Behavioral Analysis

In Partial Fulfillment
Of the Requirements for the subject
NCM 218B: Care of Clients with
Maladaptive Patterns of Behavior,
Acute and Chronic (Adult) (RLE)

Submitted to:
Charisse Ariane Sombito, MAN, RN
Clinical Instructor

Submitted by:
Sylvanus Rein B. Langreo
Marian M. Ledesma
BSN 3B | Group 3

Second Rotation, Second Semester

Academic Year 2023-2024
NCM 218 B - CARE OF CLIENT WITH MALADAPTIVE PATTERNS OF BEHAVIOR (RLE)
BEHAVIORAL ANALYSIS

a. General Data

Name: L.C.N. Date of Interview: March 26, 2024, 9:00 AM

Age: 57 years old Informant: L.C.N.; A.N.
Sex: Female Relationship to Patient: Patient herself; Husband
Address: Magdalena Village Extension, Brgy. New Buswang, Kalibo, Aklan
Civil Status: Married
Nationality: Filipino
Occupation: None
Date and Time Admitted: March 14, 2024; 11:20 AM

Ward: Psychiatric Ward

Bed/Room No.: 3
Allergies: No known allergies
Religious Affiliation: Roman Catholic
Physician’s Initial: Dr. M.C.J. (Psychiatry)
Impression/Diagnosis: Schizophrenia

b. Chief complaint
According to chart: “Nagawaras according to folks”
According to client: “ I was brought here against my will. Wala naman akong
problema”
According to folk: “May makita sya and mabatian nga indi namon makita ukon
mabatian kag nagawaras sya.”

c. History of Present Illness

i. Onset, duration, or change of symptoms over time

Nine years before her admission, L.C.N experienced occasional mild episodes
of anxiety, social withdrawal, and auditory and visual hallucinations. While she
sometimes felt paranoid or uneasy in certain social situations, she didn't seek
professional help for these symptoms. Despite these challenges, she managed her
daily routine and responsibilities, albeit with difficulty during stressful periods. Her
symptoms didn't escalate to severe hallucinations or delusions, and her behavior
didn't significantly affect her functioning or relationships. However, underlying
psychological distress was evident, which L.C.N chose to downplay and manage
independently.

Two years before her current confinement, in approximately 2022, the

patient displayed symptoms of irritability, auditory and visual hallucinations, and
episodes of violence. This necessitated her admission to the psychiatric ward at
West Visayas State University - Medical Center. During her stay, she was prescribed
Olanzapine 10 mg 1 tab OD HS, Potassium Chloride tab 1 tab TID, Multivitamins +
Iron 1 tab OD, and Haloperidol + Diphenhydramine 5 mg/5 mg 1 ampoule IM for
severe agitation. However, she initially resisted taking the medication, expressing
concerns about its safety. Eventually, she agreed to treatment and showed
improvement, leading to her discharge. However, upon leaving the hospital, she
refused to continue taking the prescribed medications, asserting, "Wala akong sakit"
("I am not sick"). At this time, her husband, who was not the primary caretaker
during her hospitalization, had limited understanding of her condition.

One year before her current confinement (PTC), based on their phone
conversations, her husband observed slight improvement initially in her speech.
Eventually, he assumed the role of primary caretaker in Mandurriao. During this
period, the patient was non-violent but continued to discuss "aswangs,"
accompanied by incoherent mumbling, auditory and visual hallucinations, and an
irritable mood. She adamantly refused to eat anything not prepared by herself and
consistently rejected medication. Expressing frustration, her husband stated, "kontra
ya ako doc," as she believed he was conspiring with the "aswang." Despite his
concerns, he felt powerless to compel her to seek help, particularly as he was solely
responsible for her care. He reported instances of her wandering late at night
unbeknownst to others, only being noticed when encountered by neighbors or
relatives.

Five days before her current confinement (PTC), A.N. observed that the
patient's symptoms of schizophrenia, characterized by religiosity and auditory and
visual hallucinations, persisted. She continued to demonstrate non-compliance with
medication and refused to acknowledge her illness. As her husband had now
assumed the role of primary caretaker, he encountered growing challenges in
managing her care. These challenges included her adamant refusal to consume
anything not prepared by herself and her rejection of medication. Despite his
persistent efforts, her symptoms remained unchanged. She continued to engage in
discussions about "aswangs" and exhibited manifestations of incoherent mumbling,
auditory and visual hallucinations, and irritability.

Three days before her current confinement, A.N. reported that there was no
improvement in the situation. The patient's husband, feeling overwhelmed and
frustrated, expressed a wish to re-admit her to the hospital due to the ongoing
nature of her symptoms and her refusal to participate in treatment. However, he felt
incapable of persuading her to seek help, particularly because she firmly believed
that he was conspiring with the "aswang" and was resistant to medical intervention.

The day before her admission, the patient's condition deteriorated further.
She displayed increased irritability and began shouting intermittently. This
escalation in agitation and vocal outbursts suggested a worsening of her symptoms,
likely stemming from heightened distress or exacerbation of her hallucinations and
delusions. Her husband, witnessing this deterioration, grew even more concerned
about her well-being and safety. The heightened agitation and vocalizations
presented additional challenges in managing her care at home. Faced with the
escalating symptoms and unable to handle the situation alone, the patient's
husband sought help from psychiatric professionals at a nearby hospital.
Recognizing the urgency, they arrived and, after assessing her condition, concluded
that intervention was necessary. Given the severity of her symptoms and the
potential risk she posed to herself and others due to her agitation and outbursts, the
psychiatric team opted to restrain her.
 Hence, this led to her admission.

ii. Stressful events, especially losses

Recently, one of the stressful events L.C.N. faced was her hospitalization.
Being hospitalized and the sudden appearance of a psychiatric team at her home
left her feeling shaken and distressed. The shift to the clinical atmosphere of the
psychiatric ward was disorienting, disturbing her sense of control and safety. The
presence of the psychiatric team in her home was invasive and unsettling, causing
her to feel confused and fearful.

The choice to isolate her at home exacerbated L.C.N's feelings, leaving her
with a sense of her privacy being violated and lacking control. Despite her
husband's attempts to reassure her, she struggled to comprehend the situation. The
frightening encounter lingered with her even after the psychiatric team departed,
leaving her feeling isolated and disoriented.

During her hospitalization, L.C.N felt uncertain about what the future holds.
The distressing events exacerbated her pre-existing fears and intensified the
difficulty of managing her schizophrenia symptoms. However, despite facing
numerous challenges, L.C.N remained hopeful about the possibility of improvement,
determined to navigate through the tough times. Yet, that's not the only burden
L.C.N carries. The profound grief of losing her daughter to dengue at the age of 9
has deeply wounded her. The anguish and sorrow stemming from her daughter's
death continue to linger, especially since she mentioned, "Kaisa, I can see my
daughter."

iii. Patient perception of any change in her- or himself or the perception of

change in the patient by another individual

According to husband:
● "Okay man siya sa una, kag maubra na ang iya resonsbilidad. Mga pang-adlaw
adlaw niya nga ulubrahon maubra ya man nga siya lang.”
● "Halin sang-una, relihiyosa na gid man sya nga daan. Kis.a inoras na iya nga
pagpanghadi."
● "Permi lang na nagahinibi ang akon asawa, nagasinggit, kag pirme nagapanawag
sa Dios. Indi siya nagapati nga may ginabatyag siya nga indi normal. Sa iya, ang
tanan lang ya nga natabo sa iya, gina-ubra lang sang Dios."
● "Adlaw-adlaw, nagapangamuyo siya, kag kon gab-i, nagalagaw siya sa palibot
sang balay nga wala nabal-an sang iban.

