A Case of Undifferentiated SchizophreniaTitle

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A Psychiatric Case StudyPresented to the

Faculty of the College of NursingColegio San Agustin – Bacolod

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In Partial Fulfillment ofthe Requirements for

the course Nursing Care Management 205-B

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By:

Kim Arian M. VillanuevaName of Student

_________________________Date

COLEGIO SAN AGUSTIN-BACOLOD

College of Nursing

PSYCHIATRIC NURSING CASE ANALYSIS RECORD (PNCAR)-INITIAL

INTRODUCTION (Narrative overview of client’s diagnosis based on book view)

Schizophrenia is a chronic, severe, and disabling mental illness. It affects men and women with equal frequency. It is characterized by deteriorating personality. This disorder is characterized by disturbances in perception, thought process, reality testing, feeling, behavior, attention and motivation. However, altered perception which my client had manifested like hallucination is presented. Hallucinations are probably caused by a hyperdopaminergic state in the limbic area. In the case of my client, hallucination were noted when my client seen talking to himself.

Cigarette smoking and schizophrenia people do smoke with schizophrenia probably in the biochemical changes produced by nicotine. Nicotine increases the release of dopamine in the nucleus accumbens ( Addington, 1998). This occurs because nicotinic receptors synapse on dopamine afforests in the reward pathway that is nicotine modulates dopamine release ( Dalack iteal, 1998). Client with schizophrenia smoke so much simply because this makes them feel better. As manifested by my client who smokes every day.

Brain injury can be caused by alcohol because it has a toxic effect on the central nervous system (CNS) and can result to changes to metabolism, heart functioning and blood supply. It also interferes with the absorption of vitamin B1 (thiamine), which is an important brain nutrient. It can be associated with poor nutrition; can cause dehydration, which may lead to wastage of brain cells and can lead to falls and accidents that injure the brain.

Source:Keltner, N., Schwecke, L.H., & Bostrom, C. (2007) Psychiatric Nursing 5th pp. 339, 342, 345-

346,349.

OBJECTIVES

Within 72 hours of rendering nursing care at National Center for Mental Health Pavilion 1, ward

6, I will be able to:

KNOWLEDGE:

1. Obtain relevant data accurately.

2. Identify the different precipitating and predisposing factor that influenced client’s illness.

3. Determine the client’s mental disorder accurately.

4. Formulate appropriate nursing care for the client.

5. Evaluate progress and improvement in client mental status and physiologic functioning.

SKILLS:

1. Provide a therapeutic relationship with client consistently.

2. Identify verbal and non-verbal cues of the client effectively.

3. Creatively use of therapeutic communication in interacting with the client.

4. Formulate question therapeutically when conducting interview.

5. Document every data gathered from the client.

ATTITUDE:

1. Accept criticism positively.

2. Maintain confidentiality of the client’s identity and data gathered.

3. Consider client’s feeling and emotion professionally.

4. Value each member of the health care team and the time spend.

5. Manifest different Augustinian value imparted by the school.

CASE ANALYSIS PROPERI. ADMISSION INFORMATION General Admission Information

Client’s initials C.N. Age 19 y.o. Gender Male Marital status SingleName of significant other J.D.L. Contact number 09306288748 Residential address: 179 Brgy. Tubigan Binan, LagunaPavilion-Unit: Pavilion 1, Ward 6Date & time of admission: March 5, 2011 4:49 p.m.Initials of Attending Physician: Dr. A.

Conditions of AdmissionCheck one (1) only: Voluntary () Involuntary ( )Accompanied by (family, friend, police, other) Family- sisterRoute of admission (ambulatory, wheelchair, trolley) Ambulatory Admitted from (home, other facility, street, OPD section) Home

Other Significant Information upon Admission

Vital signs: Pulse 92 bpm BP 120/70 mmHg Respiration 20 cpm Temperature 36.7 ˚CHeight 5’2 Weight 118 Race Filipino Dominant Language FilipinoOrientation (person, place, time, situation) Not oriented to time, place, and person, cannot follow commands.Discharge to: (home, facility, other) Home Estimated length of stay 2 months Diagnosis: Upon admission Undifferentiated Schizophrenia Current

T/C F32.2 Major Depression Disorder with Psychotic symptoms

Chief Complaint/s (as verbalized by clients or significant others/informant)

According to significant others: “nag-uuntog ng ulo sa pader”

