NCM 105 Requirement

Comprehensive Psychiatric Case Study

“Undifferentiated Schizophrenia”

Chapter 1 – Introduction
 Introduction to Psychopathology

Schizophrenia is characterized by a broad range of behaviors marked by a loss of the

person’s sense of self, significant impairment in reality testing, and disturbances in
feelings, thinking and behavior. The pathophysiology of schizophrenia has long
remained a mystery and still today, even with various hypotheses, remains somewhat
uncertain: there are too many variants; not enough consistency in findings; and, despite
research, a lack of documented proof. The most well-known and respected hypothesis
with regards to the pathophysiology of schizophrenia began in the 1990s and consisted
primarily of the notion there is a problem with the dopamine levels in the brain of
schizophrenics. Dopamine is both a hormone and a neurotransmitter, which means that
it activates five different receptors in the brain, aptly named D1, D2, D3, D4, and D5.
That said, it may not be the only neurotransmitter involved in the pathophysiology of
schizophrenia. Glutamate and Serotonin have also been implicated. Contributing to tHer
hypothesis is the fact that drugs administered to aid dopaminergic activity bring on
schizophrenic characteristics such as psychosis, in a patient, whereas drugs
administered to block them help reduce, or eliminate symptoms of schizophrenia
altogether.

Additional studies affecting the pathophysiology of schizophrenia include

suggestions that maternal factors such as infection, malnutrition, location of birth,
season of birth, and delivery, may play a significant part in the formation and
subsequent appearance of schizophrenia. Studies have shown that the worldwide rate
of births affected with schizophrenia is up to 8% higher when occurring in spring or
winter, though no explanation for tHer can be offered. Another aspect of the
pathophysiology of schizophrenia that has been explored in relative detail is that of
genetics, and their relation to the likelihood of immediate relatives being born with the
disease. Shockingly, it has been found that 10% of all immediate family members of an
infected person will be struck down with the disease. There is specifically in relation to
parents, siblings, and children.

With regards to twins or other multiple births, the chances they will share the
disease is 50%. Genetic reports suggest that it is the X chromosome which determines
whether or not a person is infected with schizophrenia, specifically, chromosomes 1, 3,
5, and 11, however further studies are needed in order to prove their theory. Though
there are many theories and hypotheses regarding the pathophysiology of
schizophrenia, there is, unfortunately, still no cure for the disease. The best a sufferer
can hope for nowadays is to benefit from available medication which keeps the disease
under control or in remission for the duration of time for which it is taken.
 There are several factors that cause schizophrenia when it comes to biologics
theories. First are the genetic factors which states that when there is family History of
schizophrenia there are 50% risk of schizophrenia in identical twins, 15% risk in
fraternal twins and if one biologic parents have History of the disorder there is a 15%
risk and if both parents has the History there is 35% risk. Second is the neuroanatomic
and neurochemical factors, findings have demonstrated that people with schizophrenia
have relatively less brain tissue and cerebrospinal fluid than those who do not have
schizophrenia, enlarged ventricles in brain and cortical atrophy can be seen through CT
scan. Glucose metabolism and oxygen are diminished in the frontal cortical structure of
the brain seen through PET scan and there is a decreased brain volume and abnormal
function in the frontal and temporal alterations in the neurotransmitter system in the
brain. There is also excess dopamine and serotonin which contributes to the
development of the disorder. Third is the immune-virologic factor wherein alteration in
brain physiology was caused by exposure to a virus or the body’s immune response to
a virus.

In diagnosing schizophrenia, self-reported experiences by the person and

abnormalities in behavior reported by the family and friends are considered. In
assessing patient; History, thought process and content, general appearance, motor
behavior, speech, mood and affect, sensorium and intellectual process, judgment and
insight, self-concept, roles and relationships, physiologic and self-care considerations
are important in the diagnosis of the disorder. There are two major categories of
symptoms of schizophrenia: positive or hard symptoms and negative or soft symptoms.
The positive symptoms consist of ambivalence,
 Chapter 2 – Assessment

1) Biographical Data

Patient. B.M. is a 35 year old woman from Marikina, Metro Manila. She was born
on August 17, 1982 as if a Roman Catholic. Prior to her admission to National Center
for Mental Health, she used to work as a waitress. She is a single mother of three
children, all of which have been sent to live with cousin. She finished elementary in her
home town then reached 2nd year High School before dropping out due to financial
issues with the family. She has been in NCMH for 15 years. The interviews and
therapies were conducted on March 6, 7, 12, 23, 2018.

2) Health History

2.1 History of Present Illness

The patient was seen wandering alongside Roxas Blvd. by herself back in
January 6, 2005, talking incoherently and laughing to no one in particular. A few days
later, she was brought in by a tricycle driver and was admitted to the hospital for a
couple of months for treatment and observation until she was discharge on June 24,
2005. During her first admission, she had denied experiencing hallucinations as claimed
by the tricycle driver that brought her. She was then readmitted November 08, 2006 by
her friend, C.B. Her admitting diagnosis was Bipolar affective disorder current manic
with psychotic symptoms. It was later changed to undifferentiated schizophrenia on
March 14, 2008 during her time in pavilion nine.

During her time in pavilion nine, she has a History of self-injury by peeling off the
nail of her 3rd digit. There was minimal bleeding and was controlled with applied
pressure. She verbalized, “Ma’am, makati po kasi.”

2.2 Past Personal History

B.M. was once an alcoholic prior to her admission. She claims she started back
in her first-year high school. The patient partied a lot and drink enough alcohol as
tolerated. She was admitted once to the hospital for injury due to the congenital
condition of her foot from running as a child.

