SPOTMAP

PATIENT’S PROFILE

Name: Mr. Beiber Jr.

Address: Lapas Uno, Lapasan, Cagayan De Oro City

Age: Sex:

33 years old Male

Marital Status: Religion:

Single Mormons

Number and ages of siblings/children:

Name Age civil status educational attainment Occupation

31 yrs.old Married College level OFW

26 years old Married College level Housewife

23 years old Single High school graduate

Contractual

20 years old Single Culinary graduate None

Occupation:

(Specify Past Occupation/s)

Construction worker Farmer sikad driver

Parents Name:

Father:

Mr. Bieber Sr. Age:53 Occupation: “Architect"

Mother:

Mrs. Bieber Age:53 Occupation: Realty Agent

Educational Attainment

Name of School

Elementary:

East City Central School

Secondary:

MOGCHS

College:

STI Manila

ANAMNESIS

INFORMANT #1

Name:

Age: 53

Relationship: Mother

Occupation: Realty Agent

INFORMANT #2

Name:

Age: 31

Relationship: Brother

Occupation: Construction Worker

INFORMANT #3

Name:

Age: 26

Relationship: Sister

Occupation: Unemployed
Mental Status Examination

A.GENERAL Good Good Good Good Good

APPEARANCE
B. GENERAL
MOTILITY
Posture Slouch Slouch Slouch Slouch Slouch
Activity determined determined attentive attentive determined
Facial distant smiling happy smiling Smiling
Expression
C. BEHAVIOR shy friendly friendly friendly Friendly
D. PATIENT Cooperative Cooperative Cooperative Cooperative Cooperative
NURSE
INTERACTION

E. SPEECH
Soft √ √ √ √ √
Loud
Hesitant
Slurred √ √
Superiority
Humor √ √ √ √ √
Frightened
F. Does his style and
vocabulary convey

Coyness √
Suspiciousness

Arrogance
Secretive
Superiority
Humor √ √ √ √ √
Fear
G. Stream of talk
Spontaneous √ √ √ √ √
Pressured
H. Organization of talk

Relevant √ √ √ √ √

Irrelevant √ √ √ √ √

Incoherent

Loose Association

Flight of ideas √ √ √ √ √

Tangentiality √ √ √ √ √

Circumstantiality √ √ √ √ √

Perseveration

Clang Association

Neologism

Echolalia

Echopraxia

I. Mood and Affect

1. Mood

Euthymic √ √ √ √ √
 Depressed

Euphoric

2. Affect

Flat

Blunt √ √ √ √ √

Angry

Elated

Anxious

Fearful

3. expression

Consistent

Labile

Anhedonic

Appropriate to the √ √ √ √ √
situation and
feelings verbalized

J. Perception

Hallucination

Auditory
 Visual

Olfactory

Gustatory

Tactile

Delusion

Grandeur

Persecutory

Reference

Others (specify)

Illusion
 Derealization

Depersonalization

Identification

Thought
Broadcasting

Déjà vu

Jamais Vu

K. Orientation and
Memory

Identifies date yes Yes Yes Yes Yes

correctly

Estimated time of the Yes Yes Yes Yes Yes

day

Knows where he is Yes Yes Yes Yes Yes

 Knows the examiner No Yes Yes Yes Yes

Recalls activities done Yes Yes Yes Yes Yes

within 24 hours

Recalls activities done Yes Yes Yes Yes Yes

within 1 week

L. Neuro-negative
Functioning

Sleep and Rest

Pattern

Normal Sleeping

Early morning
Awakening

Middle night √ √ √ √ √
Awakening

Hypersomnia

Difficulty of falling
asleep
 Interrupted √ √ √

Others

M. Elimination

Bowel 0 1 1 1 0

Bladder 1 2 1 2 2

N. Abstract Thinking Good Good Good Good Good

Ability

O. Judgment Good Good Good Good Good

Multi-axial diagnosis

AXIS I Axis I Schizophrenia, Residual type

Schizophrenia is characterized with the following:
1. residual type
2. disorganized speech
3. paranoid type
4. catatonic
AXIS II Axis II Schizoid Personality Disorder
1. Acute discomfort in relationship
2. Cognitive or perceptual distortions
3. Eccentric behavior
4. Bizarre speech
5. Affect flat and sometimes inappropriate

AXIS III Axis III General Medical Condition

Malnourished

AXIS IV Axis IV Problem related to Social Environment

Transferring from Cagayan de Oro to Manila thus changes the
environment.

