UNIVERSITY OF SOUTHERN PHILIPPINES

FOUNDATION
Salinas Drive, Lahug, Cebu City
COLLEGE OF NURSING

Care In Client with Paranoid Schizophrenia

AL GINO B. BORNAGA
BSN-4

TABLE OF CONTENTS
Title Page..Page 1
Table of Content....Page 2
Introduction....Page 35
General information and Patients Profile..Page 6
Pertinent Nursing History..Page
7

Developmental task.page 8
Gordons Functional Health PatternPage 9-11
Genogram. .Page 12
Physical Examination..page 1315
Laboratory and Diagnostic Findings...Page 16
Summary Of Significant Findings.....Page 1720
Anatomy and Physiology..Page 2122
Pathophysiology and Disease Management..Page 2327
Drug Studies...Page 2832
Nursing Care Plan....Page 3338
Discharge Plan.page 39
References.Page 40

INTRODUCTION
Schizophrenia (from the Greek roots skhizein ("to split") and phren- ("mind"))
is a severe mental illness characterized by a variety of symptoms including
but not limited to loss of contact with reality. Schizophrenia is not
characterized by a changing in personality; it is characterized by a

deteriorating personality. Simply stated, schizophrenia is one of the most

profoundly disabling illnesses, mental or physical, that the nurse will ever
encounter (Keltner, 2007). There are 5 subtypes of schizophrenia naming;
paranoid, disorganized, catatonic, undifferentiated, and residual kuwang 12.
Schizophrenia

undifferentiated

is

the

type

of

schizophrenia

wherein

characteristic symptoms (delusions. Hallucinations, disorganized speech,

grossly disorganized or catatonic behavior, and negative symptoms) are
present, but criteria for paranoid, catatonic, or disorganized subtypes are not
met.
Schizophrenia is not a terribly common disease but it can be a serious and
chronic one. Worldwide about 1 percent of the population is diagnosed with
schizophrenia. About 1.5 million people will be diagnosed with schizophrenia
this year around the world. (mentalhelp.net). Ninety-five percent (95%)
suffer a lifetime; thirty-three percent (33%) of all homeless Americans suffer
from schizophrenia; fifty percent (50%) experience serious side effects from
medications; and ten percent (10%) kill themselves (Keltner, 2007).
According to study done 697,543 out of 86,241,697 of Filipinos or
approximately 0.8% are suffering from schizophrenia (cureresearch.com).
Schizophrenia Ranks among the top 10 causes of disability in
developed countries worldwide (World Health Organization, www.who.int)
Schizophrenia is a disease that typically begins in early adulthood; between
the ages of 15 and 25. Men tend to get develop schizophrenia slightly earlier
than women; whereas most males become ill between 16 and 25 years old,
most females develop symptoms several years later, and the incidence in
women is noticeably higher in women after age 30. The average age of onset
is 18 in men and 25 in women. Schizophrenia onset is quite rare for people
under 10 years of age, or over 40 years of age (schizophrenia.com).

OBJECTIVES
General Objective:
The main goal of the group is to be able to present an extensive and
comprehensive case study of our chosen client that would present a
comprehensive discussion of Schizophrenia Undifferentiated to yield
important information for the case study.

Specific Objectives:
In order to meet the general objective, the group aims to:

Cognitive:

interpret the pertinent data gathered from the patient and his
significant others;

present the anamnesis by thorough gathering of the clients pertinent

personal data, appropriate selection of informants, and familial history
tracing;

evaluate the developmental stage of the patient according to the

theories of Erikson, Freud and Piaget;

determine the etiology factors (precipitating and predisposing) of the

mental disorder;

evaluate the presence or absence of signs and symptoms seen in the

patient in relation to the mental disorder;

present the psychodynamics of the clients diagnosis by recognizing

its predisposing and precipitating factors with appropriate rationales;
To track down the significant events during the clients developmental
stage as shown in the psychodynamics;

Interpret

and

analyze

nurse-patient

interaction

taken

through

spontaneous and effective use of therapeutic communication;

thoroughly define the complete diagnosis of the patient;

come up with a differential diagnosis with accord to the clients

maladaptive behaviors;

discuss thoroughly the Anatomy and Physiology of the involved organs

and organ systems in accord to the final diagnosis;

present the doctors order with its rationalization;

formulate effective, specific, measurable, attainable, realistic and

time-bounded nursing care plans base on identified actual and
potential nursing problems;

arrive to a general realistic prognosis drawn from the information

gathered and factors affecting the patients condition;

provide the significance of the case study;

Psychomotor:

gather pertinent data about the client through detailed chart taking,
and effective therapeutic communication and interaction with the
client and his significant others;

commence the patient with his personal data and present and past
health history;

trace the health history of the client and family illnesses (past and
present) through a genogram;

assess clients mental status thoroughly during the orientation and

termination phase as well as the Multi-Axial diagnosis;

present the medications given to the client, including their respective

modes of action, indications, contraindications, side effects, adverse

reactions, nursing responsibilities, and importance to the clients

condition;

render quality nursing care in line with the formulated nursing care
plans;

impart appropriate recommendations to the client, his significant

others and community, medical world, and the group as a part of the
nurses holistic care.

