Chapter I

INTRODUCTION
Schizophrenia is an extremely complex mental disorder. n fact it is
probably many illnesses masquerading as one (Nursing Crib 2011). A
biochemical imbalance in the brain is believed to cause the symptoms. Recent
research reveals that schizophrenia may be a result of faulty neuronal
development in the fetal brain, which develops into full-blown illness in late
adolescence or early adulthood.
t also causes distorted and bizarre thoughts, perceptions, emotions,
movement, and behavior (Townsend 2008). t cannot be defined as a single
illness; rather thought as a syndrome or disease process with many different
varieties and symptoms. t is usually diagnosed in late adolescence or early
adulthood. Rarely does it manifest in childhood. The peak incidence of onset is
15 to 25 years of age for men and 25 to 35 years of age for women.
This disease can also be defined as a severe form of mental illness
affecting about 7 per thousand of the adult population, mostly in the age group
15-35 years. Though the incidence is low (3-10,000), the prevalence is high due
to chronicity according to the World Health Organization as of 2011. t affects
about 24 million people wordwide. t is a treatable disorder, treatment being more
effective in its initial stages. More than 50% of persons with schizophrenia are
not receiving appropriate care and 90% of people with untreated schizophrenia

are in developing countries. By 2007, the Department of Health reported that

2, 416 972 of the total Filipino population have schizophrenia regardless of the
undiagnosed. As of August 2011 in Vicente Sotto Memorial Medical Center,
Center for Behavioral Sciences, Cebu City, Philippines, out of 81 male patients,
23 have schizophrenia and 72 female patients, 19 have schizophrenia.
Further, care of persons with schizophrenia can be provided at community
level, with active family and community involvement. This is why, studies to be
conducted about this broad disease is of great help for better understanding of
the condition as well as to giving care and treatment.

Chapter II
ASSESSMENT
Patient's Vitae
The patient has the initials of AE, female and already 41 years of age. She
came from Sagkahan Picas, Tacloban City, Leyte. She was married to Doming
who according to her was only 30 years old. She has two children, Enday and
Entoy who, also according to her were ages eight and three.
She was born to the Basilio and Teodora Esquierdo as the third child
among five siblings. They are Gina, Lilibeth, Catcat, and Mary Jean Esquierdo
whose ages she cannot recall anymore.
istory
The client has been admitted to Vicente Sotto Memorial Medical Center-
Center for Behavioral Sciences (CBS) the third time last November 2000. Prior to
admission, patient had complaints of mumps.
On her first interview, according to the client, she has no idea why she
was sent in CBS. But when asked the second time, she said that she lied down
on the floor of a public place, the reason why the policeman caught her and sent
her in the place. Also, according to the policeman who caught her, she was
singing loudly without minding the people around her and regardless of the place
she was in.

She also viewed her admission as an opportunity for her to work. She was
also able to verbalize that her father, Tatay Basilio accompany her in CBS for her
to have work. According also to the patient, she used to earn Php 10, 000.00
through her work in CBS.
:nctionaI eaIth Patterns
Health Perception- Health Management Pattern. The client viewed her
health condition optimal. According also to the client, she can be discharged
anytime but she just cannot understand what keeping her for a long time inside
the ward.
Nutritional- Metabolic Pattern. For his 24- hour diet recall, she had rice,
fried egg, longganisa, banana, and one glass of water for breakfast. During lunch
she had rice, ground pork, two glasses of water. For dinner, he had rice, fried
bangus, and two glasses of water.
Elimination Pattern. The patient used to urinate 4 to 6 times a day and
eliminate bowel once a day. She had an amber- colored urine with the amount of
350 cc. Her stools were formed and light brown. The patient had no complaints of
having difficulty in urination nor straining upon defecation.
Activity- Exercise Pattern. The patient usually wakes up at 5:30 in the
morning. She considers their morning stretch in the ward every morning and
dance therapies in the afternoon her main exercise. While joining the different
therapies lead by different student nurses her main activity.

Sleep- Rest Pattern. The patient gets up around 5:30 in the morning. At
around 2:00 to 4:00 in the afternoon, she takes a nap before or after the
therapies conducted.
Cognitive- Perceptual Pattern. The patient is coherent and still has a good
memory as well as good memory retention skills. She can read the newsprint
clearly at the distance of 14 inches. She can still hear whispers clearly up to 2 ft.
Also, the patient senses of smell and taste were still doing fine. She can still also
recognized tactile sensations.
Self- Perception- Self- Concept Pattern. The patient is optimistic about her
condition. She perceives her as a healthy individual has healthy thoughts about
herself.
Role Relationship Pattern. The client remembered that she has parents.
They had a peaceful relationship. She even remembered that they were in a
garden with many flowers and catching butterflies.
Sexuality- Reproductive Pattern. The client had no idea about her
sexuality and reproductive pattern. She was able to mention that she has two
children, 8 years old and 3 years old respectively.
Coping- Stress Tolerance Pattern. When feeling bad, according to the
client, she just sleeps. The moment she woke up, she feels okay then.
Values- Belief Pattern. The patient attends the mass conducted in the
ward every Sunday together with other patients for their spiritual well- being. She

also believe in Filipino traditions such as celebrating the fiesta and hosts
thanksgiving masses.
PhysicaI Assessment
The patient appeared congruent to stated age, with fair complexion and
presence of lentigo senilis(age spots) on exposed parts of the body, and with
clean and well- groomed clothing. Thickened and brittle fingernails and toenails
were cut short. Her posture was erect, can support whole body weight while
standing and walking. Client had arrhythmic gait and limps while walking.
The head was round and erect, and in midline of the body. Her scalp was
moist with visible baby lice in most of her hair strands. However, hair feels coarse
due to aging. The eyes were bilaterally symmetric as well as the ears. The
patient's head was hard and smooth without lesions. The temporal artery is
elastic and not tender upon palpation. There were no swelling and tenderness
elicited upon palpation.
The neck was symmetric as well as head was centered and without
bulging masses. The thyroid cartilage, cricoids cartilage, and thyroid gland move
upward symmetrically as the client swallowed. The patient has slowed flexion
and extension, lateral bending, and rotating of the neck but these were done
without resistance and pain elicited. The trachea was also in midline. The thyroid
felt nodular upon palpation due to fibrotic changes that occur with aging. t was
also felt in the lower neck because of age- related structural changes (Kelley &

Weber 2007). There were no swelling, enlargement, and tenderness palpated.

Also, there were no bruits auscultated.
Yellowing of the lens of the eyes of the patient was apparent. On both
eyes the conjunctiva was pink. Her eyelids have no lesions and redness. She
had clear sclera. Her pupils were equally round and reactive to light. Her
earlobes were attached. Auricles aligns with the outer canthus of each eye.
There were no cerumen seen in the external structures of both ears. Also, there
were no lesions, swellings, and tenderness elicited during palpation. Her lips
were well- moistened. No lesions and swelling on lips, gums, tongue and buccal
mucosa were noted. Her tongue was moist and in midline when at rest and on
protrusion, and her tonsils were not obstructing. Her uvula was also on midline.
The patient has a respiratory rate of 24 cpm. His sternum was positioned
in midline and was straight. There were no retractions of intercostals spaces
noted. Her spinous processes appeared straight. Her chest appeared symmetric.
There were no palpable lymph nodes, masses and tenderness noted. Also, no
rashes or signs of infection were noted in the breast and in axillae. There was
also no tenderness palpated on the area of the anterior and posterior thorax. The
expansion of the lower chest was evident during inspiration and unevident during
expiration. There were no high- pitched short popping sound heard upon
auscultation as well as no wheezes, rales and murmurs were heard over the
lungfield area.