AXIS V Axis V Global Assessment of Functioning

Moderate symptoms- Mr. Bieber Jr. has blunted affect
Moderate difficulty in social functioning- Mr. Bieber Jr. has only few friends

Actual nursing diagnosis

S “usahay kay dili jud namu masabtan ang iyang mga ginaistorya” as
verbalized by the patient sister.

O • Speaks or verbalizes with difficulty

A Impaired verbal communication related to physiological barriers.

P 1. Short term: At the end of 2 hours, the patient was able to
Establish method of communication in which needs can be
expressed.
2. Long term: At the end of 5
3. days the client will be able to communicate openly.

I 1. Interacted with patient in a clear and consistent

manner.
2. Encouraged participation in the discussion about life
and present day event.
3. Was able to listen to the client in the attempt to
communicate.
4. Provided activity such as singing.

E At the end of 2 days, our goal had met with the patient communications
based on the patient’s interactions and able to respond reality.

S “Bilar ko, makamata man ko inig gabie” as verbalized by the patient

O • Speaks or verbalizes with difficulty

A Disturbed sleep pattern related to daytime activity pattern and position

P At the end of 2-3 days, the patient was able to verbalize the
improvement in sleep and feeling rested.

I 1. Explored other sleep aids.

2. Encouraged patient’s participation in regular
exercise.
3. Instructed the significant others to provide comfort
measures.
4. Listened to subjective reports of sleep quality.

E At the end of 2-3 days, the patient was able to verbalize the
improvement in sleep and felt rested

S “usahay ka’y malipasan na siya ug kaon, usahay iyahang kaonun kay sugar ug
kan-on” as verbalized by the patient
O 59 kls
5’11
Malnourished

A Imbalanced Nutrition, less than body requirements related to inability to absorb

nutrients because of psychological or economical factors

P At the end of 4-5 days, the patient was able to gain his weight and able to eat
properly

I 1. Provided a diet list for the patient.

2. Encouraged to eat on time.
3. Encouraged the patient’s significant others to provide
adequate and nutritious foods for the patient. Nutritious foods
provide energy to the patient thereby increasing the patient’s
capabilities to do his activities of daily living.

E At the end of 4-5 days, the patient was able to gain his weight and was able to
eat properly

Prognosis
CRITERIA GOOD PROGNOSIS POOR PROGNOSIS

a. Onset of Illness √

b. Duration of Illness √

c. Precipitating Factors √

d. Mood and Affect √

e. Attitude and willingness √

toward taking medication
and treatment

f. Any depressive features √

g. Family support √

as shown the table, our patient falls onto good prognosis because 5 out of
7 are listed under good prognosis. his onset of illness was early when he was 18 years
old which according to the author of the book, Videbeck, the peak onset of
schizophrenia for male is 15 to 25 years of age which our patient belong to the said
range of age. speaking with the duration, the patient no longer displays prominent
symptoms. in such cases, the schizophrenic symptoms generally have lessened in
severity. but the manifestations are significantly diminished in comparison to the acute
phase of the illness. one of the precipitating factors that cause Mr. Bieber jr., developed
this kind of disorder was the feeling of untrustworthy since his mother entrusted more
responsibilities to his younger brother than to himself. he also seeks for attention from
his father. his mood is euthymic and affect is blunted. good family support is provided to
the client.

Recommendations

Schizophrenia leads into many causes such as impairment of social skill,

loss of initiative, and frequently paranoia. The result is often active social avoidance.
We advice the client’s family member that they must help the patient to undergo a
supportive psychotherapy which will provide the client with encouragement, practical
advice such as access to community resources of how to develop a more active social
life, vocational counseling and above all, hope that the client’s life will be improved. All
discussions must be focus on the present situation and not on the past since the patient
can developed his self and tries to meet the exigencies in life despite a handicapping
brain disease.

In this kind of situation in life, family’s role should be one of support rather
than direction. We encouraged the family to continuously support, guide, provide care,
and love towards the client in order for him not to feel alone and disregarded. We also
recommend that the client’s family should always aim at helping the client to become as
independent so that the client will be able to learn by himself in doing things in the
extent of his disability.