“umiihi na ihi”

“ayaw uminom ng gamot”

BIOPSYCHOSOCIAL HISTORY ASSESSMENT

Predisposing Factors I. Genetic/biologic influences (related to mental and other illnesses)

Structural assessment of the family:

Use a genogram as applicable: Family of origin/culture extended and present family/significant persons. (Refer to prescribed format of genogram)

Family of origin:

C.D H.A L.N C.N

J. D E. D R. D. R.A G.A C.N A.N R.N R.N

Present family (if married):

Family History

Family members (indicate if mental illness has affected other members from family of origin; specify name of disorder)

The family of Mr. N. does not have any history of psychological problem. When client asked about problems related mental health, he stated, “wala naman, lahat sila magagaling.”

II. Family dynamics (describe significant relationships among family members)

Family living arrangement

Mr. N. mother married thrice. In her first husband, they have three children. In her second husband, they have 2 children. In her third husband, they got four children. Recently, her mother is separated from her third husband. All in all, there are 10 members in Mr. N.’s family living in the same house which includes her mother and his 8 siblings.

Type of neighborhood The client lived in a peaceful environment. He stressed that he rarely seen disagreement among his neighbors. He verbalized, “Tahimik lang sa lugar naming. Minsan lang ako nakakakita nag-aaway ang kapitbahay naming kung meron man ay nareresulba ito kaagad.” Their barangay captain according to the client always set to it that rules are properly implemented and makes sure that people living in their place obeys it.

III. Health Care HistoryGeneral health careRegular medical check-up with a general practitioner or specialist (if so, frequency of visits & date of last examination Mr. N. rarely goes to a general practitioner or specialist for health consultation. He cannot remember the date of his last examination. He just added that he usually goes for check-up when he got a flu or fever. He usually accompanied by his mother.

Cardiac /Renal/hepato-problems (Childhood illness such as: rheumatic fever, AGN etc., history of heart attacks, strokes, or hypertension and liver disease) Mr. N. does not have any problem in the heart and renal except recently he experienced frequent urination and later found out to be urinary tract infection.

Diabetes and endocrine disturbances (Thyroid and adrenal function) Mr. N. does not have diabetes and any endocrine disturbances.

Allergies, immunizations, Chest x-ray & ECG, & TB testMr. N. has allergy to seafood especially to shrimp. He verbalized, “ hindi talaga ako kumakain ng hipon. Nagkakaroon kasi ako ng mga pantal sa buong katawan ko.

History of Hospitalizations (When, why indicated, treatments, and outcome)TYPE OF

HOSPITALIZATIONWHEN REASONS FOR

HOSPITALIZATIONTREATMENT/DIAGNOSTIC

TEST TAKENOUTCOME

A. MEDICAL

No history of hospitalization

B. SURGICAL

C. OTHERS

Neurologic impairment (diagnosed brain problem, head trauma, details of accidents or periods of unconsciousness for any reasons: blows to the head, electrical shocks, high fevers, seizures, fainting, dizziness, headaches, falls and others)Mr. N. does not have any neurologic impairment.

Cancer (full history, any metastases: lung, breast, G.I. tract, kidney; results of treatments)Client does not have cancer.

Lung problems (Condition or event that restricts the flow of air to the lungs for more than 2 minutes or adversely affects oxygen absorption: COPD, near drowning, near strangulation, or resuscitation events) Mr. N. doesn’t have any lung problem but he revealed that he is an active smoker before he was admitted to NCMH. He can’t remember the number of sticks he can have per day but he admitted that he smokes every day.Female:Menstrual historyAge of menarche________Last menstrual Period______ Regularity and duration of period_________

Presence of premenstrual syndrome: YES________NO_______

Impact on Lifestyle:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Concerns about sexuality: Describe feelings about being a man or woman Mr. N. is really certain that he is a man. He is actually glad being a man as he verbalized, “Ang mga babae kasi maraming arti. Marami din sila mga pangangailangan kaysa sa mga lalaki.” To whom is the client more attracted to? (Male or female) He is more attracted to female. He also added that he had three girlfriends in the past.