According to patient herself:

● "Sa tingin ko sa sarili, wala akong pinapansin na pagbabago sa aking sarili. Sa
aking isipan, ang aking pananampalataya sa Divos ang nagbibigay sa akin ng
kapayapaan at kaligayahan. Sa palagay ko, ang aking mga gawa at inisip ay
tinuturo ng Diyos, at wala akong nararamdaman na hindi normal. Minsan,
tumatawa ako sa aking sarili kapag minamahal ako ng Panginoon." “Hindi ito
 aking katawan. Ang katawan ko ay maitim at malamig. Kagagawan ito ng devil
witch.”

iv. Previous psychiatric illness or treatment

1. Medications
● Multivitamins and Minerals + Iron 1 tab OD
● Potassium chloride 1 tab TID
● Olanzapine 10mg/tab, 1 tab od @ HS
● Haloperidol + Diphenhydramine 5 mg/ 5 mg 1 ampoule IM

2. Hospitalization
In November 2022, she was admitted to the Psychiatric Ward at West
Visayas State University Medical Center for 15 days. According to her husband,
"May gina wakal siya about sa mga aswang kag gawaras." Additionally, her
admission was attributed to her failure to adhere to the prescribed medication
regimen. She stopped taking the medications, claiming their insignificance
because of her belief that God would heal her.

3. Other therapy
Unrecalled

4. Responses to treatment
As per the client's account, she experiences relaxation and improved sleep
quality when she consistently takes her medication. However, when asked about
the purposes of her medications, she says, "Wala naman. Binibigay lang nila
hindi naman naexplain kung para saan. Kumakalma lang ako tapos siguro
gumaganda tulog ko pero, yun lang." According to the patient's husband, the
current medications do not seem to alleviate her symptoms as effectively as her
previous prescription. He stated, "Daw wala gani gawa gaepekto kumpara sa
una ya nga gina inom."

v. Legal issues with respect to current illness

None as claimed.

vi. Secondary gain

During her admission, the unintended benefits the patient received are as follows:

● Relief from Responsibility: According to L.C.N, she views her admission as a

temporary break from her everyday duties and sources of stress. She
expressed, "Maka pray ako po na walang nag interrupt."
● Relief from the judgment and scrutiny of her neighbors: L.C.N verbalized, "Wala
po masyadong gajudge na tao rito."

d. Past History
(+) Schizophrenia - diagnosed in 2022 and was admitted at WVSUMC
last August 2022

e. Family History
Family members who have:
 i. undergone psychiatric hospitalization or any other
mental health treatment?
None as claimed

ii. attempted suicide?

None as claimed

iii. problems with alcohol?

None as claimed

iv. other psychiatric problems?

None as claimed

f. Past Personal History

i. Developmental milestones

1. Patients’ early development

In her early development, L.C.N. mentioned being
delivered via a normal spontaneous vaginal delivery
(NSVD), indicating an uncomplicated childbirth process. She
recounted that her mother regularly attended prenatal
check-ups during pregnancy, demonstrating a proactive
stance toward maternal healthcare. Additionally, she
remembered being a crybaby when encountering unfamiliar
faces during infancy. Throughout her infancy, L.C.N received
attentive care from her parents, fostering a sense of trust
and security. This attentive caregiving contributed to a
strong bond with her parents as she grew up.

2. Temperament as a child
As a child, L.C.N exhibited a vivid imagination and
enjoyed engaging in imaginative play. She often created
elaborate fantasy worlds, complete with imaginary
characters and intricate storylines. L.C.N was particularly
fond of role-playing different roles, from pretending to be a
teacher who teaches her stuffed toys during school days to
pretending to be a princess. Her imaginative play allowed
her to explore different scenarios and express herself
creatively, fostering a rich inner world of imagination and
wonder. In Filipino culture, children often engage in
imaginative play, drawing inspiration from folklore,
mythological creatures, and traditional stories. This cultural
context adds depth to L.C.N's imaginative exploration and
explains why she has such intricate ideas for play.
3. Early experiences and relationships
a. School experiences

Elementary:
During her elementary years, L.C.N described her
experience positively. She enjoyed participating in activities
and forming friendships with her classmates. She also
described it as an experience that probably everyone else
had as well. Teachers held her in high regard due to her
diligence and enthusiasm for learning. L.C.N relished the
opportunity to learn new things and engage in enjoyable
projects and games. Elementary school was a joyful period
for her, filled with fond memories and exciting learning
opportunities. One specific memory she recounted with
fondness during this period is that one time a group of
devotees of an Evangelical Church in Aklan stayed in their
house for two nights. She said that she enjoyed their stay
there and would often join them during singing sessions or
during times for prayer. It is because of this group that she
developed an appreciation for music.

High School:
Throughout high school, L.C.N consistently maintained
good grades across various subjects. While she may not
have ranked at the top of her class, she was recognized as
a diligent student who consistently dedicated herself to her
studies. She found particular enjoyment in subjects such
as English, Science, and History, demonstrating a keen
interest and proficiency in these areas. Despite
encountering challenges, L.C.N remained dedicated to her
academic pursuits and sought assistance when necessary.
High school provided her with opportunities for personal
growth, cherished friendships, and exploration of new
interests.

College:
During her college years, L.C.N pursued a secretarial
course, which equipped her with the skills needed for
administrative work. Alongside her studies, she gained
practical experience by working as a secretariat in the
regional trial court. Despite the demands of her academic
and professional responsibilities, she found fulfillment in
her college experience. During this time, she became
involved with the El Shaddai community, where she was
deeply moved by the strong sense of connection and
spirituality among its members. The camaraderie and
shared faith resonated with her, leading her to embrace
the teachings and practices of El Shaddai wholeheartedly.
Through her involvement in both her studies and the El
Shaddai community, L.C.N's college years were
characterized by personal growth, meaningful experiences,
and a deepening of her spiritual beliefs. Following her
secretarial course. Her husband also verbalized that she
also used to work in a public library in their hometown and
she used to tell him that she liked her job there as well.