2.3 Family History

a. Maternal and Paternal Lineage

On the direct bilateral lineage of the patient, she states that she does not know
any family member that had shown any conditions of mental illness. On the paternal
side, prominent family illnesses only concern some members having hypertension
and/or hypoglycemia. Aside from the condition, no other illnesses run the family. On the
maternal line, the patent did not recall any illness that run in the family, except one
family member (her grandmother) having diabetes, an illness condition occurring
singularly to be considered familial. Generally, no mental illness can be traced on both
sides of the family according to the patient.

b. Father

The father was between Her 30-40’s when he passed away, a small-time
businessman that had spent some of Her time travelling either due to business or to
visit family members. He impregnated the patient’s mother, when he was only in Her
late 20’s years old, then eloped with her. As a father, he was lenient in Her relationship
with Her children. Most of Her time is spent travelling related to business, but he did
bring the patient with him whenever he can. Most times to bring her to see her
grandmother when she was still alive. Moreover, he was a kind of father who would not
spank or scold Her children and he seldom verbalizes what he feels. According to the
patient, he would only speak to Her children wherever they do something in-correct. He
died in a construction accident.

c. Mother

The mother is currently living with one of the patient’s relatives, but the last the
patient heard was that her mother was in the hospital due to her own medical
complications. The mother owned a sari-sari store as extra in-come.

3) Mental Status Examination

GENERAL APPEARANCE (during interview)

The patient appears appropriate to her real age which is 35. During the interview
at National Center for Mental Health, she wore the standard clinical gown that is
provided to all the patients at Pavilion 10. The patient appears tidy. She maintains her
appearance by keeping her clothing as clean as possible until she takes another bath,
washed hair that is always held in a bun with a hair clip, fingernails and toenails kept
short with no dirt which evidently seen on both sides. At the time of the interview, the
patient was alert and responsive.

GENERAL MOBILITY & BEHAVIOR (during interview)

The patient slouches when seated if not spoken to, but when she’s interested
she slightly sits up. She holds herself erect when standing and walking, but limps due to
the long time congenital abscess of her right foot, rendering her incapable of running.
Although she still walks at a normal pace without any further problems. Her mannerisms
include manually scratching certain parts of her arms. Some parts of her skin appear
reddish upon further inspection but does not complain of any pain. The patient’s
movement are organized and purposeful during the interview and therapies. She moves
in a normal pace and does not show any signs of over and under activity.

The patient’s facial expressions are very much appropriate to Her verbal
responses during the interview. She was composed and receptive to whatever the
group asks him. However, when recalling certain parts of her time prior to her
admission, she forces a smile while holding back her tears. The patient was friendly and
warm to during introductions and during the first nurse-patient interaction interview. She
was sitting on her seat calmly. She interacts well with the rest of the students and as
what I had observed; she has a good relationship with many of the patients at the
pavilion. The patient accepted (me) the student-nurse warmly. She entertained the
questions and answered almost all of them.

She maintains good eye-contact. However, there were certain topics that caused
her to break eye contact and stare down as she fiddles with her hands. If topic is set
aside or changed, she resumes eye-contact and continues talking.

SPEECH PATTERN

During my conversation with the patient, I noticed that she is spontaneous at

times. However, there are times in which blocking is evident in between her speech. Her
articulation words were clear. The patient was eager to talk with me during the
interview. He tries to answer every question the group asks him however, in Her
answers, we apparently observe succession of circumstantiality and tangentiality. He
provides a very detailed answer when it’s related to her family or what her life was like
during her youth, or at times, she gives a very short response (ex. “Masaya ako” or
“Wala naman.”), especially if they are questions aimed to assess her current emotional
state after a certain therapy she participated in or how she currently feels.

THOUGHT CONTENT & PROCESS

During the interview, when questioned about why she was admitted to the
hospital, she admits to having auditory hallucinations. When further questioned, she
verbalizes, “Ang dami narinig ako dati. Kapag hindi ako na uminom yung meds ko, na
babalik yung ibang boses. Gawa akong isang araw ayaw uminom, nandoon ng ibang
boses. Aka la ko dati, yung mga anak ko, pero sa totoo hindi daw. Yung ang sabi ng
ibang tao sa akin. Ng sabi yung mga boses ‘Wag ka kumain,’ ‘Wag ka matulog,’
‘Sampalin sya,’ ang dami.” It was mentioned in the nursing notes she used to deny that
she had any visual hallucinations however, the stranger that brought her in and her
friend said to the nurses (as stated straight from the notes) that during tantrums, the
patient verbalizes that she hears someone whom they cannot hear. She even saw
someone that wasn’t even there to begin with.

There are several types of delusions that are currently being managed from the
patient through the prolonged medical treatment she has been receiving on a daily
basis. First, the patient once believed that there was something trying to manipulate her

– which is a clear sign of persecutory delusion. He also has a feeling that others,
especially Her friends, hate him because they are jealous of him.

NEUROVEGETATIVE STATE

The patient usually sleeps at 6pm during the night and usually wakes up at 5am
get-ting at least 5 hours of sleep. She says that he finds it hard to sleep at night and
instead, sshe just spends Her time watching television until he falls asleep. Five in the
morning for the patient is too early for him to wake up that is why he attempts to go back
to sleep, but then, he is unable to do such. THer is a manifestation of late or terminal
insomnia.

Appetite - The patient has increased appetite. He eats a lot however, he is choosy in
Her food. “Kumain ako ang tatlong tinapay may laman sa loob sa umaga.”, reported by
the patient. “Kailangan na kumain ako marami

Diurnal Variation - The patient’s mood varies during the day. He is usually fine in the
morning and gets, uneasy, restless, and irritable as the day progresses. Other times,
Her day starts out worse in the morning and feels better later on.

GENERAL SENSORIUM AND INTELLECTUAL FUNCTIONING (Orientation, Memory &

Judgement)

The patient is well oriented of the time, place and person. When asked during the
interview if what date and time was it, he answered correctly. However, as the
conversation progressed, we noticed that he is confused and not well oriented with the
time. When asked, when did she last drank alcohol, she answered, “Mga 2005.” When
recalling the time, the patient would first question herself on the previous date then
answer what the current date is. She uses her fingers to count, either the year of the
dates. The patient has slight difficulty recalling remote memories. When asked what her
age was, she took a moment before she answers; “Parang… twenty-three pa ako?
Hindi ko sure kasi medyo tagal ako dito sa NCMH. Pero alam ko talaga thirty-five na
ako ngyaon araw.” Other than that, the patient has a good memory when it comes to
remembering recent and immediate memories.