Affective:

establish rapport to the patient and the patients significant others;

and

establish a trusting nurse-patient relationship with the client and his

significant others through provision of holistic care toward the client
and

use

of

appropriate

verbal

and

non-verbal

therapeutic

communication skills with the client and significant others during the
data gathering;

III.
Personal Data
Name:
Age:
Sex:
Citizenship:
Civil Status:
Religion:
Date of Birth:
Address:
Education:
Date and time of admission:
Admitting Diagnosis:
Attending Physician:
Informant:

J.Y.
48
Male
Filipino
Single
Roman Catholic
May 11,1967
casahar Guadalupe, Cebu city
2nd
college
June 6,2015
c Schizophrenia
Dr. Costas
JBs Brother

Pertinent Nursing History

History of Present Illness
Patient J.Y. 25 years old . Sick for more than 6 years, an Information
technology student failed to pass his subject and took illegal drugs. After 5
months of using, his mother have seen him talking with nobody in his room,
shouting and looks paranoid. He brought to Mara Josefa Recio Therapeutic
Centre to be diagnosed and the result was a mental disorder called paranoid
schizophrenia, and admitted during that day as prescribed by the
Psychiatrist.
Previous Hospitalizations

No previous hospitalization
Family History
His father has diabetes.
Medical History
No known allergy

Category

Before Hospitalization

During Hospitalization

I. Health Perception
and Health
Maintenance

Considers himself
healthy and strong, as
verbalized.
Does not see a doctor
right away if not feeling
well.
Takes multivitamins
seldom.

Stated that his weak

because of the
medication.
Follows doctors orders

II. Nutrition and

Metabolism

Eats 3x a day; for

breakfast, he usually
eats rice and pork
prepared; for Lunch and
Supper, he usually eats
rice, fish (most of the

On full diet or on DAT

For breakfast, he would
usually take meals
served by the pantry.
No known allergies.

time dried & salted),

vegetables, meat and
poultry
Drinks plenty of water
III. Elimination

Urinates at least 4x daily; Urinates at least 3-4x

voids freely; defecates
daily; voids freely;
once daily.
defecation pattern is
once every other day.

IV. Activity and

Exercise

Stated that he walks

every morning for 30
minutes

Client cooperate the

morning stretching and
dance given by the
Student nurses

V. Cognition and
Perception

S.O. stated that the

client was not able to
pass exam

All senses are intact.

Able to understand
simple instructions and
carry them out correctly.
Feeling upset, bored
and a little impatient.
Sometimes mentally
drained with the
financial problem that
his family is currently
going through, as
stated.

VI. Sleep and Rest

Stat that client usually

sleeps at around 11:00
pm and wakes up at
around 8:00 am.

Stated that he gets 5 to

4-6 hours of sleep
every night, and takes
short naps during the
Seldom take naps during day.
the day.
VII. Sexuality and
Reproduction

Stated that client is sexually active

VIII. Self - Perception

and Self Concept

Stated that he is slow

learner

he wants to be cured
and go home with his
family

IX. Roles and

Relationship

he is the second child in

four siblings

Expresses concern
about the his Mental
status

X. Stress Tolerance
and Coping

stated that whenever he

had problems, he tends
to keep it to himself or
take take illegal drugs

stated that talking to

other patients in the
ward is therapeutic; it is
provides diversion from
feeling of sadness,
boredom, and pain.

XI. Values and Belief

he stated that he pray

before sleeping.

Client is religious and he

strongly believed that
God exist.

Mental Status Examination:

General appearance and behavior
Hygiene :
Posture:
Eye contact:

with good personal hygiene

sitting upright
can look straightly

Cooperativeness & Speech pattern

Cooperative, slow and mumbling
Mood & Affect:
Mood is express in an appropriate affect
Perception
Suspicious
Thought content /Process:
Flight of ideas

Level of Consciousness
Disoriented
Judgment and Insight
Level of awareness unaware

LABORATORY RESULT
Electrolytes
Sodium
Potassium
Urinalysis
RESULTS
Color:
Yellow
Transparency:
Clear
Reaction:
Albumin:
Acidic Albumin

Result
136
3.98
SIGNIFICANCE
Within normal range
Within normal range

Within normal range

Normal Values
135-145
3.5-5.0
RESULTS
Sugar:
negative
Specific gravity:
1.010
Microscopic:
Pusleukocytes:
Erythrocytes:

Roentrogenological report
Findings:
There are hazy infiktrates at both suprahilar area heart is not enlarged
diaphragm and sulci are intact
Impression
Suprahilar pneumonitis, bilateral koch's etiology not ruled out

ANATOMY AND PHYSIOLOGY

The nervous system is an intricate, highly organized network of billions
of neurons and neuro ganglia. The structures that make up the nervous
system include the brain, cranial nerves, spinal nerves, ganglia, enteric
plexuses and sensory receptors. The two main subdivisions of the nervous
system are the central nervous system and the peripheral nervous system.
The central nervous system consists of the brain and spinal cord. The
brain is the center for registering sensations, correlating them with one
another and with stored information, making decisions and taking actions. It
also is the center for the intellect, emotions, behavior, and memory. The
major parts of the brain include: the brain stem, cerebellum, diencephalon,
and cerebrum. The spinal cord is connected to a section of the brain called
the brainstem and runs through the spinal canal. Cranial nerves exit the
brainstem. Nerve roots exit the spinal cord to both sides of the body. The
spinal cord carries signals (messages) back and forth between the brain and
the peripheral nerves.

The brain stem is continuous with the spinal cord and consists of the
medulla oblongata, pons, and midbrain. The medulla oblongata forms the
inferior part of the brain stem. The medulla contains the cardiac, respiratory,
vomiting and vasomotor centers and deals with breathing, heart rate and
blood pressure. The pons is a bridge that connects parts of the brain with
one another. The midbrain extends from the pons to the diencephalon. The
midbrain is a short section of the brain stem between the diencephalon and
the pons.
Posterior to the brain stem is the cerebellum. Traditionally, the
cerebellum has been known to control equilibrium and coordination and
contributes to the generation of muscle tone. It has more recently become
evident, however, that the cerebellum plays more diverse roles such as