Reproductive history (Number of pregnancies, births, children & their ages; assess birth control methods used if any) T (Term) P (Preterm) A (Abortion) L (Living Children)

Name AgeType of Delivery

Use of Family Planning Methods

Remarks (TPAL)

IV. LifestyleEating (Unusual or unsupervised diets, appetite, weight changes, cravings, and caffeine

intake) According to Mr. N. although they have a large family size, they can still eat 3 times a day. However proper balanced diet was not given much emphasis. Before his admission, he was not thin as now however he shared that because of vices he loses weight. He has a good appetite to eat food.

Drug history assessmentUse of Prescribed Drugs: Current

Name Dosage Prescribed For Results/EffectsRisperidone 2g schizophrenia Constipation, sexual problems, drowsiness,

body weaknessSertrazine 50g  major depression nausea, diarrhea, insomnia, and sexual side

effects; however, its effects on cognition are mild

Fluoxetine 2g  major depression 

nausea , insomnia , somnolence , anorexia , nervousness, tremor , sexual dysfunction

Use of Over-the-counter /Non-prescription Drugs

Client does not use OTC/ non prescribed drugs.

Name Dose/Amount Used Reason for Use Results/Effects

Use of herbal and/or alternative medicines

Mr. N. revealed that his mother used to boil lemon grass every time he got cold and cough. He added that it soothes his throat.

Toxins (Overcome by automobile exhaust or natural gas; exposure to lead, mercury, insecticides, solvents, cleaning agents, & garden chemicals) Mr. N. before his admission works as a construction worker. In line with his work are the toxins from the different working material such as cement and paint.

Occupational hazards (Current/past; chemicals in the workplace: farming pesticides, paint solvents; work-related accidents; military experiences; stressful job circumstances) Occupational hazards are the heavy equipments, falling debris such as hallow blocks and the risk for fall.

Injury (Contact sports & sports-related injuries; exposure to violence or abuse; rape or molestation; risk for falls or skin breakdown) When he was ten years old according to the client, he was hit by a tricycle resulting to minor injury and abrasions.

Impairment/Disability (Blind, deaf, missing extremities, & etc.) Client don’t have any impairment/ disability.

Use of assistive devices (Eyeglasses, hearing aids, dentures, canes, etc.) Client don’t use any assistive devices.

V. Socio-cultural History

Financial factors relevant to current adaptation (e.g. loss of income, poverty or bankruptcy)

A financial factor identified to Mr. N. is Poverty. Her mother works as a vendor. He earns P 2000 a month which can’t sustain their daily needs. Mr. N. shared that when he was 16 years old, he had worked in a construction however it still not enough to provide all their needs.

Other significant environmental factors (describe)

Health beliefs and practices (describe)Personal responsibility for health & wellness: Client believes that health is vital and must be given proper attention. Client verbalized, “Ako po ay naliligo araw-araw. Noon po ay pinapakain kami ng masustansiyang gulay ni nanay ngunit ditto kinakain ko na lang kung ano man ang inihain para sa amin.”

Ritualistic behavior/practicesClient doesn’t have any ritualistic behavior/ practices.

Religious/Spiritual values

Religious/spiritual values, beliefs & practices (describe) Mr. N. believed that God has a good reason for allowing problems to set in his life. He also believed that these problems would make him a better person in the future. He verbalized, “ kailangan lang natin manalig sa Diyos upang maunawaan nating mabuti ang nais niyang ipahiwatig sa atin.”

Educational history/backgroundHighest level of education attained Elementary graduate

Reasons for dropping out, transfer or quitting school (if applicable)

Client did not proceed to high school due to financial problem.

Achievements during school days (curricular & extra-curricular) Mr. N. was a basketball player during his school days. According to him, he got many medals from different interschool basketball competition.

Occupational background Current occupation: Currently, Mr. N. is unemployed. Other job interests: Mr. N. wanted to have any business that could help in financing their daily needs.

Previous jobs work employment:

Mr. N. had worked in a construction when he was 16 years old.

Alcohol and Substance Use HistoryExplore possible client use of alcohol and drugs (to ascertain co-morbidity); history of

nicotine and caffeine should also be explored since these are aggravating factors of symptoms.Mr. N. claimed that he drinks alcohol and smokes every day before his admission at NCMH. He blamed it to his friends who according to him influenced him in these vices. He also admitted that he used drugs like marijuana.

History of Present Illness/Current episode or Precipitating Events

Describe the situation or events that precipitated this illness/hospitalization which may be negative (e.g., job loss) or positive (e.g., job promotion); include development of symptoms from onset & duration until admission; changes in somatic functioning (sleep pattern, appetite, cognitive ability, sexual functioning) should be noted.

