DIZON, DEXIE

BSN IIIA

Psychiatric RLE - Learning Activity #1

Situation:

Situation: Mr. Santos, 42 years old, male, married with 5 kids (ages 18, 15, 12, 5 and 2) was admitted
to the psychiatric area due to disorganized behavior. For 1 and a half month now, he fails to perform
his usual function particularly going to the farm. He seems afraid to get out of the house, prefers to
be alone in their room lying in bed most of the time, refuses to communicate with any family
member, fails to perform self-care activities such as bathing and oral hygiene; and worst, he smeared
his feces on the walls of their room for 2x now. He only eats when food is brought into his room by
his wife.

He claims, he is hearing voices telling him that there are people who are spying on him and wanted to
get the map he is keeping. This map apparently contains the details where the Japanese kept several
bars of gold during the 2nd world war in 1940’s. He would frequently instruct his wife to tell anyone
looking for him to informe them that he went for a trip to a place he calls “Sampulanggit”. History
reveals his condition started 2-days after the super typhoon struck the province which caused his
crops massive devastation.

Instructions: Given the case above,

1. Identify all possible nursing diagnoses (2-3 parts) applicable for the case.

 Impaired Social Interaction related to overwhelming stressful life events as manifested by

dysfunctional interaction with peers, family, and/or others.

 Impaired Verbal Communication related to Altered Perceptions as evidenced by loss of

interest in interacting with peers, family, and/or others.

 Disturbed Thought Process related to overwhelming stressful life events as manifested by

dysfunctional interaction with peers, family, and/or others.

 Self- care deficit related severe level of anxiety as manifested by improper grooming, body
odour and halitosis.

2. Make a NCP for the first priority problem. (6 columns NCP). Use landscape orientation.
 ⮚ Problem/Nursing diagnosis with cues

⮚ Explanation of the problem

⮚ LTO & STO

⮚ Nursing Interventions

⮚ Rationale

⮚ Outcome

References: https://nurseslabs.com/schizophrenia-nursing-care-plans/2/

Problem/Nursi Explanation of Goal Nursing Rationale Outcome

ng diagnosis the problem Interventions
with cues

Subjective : STG: Assessed if the Many of the STG : Goal

‘’Natatakot Social After 3 hours medication has positive Fully Met
ako lumabas“. isolation is of effective reached symptoms of
the nursing therapeutic levels. schizophreni After 3 hours
Objectives: condition of interventions, a of effective
- Prefers to be aloneness the patient (hallucinatio nursing
alone most of will be able ns, interventions
experienced
the time to improve delusions, , the patient
by the
social racing was able to
- Fails to individual interaction as thoughts) improve
perform his and manifested will subside social
usual function perceived by functional with interaction as
such as as imposed interaction medications, manifested
communicate by others through which will by functional
with any family and as a expression of facilitate interaction
member negative or thoughts and interactions. through
threatened active expression of
-Fails to state listening. Identified with thoughts and
perform self- client symptoms Increased active
care activities he experiences anxiety can listening.
such as bathing when he begins to intensify
and oral feel anxious agitation,
hygiene around others. aggressivene
LTG: ss, and LTG:
-Only eats After 3 days suspiciousne Goal Fully
when food is Psychologica of effective ss. Met
brought into l distress nursing
his room by his interventions, Structured After 3 days
wife. the patient activities that Avoids of effective
 will be able work at the pressure on nursing
-afraid to get to client’s pace and the client interventions
out of the demonstrate activity. and sense of , the patient
house appropriate failure on was able to
skills to part of nurse demonstrate
Nursing initiate and /family.This relevant
Diagnosis: maintain an sense of skills to
Impaired Social Reduced self interaction as failure can initiate and
Interaction esteem evidenced by lead to maintain an
related to Multi-tasking mutual interaction as
overwhelming such as withdrawal evidenced by
stressful life Interacting Multi-tasking
events as with others Structured times such as
manifested by while each day to Client can interacting
dysfunctional completing include planned lose interest with others
interaction an activity times for brief in activities while doing
with peers, Increased like card interactions and that are too activities like
family, self and depression games or activities with the ambitious, simple board
others. board games. client on one-on- which can game,
one basis increase a drawing and
sense of colouring.
failure.

Spent frequent,
short period with Helps client
Increased clients whenever to develop a
anxiety client is unable to sense of
respond verbally safety in a
or in a coherent non-
manner. threatening

Set an
entertainment An
Impaired activity whenever interested
verbal and client is found to presence
nonverbal be very paranoid, can provide
communica to boost a sense of
tion concentration. being
worthwhile.

Maximized
resources and Client is free
provided simple to choose
colouring/puzzle his level of
activities with interaction;
Reduced
client whenever however,
quality of life
client is the
 delusional concentratio
/hallucinating, or n can help
is having trouble minimize
concentrating. distressing
paranoid
Impaired thoughts or
social voice.
function
Incorporated the Learn to feel
> is an strengths and safe with
insufficient interests that the one person,
or client had when then
excessive not as impaired gradually
quantity or into the activities might
ineffective planned based participate
quality of from client history in a
social and available structured
resources group
exchange.
activity.

Taught client to Increase

remove himself likelihood of
briefly when client’s
feeling agitated participation
and work on some and
anxiety relief enjoyment.
exercise like deep
breathing
exercises.

Taught coping Teach client

skills that the skills in
client may need dealing with
including anxiety and
conversational and increasing a
being upbeat sense of
control.

Acknowledged and These are

recognized for fundamental
positive steps skills for
client takes in dealing with
increasing social the world,
skills and which
appropriate everyone
interactions with uses daily
others. with more
or less skill.

Provided Recognition
opportunities for and
the client to learn appreciation
adaptive social go a long
skills in a non- way to
threatening sustaining
environment. and
Initial social skills increasing a
training could specific
include basic social behavior.
behaviors (e.g.,
appropriate
distance, maintain
good eye contact,
calm
manner/behavior,
moderate voice
tone).

Provided the client Social skills

with graded training
activities helps the
according to the client adapts
level of tolerance and
e.g., (1) simple functions at
games with one a higher
“safe” person; (2) level in
slowly add a third society, and
person into “safe”. increases
the client’s
quality of
life.

Engaged other Increases

clients and client’s
significant others ability to
in social derive social
interactions and support and
activities with the decrease
client (card games, loneliness.
ping pong, sing-a- Clients will
songs, group not give up
sharing activities) the
at the client’s substance of
level. abuse unless
they have
alternative
means to
facilitate
socialization
they belong.