participating in some types of memory and exerting a complex influence on

musical and mathematical skills.
Superior to the brain stem is the diencephalon, which consists of the
thalamus, hypothalamus, and epithalamus. The thalamus acts a relay center
for all sensory impulses, except smell, to the cerebral cortex. The
hypothalamus is involved in the acceleration or deceleration of the heart.
Impulses from the posterior hypothalamus produce a rise in arterial blood
pressure and an increase of the heart rate. Impulses from the anterior
portion have the opposite effect. The hypothalamus is also involved in bodytemperature regulation. If the arterial blood flowing through the anterior
portion of the hypothalamus is above normal level, the hypothalamus
initiates impulses that cause heat loss through sweating and vasodilation of
cutaneous vessels of the skin. A below-normal blood temperature causes the
hypothalamus to relay impulses that result in heat production and retention
through the initiation of shivering, the contraction of cutaneous blood
vessels. The hypothalamus is also involved in the regulation of hunger and
control of gastrointestinal activity. Low levels of blood glucose, fatty acids
and amino acids are partially responsible for the sensation of hunger elicited
from the hypothalamus. When sufficient amounts of food have been
ingested, the hypothalamus inhibits the feeding center. It also regulates
sleeping and wakefulness. A specialized sexual center in the hypothalamus
responds to sexual stimulation of the tactile receptors within the genital
organs. Also, the hypothalamus is associated with specific emotional

responses, such as anger, fear, pain and pleasure. The hypothalamus

produces neurosecretory chemicals that stimulate the anterior pituitary
gland to release various hormones. The epithalamus is the posterior portion
of the diencephalon.
Supported on the diencephalon and brain stem is the cerebrum, which
is the largest part of the brain. The cerebrum is the largest part of the brain
and controls voluntary actions, speech, senses, thought, and memory. The
surface of the cerebral cortex has grooves or infoldings (called sulci), the
largest of which are termed fissures. Some fissures separate lobes.
The convolutions of the cortex give it a wormy appearance. Each
convolution is delimited by two sulci and is also called a gyrus (gyri in plural).
The cerebrum is divided into two halves, known as the right and left
hemispheres. A mass of fibers called the corpus callosum links the
hemispheres. The right hemisphere controls voluntary limb movements on
the left side of the body, and the left hemisphere controls voluntary limb
movements on the right side of the body. Almost every person has one
dominant hemisphere. Each hemisphere is divided into four lobes, or areas,
which are interconnected.

The frontal lobes are located in the front of the brain and are
responsible for voluntary movement and, via their connections with other
lobes, participate in the execution of sequential tasks; speech output;
organizational skills; and certain aspects of behavior, mood, and memory.
The parietal lobes are located behind the frontal lobes and in front of
the occipital lobes. They process sensory information such as temperature,
pain, taste, and touch. In addition, the processing includes information about
numbers, attentiveness to the position of ones body parts, the space around
ones body, and one's relationship to this space.
The temporal lobes are located on each side of the brain. They process
memory and auditory (hearing) information and speech and language
functions.
The occipital lobes are located at the back of the brain. They receive
and process visual information.

Neurotransmitters are chemicals which relay, amplify, and modulate signals

between a neuron and another cell. Some neurotransmitters are commonly
described as "excitatory" or "inhibitory". The only direct effect of a neurotransmitter
is to activate one or more types of receptors. Examples of neurotransmitters are
acetylcholine,

dopamine,

gamma-aminobutyric

acid,

dopamine,

glutamate,

aspartate, and serotonin. The chemical compound acetylcholine (often abbreviated

ACh) is a neurotransmitter in both the peripheral nervous system (PNS) and central
nervous system (CNS) in many organisms including humans. In the peripheral
nervous system, acetylcholine activates muscles, and is a major neurotransmitter in
the autonomic nervous system. In the central nervous system, acetylcholine and
the associated neurons form a neurotransmitter system, the cholinergic system,
which tends to cause excitatory actions. Gamma-Aminobutyric acid (GABA) is the
chief inhibitory neurotransmitter in the mammalian central nervous system. It plays
a role in regulating neuronal excitability throughout the nervous system. In humans,
GABA is also directly responsible for the regulation of muscle tone.
Dopamine has many functions in the brain, including important roles in
behavior and cognition, voluntary movement, motivation, punishment and reward,
inhibition of prolactin production (involved in lactation and sexual gratification),
sleep, mood, attention, working memory, and learning. In the frontal lobes,
dopamine controls the flow of information from other areas of the brain. Dopamine
disorders in this region of the brain can cause a decline in neurocognitive functions,
especially

memory,

attention,

and

problem-solving.

Reduced

dopamine

concentrations in the prefrontal cortex are thought to contribute to attention deficit

disorder. Dopamine is commonly associated with the pleasure system of the brain,
providing feelings of enjoyment and reinforcement to motivate a person proactively

to perform certain activities. Dopamine is released (particularly in areas such as the

nucleus accumbens and prefrontal cortex) by naturally rewarding experiences such
as food, sex, drugs, and neutral stimuli that become associated with them. Recent
studies indicate that aggression may also stimulate the release of dopamine in

this way. This theory is often discussed in terms of drugs such as cocaine,
nicotine, and amphetamines, which directly or indirectly lead to an increase
of dopamine in the mesolimbic reward pathway of the brain, and in relation
to neurobiological theories of chemical addiction (not to be confused with
psychological

dependence),

arguing

that

this

dopamine

pathway

is

pathologically altered in addicted persons. Projection neurons that produce

dopamine are found in the diencephalon and the brainstem. In the
diencephalon, dopamine cell bodies give rise to tuberopophysial dopamine
projections, e which inhibit the release of prolactin and melanocytestimulating hormone from the anterior and intermediate lobes of the
pituitary, respectively, and the incertohypothalamic projections, which
connect the zona incerta in the posterodorsal diencephalon with the anterior
hypothalamus and septal area. A third dopamine projection system arises
from neurons scattered along the ventricular system in the periaqueductal
gray, the dorsal motor of the nucleus of the vagus, and the nucleus
solitarius. The preventricular system provides terminals in the gray matter
along the course of the ventricles.
Longer dopamine projection systems arise from the substantia nigra and
the ventral tegmental area (VTA) of the midbrain. The former, the

