DIZON, DEXIE

BSN IIIA
ACTIVITY NO.3

1a Situation: Mr. Santos, 42 years old, male, married with five kids (ages 18, 15, 12, 5, and 2), was
admitted to the psychiatric area due to disorganized behavior. For one and a half months 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. He 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 hears voices telling him that there are people who are spying on him and wanted to get
the map he is keeping. This map contains the details of where the Japanese kept several gold bars
during the 2nd world war in the 1940s. He would frequently instruct his wife to tell anyone looking
for him to inform 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.

You are a nurse in the community, and you were called to attend to this patient.

What steps should you take to address this client's health needs? \

Questions:
1a. What are the manifestations of psychosis presented by Mr. A?

 Fails to perform his usual function

 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
 Smeared his feces on the walls of their room for 2x
 Only eats when food is brought into his room by his wife
 Claims to have been hearing voices telling him that there are people who are spying on him
and wanted to get the map he is keeping
 Frequently instructs his wife to tell anyone looking for him to inform them that he went for a
trip to a place he calls “Sampulanggit”

1b. Are there any explanations for the symptoms?

•Genetic factors
  Research shows that schizophrenia and bipolar disorder may share a common genetic cause.

•Hormonal Imbalances

 Some people experience postpartum psychosis after giving birth. Due to this, and the fact that
the early signs of psychosis often occur first in adolescents, some experts have suggested that
hormonal factors may play a role in those with a genetic susceptibility.

•Brain changes

 Tests have found differences in brain chemicals — specifically, the activity of the
neurotransmitter dopamine — in people who experience psychosis.

2. Is the person having an acute manic episode? Justify your answer.

 Yes, because the patient shows an act that is brash, inappropriate, also increased kinesthetics,
and talk very quickly, often jumping from topic to topic and shows a lose touch with reality.
3a. Does the person have psychosis? Justify your answer.

 Yes being said that thepatient shows a lose touch with reality, see, hear, or believe things that
aren't real. Lack of motivation, self-care deficit and self-isolation are just but are a few of signs
and symptoms of psychosis.

3b. Is there an imminent risk for suicide?

 None that I can think of.

4. What actions are you going to do? Identify in chronological order the actions that you will carry
out.

Independent:

 Assess attention span/distractibility and ability to make decisions/ problem solution

 Interact with the client on the basis of real things; do not dwell on the hallucination.
 Set a structure of Scheduled activity and rest periods
 Reduce to minimum level provocative stimuli, negative criticism, arguments and
confrontations
 Refrain from forcing activities and communication
  Confirm that of the swallowed medications.

Dependent:

 Administer antipsychotic med as prescribed

Collaborative:

 Assist in identifying on-going treatment needs/ rehabilitation program for the client