The jugular venous pulse was not visible while the patient sits upright. The
jugular vein was not also distended. There were no blowing and swishing sounds
heard upon auscultation. Pulses were equally strong. The contour was also
smooth and rapid on the upstroke and slower and less abrupt on the downstroke.
The arteries were less elastic due to aging (Kelley & Weber 2007). The carotid
arteries were evaluated as 2+ or normal according to pulse amplitude scale. The
apical pulse is not visible. t was palpated and auscultated at 5
th
intercostal space
left of the midclavicular line with 98 bpm. The radial and apical pulse rates were
identical. There were no extra heart sounds heard during auscultation.
The arms of the patient were bilaterally symmetric and no edema and
prominent venous patterning were present. Her skin was slightly moist bilaterally
from fingertips to upper arms. Capillary beds refill in 2 seconds. Her radial, ulnar,
and brachial pulses have equal strength bilaterally which is 2+. The Allen test
was performed and pink coloration returned after the radial artery was releases
from occlusion as well as the ulnar artery. The legs of the patient were also
identical in size and shape bilaterally. His legs were free of lesions and
ulcerations. There were no pitting nor nonpitting edema were present in the legs.
His toes, feet, and legs were equally warm bilaterally. The femoral pulses were
equal bilaterally. There were no sounds auscultated over the femoral arteries.
Abdominal skin looked paler than the exposed part of the body. Lentigo
senilis were also apparent at the abdominal area. Abdomen was free from
lesions and rashes. Umbilicus was in midline at lateral line. Abdomen was also
evenly rounded and symmetric. A series of intermittent, soft clicks and gurgles

were heard at a rate of 6 tics per minute. There was no friction rub over the areas
of spleen and liver were noted. Generalized tympany predominated over
abdomen because of air in the stomach and intestines. No pain and tenderness
were elicited upon palpation.
The bladder was not distended on the time of assessment. He had an
amber- colored urine with the amount of 350 cc. The patient had no complaints of
having difficulty in urination.
The anal opening appeared hairless, moist, and tightly closed. The
surrounding perianal area was free of redness, lumps, ulcers, lesions, and
rashes. The area of the peritoneal cavity was smooth and nontender. Her stools
were formed and light brown. The patient had no complaints of having difficulty or
straining upon defecation.
The upper and lower limbs were symmetric. There were no pain nor
tenderness elicited upon palpation. The patient can extend and flex both upper
and lower extremities effortlessly and without resistance.
The client refused to have her genital assessed. But she described it free
of lesions and any swellings. The client also reported thinning of hair in his
genital.
The client correctly identified the scent of alcohol presented in each
nostril. She can also read print at 14 inches without difficulty. Her eyes move in a
smooth, coordinated motion in all directions of the six cardinal fields. Bilateral
illuminated pupils constricted simultaneously. Pupil opposite the one illuminated

constricted simultaneously. Temporal and masseter muscles contracted

bilaterally. The client also correctly identified sharp and dull stimuli and light
touch to the forehead, cheeks, and chin. The eyes blinked bilaterally. Client also
smiled, frowned, wrinkled forehead, showed teeth, puffed out cheeks, pursed
lips, raised eyebrows, and closedd eyes against resistance. Movements are
symmetrical. Client was able to identify correct flavor. Client can hear whispered
words up to the distance of two ft. uvula and soft palate raised bilaterally and
symmetrically on phonation. Gag reflex was intact. Client swallowed without
difficulty. No hoarseness of voice was noted. There was strong contraction of
trapezius muscles, sternocleidomastoid muscle on the side opposite the turned
face. Tongue movement was symmetric and smooth and bilateral strength was
apparent.
MentaI Assessment
The client stated age was parallel to her legal age which is 41 years old.
She wore a white smock gown and brought a white towel with her during the
interview. Her hair was cut short and fingernails and toenails trimmed short.
Client can also maintain erect posture though she has an arrhythmic gait and
limped. She smiled when recalling something though in general she had a flat
affect.
She had a slowed and soft speech with paucity in between statements.
The client also slowed movements but no visible psychomotor disturbance. She

tended to be suspicious if somebody joined conversation or interaction. She also

tended to leave whenever other patients converse with the student nurse.
The client stated, "Okay ra man ko 'te, when asked how she was feeling
today. She had no thoughts of harming herself and others. She used to smile
when remembers something like "Nagdakop- dakop ko ug paru-paro.
Client had episodes of auditory hallucinations. According to the client she
was able to hear something, "kung nag-istorya ta. When asked what was the
voice was saying, she answered, "Ang iya ra man isulti kay pareho sa akong
dapat itubag nimo.
The client had no recurrent or persistent thoughts and had no reports of
fear of certain objects or situations. She also has no worries about body or health
issues. She had no feelings of strangeness or unreality and experience of
depersonalization. She claimed that she had never felt being singled out,
watched out or talked about by others. She also had no experience being
controlled by an outside person nor force. She had thoughts that she possessed
special powers way back in her childhood. She also had thoughts of having her
mind read by others just by looking at them.
Client answered when asked and supplies what information was needed
by the interviewer. The client did not have difficulty understanding the questions
being asked, did not show loose associations, flight of ideas, grandiosity, and
reports of experiences of depersonalization but had thoughts of magic and
paranoia.

The client was coherent on the entire duration of interview as evidenced

by her statements. She was oriented to person because she was able to say,
"Ako si Aurea pero pwede sad ko nimo tawagun ug Auring. Her orientation to
place and time was also apparent because of this statement, "Diri sa Vicente
Sotto and "Hapon na 'te, alas-tres y medya. Her orientation to the situation was
likewise apparent because of this statement, "Nag-istorya ta karon te.
She can answer the interview questions and can recall past memories
without difficulty. From her remote memory she can remember, "Naa koy duha ka
anak. Si ntoy 8 years old. si nday 3 years old. This memory of ages by the
client was not changeable. Ten years ago during her admission, statement about
the ages of her husband and children was the same. From her recent memory,
"June katong niaging buwan. From her immediate memory, "Martes karon.
Client was capable of remaining focused on the topic of conversation. For
her calculation, she can count accurately, "tulo kabuok blue, duha kabuok green
the beads on her bracelet and able to identify that three is greater that two.
Client can retain information given such as name of student nurse
assigned to her and other student nurses introduced to her. She also knew how
to read texts as well as the time in the student nurse's watch. She judged self as
well patient and just needed to stay in the ward for no reason. She also had the
insight of time span spent in the ward but had no insight of the condition as she
verbalized, "Ambot lang ngano naa pa ko diri. 10 years na ko diri.

