Nursing Care Plan

Name of Patient: A.C.R. Patient s Health Profile: Received patient in the bench at the ground wearing clean

White t- shirt and gray short.

Age: 25 years old Sex: Male Occupation: Teacher Date of Admission: September 9, 2011 Status: Single Religion:Roman Catholic

Initial Complaints: Hallucination Diagnosis: Schizophrenia undifferentiated

Needs/ Nursing Diagnosis/ Cues Physiologic: Disturbed sensory perception related to loneliness and isolation Cues: S: Kaila ka ni Charmaigne? kinsa pangalan nimo? ahw. ahmm (nod and smile) .. ikaw pana? (stare and smile)

Scientific Analysis

Objectives After 3 weeks of student nurse-patient interaction Arnold will be able to: >verbalize reduce feelings of fear, isolation, loneliness, and rejection, and he will express a greater sense of control over his environment. >focus on real events and people in the environment. >participate in relevant conversations with staff and other patient >slow down his speech and speak more coherently.

Nursing Interventions

Rationale

Evaluation After 4 hours of student nurse-patient interaction the objectives were partially met because the patient was able to : verbalized feelings of fear, isolation, loneliness, and rejection but no sense of control over his environment, participates in relevant conversation with staff and other patient but wasn t able to focus on real events and people; speech were spoke slowly but incoherent and has no association and adhere to medication but doesn t know the importance of the medication.

O: -leaves suddenly without explanation -poor concentration -has difficulty maintaining

Schizophrenia is a disease affecting brain that causes distorted and bizarre thought, perception, emotions.movements, and behavior. It cannot be defined as a single illness; rather, it is a thought of a syndrome or a process that include many symptoms. Symptoms are divided into two categories; positive-hard symptoms which include delusions, hallucination, and grossly disorganized thinking, speech and behavior and negativesoft symptoms, such as flat affect, lack of violation, and social withdrawal or

>identify the factors that contribute to feeling of loneliness, rejection, isolation and fear.

>familiarize patient with actual activities and events in the therapeutic setting when he is rested and stress-free. >help patient to speak slowly and clearly if his speech is incoherent

>Once the nurse identify the contributing factors she can use therapeutic alliance to assist the client with strategies to growth and development. >presenting reality in a nonthreatening way distracts patient from hallucination experiences by focusing on actual events. >this help the patient to organize his thought processes and increase his ability to

conversations

diacomfort. Four primary symptoms include; affect is disturbed, autism is present, ambivalence is common and associations are loosened. It also has an accessory symptoms of hallucination and delusions. There are five types of schizophrenia. Schizophrenia paranoid type persecutory or grandiose delusions, hallucinations, and sometimes by excessive religiosity. Schizophrenia disorganized type characterized by grossly inappropriate of flat affect, incoherence, loosen association, and extremely disorganized behavior. Schizophrenia catatonic type characterized by marked psychomotor disturbances either activity, extreme negativism, mutism, peculiarities of voluntary movements, echilalia, echofraxia. Schizophrenia undifferentiated characterized by mixed schizophrenic symptoms (combination of al types) along with disturbances of thought, affect and behavior.

>adhere to medication regimen and verbalize understanding of its use to treat his symptoms.

>support the medical plan, including prescribe medication and discuss to the patient the effect and importance of the medication.

understood. >medication assists in managing the biologic factors related to the disease, and it make easier to engage the patient in psychosocial and interactive therapies. >Involving patient in milieu and group activities promotes feeling of belonging, reduces feeling of fear and isolation and increases self-esteem and mastery of social skills.

>engage in the milieu schedule and activities more frequently and willingly.

>provide environmental opportunities (group and activities) to increase social contact and skills learning.

Schizophrenia residual type characterized by at least one previous episode but not currently psychotic, social withdrawal flat affect, loose of association. Own Analysis: >Hence the client manifested mostly mixed symptoms of schizophrenic symptoms which is a combination of the symptoms of all the types of schizophrenia along with disturbances of thought, affect and behavior the client has a schizophrenia undifferentiated type. Reference: Sheila L. Videbeck, Psychiatric Mental Health Nursing, copyright by Lippincott Williams and Wilkins 2002, pp.296-298. Fortinash and Holoday Worret, Psychiatric Mental Health Nursing, Mosby Elsevier Inc copyright 2008, 4th edition, pp.267