Dr. Yangas Colleges, Inc.

College of Nursing

U N D IF F ERE N TIA TE D

SCHIZOPHRENIA
A CASE STUDY

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

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

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

OBJECTIVES
GENERAL OBJECTIVES Conduct a comprehensive case study on Schizophrenia utilizing objective and subjective data gathered through review of patients records, interview, physical examination and research-based evidences.

SPECIFIC OBJECTIVES Gather data through review of patients record, interview with the patient and patients significant others, head-to-toe physical examination and related research. Come up with patient and problem-centered nursing interventions that will address the actual and potential problems of the patient with the use of the information from the data gathered. Evaluate the results of the actions done and take note of the need for continuous giving of care.

For the Patient Help them understand his/her disease, its management and causes.

For the Community Inform the community about the disease process, its prevention, management and causes that will help to minimize the number of Schizophrenia cases. For the Nursing Profession

Enhance the knowledge of the students and to promote proper management of the client concern and through actual application of nursing process.

NURSING HISTORY

IDENTIFICATION
This is the case of J.B, a 38(?) year-old male, Roman Catholic, currently residing at YMCA Compound, Magsaysay Sur, Cabanatuan City endorsed by a DSWD worker to Mariveles Mental Hospital on July 9, 2003 with the diagnosis of undifferentiated schizophrenia.

CHIEF COMPLAINT
Nagsasalita siya mag-isa at marumi ang katawan, as the nurse verbalized. The client, that time, says Nag-iipon ako ng basura. Ayaw ko umalis sa YMCA.

HISTORY OF PRESENT ILLNESS

J.B was born to a mother (G. Pascual) who was separated. The latter was a laundrywoman that time. While growing up, he was with his stepfather (D. Bansale) whose relationship he explained Masaya naman kami, okay naman ang pagsasama namin. His stepfather was an alcoholic and was involved in gambling. J.Bs mother was passive to what his stepfather does. He grew up like any other normal children who were fond of playing marbles, shato, tumbang preso and catching fish on canals. Because of his addiction in playing marbles, he decided to quit studying while on his 1st grade in elementary. This enabled him to join his father in collecting garbage. While on his early 20s, the client met a person named Bubot he met outside the movie house where his mother was working as a ticket inspector that time. JB and Bubot ventured together as salesman of a television accessory. They gambled using their earnings and learned vices like smoking and alcoholism. During this time, there came an instance that he hit his mother for he said that he lost himself that time. He lost his mind, had delusions, hallucinations and wandered. He became a beggar at YMCA. J.B was reported of being aggressive and seen talking to himself often. Then all he remembered was that he was brought in a van and subsequently to Mariveles Mental Hospital.

DEVELOPMENTAL HISTORY
In Erik Ericksons Psychosocial Theory, as a child, he developed industry as indicated by working along with his stepfather. In young adulthood, he developed intimacy as indicated by marked good relationship with his best friend. Achievement of generativity is not reached as evidenced by being a beggar and consequently by the admission in the institution. In Lawrence Kohlbergs Stages of Moral Development, the client is on Level 1 (Pre-conventional) Stage 2 (Instrumental-Relativist Orientation) wherein actions are taken to satisfy ones needs. This is evidenced by quitting going to school because of his interest in playing marbles.

PAST HISTORY

MEDICAL

HISTORY

WITH

IMMUNIZATION

Client is a smoker and an alcohol drinker. Client is a 6 pack-year smoker. According to the client, he was never been hospitalized nor have experienced any illness except colds which was not given prompt treatment. Had undergone suturing of the left elbow secondary to fall. The client does not know if he has been immunized while he was young.

FAMILY HISTORY
The presence of hypertension, diabetes mellitus and cancer in his family is not known by the client. Presence of psychiatric or neurological illness among first-degree relatives and history concerning second degree relatives are neither known.

EDUCATIONAL HISTORY
JB just reached Grade 1. Client can read in Tagalog. Can write and express his feelings in Tagalog. The client can write his name.

SOCIAL HISTORY
PTA, the client works as a construction worker, a television accessory salesman and a garbage collector. He used to have friends outside their home and be able to develop a romantic relationship with the opposite sex. The client states that he also loves going out with his friends and goes on road trips on places like Baguio, Tarlac and the like.