Anatomy and PhysioIogy

ig:re 1.1. The Nervo:s System
The neurologic system is consists of two main divisions, the central
nervous system (CNS) and the peripheral nervous system (PNS). The autonomic
nervous system (ANS) is composed of both central and peripheral elements.
The CNS is composed of the brain and spinal cord. The PNS is composed of the
12 pairs of the cranial nerves and the 31 pairs of the spinal nerves. The ANS is
comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in
the brain and spinal cord. ts peripheral division is made up of visceral efferent
and afferent nerve fibers as well as autonomic and sensory ganglia.
The PNS connects the CNS to remote body regions and conducts
signals to and from these areas and the spinal cord. The ANS regulates body
functions such as digestion, respiration, and cardiovascular function. Supervised
chiefly by the hypothalamus, the ANS contains two divisions, the sympathetic
and parasympathetic nervous systems. The sympathetic nervo:s
system serves as an emergency preparedness system, the "flight-for-fight

response. Sympathetic impulses increase greatly when the body is under

physical or emotional stress causing bronchiole dilation, dilation of the heart and
voluntary muscle blood vessels, stronger and faster heart contractions,
peripheral blood vessel constriction, decreased peristalsis, and increased
perspiration. Sympathetic stimuli are mediated by norepinephrine.
The parasympathetic nervo:s system is the dominant controller for most
visceral effectors for most of the time. Parasympathetic impulses are mediated
by acetylcholine.

ig:re 1.2. The Meninges of the Brain
The brain is covered by three membranes. The dura matter is a
fibrous, connective tissue structure containing several blood vessels.
The arachnoid membrane is delicate serous membrane. The pia matter is a
vascular membrane. The spinal cord extends from the medulla oblongata to the

lower border of the first lumbar vertebrae. t contains millions of nerve fibers, and
it consists of 31 nerves 8 cervical, 12 thoracic, 5 lumbar, and 5 sacral.
Cerebrospinal fluid (CSF) forms in the lateral ventricles in the
choroid plexus of the pia matter. t flows through the foramen of Monro into to the
third ventricle, then through the aqueduct of Sylvius to the fourth ventricle. CSF
exits the fourth ventricle by the foramen of Magendie and the two foramens of
Luska. t then flows into the cistema magna, and finally it circulates to the
subarachnoid space of the spinal cord, bathing both the brain and the spinal
cord. Fluid is absorbed by the arachnoid membrane.

ig:re 1.3 The Brain

The brain is composed of the cerebr:m, thaIam:s,

hypothaIam:s, and the cerebeII:m. The cerebr:m is the center for
consciousness, thought, memory, sensory input, and motor activity; it consists
of two hemispheres (Ieft and right) and four lobes, each with specific functions.
The frontaI Iobe controls voluntary muscle movements and contains motor
areas, including the area for speech; it also contains the centers for personality,
behavioral, autonomic and intellectual functions and those for emotional and
cardiac responses. The temporaI Iobe is the center for taste, hearing and smell,
and in the brain's dominant hemisphere, the center for interpreting spoken
language. The parietaI Iobe coordinates and interprets sensory information from
the opposite side of the body. The occipitaI Iobe interprets visual stimuli.
The thaIam:s further organizes cerebral function by transmitting
impulses to and from the cerebrum. t also is responsible for primitive emotional
responses, such as fear, and for distinguishing between pleasant and unpleasant
stimuli. Lying beneath the thalamus, the hypothaIam:s is an automatic center
that regulates blood pressure, temperature, libido, appetite, breathing, sleeping
patterns, and peripheral nerve discharges associated with certain behavior and
emotional expression. t also helps control pituitary secretion and stress
reactions. The cerebeII:m or hindbrain, controls smooth muscle movements,
coordinates sensory impulses with muscle activity, and maintains muscle tone
and equilibrium.
The brain stem includes the mesencephalon, pons, and medulla
oblongata, relays nerve impulses between the brain and spinal cord. The spinaI

cord forms a two-way conductor pathway between the brain stem and the PNS.
t is also the reflex center for motor activities that do not involve brain control.

PathophysioIogy















ig:re 2.1. PathophysioIogy of Schizophrenia
Etiology: Unknown
Risk Factors:
O Genetics
O Physiological conditions
O Viral infection
O Anatomical abnormality
O Histological changes
O Psychological influences
O Environmental influences
Precipitating Factors:
O Stressful event
(client failed four
times in her 1
st
year
in high school)
O Viral infection
(mumps)
ncrease in
norepinephrine
ncrease in
dopamine
Decrease in
GABA
Activates
fight or flight
response
Regulates
mood can be
excited or
depressed
Regulates complex movements
and coordination(can be
excitatory or inhibitory),
emotions, sensory integration,
and voluntary decision making
Slows down
bodily
functions
Prevent
postsynaptic
excitation
nterrupts progression of
electrical impulse of
synapse
hyperactive
behavior
Flataffect Delusions/
hallucinations
incoherence catatonia

The cause of schizophrenia is still uncertain. Most likely no single

factor can be implicated in the etiology; rather, the disease probably results from
a combination of influences including biological, psychological, and
environmental factors (Townsend 2008).
The body of evidence for genetic vulnerability to schizophrenia is
growing. Studies show that relatives of individuals with schizophrenia have a
much higher probability of developing the disease than does the general
population. Whereas the lifetime risk for developing schizophrenia is about 1
percent in most population studies, the siblings or offspring of an identified client
have a 5 to 10 percent risk of developing schizophrenia (Ho, Black & Andreasen,
2003). How schizophrenia is inherited is uncertain. No reliable biological marker
has as yet been found. t is unknown which genes are important in the
vulnerability to schizophrenia, or whether one or many genes are implicated.
Some individuals have a strong genetic link to the illness, whereas others may
have only a weak genetic basis. This theory gives further credence to the notion
of multiple causations.
The oldest and most thoroughly explored biological theory in the
explanation of schizophrenia attributes a pathogenic role to abnormal brain
biochemistry. Notions of a "chemical disturbance as an explanation for insanity
were suggested by some theorists as early as the mid-19th century.

A number of physical factors of possible etiological significance

have been identified in the medical literature. However, their specific
mechanisms in the implication of schizophrenia are unclear.
Sadock and Sadock (2003) report that epidemiological data
indicate a high incidence of schizophrenia after prenatal exposure to influenza.
They state: Other data supporting a viral hypothesis are an increased number of
physical anomalies at birth, an increased rate of pregnancy and birth
complications, seasonality of birth consistent with viral infection, geographical
clusters of adult cases, and seasonality of hospitalizations. Another study found
an association between viral infections of the central nervous system during
childhood and adult-onset schizophrenia (Rantakallio et al, 1997).
With the use of neuroimaging technologies, structural brain
abnormalities have been observed in individuals with schizophrenia. Ventricular
enlargement is the most consistent finding; however, sulci enlargement and
cerebellar atrophy are also reported. Ho, Black, and Andreasen (2003) state:
There is substantial evidence to suggest that ventricular enlargement is
associated with poor premorbid functioning, negative symptoms, poor response
to treatment, and cognitive impairment. CT scan abnormalities may have some
clinical significance, but they are not diagnostically specific; similar abnormalities
are seen in other disorders such as Alzheimer's disease or alcoholism.
Cerebral changes in schizophrenia have also been studied at the
microscopic level. A "disordering or disarray of the pyramidal cells in the area of

the hippocampus has been suggested (Jonsson et al, 1997). This disarray of
cells has been compared to the normal alignment of the cells in the brains of
clients without the disorder. Some researchers have hypothesized that this
alteration in hippocampal cells occurs during the second trimester of pregnancy
and may be related to an influenza virus encountered by the mother during this
period. Further research is required to determine the possible link between this
birth defect and the development of schizophrenia.
Some studies have reported a link between schizophrenia and
epilepsy (particularly temporal lobe), Huntington's disease, birth trauma, head
injury in adulthood, alcohol abuse, cerebral tumor (particularly in the limbic
system), cerebrovascular accidents, systemic lupus erythematosus, myxedema,
parkinsonism, and Wilson's disease.
Many studies have been conducted that have attempted to link
schizophrenia to social class. ndeed epidemiological statistics have shown that
greater numbers of individuals from the lower socioeconomic classes experience
symptoms associated with schizophrenia than do those from the higher
socioeconomic groups (Ho, Black, & Andreasen, 2003). Explanations for this
occurrence include the conditions associated with living in poverty, such as
congested housing accommodations, inadequate nutrition, absence of prenatal
care, few resources for dealing with stressful situations, and feelings of
hopelessness for changing one's lifestyle of poverty.