nigrostriatal dopamine system, is particularly important

in the control of

motor function. The function of the VTAs dopamine projections to the

forebrain, called the mesolimbic and mesocortical systems, has been linked
to the complex group of disease we refer to as schizophrenia. Sociability is
also closely tied to dopamine neurotransmission. Low D2 receptor-binding is
found in people with social anxiety. Traits common to negative schizophrenia
(social withdrawal, apathy, anhedonia) are thought to be related to a
hypodopaminergic state in certain areas of the brain. In instances of bipolar
disorder, manic subjects can become hypersocial, as well as hypersexual.
This is credited to an increase in dopamine, because mania can be reduced
by dopamine-blocking anti-psychotics.
The locus ceruleus at the rostal end of the floor of the fourth ventricle on
each side marks the position of a nucleus with a rich vascular supply and
consisting of neurons containing melanin pigment. The nucleus (also known
as nucleus pigmentosus) is partly in the pons and partly in the midbrain,
lying dorsolateral to the oral pontine reticular nucleus. The locus ceruleus is
the largest of about a dozen nuclei I the brainstem that produce
cathecolamines. Most produce norepinephrine, but some of those in the
medulla produce epinephrine. A third catecholamine is dopamine, a
transmitter used by the large neurons of the substantia nigra and ventral
tegmental area, and by certain nuclei of the hypothalamus.
Serotonin

or

5-Hydroxytryptamine

(5-HT)

is

monoamine

neurotransmitter that is primarily found in the gastrointestinal (GI) tract and

central nervous system (CNS) of humans and animals. Approximately 80

percent

of

the

human

body's

total

serotonin

is

located

in

the

enterochromaffin cells in the gut, where it is used to regulate intestinal

movements.[1][2] The remainder is synthesized in serotonergic neurons in
the CNS where it has various functions, including the regulation of mood,
appetite, sleep, muscle contraction, and some cognitive functions including
memory and learning. Modulation of serotonin at synapses is a thought to be
a major action of several classes of pharmacological antidepressants.
Serotonin secreted from the enterochromaffin cells eventually finds its
way out of tissues into the blood. There, it is actively taken up by blood
platelets, which store it. When the platelets bind to a clot, they disgorge
serotonin, where it serves as a vasoconstrictor and helps to regulate
hemostasis and blood clotting. Serotonin also is a growth factor for some
types of cells, which may give it a role in wound healing.
Serotonin is eventually metabolized to 5-HIAA by the liver, and excreted
by the kidneys. One type of tumor, called carcinoid, sometimes secretes
large amounts of serotonin into the blood, which causes various forms of the
carcinoid syndrome of flushing, diarrhea, and heart problems. Due to
serotonin's growth promoting effect on cardiac myocytes, persons with
serotinin-secreting carcinoid may suffer a right heart (tricuspid) valve
disease syndrome, caused by proliferation of myocytes onto the valve.

Glutamate is the most abundant excitatory neurotransmitter in the

vertebrate nervous system. At chemical synapses, glutamate is stored in
vesicles. Nerve impulses trigger release of glutamate from the pre-synaptic
cell. In the opposing post-synaptic cell, glutamate receptors, such as the
NMDA receptor, bind glutamate and are activated. Because of its role in
synaptic plasticity, glutamate is involved in cognitive functions like learning
and memory in the brain.

CRANIAL NERVES

Cranial nerves are nerves that emerge directly from the brain stem, in
contrast to spinal nerves which emerge from segments of the spinal cord.
There are 12 pairs cranial nerves emerging from the brain, and these are:
Crani
al
nerve

Sensory,
Name

numb

Motor

Function

or Both

er
I

Olfactory nerve

II

Optic nerve

Purely

Transmits the sense of smell; Located

Sensory

in olfactory foramina of ethmoid

Purely

Transmits visual information to the

Sensory

brain; Located in optic canal

Innervates levator palpebrae
superioris, superior rectus, medial

III

Oculomotor nerve

Mainly

rectus,inferior rectus, and inferior

Motor

oblique, which collectively perform

most eye movements; Located
in superior orbital fissure

IV

Trochlear nerve

Mainly

Innervates the superior oblique

Motor

muscle, which depresses, rotates

laterally (around the optic axis),

and intorts the eyeball; Located

insuperior orbital fissure
V

Trigeminal nerve

Both

Receives sensation from the face and

Sensory

innervates the muscles of

and Motor mastication

VI

Abducens nerve

Mainly
Motor

Innervates the lateral rectus, which

abducts the eye; Located insuperior
orbital fissure
Provides motor innervation to
the muscles of facial expression,
posterior belly of the digastric
muscle, and stapedius muscle,
receives the special sense of taste

VII

Facial nerve

Both

from the anterior 2/3 of the tongue,

Sensory

and

and Motor provides secretomotor innervation to

the salivary glands (except parotid)
and the lacrimal gland; Located and
runs through internal acoustic
canal to facial canal and exits
at stylomastoid foramen
Senses sound, rotation and gravity
Vestibulocochlear
nerve (or auditoryVIII

vestibular
nerveor statoacou

(essential for balance & movement).

