Psychiatric Case Presentation

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    Undifferentiated Schizophrenia, Manageable, Moderate Mental

    Retardation

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    INTRODUCTION

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    OBJECTIES

    Cogniti!e Within 72 hours of formulating a comprehensive Psychiatric

    Case Study, we will be able to:

    1!efine the complete diagnosis of the client thorougly

    2"dentify the predisposing and precipitating factors that

    lead to client#s condition correctly

    $!etermine the signs and symptoms being manifested by

    the client accordingly

    %"nterpret data gathered from the client effectively

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    OBJECTIES

    & 'ormulate a systematic psychopathology of the client#s

    psychiatric condition

    ( )valuate the developmental stage of the client according

    to ******** correctly 7 +ecognie defense mechanisms used by the client

    during nurse-patient interaction effectively

    . !evelop a specific, measurable, attainable, realistic and

    time-bounded nursing care plan

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    OBJECTIES

    "#$cho%otor 

    1/ather pertinent data through detailed chart-ta0ing and

    effective nurse-patient interaction

    2ssess client#s affect and behavior during the course of various therapeutic activities and nurse-patient interaction

    effectively

    $tilie various therapeutic communication techni3ues

    during the gathering of data effectively

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    OBJECTIES

    % Conduct a thorough physical assessment using

    cephalocaudal approach

    & Create an effective nursing care plan based on the

    prioritied problem of the client

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    OBJECTIES

    &ffecti!e

    14anifest core values of an ugustinian student nurse at

    all times

    2)nsure confidentiality regarding client#s information in all

    aspects

    $+espect client#s norms, practices, rights and beliefs at all

    times

    %)5hibit collaboration between all members of the group inthe course of the study

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    OBJECTIES

    & )stablish a trusting relationship with the client through

    provision of holistic care and use of verbal and non-verbal

    therapeutic communication techni3ues during the course of

    the nurse-patient interaction

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    NURSIN' C&RE "(&N

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    /)6)+ 89)C;"

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    S9)C;"

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    S9)C;"

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    S9)C;"

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    89)C;"

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    NURSIN' DI&'NOSIS

    R&TION&(E S"ECI)IC OBJECTIES

    "neffective coping related

    to difficulty adapting to stress

    Stress is medical term for a wide range of strong e5ternal stimuli both physiological and

    psychological "t can directly and indirectly contribute to general or specific disorders of body and mind Stress can have ma@or impact on the physical functioning of the human body "n Selye#s general adaptation syndrome, there are $ phases: ;he alarm phase, which is the fight or

    flight response, the resistance phase which thebody is possibly trying to resolve the source of stress, and the e5haustion phase where the stress continue for a longer period of time that the body#s ability to resist is lost because its adaptation energy supply is gone Chronic stress can damage nerve cells in tissues and organs Particularly vulnerable is the hippocampus section of the brain ;hin0ing and memory are li0ely to become impaired, with tendency toward an5iety and depression 8verload, burn out, adrenal fatigue, maladaptation or dysfunction @ust leads to ineffective coping as evidenced by

    unacceptable actions or behaviors towards the stressor

     fter 72 hours of rendering effective

    nursing interventions, the client will be able to: A ssess own coping abilities and

    s0illsA!escribe and initiate alternative healthy coping strategies in adapting to stress APromote wellness by minimiing the use of defense mechanisms

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    NURSIN' INTERENTIONS R&TION&(E

    -ssess specific stressors

     

    -ssess level of understanding and readiness to learn needed lifestyle changes

    -ssess decision-ma0ing and problem- solving abilities

    -!etermine social interaction, sleeping and eating patterns

    -ccurate appraisal can facilitate

    development of  appropriate coping strategies

    -ppropriate problem solving re3uires accurate information and understanding of options

    - Patients may feel that the threat is greater than their resources to handle it and feel a loss ofcontrol over solving the threat or problem

    - ;hese mechanisms are often used when individual is not coping effectively with stressors

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    NURSIN' INTERENTIONS R&TION&(E

    -)stablish a wor0ing relationship with patient through continuity of care

    -Provide opportunities to e5press concerns, fears, feelings, and e5pectations

    -)ncourage patient to identify own

    strengths and abilities

    -)ncourage patient to communicate feelings with significant others andBor friends

    -Provide positive reinforcement for application of adaptive coping s0ills

    -n ongoing relationship establishes trust, reduces the feeling of isolation, and may

    facilitate coping

    -

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    NURSIN' INTERENTIONS R&TION&(E

    -;each use of rela5ation, e5ercise, and diversional activities

    -Provide for gradual implementation and continuation of necessary behaviorBlifestyle

    C898+;"

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    NURSIN' INTERENTIONS R&TION&(E

    -dminister P+6 medications as prescribed by the physician

    - ;o help reduce symptoms

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    E&(U&TION

     fter 72 hours of rendering effective nursing care, the client was able to:

    Assess own coping abilities and s0ills A!escribe and initiate alternative healthy coping strategies in adapting to stress