The patient was given simple mathematical tasks such as addition and
subtraction. He was able to answer all of them but there was a long pause before he
can finally give the answers to the much more complicated questions. The patient
knows basic general information like the who was the founder of SM Mall and the basic
use of a telephone/cellphone. The patient was given a maxim translated in Tagalog to
evaluate her reasoning and abstract thinking. She was asked to explain the quote Try
and try until you succeed. She was able to explain it but not profoundly. He said,
“Parang gawain mo hanagang may oras ka.” And when asked to elaborate, she refused
to. She was also given a situation in what would happen if one of the fellow patients
were to panic, what would she do. She replied, “Tawaging ako yung ibang nurse.”

EMOTIONAL STATUS AND REACTION (Mood, Affect, Insight)

Through the course of the interviews, the patient’s mood was euthymic. Her
feelings were appropriate to the situations as he relays Her answers to the group. Her
mood was just appropriate and basing from Her gestures and other nonverbal cues, Her
mood is fitting to the situation. The patient’s affect is appropriate as well. There is a
marked harmony between thought content, emotional response, and expressiveness.
When asked, “Kumuta ka ma’am? Medyo na enjoy ka sa mga ibang activity ngayon?”,
she verbalized, “Masaya ako. Mapagod na ako kasi ang daming ng gawa mo saamin,
pero masaya.” with a smile.

Patient B.M. understands that she needs to stay in the psychiatric hospital for
treatment but wonders when she’ll be able to leave to see her children again. Since
she’s been there for fifteen years, she knows that there’s a problem. She does not have
a clear understanding about her condition as she has no clue as to how it occurred or
any memory of how it began. The patient does know what her diagnosis is and is
familiar with some of the symptoms associated with her condition. She acknowledges
that she had indeed heard voices in the past. This shows an improvement in
acknowledgement as it has been shown in the past nursing notes, she used to deny
having auditory hallucinations before her transfer to pavilion 10.
 Chapter 3 – Diagnosis

1. Risk Factors
The patient has a previous history of experiencing auditory hallucinations and has
exhibited extremely disorganized behavior and speech. The patient does not recall
anyone from either side of her family that has a history of Schizophrenia, so the family
history is excluded for the risk factors. Environmental factors can be a possible link in
the development of schizophrenia. The patient mentioned that when her mother was
pregnant, her mother became ill and had to take medications. She doesn’t remember
what the illness was, all the patient thinks that the medications that were taken is the
cause for her congenital foot deformity. During her childhood, the patient lost her father
at a very young age and it took her a very long time to try and cope with her father’s
death.
2. Psychodynamics / Psychopathology
 3. Nursing Care Plan
PRIORITIZATION
NURSING DIAGNOSIS
Disturbed sensory (auditory) may
be related to overwhelming
stressful life events as evidenced
by previous history of inappropriate
non-reality-based thinking and
delusions
Situational low self-esteem related
to developmental changes (mental
impairment)
Ineffective coping related to
difficulty adapting in stress
RANKING JUSTIFICATION
This is the first prioritization as
the patient has previously
experienced auditory
hallucinations before and after
she was admitted to the
psychiatric hospital. She
mentions herself that if she were
to stop taking her medications,
1
then the voices would come
back, that’s why she’s been
compliant with taking her
medications as she doesn’t want
to accidentally harm others or
herself. She mentions that this
started after she forced herself
to leave her ex-boyfriend after
he continually meets with other
women behind her back and
sometimes physically hurting her
during an argument.
This is the second nursing
prioritization as the patient has
shown some signs of low self-
esteem, some resentment
towards herself. The patient
2
claims that she does not hate
herself but feels that she won’t
get any better due to her
prolonged stay at the psychiatric
hospital. She would degrade
herself, saying that there are
some things she can’t do right.
She refused to fully explain what
they are.
This is the third as the patient
has shown signs of ineffective
3
coping with stress as she easily
lost her patience with crafting
activities that were very hands
on and required a lot of thinking
when it comes to the stops,
which she slowly became
irritated and started to struggle.
Interrupted Family Process related
to family role shift as evidenced by
changes in communication
patterns
4 forgotten about her. What she
Risk for falls related to history of
falls
5
This is the fourth prioritization as
the patient as the patient has
voiced out her concern on
various occasions about her
about the lack of contact from
her family. Because of this, she
feels that her family has
was told was that her children
can’t visit as they are not of age
yet, but she knows that two of
them are able as two of them
are adults now. There are times
she considers that it may be
because they are busy, but she
has also said that they’ve
probably forgotten her.
This is the last as due to the
patient eagerness to move
around, the patient limps around
while attempting to run without
being careful of where she
steps.
 Nursing Care Plan
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective Data: Disturbed thought After 2 hours of nursing 1. Be sincere and honest - Patients are extremely GOAL MET
process may be interaction, the patient when communicating with the sensitive about others
“Ang daming boses related to patient. and can recognize After 2 hours of
will be able to:
na narinig ako overwhelming insincerity. Evasive nursing interaction, the
kapang hindi na stressful life events remarks reinforce patient was able to:
uminom yung gamot as evidenced by · Maintain reality mistrust.
ko. Na ginawa ako inappropriate non- orientation 2. Assess patient’s nonverbal - This assessment · The patient was able
dati. Akala ko reality-based behavior, may help to meet the to maintain reality
narinig yung boses thinking and · Demonstrate reality- such as gestures, facial patient’s needs that orientation. He is
ng mga anak ko,” as delusions based thinking in verbal expression and cannot be conveyed oriented to time when
verbalized by the and nonverbal behavior posture. through speech. asked what day it is.
patient. But he is still
· Demonstrate the ability 3. Encourage the patient’s - Probing increases preoccupied
Objective Data: needs that cannot be patient’s suspicion and With his delusions
to abstract,
conveyed through speech. interferes with the about his being
conceptualize, reason therapeutic relationship. jealous to him.
and calculate consistent 4. Show empathy to the - The patient’s
with ability to patient’s feelings, reassure experiences can be · The patient was not
interpretation. the distressing. Empathy able to demonstrate
patient of your presence and conveys acceptance reality based thinking
acceptance. of the patient your in verbal and
caring and interest. nonverbal responses.
- Avoid laughing, His mannerism is
5. Avoid laughing, whispering, or talking largely observed and
whispering, or talking quietly quietly where patient he wasn’t able to
where patient can see but not can see but not hear establish eye contact
hear what is being said. what is being said. with any of the
interviewer.