Client was apparently along well, helping in household chores when 2 months prior to admission, client displayed behavioral symptoms talking to self and crying suddenly. He was also not helping household chores and prefers to be alone.

History of Psychopathology

Information concerning client’s past psychiatric illness which may be a single event, chronic, or intermittent; indicate if there is improvement or deterioration in relation to current episode.

Mr. N. when he was still young witnessed how their parents separated. He also verbalized, “ hindi ako mahal ni tatay… pinapanigan niya parati mga iba kong kapatid.” Because of loss of financial support, he needs to quit school when he was in elementary. He also shared that when he was 16 years old; he experienced working in a construction to help his mother. Though he is not regular, still it helped them to sustain their daily needs, he stressed. He shared that he has a lot of friends in their place who according to him introduced him to different vices such as smoking, drinking and using of illegal drugs. He was admitted at NCMH because according to Mr. N. “uminom ako ng lason”. At his first week at NCMH, he was not interacting to the nurses

even to his sister who admitted him at that place. After 1 month, he recovered and is now interacting with nurses until now. PHYSICAL ASSESSMENT

Review of Physiological systems. Indicate with a () mark OR give a specific description.Skin: Warm __ __ _ Dry ___ _ _ Moist _____ Cool _____ Clammy_____ Pink _____ Cyanotic _____ Poor turgor _____ Edematous _____ Evidence of Rash __ _ __ Bruising _____ Needle Tracks _____ Hair and scalp: Hirsutism _____ Loss of hair _____Nails: (condition) Nails were not neatly trimmed. Presence of dirt was noted. Eyes: Glasses ___ Contacts ___ Swelling ___ Discharge ___ Itching ___ Blurring ___ Double Vision ___ Other observations: Eyes are symmetrical. No discharges noted.Ears: Pain ___ Drainage ___ Hearing Difficulty ___ Hearing Aid ___ Tinnitus___ Nose: (discharge) present of black heads noted.Mouth: (lesions) lesions not observedNeck: (lumps) no lumps palpated Respiration: Normal Labored _______ Rate ___18cpm___ Rhythm __regular____Breast: Pain/Tenderness Client doesn’t feel any pain or tenderness in his breast.

Swelling not noted Discharge not noted Lumps not noted Dimpling not notedPractice self -breast examination? Client doesn’t practice breast self examination.

Frequency_________________________Cardiovascular status:

Blood Pressure (usual) 120/70mmHg Pulse (usual) 87 bpmHistory of: (Check all that apply)

Hypertension ___ Palpitations ___ Heart Murmur ___ Chest Pains ______________________ Shortness of breath ____ Pain in legs___ Phlebitis ___ Ankle/leg edema______________ Numbness/Tingling in extremities ________________Varicose veins________________

Other significant observations Client doesn’t have any cardiovascular problem. His blood pressure is within the normal range. He also doesn’t any history of hypertension.Gastrointestinal status:Usual diet pattern: Client doesn’t have any diet pattern. He just eats what had prepared for them.Food allergies: Client have allergy on sea foods especially shrimp.

Dentures: Upper: _ (--) _ Lower _ (--) __ Problem with chewing/swallowing Client doesn’t have problems with chewing/swallowing.

Problem with: Indigestion/Heartburn Client doesn’t experiences indigestion/ heartburn (If yes, relieved by) ______________ Nausea/Vomiting Client experienced nausea and vomiting that can be attributed to current medication usage (If yes, relieved by) ________________________________________________________________________________________Loss of appetite __Client doesn’t experiences loss of appetite___ (Measures taken) ________________History of Ulcers Client doesn’t have any history of ulcers.Usual bowel pattern _every other day_Constipation ___ Diarrhea ___ Type of self-care assistance provided for either of these problems: Client usually increases his fluid intake to relieve him from constipation. Genitourinary/Reproductive status:Usual voiding pattern __5x a day approximately 12o cc of urine.

Frequency ______________ Urinary hesitancy _____ Nocturia _____ Pain/burning Currently client doesn’t experience pain upon urination but he had shared that a few days after his admission, he experienced burning sensation that was relieved by medication prescribed by his physician.__

Incontinence Client doesn’t experience urinary incontinence.