b. Friends, family stability, early sexual

experiences, history of neglect and abuse
L.C.N. expressed having a wonderful relationship with her
parents. She recalled how they would purchase nice
clothes for her to wear when attending Sunday masses.
Despite not being particularly affluent, her parents worked
tirelessly to provide for her and her siblings. They ensured
there was always food on the table and that they could
attend school. Regarding current relationships, L.C.N
mentions that she had a close-knit group of friends
primarily from her religious community. These friendships
were built on shared beliefs and experiences, providing her
with a strong support system and a sense of belonging.
Previously, L.C.N enjoyed a stable and positive relationship
with her family, including her husband and children.
However, in recent times, there have been imbalances and
strains within her family dynamic due to the emotional
outbursts and effects of schizophrenia. These imbalances
may stem from challenges in communication,
understanding, and coping with L.C.N's condition. The
emotional toll of schizophrenia, including symptoms like
irritability, hallucinations, and delusions, can create
tensions and disruptions in family relationships. L.C.N is a
housewife, and her husband's occupation as a seafarer is
one of their source of income. However, just this year,
when she was once again admitted to the hospital, her
husband made the decision to care for her temporarily,
prompting him to temporarily suspend his job as a
seafarer. Their daughter, who works as a nurse in London,
supports them from afar. Despite the difficulties, L.C.N and
her family are navigating through these challenges,
seeking support and understanding to restore harmony
and strengthen familial bonds.
For L.C.N, her early sexual experience holds significant
meaning as she considers sex to be sacred, influenced by
her beliefs as a member of the El Shaddai community. She
views intimacy within the context of marriage as a spiritual
and significant act. Her first sexual experience, which
occurred with her current husband, holds special
significance as it symbolizes the bond of love and
commitment within their marital relationship. As a devout
member of the El Shaddai community, L.C.N values the
sanctity of marriage and the spiritual connection shared
between partners in the union. Before her current
husband, L.C.N did not have any past relationships or
boyfriends. She remained focused on her studies and
professional pursuits, prioritizing her education and
personal development.

L.C.N asserted that she had no history of neglect or abuse.

c. Early relationships with parents, siblings, and

friends

Relationship According to According to

the Family the patient
 Member

Father Not interviewed She mentioned

that she and her
father had a
good
relationship, and
she recognized
the hard work he
dedicated to their
farm. However,
she noted that
her father had
already passed
away.

Mother Not interviewed L.C.N. also

mentioned
having a strong
bond with her
mother. She
recalled admiring
her mother as a
hero during her
younger years.
Her mother
served as an
inspiration for
her to strive for
success, as she
witnessed her
mother's
resilience and
strength as a
pillar of support
for the family. No
conflicts were
mentioned in
their relationship.

Older Sister Not interviewed According to

L.C.N., she
shares a strong
bond with her
sister, a
sentiment
echoed by her
husband. She
described her
sister as not just
a sibling but also
a best friend,
especially during
challenging
 times. Her sister
was nurturing
and supportive,
providing care
and comfort,
particularly when
her husband was
away at work.

Younger Not interviewed As he is a male,

Brother L.C.N. mentioned
that they had
numerous
differences,
which prevented
them from
sharing the same
strong bond she
had with her
older sister.
Nevertheless,
she emphasized
that she still
loves and cares
for him as she
would for an
older sister.
Despite their
contrasting
personalities,
L.C.N. stated that
they have never
experienced
major conflicts
that significantly
strained their
relationship.

Friends Not interviewed L.C.N treasures

her friendships
greatly, finding
comfort and
happiness in the
companionship of
her close friends.
They share a
profound
connection
through their
affiliation with
the El Shaddai
religious
community, often
strengthening
 their bond
through religious
activities such as
prayer meetings,
Bible studies,
and spiritual
retreats. She also
recalled a
specific instance
when she
encountered
bleeding, and
when her
condition did not
improve, the first
people she
sought help from
were her friends
from church.
They assisted her
in seeking the
help of a
"manugbulong"
(healer), and it
was through this
intervention that
she finally
experienced
healing. She
expressed
gratitude towards
her friends for
their support
during this
challenging time.

4. Assess important cultural and religious influences

that affect the patient
When questioned about the origins of her deep religious
devotion, L.C.N. once again cited her time with Evangelical
Church devotees. She recalled that this experience initially
sparked her appreciation for how religion can unite people,
although her understanding was initially shallow, primarily
driven by her enjoyment of singing and music during
gatherings. However, as she matured and reflected on her
beliefs, her faith gradually deepened. Additionally, joining
the El Shaddai community during college profoundly
influenced her, nurturing a strong spiritual connection with
God that has guided her decision-making and moral
principles.

The cultural practices of El Shaddai, including prayer

meetings, Bible studies, and spiritual retreats, are integral
 to L.C.N.'s life. Engaging in these activities allows her to
strengthen her faith, find solace in difficult times, and
connect with like-minded individuals who share similar
beliefs and values. She emphasizes the importance of daily
prayer, even while in the psychiatric room, considering it a
vital part of her routine and insisting on privacy during this
time.

According to A.N., L.C.N.'s active involvement in the cultural

practices of the El Shaddai religious community, particularly
regular prayer meetings, has deepened her religious
convictions. He notes that her increased engagement in
these practices has heightened her religiosity, which may
manifest as delusions in her behavior and thoughts.

L.C.N.'s husband may perceive that her growing

dependence on religious beliefs and practices has led her to
disregard medical interventions, resulting in her
non-compliance with prescribed medications. He mentioned
that her introduction to a folk healer by a church friend
might have contributed to this. He expresses concerns that
her dedication to cultural and religious teachings overrides
her willingness to heed medical advice, potentially
endangering her overall well-being.

ii. Social History

1. Breadth of patient’s social life

L.C.N. fondly reminisced about her early years, particularly

her toddlerhood at around 2-3 years old, as retold by her
mother when she was also younger. During this period, she
often immersed herself in solitary play, preferring the
company of her stuffed toys over interactions with peers.
She shared that her mother told her how much she enjoyed
playing with dolls during that time. Engaged in imaginative
play, she embarked on numerous adventures within the
confines of her home, allowing her creativity to flourish.

However, L.C.N. also acknowledged that her parents

mentioned she could become easily irritated if she was
prevented from playing with her dolls. She expressed that
she used to become strongly attached to her toys, and if
interrupted, she would throw tantrums. Despite occasional
bouts of irritability, her love for her dolls remained a
significant aspect of her early childhood.

Transitioning into high school, there was a noticeable

change in L.C.N.'s social behavior. Recognizing the
importance of social connections, she actively sought to
expand her circle of friends. Engaging in school activities
and socializing with peers, she pursued companionship and
camaraderie, departing from her previous solitary
tendencies to form meaningful relationships.
 However, the transition to college posed challenges for
L.C.N. Amidst academic pressures and newfound
independence, she found herself retreating into solitude
once again. The vibrant social life she enjoyed in high
school gradually diminished, replaced by feelings of
isolation. Despite initial efforts to integrate into college life,
she struggled to maintain social connections and drifted
apart from her peers.

It was during her college years that L.C.N. found solace and
connection through her involvement in her church's
organization, particularly the El Shaddai community. Joining
during college, she felt a profound connection and began to
deepen her spiritual beliefs. This newfound sense of
purpose provided stability amidst the challenges of college
life, offering her a sense of belonging and fulfillment amidst
social isolation.

2. Changes in personality

L.C.N. reflected on how her personality has evolved

significantly over time. She recounted being outgoing and
having many friends during her younger years, particularly
in high school, where she and her friends would often
spend time together. However, during her college years, her
involvement in the church organization led her to become
less socially active. Additionally, her commitments to
training in the trial court limited the time she could allocate
to socializing with friends.