An alternative view is that of the downward drift hypothesis. This

hypothesis relates the schizophrenic's move into, or failure to move out of, the
low socioeconomic group to the tendency for social isolation and the segregation
of self from otherscharacteristics of the disease process itself. Proponents of
this notion view poor social conditions as a consequence rather than a cause of
schizophrenia.
Psychodynamics




























ig:re 2.2. Psychodynamics of Dopamine ypothesis
ncrease production or
realease of dopamine
at nerve terminals
ncreased receptor
sensitivity
Too many dopamine
receptors
Excess of dopamine-
dependent neuronal
activity in the brain
Signs and Symptoms:
O Flat affect
O Delusions or hallucinations
O ncoherence
O catatonia
Persistence of signs and sypmtoms
Chronicity of condition
(Chronic Schizophrenia)

The Dopamine Hypothesis

This theory suggests that schizophrenia (or schizophrenia- like
symptoms) may be caused by an excess of dopamine-dependent neuronal
activity in the brain. This excess activity may be related to increased production
or release of dopamine at nerve terminals, increased receptor sensitivity, too
many dopamine receptors, or a combination of these mechanisms (Sadock &
Sadock, 2003).Pharmacological support for this hypothesis exists.
Amphetamines, which increase levels of dopamine, induce
psychotomimetic symptoms. The neuroleptics (e.g., chlorpromazine and
haloperidol) lower brain levels of dopamine by blocking dopamine receptors, thus
reducing the schizophrenic symptoms, including those induced by amphetamines
(Townsend 2008).
Postmortem studies of schizophrenic brains have reported a
significant increase in the average number of dopamine receptors in
approximately two thirds of the brains studied. This suggests that an increased
dopamine response may not be important in all schizophrenic clients. Clients with
acute manifestations (e.g., delusions and hallucinations) respond with greater
efficacy to neuroleptic drugs than do clients with chronic manifestations (e.g.,
apathy, poverty of ideas, and loss of drive). The current position, in terms of the
dopamine hypothesis, is that manifestations of acute schizophrenia may be
related to increased numbers of dopamine receptors in the brain and respond to
neuroleptic drugs that block these receptors. Manifestations of chronic
schizophrenia are probably unrelated to numbers of dopamine receptors, and

neuroleptic drugs are unlikely to be as effective in treating these chronic

symptoms (Townsend 2008).

Chapter III
MANAGEMENT
MedicaI Management
A. PharmacoIogic Therapy
IdeaI
Antipsychotic drugs are often very effective in treating certain symptoms of
schizophrenia, particularly hallucinations and delusions; unfortunately, the drugs
may not be as helpful with other symptoms, such as reduced motivation and
emotional expressiveness. ndeed, the older antipsychotics (which also went by
the name of "neuroleptics), medicines like haloperidol (Haldol) or
chlorpromazine (Thorazine), may even produce side effects that resemble the
more difficult to treat symptoms. Often, lowering the dose or switching to a
different medicine may reduce these side effects; the newer medicines, including
olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal), appear
less likely to have this problem. Sometimes when people with schizophrenia
become depressed, other symptoms can appear to worsen. The symptoms may
improve with the addition of an antidepressant medication (PsychCentral 2011).
Act:aI
Risperidone (Risperdal) are antipsychotic medications that binds
selectively to dopaminergic receptors in the CNS and may interfere with

adrenergic, cholinergic, histaminergic, and serotonergic reactions. t also control

psychotic symptoms such as hallucinations and delusions. t is used for short-
term treatment of schizophrenia usually six to eight weeks. t also delays relapse
in schizophrenia therapy lasting one to two years (Schilling 2008).
t is contraindicated in patients hypersensitive to drug. t must also
be used cautiously in patients with prolonged QT interval, cardiovascular
disease, dehydration, hypovolemia, history of seizures or conditions that would
affect metabolism or hemodynamic responses. t is also used cautiously in
patients who are exposed to extreme heat and in patients with high risk for
aspiration pneumonia (Schilling 2008).
Extrapyramidal syndrome which is characterized by dystonia,
tardive dyskinesia, tremors, and akathisia may occur as side effects.
Cardiovascular side effects such as tachycardia, chest pain, and orthostatic
hypotension may also occur. Constipation, nausea and vomiting should also be
watched out for as well as urinary incontinence and increased in urination.
Weight gain, weight loss and hypoglycemia may occur as well (Schilling 2008).
Before the drug is administered, hypersensitivity must be assessd.
Baseline ECG and blood pressure must also be taken. History of cardiovascular
disease must also be known as well as history of seizures and other metabolic
conditions. Assessing for other medications taken by the patient must also be
done for drug to drug interaction concerns. The drug must be administered as
prescribed. While the medication therapy is ongoing, blood pressure, tardive

dyskinesia and other signs of EPS. After the course of medication, the
effectiveness of the drug must be re-evaluated. Hot showers must be avoided as
well as too much exposure in sunlight (Schilling 2008).
Biperiden is an anticholinergic drug that inhibits the action of the
acetylcholine at the receptor sites in the central and autonomic nervous systems
thus reducing tremors and rigidity. t is used as an adjunctive treatment to
Parkinson's disease including drug induced EPS effects and acute dystonic
reactions (Schilling 2008).
t is contraindicated to patients hypersensitive to drug, with narrow-
a ngle glaucoma, bowel obstruction, and tardive dyskinesia. When taken with
alcohol, CNS depression may be increased. ts common side effects are dryness
of eyes, blurred vision, constipation, dryness of mouth, and urinary retention
(Schilling 2008).
Before administering the drug, a baseline assessment of the
patient's condition must be obtained. Hypersensitivity must also be assessed.
Other medications taken by the patient must also be known for drug to drug
interaction concerns. The medication must be administered as prescribed. t can
be administered with food to avoid G irritation. After the course of medication,
the effectiveness of the drug must be re-evaluated. Alcohol drinking must also be
avoided. Vital signs must be monitored. Safety precautions must be instituted
throughout the course of medication therapy. ce chips, drinks, or sugarless hard
candy and gum can be provided to relieve dryness of mouth. Urinary retention

must be watched out for. Fluid and fiber in the diet must be increased to prevent
constipation. Eye drops can also be instituted to relieve dryness of eyes
(Schilling 2008).
B. Psychiatric Therapy
Gro:p Psychotherapy or Gro:p Therapy is a form of psychotherapy in
which one or more therapists treat a small group of clients together as a group.
The term can legitimately refer to any form of psychotherapy when delivered in a
group format, including Cognitive behavioural therapy or nterpersonal therapy,
but it is usually applied to psychodynamic group therapy where the group context
and group process is explicitly utilised as a mechanism of change by developing,
exploring and examining interpersonal relationships within the group. The
broader concept of group therapy can be taken to include any helping process
that takes place in a group, including support groups, skills training groups (such
as anger management, mindfulness, relaxation training or social skills training),
and psycho-education groups (Wikipedia 2011).
Art Therapy is a mental health profession that uses the creative process
of art making to improve and enhance the physical, mental and emotional well-
being of individuals of all ages. t is based on the belief that the creative process
involved in artistic self-expression helps people to resolve conflicts and problems,
develop interpersonal skills, manage behaviour, reduce stress, increase self-
esteem and self-awareness, and achieve insight. Art therapy integrates the fields
of human development, visual art (drawing, painting, sculpture, and other art