Any Genital lesions: Not able to observedDischarge_________________________ Odor _______________________________

Musculoskeletal status: Weaknesses (--) _ Tremors (--) Describe ________________________ Degree of range of motion (describe limitations, if applicable) Client can perform fully the degree of range of motion.Pain (describe) Client did not feel any musculoskeletal pain.Coordination (describe limitations, if applicable) Client’s movements are coordinated with each other.Skeletal Deformities (describe, if applicable) kyphotic spineMedication side effects (What symptom(s) is/are the client experiencing that may be attributed to current medication usage? Dizziness, Nausea and vomiting

Altered laboratory test values and possible significance (If applicable) Altered laboratory test value Normal Value Significance

Urinalysis: Date (3-6-11)Transparency: Slightly Turbid Clear Near transparent or yellowish

colored urine signifies normal conditions. While cloudy, turbid or strong urine odors are signs of urine tract infections.

Specific Gravity: 1.015 1.010 Very low concentration reveals dilute urine, while high value signifies dehydration.

Protein: + -- For a healthy person, urine protein is present in a very less amount and is rarely detected. Presence of protein in very low concentration, say 10 mg/100 ml or 150 mg/day is normal. Higher protein levels than this is a sign of proteinuria.

WBC: 14-19/ hpf 0.1 Negative test result reveals less chances of infection, a positive result is a warning sign for elevated production of WBCs and urinary tract infections.

Activity/rest patternsExercise (type, frequency, duration) Client involved himself in exercises such walking every early in the morning.Leisure activities: sleeping, listening to musicPattern of sleep: Number of hours per night: 6hrs Use of sleeping aids (music, etc.) Client doesn’t use any sleeping aids Insomnia _-- Hypersomnia --___Reversal of sleep pattern Client doesn’t experience reversal of sleep pattern. He usually sleeps at night and during the day, he sometimes mingle with the other patient.Patterns of awaking during the night:Client doesn’t experience any disruption in his sleeping time.Feel rested upon awaking? The client feel rested upon awakening and ready to face another day.Personal hygiene/activities of daily living (ADL):Patterns of self-care: Independent Client performs his activities of daily living independently. He doesn’t seek help from other people in doing his daily activities.

Requires assistance with:Mobility (--) Feeding (--) _____ Hygiene (--) Dressing (--) _____Toileting (--) Other (--) _____ Refusal to eat ___none___ Reason __________________________________________Statement describing personal hygiene and general appearance:

The client did his personal hygiene. Her general appearance is neat and clean except for her hair which has dandruff.

Other pertinent physical assessment not previously mentioned: no other pertinent data not mentioned.II. MENTAL STATUS EXAMINATION

Underline as many criteria under each category as applicable to the client

General Appearance

Cooperative Uncooperative Bored AngryUnkempt Well-groomed heavily made-up Younger looking than ageOlder looking than age Tense posture Relaxed Underweight Overweight

Bizarre behavior observed (Describe postures or psychomotor activity) Mr. N. have a kyphotic posture. He usually slouches when walking.

Emotions: Mood/Affect

Happy Sad Anxious Frightened Angry ElatedEuphoric Apathy Flat Blunted Inappropriate Labile Depressed

Congruity of mood/affect (Describe how manifested) Client’s mood/affect is appropriate to an event just like when an event have a happy theme, the client smiles.

Speech

Clear Coherent Slurred Speech Incoherent NeologismsLoose association Flight of ideas Aphasic Perseveration Verbigeration Rumination Tangential Circumstantial Slow Impoverished Speech logorrhea

Describe the speech pattern Mr. N. speaks clear and comprehensible. He doesn’t have any speech impediment. He answers questions appropriately. He has good eye contact while talking to me.

Speech Impediment (Describe if applicable            Mr. N. has no speech impediments.

Other observations

Thought Content

Delusional Obsessive Homicidal SuicidalSuspicious Memory - Recent: Loss Intact Memory – Remote: Loss Intact

Describe and support the underlined thought content     Mr. N memory from his past up to the present is still intact. He was always constant to his answers especially when you try to clarify the content of what he had said. He doesn’t have any problem like delusional, homicidal or suicidal thinking.

Thought Process

Clear Logical Illogical Easy to follow Relevant Confused

Blocking Rapid flow of thought Loose association CircumstantialConcrete thought process Capable of abstract thought

Describe and support the underlined thought processAll information coming from the mouth of the client is clear, coherent, logical, relevant and easy to follow. He doesn’t show looseness of association, or circumtiality upon giving that information.

