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Student Nurse: Jeyser T.

Gamutia BN3B Patient: RVJ Age: 23 y/o Diagnosis: Schizophrenia May 10, 2018

ASSESSMENT NURSING INFERENCE DESIRED INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS OUTCOMES

Objective: Defensive Predisposing Factors: After one week of 1) Determine level of 1) To After one week of
 Client denies coping related to  (+) Family nurse-client anxiety and determine nurse-client
the fact that he perceived lack of History of Mental intervention, the client effectiveness of degree of intervention, the
is not well. self-efficacy as Illness (Father’s will be able to: current coping impairment: client is be able to:
 Client is not evidenced by Side) mechanisms.
aware that he denial of  Introverted 1) Verbalize 2) Observe interactions 2) To evaluate 1) Client
is also obvious Personality understanding of with others to note the efficacy verbalized: “Gn
mentally ill problems. own difficulties/ability to of social kadtuan ko
just like the Precipitating Factors: problems/stressors. establish satisfactory interactions kagapon
other patients. DEFINITION:  Alcohol Abuse 2) Identify areas of relationships. with others. (Wednesday)
 Client Repeated  Peer Pressure concern/problems. 3) Convey attitude of 3) To assist sang doctor,
verbalized: projection of  Lack of familial 3) Demonstrate acceptance and client to deal ma’am. Hambal
“Ambot ngaa falsely positive contact (while acceptance of respect with current niya kay mama
gin dala ko na self-evaluation working in responsibility for (unconditional situation. obserbahan pko
di nila ah. based on a self- Boracay, he was own actions, positive regard) to nila basi dason
Wala man ko protective far from his successes, and avoid threatening semana ka gwa
sakit. Ang pattern that family.) failures. client’s self-concept, naman ko. Mas
mga tawo di defends against 4) Participate in preserve existing mayo na lang
ya mga lala underlying treatment self-esteem. tuod nga ari ko
nana di ya. perceived threats program/therapy. 4) Encourage client to 4) To promote diri para mag
Indi ko ya to positive self- NEURO CHEMICAL: 5) Maintain learn relaxation overall ayo gid ko.”
lagtok, regard.  Abnormal involvement in techniques, use of wellness of Client was able
ma’am” hyperactivity of relationships. guided imagery, and the client to perceive the
REFERENCES: the brain positive affirmation severity of his
Subjective: North American functions of self in order to condition as
 Client Nursing incorporate and stated. GOAL
Diagnosis practice new MET.
verbalized:  Excessive
“Natak-an ko Association behaviors. 2) Client was able
discharge of
di, ma’am. https://nurseslab 5) Promote 5) To assist to identify his
neurotransmitters.
Gusto ko na di s.com/ involvement in client in shyness and
Student Nurse: Jeyser T. Gamutia BN3B Patient: RVJ Age: 23 y/o Diagnosis: Schizophrenia May 10, 2018

mag gwa. schizophrenia- NEURO ANATOMY: activities/classes building introverted


Wala kami di nursing-care-  Decreased brain where client can lasting and personality as
gina ubra ya. plans/5/ tissue and practice new skills more stable one of his
Ka boring.” cerebrospinal and develop new relationships weaknesses.
fluid. relationships. with others. Also, his other
concern was he
Strengths:  Ventricle 6) Use confrontation 6) To assist might regress to
 Strong family enlargement judiciously to help client in his old behavior
support client begin to gaining a and vices once
 Financially PSYCHOLOGY: identify defense sense of discharged.
stable  Changes in neural mechanisms (e.g., reality to GOAL MET.
activity. denial/projection) self. 3) Client stated that
Weaknesses: that are hindering it was because
 Low self-  Added mental and development of of his vices and
esteem physical stressors satisfying affinity to
 Introverted relationships. women that led
personality  Presence of visual to him being
and auditory diagnosed with a
hallucinations. mental disorder.
He realized that
 Perceived lack of his lifestyle
self-efficacy. paved the way
for his condition
to manifest.
 Denial of obvious
problems GOAL MET.
4) Client
participated in
 Defensive coping
every activity
such as hataw,
body tracing,
fan designing
and nurse-
patient
Student Nurse: Jeyser T. Gamutia BN3B Patient: RVJ Age: 23 y/o Diagnosis: Schizophrenia May 10, 2018

interactions.
5) By the end of
the first week of
exposure, client
was still a bit
reluctant to
mingle and
interact with
others. He
would interact
with the others
when being told
to do so but he
wouldn’t do it at
his own volition.
Someone still
has to tell him to
interact with
others in order
for him to
mingle with
others,
otherwise, he
wouldn’t be the
one to initiate
the conversation.
GOAL NOT
MET.

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