Mostly
sensory

stic nerve)

More specifically. the vestibular

branch carries impulses for
equilibrium and the cochlear branch
carries impulses for hearing.;
Located in internal acoustic canal

IX

Glossopharyngeal

Both

Receives taste from the posterior 1/3

nerve

Sensory

of the tongue, provides secretomotor

and Motor innervation to the parotid gland, and

provides motor innervation to

the stylopharyngeus (essential for
tactile, pain, and thermal sensation.
Some sensation is also relayed to the
brain from the palatine tonsils.
Sensation is relayed to opposite
thalamus and some hypothalamic
nuclei. Located in jugular foramen
Supplies branchiomotor innervations
to most laryngeal and all pharyngeal
muscles (except
the stylopharyngeus, which is
innervated by the glossopharyngeal);
provides parasympathetic fibers to
nearly all thoracic and abdominal
X

Vagus nerve

Both

viscera down to the splenic flexure;

Sensory

and receives the special sense of

and Motor taste from the epiglottis. A major

function: controls muscles for voice
and resonance and the soft palate.
Symptoms of
damage: dysphagia (swallowing
problems),velopharyngeal
insufficiency. Located in jugular
foramen
Controls sternocleidomastoid and

Accessory nerve
(or cranial
XI

accessory nerve
or spinal
accessory nerve)

trapezius muscles, overlaps with

Mainly

functions of the vagus. Examples of

Motor

symptoms of damage: inability to

shrug, weak head movement;
Located in jugular foramen

Provides motor innervation to the

muscles of the tongue and other
XII

Hypoglossal nerve

Mainly

glossal muscles. Important for

Motor

swallowing (bolus formation) and

speech articulation. Located
in hypoglossal canal

Pathophysiology:
Host
J.y.
48 y.o.
I.T. student

Agent
unknown

Environment
Substance use
Stress
malnutrition

Gray matter Abnormalities

Affected / disturbed horn cells

Alteration in level of insights

Confused/ Compromised
perceived level of insights

SCHIZOPHRENIA

Book Based (signs & symptoms)

Postive symptoms:
Regression
Depersonalization
Projection
Denial
Fantasy

Negative symptoms:
Agitation
Bizarre behavior
Delusions- reference of something
Excitement
Hallucinations
Paranoia
Illusions
Insomnia
Anergia
Anhedonia
Asocial behavior
Avolition
Poor rapport
Poor grooming
Poverty of speech
Blunt affect

Patients centered (signs & symptoms)

Positive symptoms
Fantasy
Denial
Projection
Negative Symptoms

Agitation
Bizarre behavior
Medical
Paranoia Management and
Insomnia
Treatments:
Maintained a safe environment
Minimized stimuli
Avoided promoting dependence
Rewarded positive behavior
Engaged into activities
Explored
contents
of

hallucinations
Do not touch guest
Encouraged
compliance

of

medication regimen
Created a sense of trust
Responded to emotional needs
Encouraged guest to talk
Avoided talking or whispering or

laughing where can see

Be honest and keep all promises

Process Recording and Theme Identification

PLACE: Maria Josefa Hospitallers
DATE: January 8, 2016
TIME: 8:00 Am
PHASE: Orientation Phase
I.

Objectives
a. Client- centered objectives
1. To established trust and rapport with the nurse through
the

use

of

various

therapeutic

communication

techniques.
2. To enhance cognitive skills through participating actively
in the therapeutic activities.
3. To improve socialization of the client and reduce anxiety.
b. Nurse- centered objectives
1. To provide mental health care for the client.
2. To
implement
therapeutic
plan
necessary

for

improvement of mental illness.

3. To develop positive coping behavior through therapeutic
communication.

II.

Description of Setting
a. Describe the set up/ environment
It was a sunny thursday. We fetched our client from Male
Ward and introduced ourselves to the client. We called them for
their breakfast and afterwards

let him brushed his teeth and

waited for him to finish. After that, I went to the ruins and have
our first interaction with the client. The chairs were scattered
around the ruins facing our client. After an hour of interaction the
facilitator were assigned to ask them the time, place and
weather of that day and was given recognitions for each.
b. Describe the nature, behavior, affect and mood of the
client
Our client Mang JB was wearing his own set of red wrinkled
clothes and pants. When we greet him, he recognized us as his
new nurses for that afternoon and easily remembered our names
in particular. Mang JB did the grooming excitedly and rapidly. As
we fetched him for the activity his gait was moderate while
looking at the floor. When we interviewed Mang JB, he showed a
lot of facial expressions. He always said that he was happy, and
it shows. He seemed anxious when he was recalling things from
the past and whenever he thought of a good answer. He always
answered the questions being asked with his medium tone. He
was excited to answer some questions and stuttered because of
it.

III.

Process Recording

Nurse-

Client Therapeutic

Conversation
(include

Analysis

Communication
non- Technique Used

and

Interpretation
based on theories

verbal cues)
SN: Maayong buntag Giving

Greeting or noting

sir J.B.

Mang

C:

Recognition

(smiled

and

JBs

show

effort

that

student

nodding)

his
nurses

recognizes

his

individuality.
According

to

Sullivan, recognition
can

establish

rapport towards the

SN:

Adto

ta

sa Offering

client.
Ones The nurses

inyong male quarter self

their

para maligo naka.

client in doing self-

to

the

care.

C: (nodding)
SN:

help

offer

asa

imong

toothbrush

kay

akong kuhaon para

According to King,
human beings are
open

mak toothbrush?

systems

in

constant interaction
C: naa ra dri akong
toothbrush.

SN: Ako diay

with

the

environment

si Giving

Giving

information

gino, ug ako pud si Information

to

Mario kami imong

student nurse nimo

promotes

sa tulo ka simana.
C:

Ahh(Smiled

and nodding)

the

and

client
a

good

trusting

relationship
between the nurse
and the client.
According to Roy, a
person is an open
adaptive

system

IV.

A. Theme identification
Content Theme
The conversation was all about the clients personal data,
family backgrounds, and his condition.