6. Give simple directions
using short words and simple
sentences.
7. Never convey to the
patient that his delusions and
hallucinations are real.
8. Maintain reality oriented
relationship (if neccessary)
and environment
9. Give positive feedbacks
and acknowledge the patient
10. Do not judge or belittle
patient’s beliefs.
- Giving simple
directions lessen or · Ho wever, he was
prevent confusion of the able to exhibit a
patient. positive abstract,
- The delusion or reason, judgment and
hallucination would be calculation abilities.
reinforce if it’s accepted.
- Maintaining reality
based relationship and
environment lets the
patient know that the
relationship is
temporary and prevents
separation anxiety.
- Positive feedback
enhances sense of
well-being and makes a
more positive situation
for the patient.
- What the patient feels
or thinks is not funny for
him. The patient may
feel rejected if
approached
by attempts of humor.
 Nursing Care Plan
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective Data: Situational low After 2 hours of nursing 1. Encourage patient to - Patient may be fixed in GOAL MET
self-esteem related care, the patient will be express honest feelings in anger stage of grieving
She expressed on to developmental able to: relation to loss of prior level process, which is turned After 2 hours of
various occasions changes (mental of functioning. Acknowledge inward on the self, nursing care, the
about wanting to impairment) · Verbalize understanding pain of loss. Support patient resulting in diminished patient was be able
see her children of things that precipitate through process of grieving. self esteem. to:
again, but feels that current situation; and
her condition is 2. Devise methods for - To explore the · The patient was
getting in the way of · Demonstrate behaviors assisting patient to express feelings of the patient unable to verbalize
that. that show positive self- feelings properly. thereby allowing him to understanding of
esteem acknowledge his own things that lead to
“Gusto ko makita strength and weakness current situation
yung anak ko. Kaso, 3. Encourage patient's - The ability to
hindi ko alam kung attempts to communicate. If communicate effectively · The patient was
kailan pwede. Alam verbalizations are not with others may unable to demonstrate
ko medyo busy understandable, express enhance self-esteem. behaviors that show
yung mga anak ko to patient what you think he positive self-esteem
pero parang walang or she intended to say. It may as evidenced by
silang pag-effort na be necessary to reorient inability to have
contact saakin,” as patient frequently.
verbalized by the
patient 4. Encourage reminiscence - Reminiscence and
and discussion of life review. life review help the
Objective Data: Also discuss present-day patient resume
events. Sharing picture progression through the
 Sometimes albums, if possible, is grief process associated
avoids eye especially good. with disappointing life
contact when events and increase
a certain selfesteem as
 topic is successes are
brought up. reviewed.
 Talks only 5. Encourage participation
when asked. in group activities. Caregiver - Positive feedback
 Shows may need to accompany from group members
interest in patient at first, until he or she will increase selfesteem
activity but feels secure that the group
shows little members will be accepting,
energy regardless of limitations in
verbal communication.

6. Offer support and empathy

when patient expresses - Focus on accomplish
embarrassment at inability to ments to lift self-esteem.
remember people, events,
and places.

7. Encourage patient to be as
independent as possible in
selfcare activities.
8. Listen to patient’s concerns
and verbalizations without
comment or judgment.
- The ability to perform
Independently
preserves selfesteem.
- It enables the patient
to develop trust and
thereby establish
communication
 Nursing Care Plan
Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Ineffective After 4 hours of nursing - Assess specific stressors. -Accurate appraisal can GOAL PARTIALLY
coping intervention, the client will - Assess level of facilitate development MET
She said that her related to be able: understanding and readiness of appropriate coping
usual mood is calm difficulty to learn needed lifestyle strategies. After 4 hours of
but in times of adapting in - to describe and changes -Appropriate problem nursing intervention,
difficulty her mood stress initiates alternative - Assess decision-making solving requires the client was be able:
is mostly irritable. coping strategies in and problem-solving abilities. accurate information
adapting stress. - Determine alcohol intake, and understanding of - to describe and
The client described drug use, smoking habits, options. initiates alternative
herself as - determine degree of sleeping and eating patterns. - Patients may feel coping strategies in
“maraming anak at Impairment - Establish a working that the threat is adapting stress.
nahihirapan". relationship with patient greater than their
- deal with current through continuity of care. resources to handle - determine degree of
"Nahihirapan ako, situation. - Provide opportunities to it and feel a loss of Impairment
yunyung na fefeel express concerns, fears, control over solving the
ko.. parang - provide for meeting feelings, and expectations. threat or problem. - deal with current
gusto ko nang psychological needs. -Assess decision-making -These mechanisms situation.
bumigay". and problem-solving are often used when
When asked if how - promote wellness. abilities. individual’s is not - provide for meeting
she handled big -Determine alcohol intake, coping effectively with psychological needs.
problems in her life drug use, smoking habits, stressors.
she answered ,“Ina sleeping and eating patterns. -An ongoing - promote wellness.
away ko nalang -Establish a working relationship
asawa ko”. relationship with patient establishes trust,
through continuity of care. reduces the feeling
Objective: -Provide opportunities to of isolation, and may
- used negative express concerns, fears, facilitate coping.
forms of feelings, and expectations. -Verbalization of
coping like -Encourage patient to actual or perceived
regression identify own strengths and
abilities.
-Provide information the
patient wants and needs. Do
not provide more than
patient can handle.
-Encourage patient to
communicate feelings with
significant others.
- Instruct in need for
adequate rest and
prescribed diet.
-Teach use of relaxation,
exercise, and diversional
activities.
-Determine previous
methods of dealing with life
problems.
-Converse at client’s level,
providing meaningful
conversation while
performing care.
-Encourage and support
client in evaluating lifestyle,
occupation, and leisure
activities.
-Provide for gradual
implementation and
continuation of necessary
behavior/lifestyle.
stress can help reduce
anxiety.
-During crises, may not
be able to recognize
their strengths.
Fostering awareness
can expedite use of
these strengths.
-Patients who are
coping ineffectively
have reduced ability
to assimilate
information.
-Unexpressed feelings
can increase stress.
-These facilitate coping
strengths. Inadequate
diet and fatigue can
themselves be
stressors.
-Methods to cope with
stress.
-To identify successful
techniques that can be
used in current
situation.
-Enhances therapeutic
relationship.
-Promotes long term
development that deals
with current situation.
 Chapter 4 – Implementation
Process Recording

