CASE OF PATIENT X

BGHMC

PREPARED BY:
GLYNN I. PASIGON

HEAD NURSE:
HANEE GRACE KIMMOT

DECEMBER 2014

INTRODUCTION
Patient JB is diagnosed with paranoid schizophrenia, 24 years old, male. He
was from La union, Pangasinan.
The present condition of the client started when he was 19 years old. Due to
some circumstances, the client become hostile and showed untoward
behaviors and even hurting his neighbors. He was readmitted on December
9.2014 with a diagnosis of Schizophrenia undifferentiated type, Chronic and
unstable. He has a regular check-up and taking the medications religiously
but his condition worsened when he saw his nieces rapist.
The clients condition now was already stable and manageable.
Pathophysiology
According to Freud, schizophrenia is a form of regression, back to the oral
stage of development. The oral stage is the first stage of psychosexual
development.
A baby is born a bundle of id; ID is self-indulgent and concerned only with a
satisfaction of his/her needs. There is a need to gratify these impulses but
their experiences in the real world result in conflict. People with
schizophrenia are overwhelmed by anxiety because their egos are not strong
enough to cope with id impulses. In schizophrenia, this can lead to selfindulgent symptoms such as delusions of grandeur, Jesus Christ.
As the patient is still living in the real world, this may result in further
DELUSIONS such as hearing voices which may have an ultimate authority
such as God. This explanation suggests that schizophrenia has a
psychosomatic cause the origin is solely in the mind.
At best it could only be a partial explanation of some symptoms, e.g.
delusions. In reality, Freud is denying the very experience of patients with
schizophrenia. Its unscientific and extremely difficult to test. Concepts such
as repression are difficult to observe and measure, although this difficulty
does not invalidate the theory. The theory is based on unrepresentative
samples, case studies, from which it is difficult to generalize.
And it involves poor methodology. The theory fails to account for gender
differences - the onset for males is around 20 years, and for females 30
years. Nor does the theory explain why, prior to diagnosis, their behavior has

appeared normal. Furthermore, it excludes a consideration of the

environment.
Support for this view comes from the work of BROWN (1966) who examined
the progress of patients with schizophrenia discharged from hospital. BROWN
found that those patients who came from families characterized by high
expressed emotion (high conflict, constant interference) were more likely to
return to hospital in a shorter period of time. 58%of patients returned to high
EE families experienced a relapse compared with 10% returning to low EE
families. The implications of this research are that the environment has
significant role to play in the course of the development of schizophrenia.
However, the direction of causation is unclear, it may be that living with a
person with schizophrenia is causing hostility and high expressed emotion
within the family.
Alternatively, it may be the family that is causing the relapse. The effects of
stress on the immune system and on the incidence of disease and illness are
well-known. If stress has a role in physical illness, it may well have a role in
mental illness.

NURSING CARE PLANS

Nursing Diagnosis 1: Disturbed Sleep Pattern related to Excessive
daytime sleeping

Objective data

Subjective data

Dozing during the day

Inadequate daytime activities
Drooping eyelids
irritable

hanak makaturog ti rabii ta turog

ku met ti agsapa.

Expected Outcomes
SHORT TERM GOAL

LONG TERM GOAL

1. JB will not sleep during the day

3. He will fully Identify techniques

to induce sleep.

2. He will describe factors that

prevent or inhibit sleep.

Interventions
Interventions

Rationale

Ongoing Assessment

Assess JBs sleep

A thorough

Determine if JB has

cycle. Report time

understanding of

trouble falling

he goes to bed,

sleep cycle is

asleep or if he

ability to fall to

important to develop

wakes up in the

sleep, waking up in

strategies that will

middle of the night.

the middle of the

improve sleep

Do his voices and

night.

hygiene.

thoughts wake him?

Is there any
evidence of
nightmares?

Increase activities by

Increasing activities

Monitor JBs ability to

attending day

during the day will

stay alert and active

treatment program

help readjust sleep

at the day treatment

daily. Encourage JB

cycle.

center.

to resist urge to
sleep during the day.
Establish a daily
routine for getting
up and going to bed.
Plan with patient how
to increase physical
exercise.

Regular physical

Determine if JB is

exercise improves

willing to exercise

sleep hygiene.

and can develop a

realistic exercise
plan.

Evaluation
1. JB slept 2 hours within the shift
2. JB was able to describe factors
that prevent or inhibit sleep.

3. Has not fully Identified

techniques to induce sleep.

Nursing Diagnosis 2: Impaired Social Interactions related to

Avoidance of others

Objective data

Subjective data

Irritable
Does not talk with others

bagtit met kakadwak.

Outcomes
SHORT TERM GOAL

LONG TERM GOAL

1. A therapeutic relationship with

3. JB will be able to describe

the nurse will be stablished.

strategies to promote effective

socialization.

2. JB will be able to Identify

barriers in interpersonal

4. JB will be able to practice new

relationships that interfere with

social interaction skills.

socialization.

Interventions
Interventions

Rationale

Ongoing Assessment

Initiate a nurse-

Through a nurse-

Determine whether or

patient relationship

patient relationship,

not JB can engage in

with JB. Establish a

the patient can

a relationship.

time each day to

learn about his

meet with him to

strengths and

support him as he

limitations.

learns to cope with

his disorder.
Provide supportive
group therapy to
focus on the hereand-now, establish
group norms that
discourage
inappropriate social
behavior, and
encourage testing of
new social behavior.