Interaction Theme
Mang JB responded well on our questions and reacted
appropriately to the questions being asked. Showed interest in
answering the questions but when hes not being asked, he
only remained silent with blunted facial expression and looked
around the environment to divert his attention and ease the
boredom.

Mood Theme
Client had no sudden change in his mood. He expressed
himself through smiling with good eye contact. Clients
movement often feels restless.

V.

Nursing Interventions
We started to greet our client a pleasant afternoon. After that we
fetched him from the ward, we assisted my patient in his grooming
before the activity, I informed him of what will happen on the
therapy. I encourage him to express feelings and verbalized
concerns regarding the conducted activity. After we finished
grooming, we asked him to go with us to have conversation with
him. The orientation was conducted at the Mulitpurposearea. It was
started with asking the clients personal data and backgrounds for

us to go further. We also wanted him to gain trust and established

therapeutic

nurse-client

relationship

with

us.

The

conducted

interaction went good.

VI.

Summary and Evaluation

In the Friday afternoon, as we received the client. As we go on for
his grooming session, we observed that he has a good hygiene.
The client was very cooperative on the conducted conversation
that afternoon. He was able to follow instructions and did it well.
We gained his trust and rapport that had been established during
our interaction. We got along with him easily and he participated
actively in the group socialization.

VII.

Reference
NANDA 10th edition
Psychiatric-Mental Health Nursing 5th Edition

Name of Therapy: Role Identification Therapy

Place:
Date: January 9, 2016
Time: 9:00 AM
Phase: Working Phase (Day 4)

I.

Objectives
a. Client- centered objectives
1. To enhance the thinking and analyzing ability of the client.
2. To

analyze

and

determine

the

knowledge

and

understanding of clients with occupation roles.

3. To gain knowledge

b. Nurse- centered objectives

1. To provide mental health care for the client.
2. To implement therapeutic plan necessary for improvement
of mental illness.
3. To develop positive coping behavior through therapeutic
communication.
4. To assess clients memory status.

II.

Description of Setting
a. Describe the set up/ environment
It was a fine windy day of Wednesday around 8 :00 in the
morning of January 9, 2016 when we received our client. We
fetched him to the pantry area for grooming but he refused to, so
we proceed to the area where the role identification activity will
be held. The place was clean and the seats were arranged
alternately with the client facing the facilitators of the said
activity.

The place was conducive for the activity and they were
comfortably seated on each chair. After the warm greetings of
each facilitator and explaining the procedure of the activity, each
patient were asked to identify what were the roles of the picture
presented to them and was given recognitions for each. After the
activity, we proceed under the mango tree to find shade from
sunlight and to conduct another conversation. We reviewed Mang
JB about the recent activity and asked him what was his reaction
about it and presented another set of pictures. This time, he can
identify roles according to his own intellectual functioning, and
not

by

imitating

his

neighbors

answers.

Between

our

conversation, we gave him snacks that he seemed enjoying while

eating those. At around 11:00 am, we returned our client to his
ward after the therapy and the conversation.
b. Describe the nature, behavior, affect and mood of the
client
We received our client wearing his own set of wrinkled dirty
white Boysen shirt and green patterned shorts which was the
same as last week. His gait was slow and he always looking at
the floor with his arching back. Before the program, we
approached him and he was very excited and always laughing
with no apparent reason. He verbalized different ideas and
looking around his environment a lot of times. During the

program, he was actively participating and behaved well. When

he heard of his neighbors answer, he laughed very hard. He
displayed a lot of facial expressions like smiling, laughing, raising
eyebrows, and frowning before and during the activity. Before the
activity, he talked loudly and excitedly that he stuttered while
speaking. And during the activity, he was serious and listened
very carefully to the instructions and pictures presented to him.
As we go along on our conversation, different behaviors were
manifested, congruent affect have been projected by the client.
III.

Process Recording

Nurse-

Client Therapeutic

Conversation
(include

Analysis

Communication

and

Interpretation

non- Technique Used

based on theories

verbal cues)
SN:
Maayong Giving

The client did not

buntag Mang J.B.

look at us but he

C:

(smiled

Recognition

use gestures or non

and

verbal cues to make

nodding)

communicate

with

his student nurses.

According to Peplau,
the

initial

interaction between
the nurse and the
patient wherein the
latter

has

felt

need and expresses

the

desire

for

professional
SN: naligo nab a Placing
ka?
C:

event

assistance.
in Mang JB refused for

time or sequence
naligo

na

the

grooming

session.

ko

ganiha
SN: unsa oras ka
naligo Mang JB?

According

to

Abdellah,

she

identified

21

problems and one of

C: ganiha 6am.

it

is

to

good

promote
personal

SN: Mang JB kaila Seeking

hygiene.
The patient failed to

pa ka namu?

recognize

C: wala.

Clarification

his

student nurses.
According
Johnson,
individual
patterned,
purposeful,

to
Each
has

IV.

A. Theme identification
Content Theme
We established nurse patient interaction focused primarily
on the role identification therapy in which the client can
identify the roles of people that are represented by pictures. It
will provide the client the stimulus to assess their intellectual
functioning. Moreover, it serves as guide for their thoughts
and behavior.

Interaction Theme
Mang JB responded well on our questions and reacted
appropriately the questions being asked. Showed interest in
answering the questions but when hes not being asked, he
only remained silent looking around the environment where
he can divert his attention.

Mood Theme
The client had sudden changes in his behavior. He changed
his mood and affect suddenly according to his reactions
and situation. He always diverts his attention around his
environment whenever he didnt feel like answering some
questions.

V.

