Undifferentiated Schizophrenia,

Manageable, Moderate Mental

Retardation

INTRODUCTION

OBJECTIVES
Cognitive
Within 72 hours of formulating a comprehensive Psychiatric
Case Study, we will be able to:
1.Define the complete diagnosis of the client thorougly.
2.Identify the predisposing and precipitating factors that
lead to clients condition correctly.
3.Determine the signs and symptoms being manifested by
the client accordingly.
4.Interpret data gathered from the client effectively.

OBJECTIVES
5. Formulate a systematic psychopathology of the clients
psychiatric condition.
6. Evaluate the developmental stage of the client according
to ________ correctly.
7. Recognize defense mechanisms used by the client
during nurse-patient interaction effectively.
8. Develop a specific, measurable, attainable, realistic and
time-bounded nursing care plan.

OBJECTIVES
Psychomotor
1.Gather pertinent data through detailed chart-taking and
effective nurse-patient interaction.
2.Assess clients affect and behavior during the course of
various therapeutic activities and nurse-patient interaction
effectively.
3.Utilize various therapeutic communication techniques
during the gathering of data effectively.

OBJECTIVES
4. Conduct a thorough physical assessment using
cephalocaudal approach.
5. Create an effective nursing care plan based on the
prioritized problem of the client.

OBJECTIVES
Affective
1.Manifest core values of an Augustinian student nurse at
all times.
2.Ensure confidentiality regarding clients information in all
aspects.
3.Respect clients norms, practices, rights and beliefs at all
times.
4.Exhibit collaboration between all members of the group in
the course of the study

OBJECTIVES
5. Establish a trusting relationship with the client through
provision of holistic care and use of verbal and non-verbal
therapeutic communication techniques during the course of
the nurse-patient interaction.

NURSING CARE
PLAN

GENERAL OBJECTIVE
To facilitate awareness of self as an individual with
varying physical, emotional and developmental
needs.

SUBJECTIVE CUES
Inaaway ako ng pamilya ko tsaka sinasaktan ako
ng asawa ko kapag lasing siya. client smiled as
she answered.
Pero mabait naman sila.

SUBJECTIVE CUES
When asked how she copes with her problems:
Di ko pa rin sinasabi yung problema ko sa iba
para hindi na madagdagan ang problema ko.

SUBJECTIVE
When asked about her mood:
Kalmado lang ako tsaka masaya lagi pero
may pagkakataon na madali akong mairita.

OBJECTIVE CUES
o
o
o
o
o

Emotional lability noted

Use of defense mechanisms noted
Incongruent affect noted
Easy distractibility noted
Lack of goal-directed behavior as evidenced by
showing no interest of going out of the institution

NURSING
DIAGNOSIS
Ineffective
coping related
to difficulty
adapting to
stress

RATIONALE

SPECIFIC
OBJECTIVES

Stress is medical term for a wide range of strong

external stimuli both physiological and
psychological. It can directly and indirectly
contribute to general or specific disorders of body
and mind. Stress can have major impact on the
physical functioning of the human body. In
Selyes general adaptation syndrome, there are 3
phases: The alarm phase, which is the fight or
flight response, the resistance phase which the
body is possibly trying to resolve the source of
stress, and the exhaustion phase where the
stress continue for a longer period of time that
the bodys ability to resist is lost because its
adaptation energy supply is gone. Chronic stress
can damage nerve cells in tissues and organs.
Particularly vulnerable is the hippocampus
section of the brain. Thinking and memory are
likely to become impaired, with tendency toward
anxiety and depression. Overload, burn out,
adrenal fatigue, maladaptation or dysfunction just
leads to ineffective coping as evidenced by
unacceptable actions or behaviors towards the
stressor.

After 72 hours of
rendering effective
nursing
interventions, the
client will be able
to:
Assess own
coping abilities and
skills.
Describe and
initiate alternative
healthy coping
strategies in
adapting to stress.
Promote wellness
by minimizing the
use of defense
mechanisms

NURSING INTERVENTIONS

RATIONALE

-Assess specific stressors.

-Accurate appraisal can facilitate

development of
appropriate coping strategies.

-Assess level of understanding and

readiness to learn needed lifestyle
changes.

-Appropriate problem solving requires

accurate
information and understanding of options.

-Assess decision-making and problemsolving abilities.

- Patients may feel that the threat is greater

than their resources to handle it and feel a
loss ofcontrol over solving the threat or
problem.

-Determine social interaction, sleeping and

eating patterns.

- These mechanisms are often used when

individual is not coping effectively with
stressors.

NURSING INTERVENTIONS
-Establish a working relationship with
patient through continuity of care.

RATIONALE
-An ongoing relationship establishes trust,
reduces the feeling of isolation, and may
facilitate coping.

-Provide opportunities to express concerns, -Verbalization of actual or perceived stress

fears, feelings, and expectations.
can help reduce anxiety.
-Encourage patient to identify own
strengths and abilities.

-Encourage patient to communicate

feelings with significant others and/or
friends
-Provide positive reinforcement for
application of adaptive coping skills.

-During crises, may not be able to

recognize their strengths. Fostering
awareness can expedite use of these
strengths.
-Unexpressed feelings can increase stress.

- Positive reinforcement enhances self

esteem and encourages repetition of
desirable behaviors.

NURSING INTERVENTIONS

RATIONALE

-Teach use of relaxation, exercise, and

diversional activities.

-Methods to cope with stress.

-Provide for gradual implementation and

continuation of necessary
behavior/lifestyle.

-Enhances commitment to plan.

COLLABORATIVE:
-Cognitive Behavioral Therapy

Relaxation techniques, desensitization, and

guided imagery can help clients cope,
increase their sense of control, and allay
anxiety. Music is not a cure, but it can lift
the human spirit, comfort the heart, and
inspire the soul. Imagery is useful for
relaxation and distraction. The provision of
information and general mastery may play
a role in decreasing helplessness and
dysfunctional coping

NURSING INTERVENTIONS
-Administer PRN medications as
prescribed by the physician.

RATIONALE
- To help reduce symptoms

EVALUATION
After 72 hours of rendering effective nursing care, the client was able to:
Assess own coping abilities and skills.
Describe and initiate alternative healthy coping strategies in adapting to stress.