NUTRITIONAL ELIMINATION

HISTORY

WITH

PATTERNS

OF

The client eats three times a day. Meals are mainly composed of vegetables, fish and processed food. Client drinks approximately three and a half (3 ) glasses of water from nawasa. Voices no dislike and food intolerances. He has a normal bowel elimination pattern. His micturition pattern depends upon how much water he drinks.

HYGIENE
Client bathes himself twice a day on a river nearby.

SEXUAL HISTORY WITH FANTASIES AND DREAMS

The client is sexually-active. He can remember having three girlfriends who, each he went to the hotel for lovemaking. JB had sex even if they are not his girlfriend. Do sexual intercourse during his free time (whenever he doesnt have work).

VALUES
Religious preference is Catholic. Verbalizes belief in God. Client prays. Go to church approximately twice a week.

PHYSICAL ASSESSMENT
GENERAL SURVEY Patient received standing, smiles upon seeing the nurse. Dress dry, slightly untidy.

VITAL SIGNS
Time Temperature Pulse Rate Respiratory Rate Blood Pressure

JULY 13, 2011

8:45 AM 37.5C 72bpm 18bpm 100/80mmHg

AREA
Neurologic

FINDINGS
July 13, 2011 (8:45AM)
Client appears relaxed. Sitting still with eyes looking away occasionally from the examiner. Wears blue shorts and blue t-shirt and does not seem to have clear attention to details. Slightly soiled and wrinkled clothes. Dress is appropriate to the weather. Client is too active (eg. answers eagerly) Hair is semi-calbo. With white hair unequally distributed. Scalp is dry. Fine hair evenly distributed on arms and legs bilaterally. Neither tenderness nor masses was found. Tanned. Dry and rough. Good skin turgor (3 sec.) Warm to touch. With calluses on both hands and lichenification on both heels and palms. Without presence of edema. With scar on left elbow (3 inches). Scars unequally distributed on lower extremities. Long-length. Dirty, hard, broken and basically immobile. Nail plate firmly attached to the nail bed. No clubbing, beau lines or splinter hemorrhages. Good capillary refill less than 2 seconds.

SIGNIFICANCE

An example of psychomotor agitation

Hair & Scalp

NORMAL Calluses and lichenification are due to manual labor. Scar on left elbow is due to falls. Scars on lower extremity are due to climbing trees.

Skin

Nails

NORMAL

Head & Neck

Eyes

Ears

Nose

Mouth & Throat

Cardiac

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

Scar on left temple is due to being hit by stone. Scar on left submantibular area is due to boils.

Due to agitation.

NORMAL

NORMAL

Due to history of smoking and poor hygiene.

NORMAL

Thorax and Lungs

line. Without pulsations or lesions. No tenderness. Fremitus is symmetric. No adventitious sound noted. Respirations even, unlabored and regular Rounded, symmetrical without masses, striae, lesions, pulsation or peristalsis noted. Presence of hair without bruises was also noted. Umbilicus in midline without discharge. Sunken umbilicus. No tenderness. Neither hepatomegaly nor splenomegaly. (-) Psoas sign (-) Murphys sign (-) Rovsings sign. Bowel sounds of 12/min during auscultation. Good ROM without tenderness in the upper and lower extremities. No edema and joint swelling. Spasticity, rigidity and flaccidity absent. Muscle strength 5/5 all throughout. No effusion; (-) Ballottement; (-) Balloning. Client able to shrug shoulder against resistance (CN XI)

NORMAL

Abdomen

NORMAL

Musculoskeletal

NORMAL

MENTAL STATUS EXAM

APPEARANCE AND BEHAVIOR
Client appears active (participates eagerly on activities). Sitting still with eyes looking away occasionally from the examiner. Wears blue shorts and blue t-shirt and does not seem to have clear attention to details. Slightly soiled and wrinkled clothes. Dress is appropriate to the weather. Toenails untrimmed. Hair is black with unequally distributed white hair. Clients posture upon standing is upright. Clients posture while sitting is slouched. Gait is unsteady (walks like he has unequal leg length). Gestures and facial expressions are appropriate to what the client is saying with different hand movements especially when thinking (interlacing fingers, rubbing the chin, and rubbing the scalp)

MOOD AND AFFECT

Mood is happy. Affect is blunted (with few observable facial expressions). Affect is inconsistent with mood, at times, as evidenced by smiling while having blank eyes. Affect is congruent with thought content as evidenced by the client saying Masaya kami ng girlfriend ko in a happy intonation while smiling. Anhedonia is absent as evidenced by the statement, Na-enjoy ko ang ginawa natin (therapy). Client feels all-knowing as reflected by the statement, Karamihan sa mga binibigyan nila (nurses) ng gamut ay namamatay. Pinag-

eeksperimentuhan niyo kami.