Perceptual DisturbancesIllusions Hallucinations Depersonalization Derealization

Describe and support the underlined thought process Mr. N. doesn’t show any perceptual disturbances. He sees things as it is. Although Mr. N. once shared that he had experienced some episodes of auditory hallucinations before he was admitted, he now verbalized that he no longer hear those voices.

Impulse Control

Describe client’s ability to delay, modulate, or inhibit the expression of behaviors and feelings Every time I asked Mr. N. regarding sensitive, I could observe that he knows how to control his feelings; he can now understand his situation with no regrets. He is always willing to express his thoughts and feelings.

Cognition and Sensorium

Level of consciousness

Conscious, alert and awake___ ___ Stuporous _________

Drowsy,confused,lethargic ___________ Responds to external stimuli________

Memory Remote His memory about his past is still intact. He could still remember the time when

his parents separated. He could still keep in mind, how their family became affected by that separation.

Recent Mr. N. memory about recent happenings is still intact. He could able to tell about the recent activities and people who conduct such activity.

Focus/Concentration Client can easily be distracted by some external stimuli such as noise and people playing basketball.

Orientation Encircle Y or N (Yes or No).Oriented to a. Time: Y N b. Person: Y N c. Place: Y N d. Situation: Y N

Describe other significant observations Mr. N. is oriented to time, person and place. He knows his present situation.

Knowledge and Judgment

Describe client’s answer to a hypothetical question (What will you do if you find a fifty peso bill while going around SM?)

When I asked Mr. N. this question, he answered me that he will return the money to the rightful owner. His answer was based on his idealistic view that a person must return anything that does not belong to him.

Insight

Client’s perception of illness and expectations of hospitalizations.

Client has a good insight regarding his present situation and he knows what had brought him to NCMH.

III. PSYCHOLOGICAL TESTS

Document results of psychological tests that were administered to the client (If any). 

There were no any psychological tests that were reflected on the chart of the client.

IV. COPING AND ADAPTATION RESPONSES

Current resources

Growth and stages of development (Based on Freud’s, Erickson’s, Sullivan’s Theories- whichever is/are applicable)Theoretical explanation

Based on the Erickson’s Psychosocial Development, the client belongs to the stage of

adolescents, 14-24 years old. The psychosocial crisis in this stage is the identity VS role

confusion. Erikson stressed that in this stage, adolescent is concerned most with how they appear

to others. Superego identity is the accrued confidence that the outer sameness and continuity

prepared in the future are matched by the sameness and continuity of one's meaning for oneself,

as evidenced in the promise of a career. The ability to settle on a school or occupational identity

is pleasant. In later stages of Adolescence, the child develops a sense of   sexual identity . The

problem of adolescence is one of role confusion—a reluctance to commit which may haunt a

person into his mature years. Given the right conditions—and Erikson believes these are

essentially having enough space and time, a psychological moratorium, when a person can freely

experiment and explore—what may emerge is a firm sense of identity, an emotional and deep

awareness of who he or she is.

While on the Freud’s Psychosexual Development, the client is in the genital stage. This begins at

puberty involves the development of the genitals, and libido which begins to be used in its sexual

role. However, those feelings for the opposite sex are a source of anxiety, because they are

reminders of the feelings for the parents and the trauma that resulted from all that.

On the Sullivan’s Interpersonal theory, Mr. N. is in the late adolescence stage. Late adolescence

may start at any time after about age 16, but psychologically, it begins when a person is able to

feel both intimacy and lust toward the same person. Late adolescence is characterized by a stable

pattern of sexual activity and the growth of the syntaxic (Experiences that can be accurately

communicated to others) mode, as young people learn how to live in the adult world. Sullivan

believed that people acquire certain images of self and others throughout the developmental

stages and he referred to these subjective perceptions as personifications. The ‘Me’

personification which usually observed during infancy children acquire three “me”

personifications: (1) the bad-me, which grows from experiences of punishment and disapproval,

(2) the good-me, which results from experiences with reward and approval, and (3) the not-me,

which allows a person to dissociate or selectively not attend to the experiences related to anxiety.