According to her husband, A.N., there has been a noticeable

change in L.C.N.'s demeanor since her diagnosis. Previously
affectionate, she has become irritable and withdrawn.
"Sang.una teh batyagan ko gid na ang pag.ulikid niya sa
amon nga iya pamilya. Pero sang gin admit na siya tungod
sa mga aswang aswang nga na, wala na siya gawa
gapanapak kag wala ko naman ginasabad kay dasig siya
mairitar. Ginakontra ya na ko subong.” he verbalized.

3. Marital status or involvement in an intimate

relationship; current level of sexual functioning and
sexual orientation

Currently, patient L.C.N. reported being married and

accompanied by her husband during her current
hospitalization. She disclosed having had no other previous
intimate partners during her high school and college years.

"Wala naman ako masyadong madaming friends at that

time," she remarked. When questioned about any intimate
involvement with the opposite sex before, she firmly denied
it, citing religious reasons. "Hindi, kasi hindi yan gusto ng
ating Panginoon. Dapat kasi talaga yung babae ibinibigay
 lamang ang kaniyang sarili sa kaniyang asawa lamang
pagkatapos nilang magpakasal." L.C.N. emphasized.

Additionally, she noted that they now rarely engage in

sexual activity, especially as they are aging. According to
her husband, they now feel somewhat distant due to recent
behavioral changes in L.C.N.

4. Employment history
a. Number of jobs held; reasons the jobs were terminated
L.C.N. mentioned that she finished a Bachelor of Science
degree in Secretarial Administration during college and
underwent training at the trial court office, although she
couldn't recall specific details like the duration of the
training. However, during this training, only one person out
of the 14 trainees would be chosen for employment, and
unfortunately, she was not selected, leading to her
unemployment. Afterward, she began working at a public
library but eventually resigned after two or three years.
The reason for her resignation was not disclosed.
Subsequently, she became significantly involved in their
church and joined as a member during that period.

b. Problems with alcoholism

None as claimed.

c. Presence of antisocial behavior at work

None

iii. Family history

Families often deny significant psychiatric history
1. Genetic risk for mental disorders
The patient's paternal grandmother was identified as having
a genetic risk, as she experienced auditory and visual
hallucinations, although she was never formally diagnosed,
according to her husband.

2. Family attitudes toward mental illness and

treatment
In general, L.C.N.'s family, particularly her husband, is
cautious yet accepting and supportive of her mental illness.
Throughout her current admission, her husband has been
accompanying her. He was also noticed to be watching
informational videos about schizophrenia on YouTube,
indicating his interest in gaining further understanding of
his wife's diagnosis. As a result, he has requested
healthcare workers to be responsible for transporting her,
expressing concern about her unpredictable behavior.

Despite these difficulties, he remains dedicated to

supporting L.C.N., ensuring she receives the necessary care
from medical professionals and essential medications.
 3. Is any family member successfully using any
psychotropic medication for the same illness?
None as claimed.

4. Is any family member successfully using any

psychotropic medication for the same illness?
None as claimed.

iv. Previous psychiatric history

1. Note the recurrence of an earlier problem

DATE PSYCHIATRIC HISTORY

2015 Bleeding occurred; Manifested signs and symptoms of

Schizophrenia (Auditory and Visual hallucinations);
Persecutory delusions; Social withdrawal

2015 Diagnosed with Schizophrenia

2022 First hospital admission (WVSU-MC)

2023 Showed slight improvements however, was still not

properly adhering to medications. She also still talks
about “aswangs” accompanied with autistic mumbling.

2024 Exhibited more signs and symptoms such as Religious

delusions; violent tendencies; auditory and visual
hallucinations persisted.

March 2024 Second Admission at WVSU-MC

2. Note and record any previous treatments in

chronological order

Name of Length of Medications Outcome of

Therapist Treatment treatment

Dr. M.C.J. It was prescribed Multivitamins and According to A.N.,

during L.C.N.’s first Minerals + Iron 1 tab the medications
admission to OD; Potassium were showing
WVSU-MC. However, promising outcomes
chloride 1 tab TID;
it is difficult to recall (non-violent; was
the length of Olanzapine improved and logical
treatment accurately 10mg/tab, 1 tab od when speaking).
as L.C.N. does not @ HS; Haloperidol + However, there is
adhere to the Diphenhydramine 5 still autistic
treatment properly. mg/ 5 mg 1 ampoule mumbling, auditory
IM and visual
hallucinations, and
irritable mood.
Additionally, the
 reason that the
client stopped
taking the
medications is
because she was
having headaches
according to A.N.

Dr. M.C.J. Olanzapine 10mg/tab As per the client's

1 tab OD @ 8AM and account, she
1PM; Sodium experiences
Valproate + Valproic relaxation and
Acid 250 mg/tab 1 improved sleep
tab OD @ 8 AM quality when she
consistently takes
her medication.

v. Substance use and abuse

1. Alcohol and drug problems
L.C.N. stated that she refrains from using illegal substances.
She mentioned occasional alcohol consumption, typically
during special occasions like birthdays, festivals, and
Christmas, but only in moderation. "I only drink on
occasions, and I only have a small amount," she explained.
Additionally, she emphasized responsible drinking, stating
that she has never been excessively intoxicated. L.C.N.
began drinking alcohol at the age of 18, influenced by her
family and peers.

2. Use of tobacco
When questioned about smoking habits or smoking history,
L.C.N. asserted that she does not smoke as she does not
like the smell of it. "I don't like the smell of cigarettes, and
fortunately, my husband doesn't smoke," L.C.N. mentioned.

3. Note any negative consequences of substance use

No history of substance use or abuse. None as claimed.

g. Relevant Family History

i. Childhood
In her early childhood, L.C.N. was described as a cheerful and
imaginative presence, bringing joy and creativity into her
family's home. From as young as 2-3 years old, she
demonstrated a remarkable ability to engage in imaginative
play, often spending hours lost in fantastical worlds with her
stuffed toys. Despite her lively imagination, L.C.N. tended to
prefer solitary play and had limited interaction with other
children her age.

According to A.N., by the age of 5, L.C.N.'s imaginative nature

continued to flourish, with her captivating her family with vivid
storytelling. However, alongside her creativity, there were
subtle signs of inner turmoil, as she would occasionally
 withdraw into herself, appearing unusually quiet and
introspective. Despite the initial dismissal of these behaviors as
shyness, concerns about her emotional well-being began to
grow.

As L.C.N. approached 7 years old and began school, her

behavior took on a new dimension. While excelling
academically, she struggled to form deep connections with her
peers, often feeling like an outsider in social situations. Despite
her efforts to fit in, she found solace in her thoughts rather
than seeking the company of others on the playground.

ii. Adolescence
At 13, L.C.N. entered adolescence with a desire to explore
social connections, cultivating friendships, and immersing
herself in the dynamics of her peer group. This transition
provided her with a sense of camaraderie and belonging,
offering relief from the challenges of her childhood. However,
amid her expanding social circle, subtle signs of inner turmoil
began to emerge.