SPEECH
Client converses in Filipino. Words are common. Tones and pitch of voice appropriate to statements. Client exhibits thought blocking as evidenced by abrupt cessation of speech. He also exhibits circumstantiality as evidenced by the statement Masaya ang mga ibon pag nakakakain ng mga prutas, parang ang mga tao yan na masaya sa bahay. Tuwing alas-tres ginigising ako ng paghuni ng ibon. Parang mga tao yan masaya sa bahay. He exhibits alogia (lack of substance in what the client says) as evidenced by saying Ewan ko usually. Answers questions with hesitations. Speech rate is fast. Speech is slurred. Volume is loud.

THINKING
Thoughts illogical and disorganized as evidenced by circumstantiality. Blocking of thoughts evidenced by hesitant speech. Hallucinations, illusions, delusions, obsessions, compulsions, phobias, depersonalization, suicidal thought are not present.

SENSORIUM
Oriented to time, person and place. Client is alert. Can perform serial 7s up to 42. Unable to perform backward 100. Recent memory is intact as evidenced by being able to recall his activities three days ago. Remote memory is intact as evidenced by being able to recall how he was brought to the institution. Short-term memory intact as evidenced by being able to recall the three objects shown and named earlier. Able to tell the similarities between a cat and a dog. Unable to interpret the proverb Ang naglalakad ng matulin, kung matinik ay malalim. His interpretation is Kung wala kang tsinelas syempre matitinik ka, kung may tsinelas ka e hindi. Writes name and draws/copies simple figures.

INSIGHT
Insists that he is not mentally-ill, instead he says he is normal (a man picking up garbage)

JUDGMENT
When asked Ano ang gagawin mo pag nakapulot ka ng wallet na may pera, JB answered Ipagtatanung-tanong ko at kung walang may alam e itatago ko na lang.

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

TERMINATION PHASE Guide the client in their own identification of the specific changes in thoughts, feelings, and behaviors that have occurred.

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

THERAPEUTIC COMMUNICATION

NURSE

CLIENT

THERAPEUTIC COMMUNICATION TECHNIQUE

ANALYSIS

PRE-ORIENTATION PHASE
Assigned client is a 38(?)-year old male with undifferentiated schizophrenia from YMCA Compound Magsaysay Sur, Cabanatuan City. Admission complaints include madumi ang katawan, may mga dalang basura, mahaba ang kuko at balbas, nagsasalita mag-isa to name a few. Client is endorsed by a DSWD worker. The nurse had self-awareness activity.

ORIENTATION PHASE
Magandang hapon. Ako si Icor at siya naman si Talit. Maaari ko po bang malaman ang pangalan niyo? Ako si Jun-jun Bansales QUESTIONING
Using open-ended questions to achieve relevance and depth discussion.

Magandang umaga Mang Jun-jun, Kami ang mga nurses mo ngayon at sa mga susunod pang pagkikita natin. Andito ako ngayon para tulungan kang makagawa ng hakbang para masolusyonan ang kalagayan mo. Sasamahan muna kita dito; hindi mo kailangang magsalita pwera na lang kung gusto mong makipag-usap.

Client nods.

OFFERING SELF

Making self available and showing interest and concern.

WORKING PHASE
Mukhang masaya ka ngayon Junjun? Jun-jun (client) gestures opening of mouth and smile. MAKING OBSERVATION
Verbalizing what is observed in the client for validation and to encourage discussion. Using open-ended questions to achieve relevance and depth in discussion. Using open-ended questions to achieve relevance and depth discussion.

Kamusta ka ngayon? may gusto ka bang sabihin o ikwento sa amin?

ok lang,yung pamilya ko gusto ko na sila makita. Gusto ko na umuwi sa amin. ok naman Masaya naman,nanunuod kame ng sine, namamasyal sa park, kumakain kami sa jollibee, pumunta kami sa

QUESTIONING

Paano ba ang naging relasyon mo sa pamilya mo nung nasa inyo ka pa?