Actual behavior

Mr. N. had faced different stressors in life which he did not cope well and had hindered him to achieve the sense of identity. He was confused by the different changes he newly met. He coped with it negatively by drinking and smoking. On Freud’s Psychosexual theory he had reached the final stage which is genital wherein before he had involved himself to have true intimacy but because of uncontrollable circumstances that feeling was vanished. Based on the Sullivan’s Interpersonal Theory, Mr. N. acquired the bad-me personification. This was because of his past experiences with his father wherein he can’t find love from him. He further stressed that his father always gives good complements to his other siblings and when it comes to him all his achievements were neglected. He would always relate this experience with his relationships with other people. He always has the feeling that other would as well neglect him. As a result, he would often hide his feelings and emotions within himself which is a negative way of coping to stress.

A. Previous patterns of coping with grief and stress

Significant losses / changes /grief responses. (Generally, how does the client respond to loss of significant persons, opportunities, relationships, & etc?)

He was greatly affected when h is father live them. He shared that he was upset during those time especially when he witness his mother depression. It was further worsen when they were forced to quit school because their mother can’t pay all their school fees.Consider the following elements:

• How does the client solve his/her problems?• Classify each into Adaptive, Palliative, Maladaptive, or Dysfunctional

Mark with a () and Identify: (may be several)

Pattern of Coping with Stress Classification____ Fight or flight ________________ Dependence on other’s decision Maladaptive

Acceptance of fate or destiny Adaptive____ Use of physical illness _____________________ Blaming others/self Maladaptive

Use of problem-solving coping skills Adaptive

B. Situations where and how patterns of coping were applied

Mr. N. verbalized that he just accepted his destiny or fate. He searched for work to help his mother. He found a work in a construction with his uncle.

Support systems (before and during admission)Family All his family members gives him support and encouragement until now.Friends Although Mr. N. friends were not able to visit him, he said that he could still feel their love and care.Community: On the community, especially inside the Pavilion 1, his support systems were his friends, the nurse and the attendant.

Economic security (sources of family income, assistance from relativesHis mother worked as a vendor before she became ill. All the finances before were

supported by his mother and his sister who worked as a seamstress. After he became, all the finances were turned on to his sister.

Role contributions and responsibility for others (family, job, community)Before he was admitted at NCMH, he worked in a construction. He verbalized that he gives all what he earned to support all their daily needs.

Adaptation responses

A. Psychosocial responses1. Level of anxiety (Underline particular level and the behaviors that apply to it)

MILD MODERATE SEVERE PANIC

Calm Friendly Passive Alert Perceives environment correctly Cooperative Impaired attention “Jittery” Unable to concentrate Hypervigilant Tremors Rapid speech Withdrawn Confused Disoriented Fearful Hyperventilating Misinterpreting the environment (hallucinations/delusions) Depersonalization Obsessions Compulsions Somatic complaints Excessive hyperactivity

Other behaviors (Describe) Mr. N. level of anxiety when it comes to mild are calm and

cooperative, it was evidenced by the client’s cooperation during our activity and interaction however he can easily be distracted. He was calm and he doesn’t easily escalate. He doesn’t suspect me even in our first day of interaction. He perceives his environment correctly.

2. Ego defense mechanism (Underline as many as applicable)

Projection Suppression Undoing Displacement Intellectualization Denial Rationalization Repression Reaction formation Fantasy Religiosity Sublimation Compensation Symbolization Introjection Regression Conversion Denial Fixation Identification Substitution Isolation Splitting (Dissociation)

Describe how the identified responses are used by the client When Mr. N. opened up about his experiences that cause his anxiety, he usually focused

on the intellectual aspects to avoid unacceptable emotions (intellectualization). Just take for example his experience when his parents separated. When I asked him of his feelings during those times, he told me nothing instead he gives more emphasis on things he done to help his family to survive. He had also added during our conversation that he never felt love from his father and he associated this with a logical reason rather with the real reason (rationalization). He sometimes blamed himself for their misfortune (Introjection). During our interaction, he once verbalized, “Ako kasi hindi nakapagtapos. Kaya nga wala akong makitang regular na trabaho.”

3. Level of self-esteem: (Underline one) LOW MODERATE HIGH

Characteristics that the client likes about self According to Mr. N. he likes his being simple and silent type. He would always stress

that he find peace in silence. He further said that he would always keep himself distant from other client to avoid any conflicts to form. He would always keep in mind what his elder sister told him that he must always stay away from conflicts.