Day #1 – Orientation Phase

Nurse Patient Analysis
Verbal Nonverbal Verbal Nonverbal Themes Therapeutic
Techniques
Magandang The student sits Kumusta! Ako The client is Orientation
umaga po, across from the ay si Barbara. smiling back and rapport Offering self,
ako ay si patient and and shows to between actively listening.
Andrea, isang starts eye be student and
istudyante ng contact. comfortable in nurse.
nursing sa talking to the
CEU Makati. student.
Nandito po
ako para
gumugol ng
oras sa iyo.
The nurse The client
Ilang taong maintains eye Ang edad ko ay shares Questioning,
gulang na ho contact and 35. Kulyo 31 enthusiasm actively listening.
kayo? reacts/comments ang kaarawan upon sharing
when ko. her birthday.
appropriate.
Same as above. The client
Saan ka Sa Bataan. remains calm Same as above
pinanganak? Doon ako when briefly
lumaki at explaining
nagtapos ng some parts of
elementarya. her
childhood.
Same as above. The client is
Puwede mo Nandito tayo sa careful when Orienting to time
bang sabihin National Center reciting the and place
sa akin kung of Mental name of the
nasaan tayo Health. Ngayon institution as
ngayon at ay.. kahopn ay it is in
kung ano ang ika-lima ng English. In
petsa ngayon? Marso … order to
Marso 6. Ika- recall today’s
anim ng Marso date, she has
to recall
yesterday’s
date.
Same as above. The client
Ano ho ang Dalawang looks at nurse Questioning,
inalmusal piraso ng while smiling. actively listening.
ninyo? tinapay na may
cheese. Gusto
ko palagi
kumain ng
limang
pirasong
tinapay
 Same as above. Doon ho! The client
Saan kayo gets up and Questioning,
natutulog? guides the actively listening.
student to the
ward she
sleeps in and
points to her
bed.
Same as above. The client
Ano ang mga Nagwawalis demonstrates Questioning,
Gawain ninyo ako ng sahig, this by doing actively listening.
ditto sa nagpupunas ng sweeping and
pavilion 19? mesa at circulation
naghuhugas ng motions with
pinagkainan. her hands
Same as above. The client’s
Kasal ba Hindi, mood slightly Questioning,
kayo? nagsasama changes. actively listening.
kami date pero Despite her
hindi kami smile, her
kasal. Ayokong voice is
magpakasal lowered and
kasi looks down
pakiramdam ko at the
parang akong ground.
nakatali pag
ginawa ko iyon.
Same as above. The client The client is
Ang Takot lang ako nods several conflicted in Summarizing,
pangunahing sa mga times. her current focusing
dahilan kung responsibilidad relationship
bakit ayaw na kasama sa with her
mong pagpapakasal. partner.
magpakasal Pakiramdam ko
ay dahil na hindi pa ako
pakiramdam handa.
mo ay
mapipigilan
kang gawin
ang gusto
mo?
Same as above. The client The client
Kagaano na Matagal na. maintains eye doesn’t recall Focusing
kayo katagal Nagkakilala contact, her the exact
magkasama kami sa mall sa body starts to amount of
ng karelasyon Guadalupe. relax in her time but has
mo? position as no trouble
she keeps describing
talking. situations.
Same as above. Same as Long term
Saan ka at Doon din sa above memory Questioning,
ang pamilya Guadalupe. actively listening.
mo dati
nakatira?
Do you have Same as above. Same as The client
any kids? How Oo, meron above appears and Focusing
old are they? akong tatlo. sounds
Dalawang happy when
May mga anak babae at isang questioned
ka ba? Ilang lalaki. Yung about her
taon na sila? mga babae at children.
19 at 18 at
yung lalaki ay
17.
Same as above. The client’s The client is
Binibisita ka Oo pero himdi mouth forms visibly upset Focusing
ba ng pamilya madalas. Yung a line, eyes on the little
mo? Kelan mo kasama ko ay are slightly visits of her
sila huling apat na beses furrowed, and family and
nakita? pa lang her tone appears
bumibisita. May sounds sad at depressed,
nakapagsabi sa the mention of which relates
akin na yung her children. to the lack of
mga anak at Her contact with
masyadong expression her children.
maraming slightly
inaatupag sa brightens
kanilang pag- when
aaral o wala pa mentioning
sa tamang her parent.
edad para
bumisita sa
akin. Nasa
tamang edad
naman yata
yung dalawang
anak ko para
bumisita. Mga
litrato lang nila
ang nakikita
tuwing
bumibisita yung
kasama ko.
Gaano katagal Same as above. The client The client’s
ka nang Halos 14 na was quick to response is Questioning,
nakatira dito taon na. answer quick and actively listening.
without short, not
showing any wanting to
signs of recall further
issues. discuss it.
Same as above. Her voice The client
Kumusta na Yung nanay ko slightly cracks tries to Questioning,
ang mga ay nakatira sa at the mention control her making
magulang mas bata kong of her father emotions observations,
mo? Nakita kapatid na and appears when actively listening.
mo ba sila lalaki. Bata pa ready to cry mentioning
mula ng ako nang after her father.
tumira ka dito? pumanaw ang expressing
tatay ko. some of her
Nangungulila feelings of his
nga ako sa passing.
kanya.
You don’t The student The client’s Although it
have to say leans slightly Isa siyang cheeks are was not Making
anymore. I forward and banyaga galling raised but the questioned, observations,
can tell that gently squeeze ng Amerika at corner of her the client actively listening.
you and your the client’s hand ang nanay ko lips is still wanted to
dad must have then goes back ay isang downwards share certain
been really to previous Negrita. things she
close. position. Sinasama niya remembered
ako noon fondly about
Hindi mo na tuwing siya ay her father.
kailangan nangingibang
sabihin. bansa.Sinama
Napapansin nga niya ako
ko na malapit para Makita ko
kayo ng tatay ang lola ko.
mo.
The student The client’s The client’s
Ano ang mga changes subject Mahilig ako expression mood Questioning,
libangan mo and maintains magluto. changes and changed to using open
bago ka minimal Marunong ako appears more relief when ended
nakapasok distance, as well magluto ng animated the topic was questions,
dito sa as maintaining spaghetti, itlog, upon the changed. actively listening.
NCMH? eye contact. pansit, subject being
sinigang, sisig. changed.
The student The client The client
Sino ang maintains eye Oo, yung appeared glows with Questioning,
nagturo sa iyo contact and nanay ko kasi happier to pride. clarification,
magluto? Ang responds when nagtrabaho dati mention her actively listening.
nanay mob a? appropriate bilang isang mother.
chef. Minsan ko
siyang nakitang
nagluluto sa
bahay at
nakiusap akong
tutuan niya
ako.
 Day #2 – Working Phase
Nurse Patient Analysis
Verbal Nonverbal Verbal Nonverbal Themes Therapeutic
Techniques