QUESTIONING

baguio,tagaytay, at sa nueva ecija. Tapos? Kasi sa Nueva Ecija Nakatira Yung tatay ko. Pumupunta ako duon kapag pasko o fiesta. Hindi. Kasi naghiwalay yung nanay at tatay ko nung pinagbubuntis pa lang niya ako. GENERAL LEADS
. Asking for relationship among events.

Kanina sinabi mo sa amin na tinutulungan mo sa construction ang tatay mo, ibig sabihin ba nito ay pumupunta ka pa sa Nueva Ecija? Ang ibig sabihin nito ay step father mo ang asawa ng nanay mo ngayon?

FOCUSING

Pursuing a topic until its meaning or importance is clear.

Oo, step-father ko lang siya.

CLARIFICATION

It helps the client to articulate thoughts, feeling and ideas clearly. Providing a view of the meaning or importance of something. Using open-ended questions to achieve relevance and depth discussion Stating main points of discussion to clarify relevant points. Use to review a health teaching session

Sa palagay mo, ano ang naging dahilan ng paghihiwalay ng nanay at tatay mo?

Hindi ko alam kasi buntis palang nanay ko nung naghiwalay sila.

FOCUSING

Hindi mo ba sinubukan itanong sa nanay mo kung ano ang naging dahilan ng paghihiwalay nila? Ngayon ay napag-usapan natin ang mga bagay tungkol sa inyong pamilya.Umaasa ako na bukas ay magiging produktibo rin ang ating pag-uusap. Kahapon, ibinilin namin na alalahanin niyo ang mga nagyari sa buhay at pamilya mo. May naalala ka bang nagyari sa iyo?

Hindi.Hindi ko na tinanong.

QUESTIONING

Oo, ayos lang.

PLANNING AND SUMMARIZING

Yung tatay ko naninigarilyo tapos palaging umiinom, nagsusugal lalo pag wala siyang ginagawa o walang trabaho.

SEEKING INFORMATION

Ikaw ba Mang Junjun, may mga bisyo ka ba dati?

Naninigarilyo ako at saka umiinom ng alak. Kapag may oras, walang kontruksyon. Dati ayoko tigilan dahil napapagaan nito ang pakiramdam ko e. Pero ngayon makakatulong kung magbabago na ako para makauwi na ako. Oo, ayos lang.

FOCUSING

Providing in a simple and direct manner, specific factual information the client may or may not request. Providing a view of the meaning or importance of something Stating main points of discussion to clarify relevant points. Use to review a health teaching session.

May ginawa po ba kayong paraan upang matigil ang inyong paninigarilyo at pag-inom ng alak?

QUESTIONING

Sa sinabi mo ay mukhang naliwanagan ka na sa mga tamang

VERBALIZING THE IMPLIED

Asking client is to elaborate ideas or feelings to foster description.

bagay na maari mong gawin. Tama ba ang pagkakaintindi ko?

TERMINATION PHASE
Sa ating pagsasama sa konting sandali ay nakita ko ang determinasyon mong magbago para muling makita ang iyong pamilya at makapagsimula muli ng panibagong buhay. Ipagpatuloy mo lamang ang iyong magandang adhikain upang tuluyan mo nang makita aang iyong pamilya. Mag-iingat ka palagi at patuloy na magtiwala sa ating Panginoon.

Client smiles.

SUMMARIZING

Stating main points of discussion to clarify relevant points. Use to review a health teaching session

NURSING CARE PLANS

ASSESSMENT PLANNING

Hindi pa ako naliligo, as client verbalized. pungent odor soiled clothing untrimmed fingernails visible dental plaques unshaved facial hair

Short-term Goal Partiallycompensatory After 15 minutes of NI, the client will be able to perform grooming activities for oneself.

INTERVENTION Facilitate determination of factors such as language barriers and existing medical conditions. Facilitate on performance/ assistance with meeting clients needs when he is unable to meet own needs Facilitate promoting clients participation in problem identification and desired goals and decision making. Facilitate practice and promotion of short-term goal setting and achievement Facilitate accessibility of grooming equipment within easy reach Facilitate assistance of the client to become aware of the responsibilities in healthcare and to assess with them their strengths Physical, emotional and intellectual

RATIONALE This helps in determining the ability of individual to participate in own care Personal care assistance is part of nursing care and should not be neglected while promoting self-care independence. This enhances commitment to plan, optimizing outcomes, and health promotion. To recognize that todays success is as important as any long-term goal. Avoids frustrations on performing personal care Promotes reinforcement

EVALUATION Clients condition improved.