forms), and the creative process with models of counseling and psychotherapy
(Wikipedia 2011).
Psychodrama is a method of psychotherapy in which clients are
encouraged to continue and complete their actions through dramatization, role
playingand dramatic self-presentation. Both verbal and non-verbal
communications are utilized. A number of scenes are enacted, depicting, for
example memories of specific happenings in the past, unfinished situations, inner
dramas, fantasies, dreams, preparations for future risk-taking situations, or
unrehearsed expressions of mental states in the here and now. These scenes
either approximate real-life situations or are externalizations of inner mental
processes. f required, other roles may be taken by group members or by
inanimate objects. t is mostly used as a group work method, in which each
person in the group can become a therapeutic agent for each other in the group
(Wikipedia 2011).
M:sic Therapy is an allied health profession and one of the expressive
therapies, consisting of an interpersonal process in which a trained music
therapist uses music and all of its facetsphysical, emotional, mental, social,
aesthetic, and spiritualto help clients to improve or maintain their health. Music
therapists primarily help clients improve their health across various domains
(e.g., cognitive functioning, motor skills, emotional and affective development,
behavior and social skills, and quality of life) by using music experiences (e.g.,
singing, songwriting, listening to and discussing music, moving to music) to
achieve treatment goals and objectives. t is considered both an art and a

science, with a qualitative and quantitative research literature base incorporating

areas such as clinical therapy, biomusicology, musical acoustics, music
theory, psychoacoustics, embodied music cognition, aesthetics of music,
andcomparative musicology. Referrals to music therapy services may be made
by other health care professionals such as physicians, psychologists, physical
therapists, and occupational therapists. Clients can also choose to pursue music
therapy services without a referral (i.e., self-referral). Music therapists are found
in nearly every area of the helping professions. Some commonly found practices
include developmental work (communication, motor skills, etc.) with individuals
with special needs, songwriting and listening in reminiscence/orientation work
with the elderly, processing and relaxation work, and rhythmicentrainment for
physical rehabilitation in stroke victims (Wikipedia 2011).
Dance Therapy, or Dance Movement Therapy is
the psychotherapeutic use of movement and dance for
emotional, cognitive, social, behavioral andphysical conditions. As a form
of expressive therapy, DMT is founded on the basis that movement and emotion
are directly related. The ultimate purpose of DMT is to find a healthy balance and
sense of wholeness. This can also served as a channel of hyperactivity of manic
patients (Wikipedia 2011).
Remotivation Therapy help patients increase emotional health through
dealing with the unwounded areas of the patient's personality and to stimulate personal
growth and integration on the cognitive, affective, and behavioral levels. The use of
remotivation begins in all cases in a one to one relationship. Remotivation

sessions can be conducted individually with one person in their home, in their
room at a residential facility or at any comfortable location agreeable to both
parties. ndividual remotivation is practiced one to one when the person cannot or
will not meet with a group (Scribd 2011).
N:rsing Management
A. Therape:tic and SociaI Contract
LAGDA
Ako si ___________________________ug si
_____________________________, estudyante sa Cebu Normal University kay
nagsabot na magkita sa mga adlaw nga naa ko dri sa ward kada alas dos hantod
sa alas sais sa hapon. Nagsabot mi nga magkita sa mess hall sa pambabae na
ward ug nagsabot mi nga magtinabangay mi sa mga musunod:
1. Pagkooperar sa mga buluhaton nga apil sa therapy
2. Pagligo ug pag-ilis kada adlaw aron presko ug hayahay ang paminaw
3. Pagpaminaw ug pagtubay sa mga pangutana nga alang sa kaayuhan sa
pasyente
4. Pagsturya sa gibati sa kalmadong pamaagi
5. Ang among gistoryahan kay magpabilin kanamong duha ilabina kung kini
makadaot sapasyente
6. Pagpabiling kalma ug dili manghagis o manakit sa kaugalingon,sa
estudyante nga nurse o sa mga ubang pasyente
7. Pag-inom sa tambal nga ipatumar alang sa kaayuhan sa pasyente

8. Pagtuman sa balaod sa ospital

9. Sa paghuman sa among panag-uban mutuman gihapon ang pasyente sa
buluhaton sa therapy og magpuyu
___________________________ _________________________
Student Nurse Kliyente
B. N:rsing Care PIans
Impaired SociaI Interaction ReIated to eeIing Threatened In SociaI
Sit:ations
Theoretical basis for the nursing diagnosis of impaired social interaction
related to feeling threatened in social situations states, "schizophrenias are
severe and persistent neurologic diseases. These affect a person's perceptions,
thinking, language, emotions, and social behavior. Major symptoms seen in
psychotic disorders are hallucinations, delusions, and disorganized thinking.
Phase or long term course is the course that severely and persistently
mentally ill client follows, the intensity of psychosis might diminish with age;
however, the long term dysfunctional effects of disorder are not as amenable to
change (Varcarolis 2007).
The patient verbalized, "Muadto sa ko, when another patient joined the
conversation with the student nurse. She tends to be alone and prefers to do
activities alone. She does not initiate and respond to social advances. She
wanders along the hall. This was observed during the preinteraction phase.

The short term goal aimed that after four hours of nursing interventions,
client will be able to engage in one activity with the student nurse by the end of
the shift. Whle the long term goal aimed that after four days of nursing
intervention.
For the intervention, assessing if medication has reached therapeutic
levels must be done. Many of the positive symptoms such as paranoia,
delusions, and hallucinations will subside with medications which will facilitate
interactions (Weber 2003). Ensuring that the goals set are realistic whether in the
hospital must be considered because this avoids pressure on the client and
sense of failure on the nurse (Videbeck 2004). The client must also be kept in an
environment free of stimuli as client may respond to noises and crowding with
agitation, anxiety, and increased inability to concentrate on outside events
(Kozier et.al. 2008). Touching the client must also be avoided as touch by a
"stranger can be misinterpreted as a threatening gesture (Videbeck 2004).
Structure times each day to include planned times for brief interactions and
activities with the client on a one on one basis. This helps the client to develop a
sense of safety in a nonthreatening environment (Varcarolis 2007). Also structure
activities that work at the client's phase and ability. Client can lose interest in
activities that are too ambitious, which can increase a sense of failure (Varcarolis
2007). Remember to give acknowledgement and recognition for positive steps
the client takes in increasing social skills and appropriate interactions with others.
Recognition and appreciation go a long way to sustaining and increasing specific
behavior (Doenges et.al. 2008).