By age 18, L.C.N.'s adolescent journey took a more complex

turn. Despite academic success and maintaining friendships,
moments of disconnection and unease surfaced in her
interactions. Despite attempts to fit in, she often felt like an
outsider, struggling to fully connect with her peers. Additionally,
she occasionally exhibited unconventional beliefs or
perceptions, raising concerns among those around her and
hinting at underlying challenges not yet fully understood.

iii. Use of Drugs

L.C.N. stated that she has not tried any form of drugs. “I have
not tried at all, and indi ko man gusto. People who do that have
weak resolve you know?”

iv. Family physical or mental problems

L.C.N. reported that her paternal grandmother experienced
similar hallucinations, including seeing and hearing things
related to spirits and "aswangs." However, there was no official
diagnosis made regarding her condition, according to L.C.N.

v. Was there an unusual or outstanding event the client

would like to mention?
The client recounted the beginning of her ordeal, which
commenced with unexplained bleeding. Despite seeking
medical help at the hospital, her condition did not improve. It
was only upon the suggestion of a church friend that she
visited a folk healer, where she found relief. L.C.N. described
undergoing a cleansing ritual with eggs, which led to her
realization that she was being targeted by a "devil witch" or
"mangkukulam."

B. Mental Status Examination – March 26, 2024; 10:00 AM

a. Appearance - Awake, in a semi-fowler’s position on the bed, with a
distance of approximately 2 feet away from the student nurses; no
contraptions; wearing a dark green t-shirt and her legs are completely
covered under the blanket, clothing appropriate for weather; appears
slightly disheveled; appearance congruent to stated age of 57; with an
ectomorph body type; long, waist-length black hair; no noticeable body
or breath odor; can hold eye contact but after a while chooses to avert
her eyes.

b. Affect - Broad affect, the client showed a full range of emotional

expressions; appropriate affect to thought.

c. Mood - Mood congruent to affect. The client is generally indifferent.

d. Memory - Refused to take part and follow instructions, and claims that
she could not understand the instructions. When the student nurses
repeated the instructions, she dismissed them and shook her hands left
and right indicating her refusal to further participate.

e. Attention - Good attention. Appears attentive as indicated by her

constant nodding when being asked questions by the student nurses.
Responds appropriately to the questions asked.

f. Concentration - Refused to take part and follow instructions. Verbalized

that she does not like math and numbers and is bad at it. Once again,
shook her head and hands no.

g. Eye Contact - Good eye contact. Can hold eye contact but after a while
chooses to avert her eyes.

h. Motor activity - In a semi-fowler’s position on the bed. Exhibits no

abnormal motor behavior or mannerisms.

i. Speech - Talks in a soft voice; talks without pause

j. Delusion - Exhibits religious and persecutory delusions. Verbalized that

she has abilities given by God that can help people in need even if they
are far away. L.C.N. also stated that the “devil witch”, referring to
“mangkukulams” is the one causing her suffering and the reason why
she is in the hospital.

k. Intellect - Average intellect. The client was asked who is the current
president of the Philippines and she answered “Ah. Si Marcos Jr.
Bongbong Marcos.” The student nurses then asked her again how about
the vice president, and she stated, “Si Duterte. Sara Duterte.”

l. Judgment - Poor judgment. When asked what she would do if she saw
smoke in the theater she answered “Ay hindi ako mahilig sa mga
ganyan.” The student nurses rephrased the question and asked her
what she would do if she saw and smelled smoke in her house instead.
She stated, “Ah hindi ako pumapayag na may nagssmoke sa loob ng
bahay. Ang mga panday namin noon? Pinapalabas ko yan sila.”
 m. Hallucinations - Exhibits auditory hallucinations. Stated that she hears
people ask for her help sometimes.

n. Insight and problems - Poor insight into problems. The client denies
that she has a problem and does not adhere to treatments and
diagnostic laboratory tests in the hospital.

o. Orientation - oriented to person, place, and time. When asked what

her name was, she raised her nametag given to her by the student
nurses for the orientation program while saying, “Ari hu. Lucila.” She
also knows that during the MSE it was morning and that she was in the
Hospital. However, she did not know why she was there and believed
she did not have any problems.

p. Thought Content - The client exhibited delusions and hallucinations.

She exhibited religious and persecutory delusions as well as auditory
hallucinations.

q. Suicidal Ideations - L.C.N. has not thought about harming or killing

themselves.

r. Homicidal Ideations - L.C.N. has not thought about harming or killing

other people.

s. Thought Process - The individual demonstrates grandiose thoughts,

perceiving herself as unique and self-sufficient, often avoiding
assistance from others. She maintains her independence and diverges
conversations away from herself. Despite repeated inquiries or
instructions, she persists in her own course of action and adamantly
stands by her responses, even if they do not directly address the main
point.

t. Interview Behavior - Engaged and communicated during the parts of

the interview that were very subjective. However, she refused to
participate in some parts of the MSE as the answers were more
objective. She stated, “Indi lang ko sa dira ya. Gusto ko maisturya lang
ako.”; shifts position from time to time; from hugging her legs to
leaning on the wall next to her bed facing the student nurses.

C. Diagnosis Formulation or Nursing Impression

a. Client’s central problem in diagram form

b. Identify contributory problem/s

 1. Disturbed thought process
Schizophrenia often involves disturbances in thinking, including
disorganized thoughts, difficulty concentrating, and impaired reasoning.
These cognitive symptoms can make it challenging for individuals to
process information accurately and make sense of their experiences.
Disturbed thought processes can manifest as delusions (fixed false
beliefs) and hallucinations (perceiving things that are not present). These
symptoms can profoundly impact an individual's perception of reality,
leading to a distorted understanding of the world around them.
2. Nonadherence to Treatment
Treatment for schizophrenia typically involves antipsychotic
medications to manage symptoms. However, the patient has
non-adherence to their prescribed medication regimens. This can be due
to various factors such as lack of insight into their illness, among many
others.
Failure to adhere to medication can result in symptom
exacerbation, relapse, and functional decline. It can also lead to increased
healthcare utilization, including hospitalizations or emergency room visits,
further disrupting the client’s life and adding to the burden of the illness.
3. Social Isolation
Social isolation is common among individuals with schizophrenia,
partly due to symptoms such as paranoia or social withdrawal. Difficulty
in forming and maintaining relationships can exacerbate feelings of
loneliness and isolation.
Stigma surrounding mental illness can contribute to social isolation
by fostering fear, misunderstanding, and discrimination against individuals
with schizophrenia. This societal stigma may lead to social exclusion,
rejection, and limited opportunities for employment or social participation.
Social isolation can also result from a lack of supportive social
networks or resources. Without meaningful connections and social
support, individuals with schizophrenia may experience heightened
distress and struggle to cope with the challenges of their illness.