Nursing Interventions
According to Abraham

Maslow

Hierarchy

of

needs,

after

physiological and safety needs are fulfilled, the third layer of human
needs is social and involves feelings of belongingness. Humans
need to feel a sense of belonging and acceptance, whether it comes

from a large social group, such as clubs, office culture, religious

groups, professional organizations, sports teams, gangs, or small
social connections (family members, intimate partners, mentors,
close colleagues, confidants). They need to love and be loved
(sexually and non-sexually) by others. In the absence of these
elements, many people become susceptible to loneliness, social
anxiety, and clinical depression.
We encourage Mang Jb to talk with other client while waiting with
the others to arrive, this will help Mang JB to realize that talking with
other people will make him feel that he belong to a group. We
encourage him to sing to the group, this will help to develop his self
confidence. We provide activity that will help Mang JB to relate his
life on the character. We encourage Mang JB to verbalize his feeling
regarding the activity and give the moral lesson he gain in the story.
We give recognition to the answer of Mang JB by doing this the
client will feel that people around him appreciate the effort he give.
We provide a quiet environment for the activity and conversation
with our client. During the conversation with Mang JB, we encourage
him to verbalize everything on his mind, by doing this we will able
to identify the possible problem that maybe the reason why Mang JB
has no relationship.
VI.

Summary and Evaluation

Today, we held an activity that can assess the intellectual
ability of the patient by conducting the role identification

therapy. Weve prepared a conducive, quiet area with less stimuli

to let the patient concentrate for the said activity. The flow of the
activity went good and we can say that Mang JB enjoyed it as
manifested by his laughs. After that, we had our one on one
conversation with the client and we observed that the client had
sudden change in his mood and affect.
VII.

Reference

Videbeck, Sheila L. (2008). Psychiatric-Mental Health Nursing. Philadelphia.

Lippincot. Williams and Wilkins. (5th Edition).

Assessmen
t

Nursing
Diagnosi
s

Planning Interventions

Rationale

Evaluation

Subjective:

Disturbe
d
thought
processe
s related
to
delusion
al
thinking.

After 12 days
of
renderin
g
nursing
interven
tions,
the
patient
will be
able to
develop
trusting
relation
ship
with
nurse

Delusional
clients are
extremely
sensitive about
others and can
recognize
insincerity.
Evasive
comments or
hesitation
reinforces
mistrust or
delusions.

After 2
days of
rendering
nursing
interventio
ns, the
patient was
develop
trusting
relationshi
p with
nurse

Objective:
>
restlesness
Noted
-lack of
interest

Be sincere and
honest when
communicating
with the client.
Avoid vague or
evasive remarks.

Be consistent in
setting
expectations,
enforcing rules,
and so forth.
Do not make
promises that
you cannot keep.

Clear,
consistent
limits provide
a secure
structure for
the client.

Encourage the
client to talk with
you, but do not
pry for
information.

Broken
promises
reinforce the
clients
mistrust of oth
ers.

Explain procedur
es, and try to be
sure the client
understands the
procedures
before
carrying them
out.

Probing
increases the
clients
suspicion and
interferes with
the
therapeutic
relationship.

Initially, do not
argue with the
client or try to
convince the

When the
client has full
knowledge of
procedures, he

client that the

delusions are
false or unreal.

or she is less
likely to feel
tricked by the
staff.
Logical
argument does
not dispel
delusional
ideas and can
interfere with
the
development
of trust

Assessmen
t

Nursing
Diagnosi

Planning Interventions

Rationale

Evaluation

s
Subjective:
Objective:
>wants to
be alone
-lack of eye
contact

Fear
related
to

After 12 days
of
renderin
g
nursing
interven
tions,
client
will
identify
feelings
of
isolation

>establish a
therapeutic
relationship by
being
emotionally
present and
authentic
>observe for
barriers to social
interaction

>provide
positive
reinforcement
when the client
seeks out others
>discuss causes
of perceived or
actual isolation

>being
emotionally
present and
authentic
fosters growth
in relationships
and decrease
isolation
>adequate
information
should be
gathered so
appropriate
interventions
can be
planned
>social
support
contributes to
positive well
being
>the
individuals
experience of
illness; the
circumstances
of everyday
living that
influence a
quality of life
Safe and
quality nursing
care
1.identifies
physiologic
and
psychologic
manifestations
consistent with

After 1-2
days of
rendering
nursing
interventio
ns, client
will identify
feelings of
isolation

patients
diagnosis
2. identifies
the health
needs of the
patient
Management
of resources
and
environment
Plans
performance of
tasks or
activities
based on
priorities
-determines
the resources
needed for
planned
activity
Health
education
Assesses
Patients
learning needs
Legal
responsibility
Documents
care rendered
to the patients
appropriately
Ethicomoral
responsibility
Maintains
confidentiality
of the pt and
his records
-respect the
rights of the
psychiatric
client.
Personal and
professional
development

Wears clean,
complete and
appropriate
duty uniform
-reports t
clinical area
regularly and
on time
Quality
improvement
-detects in the
patients
behavior from
day to day
-constructs
and implement
therapeutic
solutions for
the well being
of the pt.
Research
-makes
comprehensive
case study
Make relevant
annotated
readings on
pts case
Record and
management
Complete
updated
documentation
of pt care
Collaborative
and teamwork
Participates
participates
actively in the
group
psychotherape
utic activities
-acts as
advocate of
the patient
-refers patient

to appropriate
personnel

Assessm Nursing
ent
Diagnos
is

Planning Interventions

Rationale

Evaluatio
n

Subjecti
ve:

After 23 hours
of
renderin
g
nursing
interven
tions,
the
patient
will
verbaliz
e
underst
anding
of
things
that
precipit
ate
current
situatio

Client may be
fixed in anger
stage of grieving
process, which is
turned inward on
the self, resulting
in diminished selfesteem.