For dependent interventions, as the client progresses, coping training

skills training should be available to her. this increases client's ability to derive
social support and decrease loneliness (Varcarolis 2007). For collaborative
interventions, eventually engaging other clients and significant others in social
interactions and activities in the client can be done. With this, client continues to
feel safe and competent in a graduated hierarchy of interactions (Varcarolis
2007).
Dist:rbed Sensory Perception (A:ditory) ReIated To ormaI Tho:ght
Disorder
Disturbed sensory perception (auditory) related to formal thought disorder
was the nursing diagnosis supported by the theoretical basis of, "Hallucinations
are false perceptual distortions that occur in maladaptive neurobiological
responses. The client actually experiences the sensory distortion as being real
and responds to it accordingly. Auditory hallucination is being described as
hearing noises or sounds, most commonly in the form of voices. Sounds that
ranges from a simple noise or voice, to a voice talking about the patient, to
complete conversations between two or more people about the patient (Laraia
and Stuart 2005).
The client verbalized, "Naa koy madunggan na laing tingog 'te samtang
nag-istorya ta 'te. Auditory distortions noted. Tilting of the head as if listening to
someone was also observed on the patient. Frequent blinking of the eyes and
grimacing were also noted. Altered communication pattern and inappropriate

response were also observed on the patient. This were observed during the
preinteraction phase.
The short term goal aimed that after four hours of nursing interventions,
client will be able to state using the scale of 1 to 10 that the voices are less
frequent and threatening. While the long term goal aimed that after three days of
nursing intervention, client will be able to demonstrate techniques that help
distract her from the voices.
f voices are telling the client to harm self or others, necessary
environmental precautions must be taken. Early assessment and intervention is
better than intervening after possible harm was done (Varcarolis 2007).
Environmental stimuli must be decreases whenever possible as this also
decrease the potential for anxiety that may also trigger hallucinations. This also
helps calm the client (Doenges et.al. 2008). Validating that your reality does not
include voices can help the client cast "doubt on the validity of her voices (Laraia
and Stuart 2005). Stay in the clients' side when she start to hallucinate, and
direct them to tell the voices to go away. This must be repeated in a matter-of-
fact manner. Clients can sometimes learn to push away voices aside when given
repeated instruction especially within teh framework of trusting relationship
(Videbeck 2004). Keep to simple, basic, reality- based topics of conversation.
Help the client focus on one idea at a time (Varcarolis 2007). Exploring the
hallucination and sharing the experience can give the prson a sense of poer that
she might be able to manage the hallucinatory voices (Varcarolis 2007). Help the
client to identify the needs that might underlie the hallucination. Hallucinations

might reflect needs for power, self- esteem, anger, and sexuality (Laraia and
Stuart 2005). The client must also be helped in identifying times when
hallucinations are most prevalent and frightening. This helps both the nurse and
the client identify situations and times that might be most anxiety- producing and
threatening to the client (Varcarolis 2007). The client must be engaged in simple
physical activities or tasks that channel energy such as writing and drawing.
Redirecting client's energies to acceptable activities can decrease the possibility
of acting on hallucinations and help distract from the voice (Varcarolis 2007). Be
alert for signs of increasing fear, anxiety, or agitation. These might herald
hallucination activity and patient might act upon command (Doenges et.al. 2008).
For dependent nursing interventions, intervene with one-on-one,
seclusion, or PRN medications as ordered when appropriate and before anxiety
begins to escalate (Schilling 2008). For collaborative care, working with the client
and the rest of the health care team to find activities that help reduce anxiety and
distract the client from hallucinatory material. f client's stress triggers
hallucinatory activity, they might be more motivated to find ways to remove
themselves from a stressful environment or try distraction techniques (Doenges
et.al. 2008).
Dist:rbed Tho:ght Processes ReIated To Tra:ma EarIy In Life
"Major symptoms seen in psychiatric disorders are hallucination,
delusions, and disorganized thinking (Laraia and Stuart 2005). The schizophrenia
are severe, biologically based mental illnesses. Current theories of schizophrenia

involved neuroanatomical and neurochemical abnormalities which might be

induced either genetically or environmentally (Varcarolis 2007). This theoretical
basis supports the nursing diagnosis of disturbed thought processes related to
trauma early in life.
This can be manifest as when the patient does not maintain eye contact,
whispers in the air, and even pats the air. She seemed to listen to the air as if
somebody was talking to her. she even stared at the ceiling for a long time then
turned to her side. She also wandered alone along the hallway. These were
observed during the working phase.
The short term goal aimed that after four hours of nursing interventions,
client will be able to express that the thought are less intense and frequent with
the aid of medications and nursing interventions. While the long term goal aimed
that after three days of nursing interventions, the client will be able to
demonstrate effective coping skills that minimize delusional thoughts.
For independent nursing interventions, utilizing safety measures to protect
clients and others must be instituted. Client's delusional thinking might dictate
that they might have to hurt others or self in order to be safe (Doenges et.al.
2008). Attempt to understand the significance of these beliefs to the client at the
time of their presentation. mportant clues to underlying fears and issues can be
found in the client's seemingly illogical fantasies (Varcarolis 2007). Be aware that
the client's delusions represent the way she experience reality. This allows the
nurse to understand the client's feelings (Varcarolis 2007). dentify feelings

related to delusions. When people believe that they are understood, anxiety
might lessen (Varcarolis 2007). Do not argue with the client's beliefs or try to
correct false beliefs using facts. Arguing will only increaseclient's defensive
position, thereby reinforcing false beliefs. This will also result in the client feeling
more isolated and misunderstood (Varcarolis 2007). The client must be touch
with careful gestures. A psychotic person might interpret touch as aggressive or
sexual in nature. People who are psychotic need a lot of personal space
(Videbeck 2004). nteract with the clients on the basis of things in the
environment. Try to distract client from their delusions by engaging them in
reality- based activities. When thinking is focused on reality- based activities, the
client is free of delusional thinking during the time. t also helps the client focus
attention externally (Videbeck 2004).
For dependent nursing care, the medication regimen of the client must be
maintained. This will keep the client in remission (Schilling 2008). For
collaborative care, teach the client coping skills that minimize "worrying
thoughts such as singing, talking to someone, and thought- stopping techniques
(Doenges et.al. 2008).
Ineffective Individ:aI Coping ReIated To Tra:ma EarIy In Life
neffective individual coping related to trauma early in life was the nursing
problem identified that need to be addressed to in the working phase. This is so
because, paranoid clients initially mistrust their therapist's motives and find it
difficult to share personal information. They are vigilant and suspicious of other's

motives. They believe people are mean to exploit, harm, or deceive them in
some manner. They may bear grudges and may be unforgiving. These clients
may also have difficulty establishing close relationships and prefers to work
alone. They may be very critical of others but have a great deal of difficulty
accepting criticism (Laraia and Stuart 2005).
The client manifests superficial relationships with others. She tended to
also manipulative of others. Dependency was also noted.intense emotional
dysregulation was also noted. Extreme distrust to others and demonstration of
paranoia were also noted.
The short term goal aimed that after four hours of nursing interventions,
the patient will be able to spend time with the nurse and focus on one thing she
would like to change. While the long term goal aimed that after two days of
nursing interventions, the client will be able to focus on the problem and work
through the problem solving process with the nurse.
dentifying behavioral limits and behaviors that are expected. Client needs
clear structure. Maintaining these limits can enhance feelings of safety in the
client (Videbeck 2004). When limits or policies are not followed, enforce the
consequences , in a matter-of-fact nonjudgmental manner (Varcarolis 2007).
Approach client in a consistent manner in all interactions. t enhances feeling of
security and provides structure. Exceptions encourage manipulative behaviors
(Videbeck 2004). Refrain from sharing personal information with the client. This
opens up areas for manipulation and undermines professional boundaries