c. Conceptualization of client’s problem

 The image seen above of a woman clinging onto a cross is the visual
representation of the client’s problem. The woman in the image represents the
individual living with schizophrenia. She embodies the human aspect of the
disorder, experiencing its symptoms and struggles firsthand.
The act of clinging onto the cross suggests a strong attachment or
reliance on something that may not be based in reality. In the context of
schizophrenia, this could symbolize the patient's delusions or false beliefs.
Delusions are often deeply ingrained and resistant to rational questioning,
leading the individual to hold onto them despite evidence to the contrary.
The cross is a powerful symbol with multifaceted meanings. In this
context, it represents the delusions that the patient holds onto as truths. These
delusions may take various forms, such as religious, grandiose, paranoid, or
persecutory beliefs. The cross could embody religious delusions, where the
patient believes they have a special connection to a deity or are undergoing a
divine mission.
The cross is also a symbol of suffering and sacrifice, as well as hope and
redemption in Christianity. In the context of schizophrenia, it reflects the dual
nature of the patient's experience – the suffering caused by the disorder's
symptoms, yet also the hope for relief and recovery through treatment and
support.
The woman clinging onto the cross may also suggest feelings of isolation
and alienation experienced by individuals with schizophrenia. They may feel
misunderstood or disconnected from others due to their symptoms and beliefs,
further intensifying their attachment to their delusions as a coping mechanism or
source of comfort.
Just as the cross is a complex symbol with multiple layers of meaning, so
too are the delusions experienced by individuals with schizophrenia. Delusions
 often arise from a combination of biological, psychological, and environmental
factors, and they can profoundly shape the individual's perception of reality.
In summary, the image of a woman clinging onto a cross offers a
poignant visual representation of the challenges faced by the client, particularly
concerning the grip of delusions on their thoughts and beliefs. It captures the
complexity, suffering, and hope inherent in the experience of living with this
mental disorder.

d. Criteria for making diagnosis: behavioral symptoms, mental status, history, physical
and laboratory examinations

Diagnostic Criteria for Schizophrenia Signs and symptoms found in patient

A. Two (or more) of the following, each present for

a significant portion of time during a 1-month
period (or less if successfully treated). At least
one fo these must be (1), (2), or (3): (+) Religious and Persecutory delusions (2015 -
1. Delusions present)
2. Hallucinations (+) Auditory and Visual (2015 - present)
3. Disorganized speech (+) Autistic mumbling (2023 - present)
4. Grossly disorganized or catatonic (-)
behavior
5. Negative symptoms (-)
B. For a significant portion of the time since the (+) Stopped working (2015 - present)
onset of the disturbance, level of functioning in
one or more major areas, such as work,
interpersonal relations, or self-care, is markedly
below the level achieved prior to the onset (or
when the onset is in childhood or adolescence,
there is failure to achieve the expected level of
interpersonal, academic, or occupational
functioning).
C. Continuous signs of the disturbance persist for at (+) Persistent hallucinations and delusions (2015
least 6 months. This 6-month period must include - present)
at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods
of prodromal or residual symptoms. During these
prodromal or residual periods, the signs of the
disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in
Criterion A present in an attenuated form (e.g.,
odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled (-)
out because either (1) no major depressive or
manic episodes have occurred concurrently with
the active-phase symptoms or (2) if mood
episodes have occurred during active-phase
symptoms, they have been present for a minority
of the total duration of the active and residual
periods of the illness.
E. The disturbance is not attributable to the
physiological effects of a substance (e.g., a drug (+) no substance use or abuse
 of abuse, a medication) or another medical
condition.
F. If there is a history of autism spectrum disorder
or a communication disorder of childhood onset, (-)
the additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations, in
addition to the other required symptoms of
schizophrenia, are also present for at least 1
month (or less if successfully treated).

e. Diagnostic Classification based on DSM 5

Diagnostic Features of Schizophrenia:
The characteristic symptoms of schizophrenia involve a range of cognitive,
behavioral, and emotional dysfunctions, but no single symptom is pathognomonic of the
disorder. The diagnosis involves the recognition of a constellation of signs and symptoms
associated with impaired occupational or social functioning. Individuals with the disorder
will vary substantially on most features, as schizophrenia is a heterogeneous clinical
syndrome.

At least two Criterion A symptoms must be present for a significant portion of

time during a 1-month period or longer. At least one of these symptoms must be the
clear presence of delusions (Criterion A1), hallucinations (Criterion A2), or disorganized
speech (Criterion A3). Grossly disorganized or catatonic behavior (Criterion A4) and
negative symptoms (Criterion A5) may also be present. In those situations in which the
active-phase symptoms remit within a month in response to treatment, Criterion A is still
met if the clinician estimates that they would have persisted in the absence of
treatment.

Schizophrenia involves impairment in one or more major areas of functioning

(Criterion B). If the disturbance begins in childhood or adolescence, the expected level
of function is not attained. Comparing the individual with unaffected siblings may be
helpful. The dysfunction persists for a substantial period during the course of the
disorder and does not appear to be a direct result of any single feature. Avolition (i.e.,
reduced drive to pursue goal-directed behavior; Criterion A5) is linked to the social
dysfunction described under Criterion B. There is also strong evidence for a relationship
between cognitive impairment (see the section “Associated Features” for this disorder)
and functional impairment in individuals with schizophrenia.

Some signs of the disturbance must persist for a continuous period of at least 6
months (Criterion C). Prodromal symptoms often precede the active phase, and residual
symptoms may follow it, characterized by mild or subthreshold forms of hallucinations or
delusions. Individuals may express a variety of unusual or odd beliefs that are not of
delusional proportions (e.g., ideas of reference or magical thinking); they may have
unusual perceptual experiences (e.g., sensing the presence of an unseen person); their
speech may be generally understandable but vague; and their behavior may be unusual
but not grossly disorganized (e.g., mumbling in public). Negative symptoms are common
in the prodromal and residual phases and can be severe. Individuals who had been
socially active may become withdrawn from previous routines. Such behaviors are often
the first sign of a disorder.

Mood symptoms and full mood episodes are common in schizophrenia and may
be concurrent with active-phase symptomatology. However, as distinct from a psychotic
mood disorder, a schizophrenia diagnosis requires the presence of delusions or
hallucinations in the absence of mood episodes. In addition, mood episodes, taken in
 total, should be present for only a minority of the total duration of the active and
residual periods of the illness.

In addition to the five symptom domain areas identified in the diagnostic criteria,
the assessment of cognition, depression, and mania symptom domains is vital for
making critically important distinctions between the various schizophrenia spectrum and
other psychotic disorders

D. Psychodynamic Formulation – use of theories like E. Erikson, S. Freud, J. Piaget,

Kohlberg (present in tabular form – stage of development, developmental task according to
textbook, developmental task of client, analysis)
* Cite references APA format
a. Description of Client’s Current Developmental Stage

Stage of Description According Client’s Behavior Analysis

Development to Book
(According to Freud
or Erickson)
Trust vs. mistrust Task: Viewing the L.C.N. stated that Trust is achieved.
(infant) world as safe and when she was young,
reliable; relationships she was treated very
as nurturing, stable, well by her parents.
and dependable She remembered
Virtue: Hope being a crybaby
when encountering
unfamiliar faces
during infancy.
Throughout her
infancy, L.C.N
received attentive
care from her
parents, fostering a
sense of trust and
security. This
attentive caregiving
contributed to a
strong bond with her
parents as she grew
up.