Assess JBs ability to

The negative
symptoms of

interact in the
group.

schizophrenia can
make it difficult to
automatically recall
appropriate social
behavior.
Reinforcing
appropriate
behavior in a group
can help the patient
add new skills to a
limited repertoire of

Role-play certain
accepted social

behaviors.
Through practicing
Assess JBs willingness

behaviors. Foster

social interaction,

development of

the patient can

to participate with

relationships among

become

others. Assess the

group members

comfortable in

availability of people

through self-

social situations.

who are his age and

disclosure and

have similar

genuineness.

interests.

Encourage members
to validate their
perception with
others.
Monitor adherence to

medication regimen.
Encourage JB to
attend medication
group. Ask patient
about specific side
effects and symptom
exacerbations.
Encourage JB to
attend the evening
symptom
management group.
Identify the
environment in
which social
interactions are
impaired (living,
learning, working,

Assess for nonverbal

Patients may not be
aware that
symptoms are
erupting. By

cues that symptoms

are present. Monitor
for evidence of
relapse.

specifically asking
about symptoms
and medication side
effects, patients
can focus on
specific experiences
that represent
symptomatology.
Different social skills
are needed in
different situations.

Assess for readiness

to return to learning
and working
environment.

leisure).
Role-play aspects of
social interactions
such as
initiating/terminating
a conversation,
refusing a request,
asking for
something,
interviewing for a
job, asking someone
to participate in an
activity (going to a

By practicing specific
skills, patients will
be able to use them
in specific
situations. It is then
possible to assign a
patient to practice a
specific social skill.
Too much feedback
adds confusion and

Assess for ability to

engage in social
interactions.

movie). Give positive

increases anxiety.

feedback. Focus on
no more than three
behavioral
connections at a
time.
Assist family and
community

Family members are

members in

often the patients

understanding and

main source of

providing support.

support. The family

With JBs permission,

needs help and

develop an alliance

support in dealing

with the family.

with the care of a

Encourage them to

person with a long-

attend a support

term mental illness.

group.

Evaluation
JB was able to establish a
therapeutic relationship with
one of the nurses. Through the
relationship and the group, JB
identified barriers in his
interpersonal relationships.
JB was able to practice various
communication strategies and
eventually was able to

Assess family
interaction.

communicate with others

sharing leisure activities with
them.

NURSE PATIENT INTERACTIONS

FIRST INTERACTION
A. Setting: psychiatric ward of BGHMC inside the male ward. LEARNING
OBJECTIVES
After one hour of nurse patient interaction student will be able to:
1. Build trust and rapport by demonstrating trust
2. Establish therapeutic environment and privacy
3. Establish mode of communication acceptable to both patient and to
the patent

NURSE PATIENT CLIENTS

INT.
INFERENCES
Nmagandang
hapon
po
sir
siyak gayam ni
Glynn shak ti
student nurse yo
tadta hanggang
7pm.

NURSE
MODIFICATIONS
INFERENCES
Giving facts
or relevant
information
would help
facilitate
establish
rapport and
therapeutic
communicat
ion

 Greeting the
patient
would
let
patient
identify she
is part of
the
interaction.

P- he nods and
looked at the
floor

The patient
serious and
looks
irritated

N- kumusta kayo
ngay met sir?

P- mayat met

N- kayat yo ba ti
danum?

Recognizing
the feelings
of
the
patient

Patient
shows
cooperation
but

Shows
initiative to
address to
patients
needs
Helps
the
patient
to
identify
solutions to

problems

P- haanen uray
mandamdaman
maturog ak pay

Conversant
to
the
student
nurses

Nocge
po,
agibaga
kayo
lang
nu
kailangan yo ti
danum.

Pocge(nods
head)

N- apay ayna
gayam ti ayan yo
tadta sir?

Shows
initiative to
address to
patients
needs
Shows
willingness
to
accept
suggestions

Trying
to
orient
the
patient with
her location.
Helps
the
patient
to
recall where
he is.

Pditoy
psychiatric
ti
BGHMC

The patient
shows he is
oriented
with reality
and ha sa
good
retention
and recall

N- apay ayana ti
nagapuan yo sir?

P- La union

N- anya ngai me
ti kayat yo nga
pasauan
tayo
tadta?

Trying
to
explore the
origin of the
patient and
to let the
patient
recall
his
origin
to
present
reality

The patient
is is able to
answer
question

Giving
opportunity
to patient to
open topics
she
might
to
talk
about

P- dakayo ah nu
anya ti kayat yo
nga
maamuan(yawns
and
appears
sleepy)

Shows he is
willing
to
talk
some
things
about
his
but is not
able
to
start

N- sir ibaga yo
lang
ah
nu
makaturturog
kayo

P- wen kayat ko
nga maturog

N- ceg garud sir

maturog
kayo
pay
sakaminto
agsubli
nu
sabado ti kastoy
metlang nga oras

Allowing the
patient
to
take some
time to rest

he
addresses
biological
needs

Informing
the patient
about when
to return.
Builds
a
more
trusting
relationship
with
the
patient.

P- ocge salamat!

Nwen sir
salamat met!

Looking
forward
that
the
students
will return.

Ensuring
the patient.

EVALUATION:
Objectives of the first nurse patient interaction were met. The
student nurse was able to establish rapport. Therapeutic communication also
was achieved. And lastly, we established mode of communication acceptable
to both the patient and the student nurse by talking in either Ilocano.