(Videbeck 2004). Do not take gifts and be aware of flattery from the client.
Accepting can clouds the boundaries and give the client the idea that she is due
special consideration (Videbeck 2004). f the client becomes hostile or projects
blame onto you or staff, project a neutral, calm demeanor and avoid power
struggles. Focus on client's underlying feelings. This defuse tension and troubling
feelings such as anxiety reduction and assertive skills. ncreasing skills helps the
clients use healthier ways to defuse tension and get needs met (Varcarolis
2007). Give clients positive attention when behaviors are appropriate and
productive. Reinforcing may increase likelihood of repetition. gnoring negative
behaviors nobs client of even negative attention (Varcarolis 2007).
For dependent nursing interventions, medication regimen must be
maintained as this keeps client in remission (Schilling 2008). For collaborative
intervention, make a clear and concrete written plan of care so other staff can
follow. This helps minimize manipulations and may help encourage cooperation
(Doenges et.al. 2008).
C. Process Recording
Day 2 Preinteraction and Orientation Phase
The process recording on day two of the preinteraction and orientation
phase, the objectives focused on the attitude, behavioral, and communication
aspects of the client. The client must be able to recognize that she was being
listened to and be cooperative. The client must also be able to stay with the
student nurse on the duration of conversation and not to wander away. The client

must also be able to express and relay feelings effectively and at the same time
kept oriented to person, time, and place as well.
The conversation was started by the student nurse by saying, "Maayong
buntag Ma'am. The client smiled and responded, "Lingkod ta 'te, istorya ta. The
client recognized the presence of the student nurse and even initiated interaction.
The student nurse used the therapeutic technique giving recognition.
"Unsa man imong ganahan atong istoryahan karon? The student nurse
here used broad openings to make explicit that the client had the lead in the
ineraction. The client answered, "Nakaadto na ko sa beach kuyog akong Mama
ug Papa pagbata nako. The client remembered remote memory.
The student nurse responded with a nod. By accepting, the student nurse
indicated that she had heard and followed the train of thought of the client. The
client responded with, "Nindot didto 'te, nakaadto na mi sa Sandy beach,
Baluarte, Botanical, Mc Arthur, ug Salog. The client showed interest in the topic.
When the student nurse asked the client, "Unsa- unsa gani to na beach
inyong naadtuan Ma'am? The client used the therapeutic communication
technique of seeking information as clarifications were also made. When the
student nurse also enumerated after the client had enumerated, she was
summarizing as she brought out important points of their discussion.
The client verbalized, "Matulog sa ko nurse. The student nurse
responded "Sige Ma'am tulog lang, ari lang ko sa imong tapad. With the

therapeutic communication technique, the client was able to trust the student
nurse and was assured of having her attention.
Day 3 Preinteraction and Orientation Phase
The objectives of the process recording on the third day of the
preinteraction and orientation phase also focused on the attitude, behavioral and
communication aspects of the client. The client must be able to recognize the
therapeutic contract and alliance established by the student nurse by being
cooperative. The client must also be able to stay with the student nurse on the
duration of conversation and not to wander away and to remain focused on the
topic. The client must also be able to express and relay feelings in an effective
and calm manner and at the same time kept oriented to person, time, and place
as well.
The student nurse started the conversation by giving recognition to the
client by greeting her, "Maayong hapon Aurea. The client smiled and responded,
"Maayong hapon sad 'te. The client recognized the presence of the student
nurse.
The student nurse then used encouraging expressions by telling the client,
"Kumusta man ka karong adlawa? the client responded, "Okay ra. Niapil na sad
ko ug therapy ganiha 'te. The client benefitted from recalling recent experiences
that she was still oriented.

The student nurse then gave recognition to the client by saying, "Maayo
na siya Aurea. Then client responded, "Lagi 'te. Nagpakita sila ug daghang
pictures. The client recognized that her efforts done were being addressed to.
"Aurea, maglagda ta para naa tay tarong nga sabot, the student nurse
then suggest collaboration. "Sige 'te, the client responded and cooperated. She
then joined the therapy and had stayed calm and cooperative throughout the
shift.
Day 2 Working Phase
The objectives of the process recording on the second day of the working
phase also focused on the attitude, behavioral and communication aspects of the
client. The client must be able to recognize the therapeutic contract and alliance
established by the student nurse by being cooperative. The client must also be
able to stay with the student nurse on the duration of conversation and not to
wander away and to remain focused on the topic. The client must also be able to
express and relay feelings in an effective and calm manner and at the same time
kept oriented to person, time, and place as well.
The student nurse offered herself by saying, " Aurea, mutapad ko nimo
samtang nag-drawing ka. The client responded, "Sige te, lingkod lang. t is
important that this offer is unconditional, that is, the client does not have to
respond verbally to get the student nurse's attention.

"Wow, human na kag drawing, the student nurse gave recognition. The
client responded, "Oo 'te. This notes the efforts the client has made. This also
shows recognition by the nurse to the client as a person.
"Unsa man imong gi-drawing? the student nurse used the therapeutic
communication technique of general leads. The client responded, "Kani siya te,
flower, kani tree, kani balay, kani tawo. This indicates that the nurse was
listening and following what the client was saying without taking away the
initiative for the interaction. This also encourages the client to continue if she is
hesitant or uncomfortable to express feelings.
The student nurse encouraged expressions by asking the client, "Unsa
man imong gibati bahin sa atong art therapy? the client responded, "Nalipay ko
'te. The student nurse had heard and followed the train of thought of the client.
This does not indicate agreement but is nonjudgmental.
Day 3 Woking Phase
The objectives of the process recording on the third day of the working phase
also focused on the attitude, behavioral and communication aspects of the client.
The client must be able to recognize the therapeutic contract and alliance
established by the student nurse by being cooperative. The client must also be
able to stay with the student nurse on the duration of conversation and not to
wander away and to remain focused on the topic. The client must also be able to
express and relay feelings in an effective and calm manner and at the same time
kept oriented to person, time, and place as well.

Broad openings make explicit that the client has the lead in the interaction.
t may stimulate client to take the initiative. Thus the student nurse used this
therapeutic communication technique in starting their communication. "Unsa man
imong ganahan istoryahan Aurea? The client responded, "Ganahan ko
magsuwat 'te.
Seeking information helps the nurse avoid making assumptions. t helps
the client to articulate thoughts, feelings, and ideas more clearly. Thus, the
student nurse asked the client, "Bahin sa unsa man imong gisuwat? the client
responded, "Para na sa akong Tatay 'te, human na man kog suwat kay Nanay sa
una.
n exploring, any problem or concern can be better understood. The
student nurse asked, "Unsa man sad ang sulod sa imong gisuwat? The client
responded, "Kuan 'te, ana ko ni Tatay nga kumusta sila didto kay ako diri maayo
ra ako kahimtang.
n encouraging expressions, the nurse asks the client to consider people
and events in light of his or her own values. Doing so encourages the client to
make his or her own appraisal rather than accepting the opinion of others. The
student nurse also asked the client, "Unsa man imong gibati Aurea kahuman
nimo ug suwat? The client responded, "Syempre 'te nalipay ko.
Day 4 Working Phase