Autonomy vs. shame Task: Achieving a L.C.N. fondly Autonomy is

and doubt (toddler) sense of control and reminisced about her achieved.
free will early years,
Virtue: Will particularly her
toddlerhood at
around 2-3 years old,
as retold by her
mother when she
was also younger.
During this period,
she often immersed
herself in solitary
play, preferring the
company of her
 stuffed toys over
interactions with
peers. She shared
that her mother told
her how much she
enjoyed playing with
dolls during that
time. Engaged in
imaginative play, she
embarked on
numerous adventures
within the confines of
her home, allowing
her creativity to
flourish.
Initiative vs. guilt Task: Beginning It was during this Initiative is achieved.
(preschool) development of a period that according
conscience; learning to L.C.N. she started
to manage conflict to want to belong in
and anxiety a group. She was
Virtue: Purpose influenced by the
evangelical church
devotees that stayed
in their home
therefore she also
wanted to belong and
became active in
school and engage in
enjoyable projects
and games.
Industry vs. Task: Emerging Elementary school Industry is achieved.
inferiority (school confidence in own was a joyful period
age) abilities; taking for her, filled with
pleasure in fond memories and
accomplishments exciting learning
Virtue: Competence opportunities. She
often joined church
devotees during
singing sessions or
during times for
prayer. It is because
of this group that she
developed an
appreciation for
music. She was
happy to be a part of
something.
Identity vs. role Task: Formulating a Throughout high Identity is achieved.
confusion sense of self and school, L.C.N
(adolescence) belonging consistently
Virtue: Fidelity maintained good
grades across various
subjects. Despite
encountering
 challenges, L.C.N
remained dedicated
to her academic
pursuits and sought
assistance when
necessary. High
school provided her
with opportunities for
personal growth,
cherished friendships,
and exploration of
new interests.
Intimacy vs. isolation Task: Forming adult, She was able to find Isolation is
(young adult) loving relationships, her group of people achievedIntimacy is
and meaningful according to L.C.N. in achieved.
attachments to the form of the El
others Shaddai community.
Virtue: Love She also met her
husband whom she
formed a loving
relationship with.
However, she also
struggled at one
point in college and
started to isolate
herself from her
friends outside of the
El Shaddai
community.
Generativity vs. Task: Being creative As a result of her Stagnation is
stagnation (middle and productive; condition, L.C.N. was achieved.
adult) establishing the next compelled to halt her
generation professional
Virtue: Care endeavors, which led
to feelings of
frustration and a
sense of stagnation
in her life. She
expressed deep
concern about her
ability to move
forward and continue
with her aspirations,
grappling with the
limitations imposed
by her illness. This
forced pause in her
career trajectory
compounded her
distress, exacerbating
her sense of
uncertainty about the
future and her place
in the world.
 b. Description of Client’s Use of Defense Mechanisms

Defense Mechanism Definition As seen on the patient

Denial Failure to acknowledge an L.C.N. asserts that she does

unbearable condition; failure not have a problem. She
to admit the reality of a believes that she is in the
situation or how one enables hospital for no real reason.
the problem to continue

Rationalization Excusing own behavior to According to L.C.N., she does

avoid guilt, responsibility, not adhere to her
conflict, anxiety, or loss of medications because she says
self-respect that it may be poison.

E. Psychopathology

Derived from the Greek 'schizo' (splitting) and 'phren' (mind) with the term first coined
by Eugen Bleuler in 1908, schizophrenia is a functional psychotic disorder characterized by the
presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and
behavior. Traditionally, symptoms have been divided into two main categories: positive
symptoms, which include hallucinations, delusions, and formal thought disorders, and negative
symptoms such as anhedonia, poverty of speech, and lack of motivation. The diagnosis of
schizophrenia is clinical, made exclusively after obtaining a full psychiatric history and excluding
other causes of psychosis. Risk factors include birthing complications, the season of birth,
severe maternal malnutrition, maternal influenza in pregnancy, family history, childhood trauma,
social isolation, cannabis use, minority ethnicity, and urbanization. Due to its relative complexity
and heterogeneity, the etiology and pathophysiological mechanisms are not fully understood.
Despite a low prevalence, schizophrenia's global burden of disease is immense. Over half of the
patients have significant co-morbidities, both psychiatric and medical, making it one of the
leading causes of disability worldwide. The diagnosis correlates with a 20% reduction in life
expectancy, with up to 40% of deaths attributed to suicide.
Several studies postulate that the development of schizophrenia results from
abnormalities in multiple neurotransmitters, such as dopaminergic, serotonergic, and
alpha-adrenergic hyperactivity or glutaminergic and GABA hypoactivity. Genetics also plays a
fundamental role - there is a 46% concordance rate in monozygotic twins and a 40% risk of
developing schizophrenia if both parents are affected. The gene neuregulin (NGR1), which is
involved in glutamate signaling and brain development, has been implicated, alongside
dysbindin (DTNBP1), which helps glutamate release, and catecholamine O-methyl transferase
(COMT) polymorphism, which regulates dopamine function.
As aforementioned, there are also several environmental factors associated with an enhanced
risk of developing the disease:

● Abnormal fetal development and low birth weight

● Gestational diabetes
● Preeclampsia
● Emergency cesarean section and other birthing complications
● Maternal malnutrition and vitamin D deficiency
● Winter births - associated with a 10% higher relative risk
 ● Urban residence - increases the risk of developing schizophrenia by 2 to 4%

The incidence is also up to ten times greater in children of African and Caribbean
migrants compared to whites, according to a study conducted in Britain. The association
between cannabis use and psychosis has been widely studied, with recent longitudinal studies
suggesting a 40% increased risk, while also suggesting a dose-effect relationship between the
use of the drug and the risk of developing schizophrenia.
There are three main hypotheses regarding the development of schizophrenia. The
neurochemical abnormality hypothesis argues that an imbalance of dopamine, serotonin,
glutamate, and GABA results in the psychiatric manifestations of the disease. It postulates that
four main dopaminergic pathways are involved in the development of schizophrenia. This
dopamine hypothesis attributes the positive symptoms of the illness to excessive activation of
D2 receptors via the mesolimbic pathway, while low levels of dopamine in the nigrostriatal
pathway are theorized to cause motor symptoms through their effect on the extrapyramidal
system. Low mesocortical dopamine levels resulting from the mesocortical pathway are thought
to elicit the negative symptoms of the disease. Other symptoms such as amenorrhea and
decreased libido may be caused by elevated prolactin levels due to decreased availability of
tuberoinfundibular dopamine as a result of blockage of the tuberoinfundibular pathway.
Evidence showing exacerbation of positive and negative symptoms in schizophrenia by NMDA
receptor antagonists insinuates the potential role of glutaminergic hypoactivity while
serotonergic hyperactivity has also been shown to play a role in schizophrenia development.
There are also arguments that schizophrenia is a neurodevelopmental disorder based on
abnormalities present in the cerebral structure, an absence of gliosis suggesting in utero
changes, and the observation that motor and cognitive impairments in patients precede the
illness onset.
Conversely, the disconnect hypothesis focuses on the neuroanatomical changes seen in
PET and fMRI scans. There is a reduction in grey matter volume in schizophrenia, present not
only in the temporal lobe but in the parietal lobes as well. Differences in the frontal lobes and
hippocampus are also seen, potentially contributing to a range of cognitive and memory
impairments associated with the disease.