Good, The student sits Yes! I really Is smiling and Content – Re- Questioning,
morning across from the liked drawing sitting oriented to actively listening
ma'am! patient and the most! comfortably person
starts eye Mood -
contact. rapturous

You seemed The student We sometimes Same as Content – Making

to enjoy the silently nods do drawing above describes observations,
drawing more while listening during our enjoyment of actively
compared to therapy. It’s earlier listening.
when you always fun to activities
were making draw what I
the fan. like.

I noticed you Same as above The sticks just Frowning and Mood - Same as above
were having a wouldn’t stick making slight frustrated
little trouble to the paper. I exaggerations
finishing your keep putting with arms
fan. glue and it just when
won’t stick. demonstrating

Is that why It was hard! It Seeking

you refused to looked ugly Clarification
design it after when I tried to
it finally dried write the letters
off? of my name!

Questioning,
You drew a Same as above I just thought of Smiles a bit Mood – actively listening
picture of your my kids. I really and shift Sadness
children for miss them. It’s around in her Interaction –
your first been a very seat while slightly opens
drawing. Can long time since gazing down up, is slightly
you tell me I saw them. at the floor more trusting
why drew of student-
them? nurse.

What did you Same as above Happy. I really Looks at the Same as Encouraging
feel while you miss them… student above Descriptions of
were drawing It’s been a straight in the Perception
your kids? really long time eye and
since I saw clasps her
them in person. hangs
together
Have you Same as above Yes, but not so Bites lower lip Interaction - Questioning,
been able to often. and shift her Loneliness Focusing,
get in contact gaze Actively listening
with them at somewhere
least? else for a
moment
About your Same as above I just wanted to Shrugs Mood – Questioning,
second draw them. I Unsure seeking
drawing, you felt relaxed. Interaction – clarification,
drew some Has difficulty actively listening
fruits when the fully
music was explaining
changed. Can herself
you tell me
why?
How come Same as above I was done Smiles and Questioning
you labelled while the music readjusts Content –
the fruits? was playing, so herself in her Does not fully
I just thought of seat explain
labelling them.
I wanted to
make sure you
knew what I
drew.
When the Same as above Questioning,
drawing of I don’t know. I Takes a Content – making
your family, just felt like it moment to Unsure of her observations,
how come you while waiting. think before actions actively listening
wrote the answering. Mood -
word ‘slow’ melancholy
after labelling
the fruits?
Yesterday, Same as above My husband Shakes her Interaction – Questioning,
you told me doesn’t. My head quickly is quick to actively listening
your kids are brother is the while answer.
still going to one taking care explaining. Mood –
college, is of them. Her eyes Unexpressed
their father furrow while contempt
paying for mentioning towards
their her husband husband
education?
What is his Same as above He’s one of Pauses with Interaction – Questioning,
current job? those… guys her mouth tries to laugh focusing
that collect forming a line it off when
money for then tries to she forgets
calling the smile and
jeepney for laugh
people. Sorry I
don’t know
what they’re
called!
What was Same as above We love each Has trouble Mood - Same above
your other. We maintaining Indescribable
relationship fought a few her smile Content –
with your times. Not shows
husband like hitting each conflicting
before you other, just emotions
came here? yelling.
 towards
husband
What causes Same as above I get jealous. I Same as Mood – Same as above
you two to would see him above irritated (not
argue? around other towards the
women and I student-
get upset every nurse)
time I see it.
Did you feel Same as above No. Only when Almost frowns Same as Placing the
that way I see him at the end of above event in time or
often? holding another her sentence Interaction – sequence,
girl. and clenches expresses her Focusing
her hands irritation on
her husband’s
personality
Did it ever get Same as above He’s slapped Nods, tries to Mood - Same as above
to the point me, not hard laugh and uncomfortable
where though. Three keeps looking Interaction –
someone times I think. It somewhere open with
decides to get only happens else nurse
a little when he gets
physical? annoyed with
my jealousy.
What do you Same as above We don’t talk Shrugs Interaction – Same as above
do to calm for the rest of has nothing
down? the day then else to further
we talk again say
the next day.
Is there Same as above Never get Points to Mood - Giving broad
anything else married! It’s student nurse complex openings
you want to very stressful.
share?
I thought you Same as above We’re not, but Puts hand on Mood – Focusing,
two weren’t I’m just giving chest while cynical, cold Seeking
married? you advice. If I other moves clarification,
already felt around to actively listening
stressed just further help
living with him express
and being the herself
with our kids
the most, then
I’m sure being
married to him
will still be the
same.
 Day #3 – Termination Phase
Nurse Patient Analysis
Verbal Nonverbal Verbal Nonverbal Themes Therapeutic
Techniques