The objectives of the process recording on the fourth day of the working
phase also focused on the attitude, behavioral and communication aspects of the
client. The client must be able to recognize the therapeutic contract and alliance
established by the student nurse by being cooperative. The client must also be
able to stay with the student nurse on the duration of conversation and not to
wander away and to remain focused on the topic. The client must also be able to
express and relay feelings in an effective and calm manner and at the same time
kept oriented to person, time, and place as well.
The client initiated the conversation with, "Ate! Ate! Naligo ko karon para
sa therapy. The student nurse gave recognition to the client by praising the
client, "Wow! Maayo na Aurea. Such recognition does not carry the notion of
value, that is, of being 'good' or 'bad.' The student nurse recognized the client as
an individual.
"Apil unya Aurea sa therapy ha, para sa kaayuhan nato diri sa ward, the
student nurse suggested collaboration. The student nurse sought to offer a
relationship in which the client can identify problems in living with others, grow
emotionally, and improve the ability to form satisfactory relationships. The
student nurse offered to do tings with, rather than for the client. Thus, the client
responded, "Sige 'te ganahan ko ana 'te.
Any problem or concern can be better understood if explored in depth.
The student nurse asked the client, "Unsa man ang importansya sa imong nakita
sa drama? The client responded, "Dapat murespeto sa magulang, magbinut-an,

manghatag, ug manglimpyo sa lawas. The student nurse as well gave

recognition to the client, "Sakto na siya Aurea.
n encouraging expressions, the nurse asks the client to consider people
and events in light of his or her own values. Doing so encourages the client to
make his or her own appraisal rather than accepting the opinion of others. The
student nurse asked the client, "Unsa man imong gibati bahin sa psychodrama
therapy nato? The client responded, "Nalipay ko 'te.
The student nurse then summarized their conversation, "Ang importansiya
nga imong nakita ka yang pagrespeto, pagbinut-an, panghatag, ug panglimpyo
sa lawas ug kani siya kay nakalipay sa imong gibati. Summarizing sought to
bring out the important points of the discussion and to increase the awareness
and understanding of both participants. t omitted the irrelevant and organizes
pertinent aspects of interaction. t allowed both the client and the nurse to depart
with the same idea and provides a sense of closure at the completion of each
discussion.
D. oc:s Charting
Impaired SociaI Interaction
t was observed by the student nurse that the client tended to be aloe. She
did not make eye contact when talked to. She was not initiating eye contact nor
respond to social advances made by other clients. She preferred to do activities

alone. She also left the student nurse when another patient/s joined in the
conversation. She also wandered along the hallway.
Rapport was established with the client. She was also assisted in her
hygiene measures. The environment was kept free of stimuli. The client was
touched to a minimum. The activities were kept at client's pace and ability. Safety
precautions were also established. t was also important to stay at client's side at
all times. The client was also watched for extrapyramidal symptoms. She was
referred accordingly. Her initiated interaction with other clients were recognized.
The client was able to interact with the student nurse. The client also
enjoyed listening to other clients singing as evidenced by laughing with them.
atig:e
"Matulog sa ko 'te, as verbalized by the client. The client was observed to
yawn frequently with deep set eyes.
Rapport was re-established. The client was also oriented to reality. She
was assisted with her hygiene measures. The environmental stimuli were
decreased. Rest and sleep periods were promoted. Rest was alternated with
activity. Safety precautions were also instituted. Nursing care was clustered. The
client was referred accordingly.
The patient was seen sleeping comfortably.

Therape:tic SociaI Interaction: Dance Therapy

The client was received sitting on the bench. She was sooperative and
responsive. She initiated contact with other clients.
Willingness of the client to join the therapy was assessed. The client was
reminded of the therapeutic contract and alliance (lagda). She was encouraged
to verbalize feelings. Safety precautions were established. Nursing care was
clustered. The client was referred accordingly.
"Nalipay ko sa sayaw- sayaw, as verbalized by the client. She
participated in the dance therapy.
Impaired Tho:ght Processes
The client was roaming around the mess hall. She wandered alone. She
patted the air. She even talked alone.
Safety measures were utilized such as keeping away objects that may be
used as weapon for violence towards self or others. The significance of beliefs to
client at the time of her presentation of her hallucination was understood. The
feelings of the client towards her delusions were identified. The client was
touched to a minimum. Gestures were used carefully. nteraction with the client
was done on the basis of things in the environment.
The client remained safe. The client remained free of injury as well.

Therape:tic SociaI Interaction: Art Therapy

The client was received sitting on the bench. She initiated contact with the
student nurse. She recalled activities in the morning. She showed enthusiasm in
joining the art therapy.
Rapport with the client was re-established. She was reminded of the
therapeutic contract and alliance (lagda). Her interest in joining the art therapy
was supported. Safety measures were established. Nursing care was clustered.
The client was referred accordingly. The patient was allowed to verbalize feelings
about what she had drawn.
"Nalipay ko sa art therapy 'te, as verbalized by the client. The client had
also remained calm and cooperative throughout the therapy.
SIeep deprivation
The patient was received lying in bed. Dark circles around her eyes were
noted. She also yawned frequently.
Rapport with the client was re-established. The importance of the
therapeutic contract and alliance (lagda) was emphasized. Rest and activity
periods were encouraged to the client. Environmental stimuli were manipulated
such as noise. Safety precautions were instituted. Nursing care was clustered.
The client was referred accordingly.

The client was seen participating in the storytelling conducted by teh

missionaries after waking up.
E. Discharge PIanning
A case of AE, female and already 41 years of age. She came from
Sagkahan Picas, Tacloban City, Leyte. She was married to Doming who
according to her was only 30 years old. She has two children, Enday and Entoy
who, also according to her were ages eight and three.
The patient was instructed to procure medications and newly ordered
medications. He was also instructed to take his medications as prescribed by his
physician. The different side and adverse effects of his medications were also
taught to him. He was also instructed to report any unusualities noticed on the
course of his medication therapy such as nausea, vomiting, and skin allergies.
He was encouraged to ambulate. He was also encouraged to do active and
passive range of motion such as hand and leg flexions. He was also instructed
when to return for follow- up check up. He was encouraged to comply with his
medication therapy as it was also explained to him the importance of adhering to
her treatment therapy. Regular self and perineal hygiene were encouraged.
mportance of hygiene was also included in the health teachings. He was also
instructed to watch out for signs and symptoms of infection and complications
such as bleeding, episodes of fever, and dyspnea. The importance of early
identification of these signs was also emphasized to the patient. ncreased fluid
intake was also encouraged to the patient. He must also avoid salty food and add

more fiber in the diet such as green leafy vegetables, and fruits during meals. He
was also encouraged to attend mass and other religious activities such as praise
and worship for spiritual well- being. More to his medical management is his faith
for the Lord has a way of curing him physically and emotionally.

Chapter IV
SUMMARY, CONCLUSION, AND RECOMMENDATIONS
S:mmary
The duration of the exposure at the Vicente Sotto Memorial Medical
Center- Center for Behavioral Sciences, was three weeks. The first week was
allotted for preinteraction and orientation phase wherein the student nurses
established rapport and the therapeutic contract and alliance was made both by
the students and the clients. The second week was the working phase. This is
when the student nurses started to interact with the clients more intensely be
conducting different therapies. While the third week was the termination phase.
This serves as evaluation on the clients part as well as on the student nurses
part if the therapeutic contract and alliance (lagda) served its purpose. By the
termination phase, the client must be able to do things independently.
ConcI:sion
n order for the client to be able to comply with the therapeutic contract
and alliance (lagda), recurrent reminder and emphasis must be done. Giving
recognition to the positive attributes of the client must also be done. This can
serve as a positive reinforcement in their part.

Recommendations
After three weeks of exposure, the student nurse is able to conclude that
in order to delve into the clients, longer allotment of duty is recommended. More
to it is that a stronger rapport and nurse- patient relationship can be developed.
Also, in order to interact longer with the client, more therapies must be conducted
and process recording must really be taken into consideration seriously.

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