After 3
hours of
renderin
g nursing
intervent
ions, the
patient
was
verbalize
d
understa
nding of
things
that
precipita
te
current
situation
and
demonst
rated
behavior

Objectiv
e:
>
lacking
eye
contact
>little
interest
in
activitie
s
>lack of
social
interacti
on

Situatio
nal low
selfesteem
related
to
cognitiv
e
impairm
ent

Encourage
client to
express honest
feelings in
relation to loss
of prior level of
functioning

Revise
methods for
assisting client
to express
feelings
properly.

To explore the
feelings of the
client thereby
allowing him to
acknowledge his
own strength and
weakness

Encourage
clients
attempts to
communicate.

The ability to
communicate
effectively with
others may
enhance self-

n and
demons
trate
behavio
rs that
show
positive
selfesteem.

If
verbalizations
are not
understandabl
e, express to
client what you
think he
intended to
say. It is
necessary to
reorient client
frequently.
Encourage
reminiscence
and discussion
of life review
Encourage to
participate in
activities
Offer support
and empathy

esteem

Help client
resume
progression
through the grief
process
associated with
disappointing life
events and
increase selfesteem
Positive feedback
from group
members will
increase selfesteem
Focus on
accomplishments
to lift self-esteem
Safe and quality
nursing care
1.identifies
physiologic and
psychologic
manifestations
consistent with
patients
diagnosis
2. identifies the
health needs of
the patient
Management of
resources and
environment
Plans
performance of
tasks or activities
based on

s that
show
positive
selfesteem.

priorities
-determines the
resources needed
for planned
activity
Health education
Assesses
Patients learning
needs
Legal
responsibility
Documents care
rendered to the
patients
appropriately
Ethicomoral
responsibility
Maintains
confidentiality of
the pt and his
records
-respect the
rights of the
psychiatric client.
Personal and
professional
development
Wears clean,
complete and
appropriate duty
uniform
-reports t clinical
area regularly
and on time
Quality
improvement
-detects in the
patients behavior
from day to day
-constructs and
implement
therapeutic
solutions for the
well being of the
pt.
Research

-makes
comprehensive
case study
Make relevant
annotated
readings on pts
case
Record and
management
Complete
updated
documentation of
pt care
Collaborative and
teamwork
Participates
participates
actively in the
group
psychotherapeuti
c activities
-acts as advocate
of the patient
-refers patient to
appropriate
personnel

Disturbed Sleeping Pattern related to frequent visits of staff nurses, and

homesickness as manifested by appearing lethargic and presence of eye
bags.
Significant
Scientific Basis
Expected
Interventions
Findings
Outcomes

Subjective:
Nag mata-mata
man ko pag ka
tulog nako.. Saba
kaayo ang
pultahan kung
nay mu sulod nga
nurse inig ka
gabie.. ganahan
na jud ko mu uli..
as verbalized by
the guest.
-verbalization of
sleeping for only
5 hours
Objective:
-appears lethargic
-presence of
eyebags
-day-time
sleepiness
-yawning
-takes naps
during day-time

Sleep problems in
schizophrenia are
all too familiar to
mental health
professionals and
carers. Publications
in the past have
highlighted sleep
problems in
schizophrenia, and
more recently sleep
disturbance has
been identified as a
contributing factor
for the
development of
psychosis in young
people at risk of
schizophrenia.
(The British Journal
of Psychiatry Apr
2012, 200 (4) 273274)

SHORT TERM:
Within 8 hours of
student nurseguest
interaction, client
will be able to
prevent sleeping
during the day
time to prevent
disruption of
normal sleeping
patterns at night
and will be able
to sleep without
disturbance for
at least 8 hours
of sleep.

-assessed past patterns

of sleep in normal
environment: amount,
bedtime rituals, length,
positions, sleeping aids,
and interfering agents
-Observed and obtained
feedbacks regarding on
the usual sleeping
pattern, bedtime routine
and the usual number of
hours of sleep and rest
-Explained necessity of
disturbances for
monitoring during
sleeping hours for
ensuring safety for the
guests
LONG TERM:
-kept environment quiet
Within 3 days of
-encouraged to
student nurseparticipate in activities to
guest
prevent day-time
interaction,
sleepiness and day-time
guest will be able naps
to continue to
-encouraged to continue
prevent sleeping usual bedtime rituals to
during the day
promote relaxation and
time and will
readiness for sleep
verbalize of
having more
energy due to
increased hours
Safe and quality nursing
of sleep without
care
any disturbance. 1.identifies physiologic
and psychologic
manifestations consistent
with patients diagnosis
2. identifies the health
needs of the patient
Management of resources
and environment
Plans performance of
tasks or activities based
on priorities
-determines the

W
d
h
n
i
s
o
t
b
s
t
G
d
w
h

resources needed for

planned activity
Health education
Assesses
Patients learning needs
Legal responsibility
Documents care rendered
to the patients
appropriately
Ethicomoral responsibility
Maintains confidentiality
of the pt and his records
-respect the rights of the
psychiatric client.
Personal and professional
development
Wears clean, complete
and appropriate duty
uniform
-reports t clinical area
regularly and on time
Quality improvement
-detects in the patients
behavior from day to day
-constructs and
implement therapeutic
solutions for the well
being of the pt.
Research
-makes comprehensive
case study
Make relevant annotated
readings on pts case
Record and management
Complete updated
documentation of pt care
Collaborative and
teamwork
Participates participates
actively in the group
psychotherapeutic
activities
-acts as advocate of the
patient
-refers patient to
appropriate personnel

Medication:
Instruct patient to continue taking her medications
Do not stop abruptly taking the medications
Report any complications or severe effects of drugs to your health care
provider
Exercise:
Encourage patient to have regular exercise even he is at their home.
Treatment:
Instruct patient to continue taking her medications.
Diet:
Advise the patient to eat green leafy vegetables, rich in iron and vitamin C
Danger signs:
Instruct patient to seek medical advice to physician if she experiencing
discomfort and complications