Did you sleep The student sits Yes, it was a Is smiling and Content – Re- Questioning,
well? across from the little cold, but I sitting oriented to actively listening
patient and got slept very comfortably person
starts eye well. Mood -
contact. rapturous
Did you have Questioning,
fun with Same as above Yes! Same as Mood - Actively listening
today’s above Excited
socialization
therapy?
Is your foot Questioning,
okay? I Same as above Oh that! Well I Almost jumps Interaction – Making
noticed that wanted to win off seat but is Tries to brush Observations,
you almost fell and we did! able to off what Actively listening
when you restrain happened as
were trying herself nothing.
rush through
the today’s
activity
How do you Same as above Tired. I enjoyed Smiles while Mood – Questioning,
feel now? it. But it was talking Happy Actively
very tiring! excitedly. Listening

As you Same as above Thank you so Lip quivers, Mood - Questioning,

already have much for tries to Depressed Focusing,
guessed, spending time maintain her Actively listening
since you with us. It really smile but fails
know what means a lot. I’ll and starts to
happens after pray for you cry a bit.
socialization. and your
Is there classmates
anything you every day that
want to add or you pass your
say? board exams!

Questioning,
“Silence” Offers tissue No answer Avoids eye Focusing,
and gently holds contact Actively listening
hand
 Psychopharmacology

Generic Name Classification Dosage Mechanism of Contraindication Nursing Responsibilities

action
Chlorpromazine Antypsychotic (2012) Chlorpromazine is a Hypersensitivity; 1. Assess mental status prior to
50 mg neuroleptic that acts preexisting CNS and periodically during therapy.
HS by blocking the depression, coma, 2. Monitor BP and pulse prior to
postsynaptic bone-marrow and frequently during the period
Brand Name Indication
(2018) dopamine receptor supression; of dosage adjustment. May
Zycloran Intractable
100mg in the mesolimbic phaeochromocytoma; cause QT interval changes on
hiccup,
½ tablet dopaminergic lactation. ECG.
Psychoses,
HS system and inhibits 3. The drug may be taken with or
Nausea and
the release of without food.
vomiting
hypothalamic and 4. Observe patient carefully
hypophyseal when administering medication.
hormones. It has 5. Monitor I&O ratios and daily
antiemetic, weight.
serotonin-blocking, 6. Monitor for development of
and weak neuroleptic malignant syndrome
antihistaminic (fever, respiratory distress,
properties and slight tachycardia, seizures,
ganglion-blocking diaphoresis, hypertension or
activity. hypotension, pallor, tiredness,
severe muscle stiffness, loss of
bladder control. Report
symptoms immediately. May
also cause leukocytosis,
elevated liver function tests,
elevated CPK.
7. Advise patient to take
medication as directed. Take
missed doses as soon as
remembered, with remaining
doses evenly spaced through
out the day.
8. Do not increase dose or
discontinue medication without
consulting health care
professional.
9. Instruct patient to report
significant changes in
neurological status, such as
seizures, extreme lethargy,
slurred speech, disorientation or
ataxia.
Generic Name Classification Dosage Mechanism of Contraindication Nursing Responsibilities
action
Clozapine Antipsychotic (2012) Clozapine is a Patient w/ paralytic 1. Assess for hallucinations,
50 mg OD dibenzodiazepine ileus, uncontrolled mental status, dementia, bipolar
derivative and an epilepsy, history of disorder (initially and throughout
(2018) atypical circulatory therapy).
Brand Name Indication
100mg antipsychotics collapse, alcoholic 2. Obtain complete health
Clopixene Schizophrenia,
½ tablet HS prototype. Its or toxic psychoses, history, especially psychological,
Psychoses in
therapeutic drug intoxication, neurologic and blood diseases;
Parkinson’s
efficacy is coma or severe including blood studies: CBC,
disease
proposed to be CNS depression, WBC with differential,
mediated through severe cardiac electrolytes, BUN, creatinine,
antagonism of disease (e.g. liver enzymes.
the D2 and 5- myocarditis), bone 3. Do not let the patient engage
HT2A receptors. marrow in any hazardous activity until
It also acts as an suppression, response to the drug is known.
antagonist at α- myeloproliferative Drowsiness and sedation are
adrenergic, disorders or any common adverse effects.
histamine H1, abnormalities of 4. Let patient rise slowly to avoid
cholinergic and WBC or differential orthostatic hypotension.
other blood count, 5. Report immediately any of the
dopaminergic history of drug- following: unexplained fatigue,
and serotonergic induced especially with activity;
receptors. neutropenia or shortness of breath, suddenly
agranulocytosis. weight gain or edema of the
Severe renal lower extremities.
impairment.
Psychotherapy

A) Play Therapy

Play therapy is a form of therapy primarily geared toward children. In this form of
therapy, a therapist encourages a child to explore life events that may have an effect on
current circumstances, in a manner and pace of the child's choosing, primarily through
play but also through language. Play therapy, can help individuals communicate,
explore repressed thoughts and emotions, address unresolved trauma, and experience
personal growth and is widely viewed as an important, effective, and developmentally
appropriate mental health treatment. No name was given for the play therapy. The type
of activity the patient was given was to perform one of the three tasks that she picked at
random from three, and when she finishes that task she was instructed to stack the
stereo foam cups that were besides her in a pyramid. When all of the patients are done,
she will take them down and place the cups in the exact same position they were
previously in for the next patient when it is their turn.

Interpretation & Analysis: The patient appeared excited at first in participating in the play
therapy. However, one of the tasks she picked was numbers, meaning she had to
arrange the blocks by their numbers. While the other group had a good start, my patient
started to grow impatient. She did fine at first. But near the end of the task she felt the
pressure and struggled to find one number, which she kept search for in every block.
After a few more minutes of looking, she gave up. She refused to continue with the
blocks and continually requested to go on with the next part of the activity. The patient
was very vocal about how hard it was and noticed how others before her didn’t have
same task she faced. Others got colors or animals, the patient noticed she was the only
one with numbers.