Characteristics that the client would want to change about self

If there is a thing that he want to change in his self, that is his being introvert. He opened up that he has fear of being ignored.

Objective assessment of self-esteem

Eye contact Mr. N. had a good eye contact while we were having our interaction.General Appearance Mr. N. was neat and well- groomed except for the dandruff on his hair.Participation in group activities and interaction with others (in general) Client participates in group activities however most of the time he would just keep himself in silence. He was cooperative during our interaction. He opened up information without any hesitation.

4. Stage and manifestation of grief over life changes (impaired psychosocial functioning) Underline one (1) only.

DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE

Describe client’s behaviors that are associated with this stage of grieving in response to loss or change

  Mr. N. was now on the stage of acceptance. This was evidenced based on the client’s verbalization that he understand and accept whatever life he has right now and whatever past he had gone through.

B. Physiologic responses

Psychosomatic manifestation Describe any somatic complaint that may be stress-related; e.g., pain: chest pain,

headache, other anatomical pain or discomfort, etc. (onset, location, quality, intensity, origin; scale of 1-10: 1-3, mild; 4-6, moderate; 7-10, severe); relieved by/worsened by use of prescribed/over-the counter drugs)Client once complained discomfort in sleeping due to an abscess in his back. According to client, it is not painful. It was relieved by the use of medication prescribed by the doctor.

V. DIAGNOSES AND INTERVENTIONS

Integrating Nursing Diagnosis and Interventions with DSM-IV-TR Diagnosis

A. Nursing Diagnosis

Actual Nursing ProblemImpaired social interaction r/t low self-esteem secondary to undifferentiated schizophrenia

Potential Problem

__________________________________________________________________________________________________________________________________________________

B. Formulate Nursing Care Plan (from the identified nursing diagnosis, please use separate sheet)

C. Formulate Discharge Plan (Use separate sheet)

VI. EVALUATION OF PSYCHOTHERAPEUTIC AND OTHER INTERVENTION

Evaluation of NPR

I was glad that I had gained Mr. N. trust. He opened up much information without any hesitation.

Though he sometimes kept himself in silence during group activities but when our conversation

begins, he involves himself well.

Responses of Clients to Different Therapeutic Activities

Music and Art Therapy through Art AppreciationMr. N. was cooperative during the music and art therapy. On the mellow music, he draws mountain, sunrise, and a house which symbolizes the place where he came from. He also draws lines which form a person which is actually him. My interpretation for this is that Mr. N. really missed his family as well as his place. On the fast music, he formed a cart with trees surrounding it. During his explanation, he stated that it just came up into his mind. Remotivation TherapyDuring the remotivation therapy Mr. N. was cooperative. He was able to express his feelings and insights regarding the poem. He verbalized that he really likes the drawing that we had shown to them because it resembles the place where he came from. He was also able to express what work he wants to engage if ever he will be discharge.

Occupational TherapyIn arts and craft, Mr. N. was able to express his creativity through applying water color and joining pieces of materials given to them. During our conversation, he admitted that he had hard time in assembling the said materials however he was glad after he had done and seen his work.

Play ActivitiesWe were not able to have play activities because of some unexpected events.

Other Activities

Food PreparationMr. N. was able to follow instructions in our food preparation. He verbalized that he was glad that he had made a sandwich with a different taste.Dance TherapyMr. N. was able to follow the steps given by our group mates, during the dance therapy. The steps were familiar to him. He verbalized that he was happy because whenever a dance steps were introduced to him, he could exercise her body and could make him body active and alert.

Newspaper ReadingDuring our newspaper reading, Mr. N. was also participative. He was able to identify the different parts of newspaper. He was also able to express his thought regarding the article that we read during our conversation.

Community SingingHe was also able to participate during the community singing by joining the group in singing. During our conversation he verbalized that he like our community singing because we didn’t just introduce a song but with actions.  

CalisthenicsDuring our calisthenics, Mr.PM was able to follow all the instructions without any complains. He did his best up to his optimum level of functioning.

References: (Use APA format)

Keltner (2007). Psychiatric nursing 6th ed.

Doenges, M., Moorhouse, M. F., & Murr, A. (2004) Nurse’s Pocket Guide, 9th ed.

Doenges, M., Moorhouse, M. F., & Murr, A. (2006) Nursing Care Plans 7th ed.