain, of the Indication post Management Hypersensitivity disorders. CNS Contraindication Side Effects/ Nursing Precaution y Monitor patients sedation decreased thirst can related lead to to CNS effects for and dehydration, Toxic Effects to Drowsiness,

of psychotic drugs in those with insomnia, depression, vertigo, syndrome, severe orthostatic and hypotension, marrow photophobia, blurred nausea, vomiting, mouth, retention, anorexia. Circulatory collapse, extrapyramidal Parkinsons disease, hypotension bone suppression.

depress those brain involved in wakefulness and emesis.

vision, severe dehydration. dry y Provide urinary safety measures such siderails assistance with ambulation CNS occur. if effects as and

Generic Name: Diphenhydramine Brand Name: Benadryl Date ordered: December 8, 2010 Classification: Antihistamine Dose/ Frequency/ Route: 50 mg Mechanism Action Competitively blocks effects receptor has like and effects. of Specific Indication Treat as a Hypersensitivity of sleep aid. sites, narrowglaucoma, ulcer, asthma Contraindication Side Effects/ Nursing Precaution y Have patient dose. y Provide of safety measures CNS occurs. humidity and push fluids. if effect the void

Toxic Effects to Drowsiness,

the nighttime

drugs in those with sedation, angle dizziness, peptic epigastric bronchial distress renal or thickening bronchial secretions, urinary bradycardia.

before each

histamine at H1 atropineantipruritic sedative

hepatic impairment.

frequency rash, y Increase

X.Prognosis and recommendation GOOD PROGNOSIS POOR PROGNOSIS

CRITERIA a. ONSET OF ILLNESS

b. DURATION OF ILLNESS

c. PRECIPITATING FACTORS

d. MOOD and AFFECT

e. ATTITUDE AND WILLINGNESS TO TAKE MEDICATION AND TREATMENT f. ANY DEPRESSED FEATURES

g. FAMILY SUPPORT

Onset of Illness Since when she was in her elementary years, the patient manifested gradual changes in her personality. A poor rating was given in his aspect because it started at early age.

Duration of Illness The duration is persistent/ recurring since it always comes back whenever she cant take her medication. Patient having auditory hallucination and manifest circumstantialities. She was given the proper support by her family and even admitted her in German Doctors Hospital. She was given medication and after five (5) days was released from the hospital. A good rating given to this aspect.

Precipitating factors JRs illness according to her mother started when she was 11 years old due to traumatic experiences. They transfer 3 times and all houses were burned down. She started to manifest the symptoms after the incident, stated by the informant. A poor rating was given to this aspect.

Mood and affect Our patient was cooperative, coherent and participates in all our visits. She was able to answer our questions and even told us her story since her younger age. A good rating was given to this aspect.

Attitude and willingness to take medication She is willing to take her medications and treatment, and even willing to go to her doctor for check up. A good rating was given to this aspect.

Any depressive features Patient doesnt manifest any depressive symptoms. She doesnt know how to cope up with her sadness. A poor rating was given to this aspect.

Family support The family gives her proper support and care, but her mother only shows more affection to the patient. A good rating was given to this aspect.

Recommendation After five (5) days of exposure and interaction with JR and with the data gathered through direct observation, an interview with the patient and information gathered from her significant others. The group A4 therefore concludes and recommends the family to recognize and reinforce steps in terms of her social, cognitive, behavioral, and psychological achievements that the client need to overtime.  Treat the patient as a normal individual.  Family should be sensitive with the clients needs and develop a honest and genuine mental relationship with the patient.  The patient will promote good hygiene and consistently appear clean and well groomed.  Never give false assurance to the patient.  Avoid stressful situations.  Support for family members is important. As ordered by the patients JRs physician the guardian of the patient should get her medications in German Doctors Hospital in order to stabilized patients current health status.

XI.Bibliography Videbeck, Sheila L., Psychiatric Mental Health Nursing, Lippincott Williams and Wilkins, 2001. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders(4th ed.). Washington , DC :APA Corrigan, P.W., and Storbach, D.M (1993). Behavioral interventions for alleviating psychotic symptoms. Hospital and community psychiatry, 44(4), 341-346 Cooper, K.H (1984). Territorial Behavior among the institutionalized: A nursing perspective. Journal of Psychiatric Nursing, 22(12)6-12 Doenges, M., and Moorehouse, M. (1998). Nursing diagnosis with interventions. Philadelphia , .PA: Davis Hamera, E.et al.(1992). Teaching hospitalized patients with serious, persistent mental illness. Journal of Psychiatric Nursing, 6(6), 324-330

y y y y y