B) Music & Art Therapy

Music helps people regain inner peace and is the voice that binds people together. It
has been used to treat the sick since ancient times and frequently is used to cure
depression. Songs offer people solace in adversity and joy in prosperity. They are sung
on birthdays and even at the death of a loved one. Music is accepted as a universal
means to express one’s emotions. It was an essential component of ancient healing.
More recently, reports have indicated the usefulness of music therapy in managing
psychiatric disorders. Music has been used in psychosis and neurosis and now is being
used in addressing organic disorders such as dementia.

Interpretation & Analysis: The patient compliantly followed the facilitator’s instructions.
During the first part of the therapy, the music that was first played was in a happy tune,
and because of that the patient immediately started drawing with an instant idea in mind
on what to draw. The patient took her time when she was drawing, making sure to put a
lot of detail into her drawing, pausing every now and then before she continued after a
small amount on contemplating on what else to add. With the second drawing, the
music played was a much sadder tone. What my patient drew didn’t match up to the
music. For the happier music, she drew her family. For the sadder music, she just drew
fruit because she felt like it. When she drew her family, she puts a lot of detail into each
of their appearance in directional strokes. From the details of the hair, their clothes, and
then lastly their faces. She spent more time detailing their face during the music. The
patient’s emotions she displayed through her expressions does not match up to what
she says when explaining her drawings. She mainly focused on discussing her first
drawing compared to her second where she gave a very little explanation on the
meaning behind it. This shows that the patient has a closer attachment to the drawing of
her three children. She openly expresses how much she misses them and is easily slips
into a trance once she stares at it the picture she drew. For her second drawing, she
didn’t seem to put as much thought as her first one.

C) Bibliotherapy

The story used for the bibliography was the life history creator/owner of SM Mall, Henry
Sy. This therapeutic approach that uses literature to support good mental health, is a
versatile and cost-effective treatment option often adapted or used to supplement other
types of therapy. Proponents of the approach suggest mild to moderate symptoms of
several mood-related conditions can be successfully treated with reading activities. Both
individual and group therapy may utilize this method, which is considered appropriate
for children, adolescents, and adults.

Interpretation & Analysis: The patient expressed her interest in the story and gained a
new insight on the man and hopes that her children become just as successful as him.
She answers some questions that were presented but seemed to have trouble recalling
the important details of the story except for the fact Henry Sy is a successful
businessman.

D) Occupational Therapy

As we know, this therapy provides practical support to empower people to facilitate

recovery and overcome barriers preventing them from doing the activities (or
occupations) that matter to them. This support increases people's independence and
satisfaction in all aspects of life. The activity done for this therapy was crafting a fan with
the most basic materials; popsicle stick, a variety of colorful art paper, glue, and art
glue. They are to follow the steps given by the facilitators with little help from their
assigned nursing student.
Interpretation & Analysis: The patient was compliant at the start of the therapy and was
ready to participate. During the activity, the patient started to show signs of difficulty in
following certain instructions and performing them by herself. She needed some
assistance after a certain point and had to be encouraged to continue after getting
frustrated at how hard it was to make a fan. The final straw for her was designing the
fan, which is where she felt stressed the most and refused to continue any further until
offered by her student-nurse to design the fan for her and questioned how the patient
wants it to be designed.

Due to her client’s decreased patience, she showed increasing signs of stress
throughout the duration of the activity. She was very vocal on her opinion on the
appearance of the fan she made and shared several comparisons of her crafted work to
others before and after everyone was done. Most of the were negative. The client
seemed gratified when help was offer to her by having certain parts she found difficult
done for her, but when encouraged to do the rest by herself, she showed her
displeasure by frowning but did was told.

E) Remotivation Therapy

In the Remotivation therapy, the facilitator asks questions which is related to the topic at
hand. The topic is determined by the Remotivational therapist. One question leads to
another which is referred to as bounce questions. The Remotivational therapist also
uses visual and audio cues during the session. If the clients are suffering with cognition
deficits or A.D. there needs to be more visual cues. The facilitator creates an
environment where the clients feel safe. In this environment whatever the client says is
accepted by the Remotivational therapist in a non-judge mental manner. Thereby a
trusting relationship is established between the client and the Remotivational therapist.
The Remotivational therapist accepts and appreciates what the client provides which
could be actively participating in the session or remains silent throughout the session.
The activity the patients were supposed to participate in answering and sharing their
ideas related to the topic, which is communication and how it has affected them in their
daily lives.

Interpretation & Analysis: The patient was compliant throughout the entire therapeutic
session. She had shown great interest the moment the item that was the theme of the
remotivation therapy was an old telephone, something that she and the other patients
recognized on the spot. She was questioned what the purpose of such communication
devices was and to define the meaning of communication to her. The patient gave a
short, simple answer when it comes to the older telephones. Upon reaching modern day
cellphones, she was very open about her experiences with the cellphone and listed
several people she would call often (which mainly consists of her family)
 Chapter 5 – Evaluation

The goals of disturbed sensory (auditory) may be related to overwhelming

stressful life events as evidenced by previous history of inappropriate non-reality-based
thinking and delusions and Situational low self-esteem related to developmental
changes (mental impairment) as shown by the patient’s ability to maintain reality
orientation, demonstrate reality-based thinking in verbal and nonverbal behavior,
demonstrate the ability to abstract, conceptualize, reason and calculate consistent with
ability to interpretation, initiates participation in alternative coping strategies, adapting
stress, deal with current situation, provide for meeting psychological needs, and
promote wellness. Ineffective coping related to difficulty adapting in stress was partially
met as the patient still voices out her problem with dealing with her current situation,
which is mostly about her lack of contact with her family for the past fifteen years.

Reflection

This has been a great experience. Seeing psychiatric patients up close is different
compared to seeing such people on TV. The human mind is indeed something still to be
explored, and to discover how far certain mental damage can go is another thing that
fascinates me. With the knowledge I’ve gained on how to interact with future patients
with cases such as the ones I have met in my possible path to becoming a psychiatric
nurse. My strength is being capable of showing empathy and friendliness towards the
patient’s, which the one I was assigned to noted immediately. My one weakness is
attaching myself to my patient’s. I don’t show it, but I easily became emotionally
attached during our sessions. I was able to hold back my tears but it was hard to say
good-bye. I want to be able stop this as it will get in the way of my future job as a nurse.