Grooming selfcare deficit related to thought disturbance as evidenced by inability to maintain appearance at satisfactory level.

DIAGNOSIS

ASSESSMENT

PLANNING

Day 1: Nakahiga ako tapos bigla nagdilim mata ko at nasampal nanay ko, as client verbalized. Day 2: Nakaupo ako tapos nagbabalat ng buto ng acacia at nagdilim paningin ko tapos nasamapal ko nanay ko, as client verbalized. tangentiality circumstanciality flight of ideas loose association active (answers eagelry)

Short-term Goal Partiallycompensatory After 15 minutes of NI, the client will be able to express himself clearly.

INTERVENTION Focus on keeping communication simple, speaking in short sentences using appropriate words. Facilitate maintaining eye contact, preferably at clients eye level. Facilitate responding with simple straightforward, honest statements.

RATIONALE This will help the client to understand easily and to communicate effectively. This will help to maintain his focus on your conversation. This will help to gather thorough history of the patient and to understand clearly the clients statemements .

EVALUATION Clients condition improved.

Impaired verbal communication related to thought disturbances as evidenced by circumstantiality.

DIAGNOSIS

ASSESSMENT S Kung wala kang tsinelas syempre matitinik ka, kung may tsinelas ka e hindi, as client verbalized after being asked to interpret the proverb, Ang naglalakad ng matulin, kung matinik ay malalim. Altered attention span Decreased ability to use abstract reasoning or conceptualize . Thoughts are illogical and disorganized Answers questions with hesitations Thought blocking as evidenced by abrupt cessation of speech

PLANNING Short-term goal Partially compensato ry After 15 minutes of NI the client may be able to demonstrat e behavior changes to prevent changes in mentation.

INTERVENTION Focus on performing periodic neurological/be havioral assessment as indicated and compare with baseline.

RATIONALE For early recognition of changes promotes proactive modifications to plan of care. To provide stimulation while reducing fatigue. To maintain gains and continue progress if able. To treat condition pharmacologic ally.

EVALUATION Client`s condition improved.

Facilitate in scheduling structured activity and rest periods. Facilitate assistance ibn identifying ongoing treatment needs/rehabilita tion program for the individual. Depend on administering anti-psychotic drugs (e.g haloperidol).

DISTURBED THOUGTH PROCESSES related to mental disorder.

DIAGNOSIS

ASSESSMENT

PLANNING Short- term goal Partially compensatory After 15 minutes of nursing interventions, the patient may be able to demonstrate submissive behavior as evidence by appropriately controlled behavior.

INTERVENTION Facilitate observation and listening for early cues of distress.

RATIONALE

EVALUATION

These cues Clients may indicate condition possibility of improved loss of control and intervention at this point can prevent a blow up. This was determining violent intent.

Facilitate directly asking the person if he is thinking of acting his thought or feelings. Depend on determining the availability of homicidal means. Depend on maintaining straight forward communication . Facilitate discussion of consequences of actions if they were to follow through on intent.

DIAGNOSIS RISK FOR OTHER DIRECTED VIOLENCE RELATED TO MANIPULATIVE BEHAVIOR

This prevents the becoming of the unnecessary attempt. This avoids reinforcing manipulative behavior.

Provide an opportunity for client to look at reality of choices and potential outcomes.

HEALTH TEACHINGS
M

Instructed the client to comply with the medication regime. Provided clear, simple, and understandable explanation on each medications name, indication, client-appropriate dose, side, and adverse effects. Reinforced to client that administering medications without doctors prescription would result to serious complications; explained that when the client manifests adverse effects or requires medication, it is best to seek professional help immediately. Instructed client on how to recognize and when and where to report signs and symptoms related to drug toxicity. Reiterated the importance of a clean and safe environment (eg. Free of weapon) Provided clear, simple and understandable factual information to the client regarding the rehabilitation program. Emphasized to the client the importance of personal hygiene such as bathing, meticulous hand washing and oral hygiene.
Discussed arrangement of non-threatening activities that involved patients in doing something *eg, walking, tours and painting.

E T H

O D S

Emphasized the need for a well-balanced diet and initially a high calorie, high protein, high carbohydrate diet. Reinforced the need and importance of regular multivitamins. Facilitated identification and utilization of effective coping strategies. Encouraged the client to join groups dealing with self esteem, assertiveness, social and relationship skills and stress management.