F. Signs and Symptoms

Signs and Symptoms According to Manifested by Client

Textbook
Ambivalence (-)
Associative looseness (+) 2023 - present
Bizarre behavior (-)
Delusions (+) exhibited religious and persecutory
delusions (2015 - present)
Echopraxia (-)
Flight of ideas (-)
Hallucinations (+) Exhibited Auditory and Visual
Hallucinations (2015 - present)
Ideas of reference (-)
Perseveration (-)
Alogia (-)
Anhedonia (-)
Apathy (-)
Asociality (-)
Avolition (-)
Blunted affect (-)
Catatonia (-)
Flat affect (-)
Inattention (-)

G. Specific Nursing Problems and Interventions – Problem List

Problem List Interventions and Date Resolved

Rationale
Risk for Other-directed 1. Observe and listen for 03/25/24
Violence early cues of distress
or increasing anxiety.
This may indicate
possibility of loss of
control, and
intervention at this
point can prevent a
blowup
2. Assess client coping
behaviors already
present. The client
may believe there are
no alternatives other
than violence,
especially if the
individual has come
from a family
background of
violence.
3. Develop therapeutic
nurse-client
relationship. Provide
consistent caregiver
when possible.
Promotes a sense of
trust, allowing client
to discuss feelings
openly.
4. Help client identify
more appropriate
solutions or behaviors.
To lessen sense of
anxiety and
associated physical
manifestations.
5. Be truthful when
giving information and
dealing with client.
Builds trust, enhances
therapeutic
relationship, prevents
manipulative behavior.
Defensive Coping 1. Determine use of 03/26/2024
defense mechanisms
(e.g., projection,
avoidance,
rationalization) and
purpose of coping
strategy (e.g., may
mask low self-
esteem, unrealistic
self-expections, fear
of failure).
Recognizing client’s
use of protective or
defensive coping
strategies aids in
understanding
thought processes
and provides guidance
for choice of
interventions and
therapeutic
communications.
2. Determine level of
readiness to change
from unproductive
behaviors to a more
healthy lifestyle.
Attempting to
implement
interventions prior to
client’s readiness will
meet with resistance.
3. Develop a therapeutic
relationship enabling
client to test new
behaviors in a safe
environment. Use
motivational
interviewing, positive
reinforcement, and
nonjudgmental
approaches. Helps
client to identify
thinking, feelings,
needs, concerns, and
how client can take
control of improving
coping and sense of
self-esteem.
4. Encourage
identification and
expression of feelings.
Provides opportunity
for client to learn
 about and accept self
and feelings as
normal.
5. Encourage client to
learn and use
relaxation techniques,
deep breathing,
guided imagery,
positive affirmation of
self, emotional
intelligence, or
mindfulness
meditation.
Therapeutic
interventions enhance
coping abilities,
strengthening client’s
personality to be more
independent and
self-sufficient.
Impaired Social Interaction 1. Ascertain ethnic, 03/27/24
cultural, or spiritual
implications for the
client. Impact choice
of behaviors and may
even script
interactions with
others.
2. Observe and describe
social and
interpersonal
behaviors in objective
terms, noting speech
patterns, body
language—in the
therapeutic setting
and in normal areas
of daily functioning (if
possible)—such as in
family, job, social, or
entertainment
settings. Helps
identify the kinds and
extent of problems
client is exhibiting.
3. Determine client’s use
of coping skills and
defense mechanisms.
Symptoms associated
with social anxiety
affect ability to be
involved in social
situations, making
client’s life miserable
 and seriously
interfering with work,
friendships, and family
life.
4. Have client list
behaviors that cause
discomfort. Once
recognized, client can
choose to change as
they learn to listen
and communicate in
socially acceptable
ways.
5. Provide positive
reinforcement for
improvement in social
behaviors and
interactions.
Encourages
continuation of
desired behaviors and
efforts for change.

H. Evaluation of Interventions

Before After
3/26/2024 3/27/2024
L.C.N. denied that she has problems Client admitted that she hears voices even
from afar
3/26/2024 3/27/2024
Exhibited no concrete plans on goals to be Stated that she wants to see her children
accomplished after hospital discharge achieve more things in their life. She added
she wants to be there for them and plans to
be “better” after discharge.
3/26/2024 3/27/2024
Refused to participate in group therapy Participated in the music and arts therapy
sessions because she is not interested and and stood up to participate in the singing and
does not want to be with the other patients dancing as well.
3/26/2024 3/27/2024
Does not adhere to medications because she Took her medications and answered that she
verbalized that it may be ‘poison’ relaxes and gets better sleep when taking her
medications after being asked what outcomes
does her medication have.

I. Recommendations or Discharge Plans – medical and nursing management

MEDICATIONS - Take your prescribed medication regularly and as directed by your

healthcare provider.
- Keep track of any side effects and report them to your healthcare
provider promptly.
- Ensure you have an adequate supply of medication and refill your
 prescriptions on time.

ENVIRONMENT - Create a stable and supportive living environment to reduce stressors

/ EXERCISE and triggers.
- Engage in regular physical exercise as advised by your healthcare
provider to improve mood stability.
- Practice relaxation techniques such as deep breathing or meditation
to manage stress.

TREATMENT - Attend therapy sessions consistently to work on coping strategies and

symptom management.
- Consider participating in support groups or peer-led programs to
connect with others facing similar challenges.

HEALTH - Educate yourself and your support system about schizophrenia to

TEACHING better understand the condition and its treatment.
- Learn to recognize early warning signs of relapse and develop a plan
to address them proactively.

OUT-PATIENT - Schedule regular follow-up appointments with your psychiatrist or

FOLLOW-UP mental health team.
- Keep a journal of your symptoms and experiences to discuss during
appointments

DIET - Maintain a balanced diet rich in fruits, vegetables, lean proteins, and
whole grains.
- Limit caffeine and alcohol intake, as they may interfere with
medication effectiveness.

SPIRITUAL / - Engage in activities that bring you joy and fulfillment, whether they
SOCIAL / are spiritual, social, or recreational.
SEXUAL - Communicate openly with your partner or loved ones about any
concerns related to sexuality or intimacy.

J. Bibliography – follow APA format (11th edition)

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders,
text revision DSM-5-TR (5th ed.). American Psychiatric Association.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide: Diagnoses,
Prioritized Interventions, and Rationales (15th ed.). F.A. Davis Company.
Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2022). Schizophrenia. PubMed; StatPearls
Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK539864/#:~:text=Traditionally%2C%20schizop
hrenia%20may%20involve%20positive
Videbeck, S. L. (2023). Psychiatric-Mental Health Nursing. Wolters Kluwer Health.