ASSESSMENT Subjective: - Verbalized, anim anak ko, nagtrabaho ako, sapatero, binaril kamay ko ng hapon.

Client kept asking of the time, alas singko na ba? Objective: - Client sitting on bed, hands clasped together - Hands shake when moved - Inactivity - Disorientation - Mute when not asked - Reduced emotional expression, - In a stare - Blank facial expression - No eye contact when conversed with - Social isolation

NURSING DIAGNOSIS Disturbed thought processes r/t memory deficit as manifested by confabulation

RATIONALE Increased dopamine levels (dopamine hypothesis) causes disturbed thought processes. The dopamine neuro transmitters function is for motor movements, sensory integration and emotional behaviors.

PLANNING After 6 hours of nursing interventions, the patient will be able to establish contact with reality as evidenced by: Responding to simple questions Being able to provide self care such as urinating, defecating and bathing with or without supervision Eating food from trays and takes medications without evidence of mistrust. Continuing compliance with medication regimen

NURSING INTERVENTIONS Independent: -Monitor clients vital signs. -Assess for signs and symptoms of physical illness. -Reorient the client to person, place and time. -Encourage the patient to perform ADLs (as tolerated) and to participate in decisions about self-care, independence. Provide assistance as appropriate. -Provide emotional support, positive reinforcement.

RATIONALE

EVALUATION After 6 hours of nursing interventions, the patient was able to establish contact with reality as evidenced by:

-For continuous monitoring of clients status -Client will not complain of pain or physical symptoms (mutism). -Repeated presentation of reality is concrete reinforcement for the client. -Allowing the patient to participate in self-care promotes independence and feelings of self-control.

-Develop a therapeutic nurse-client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard. -Spend time with client; sit in silence for a while. -Encourage client to verbalize feelings.

-Help the client reestablish what is real and unreal. Validate the clients real perceptions, and correct the clients misperceptions. Dependent: -Administer antipsychotic (such as Risperidone) and other drugs as ordered.

Responding to simple questions Being able to provide self -Providing support and encouragement during the care such as experience increases the patients sense of security and urinating, control. Positive reinforcement enhances self-esteem. defecating and bathing (with -Presence, acceptance and conveyance of positive supervision) regard enhance the clients feelings of self-worth. Eating food from trays and takes medications -Your presence may help improve client's perception of self as without a worthwhile person. Physical presence is reality. evidence of mistrust. -Verbalization of feelings in a nonthreatening Continuing environment may help client come to terms with long compliance with unresolved issues. medication regimen -Reality must be reinforced. Reinforced reality and behavior will recur more frequently.

-Anti-psychotic drugs affect neurotransmitters that allow communication between nerve cells. Giving medications promptly helps ensure that the patient's thought processes are decreased. Risperdal is a monoaminergic antagonist of D2 and 5-HT2 postsynaptic. It is indicated for the management of the manifestations of psychotic disorders.

ASSESSMENT Subjective: - Nandyan lang yan si tatay di gumagalaw, tumatayo lang pagkakain, as verbalized by the staff who takes care of the client Objective: - Client sitting on bed, hands clasped together - Hands shake when moved - Inactivity - Disorientation - Mute when not asked - Reduced emotional expression, - In a stare - Blank facial expression - No eye contact when conversed with - Social isolation - Prolonged sitting position

NURSING DIAGNOSIS Impaired motor activity r/t catalepsy secondary to catatonic schezophrenia as manifested by immobility

RATIONALE The patient is unable to do ADLs or any activity due alteration in the connections of neurons. Impaired motor activity is not a disease in itself but may be a characteristic of a catholic catatonic. Slowed, limited movement and report of discomfort

OBJECTIVES After 6 hours of nursing interventions, the patient will be able to manifest an optimum mobility level as evidenced by: Demonstrating techniques that enable resumption of activities Maintaining position of function performing activities of daily living (ADLs) and desired activities maintaining skin integrity

NURSING INTERVENTIONS Independent: -Assess degree of immobility produced by injury/treatment and note patients perception of immobility.

RATIONALE -Patient may be restricted by self-view/self-perception outof proportion with actual physical limitations, requiring information/interventions to promote progress toward wellness. -For continuous monitoring of clients status. -Patient may be restricted by self-view/self-perception outof proportion with actual physical limitations, requiring information/interventions to promote progress toward wellness.

-Monitor vital signs. -Encourage participation in recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, and visits from family/friends. -Assist with/encourage self-care activities (e.g., bathing, grooming).

EVALUATION After 6 hours of nursing interventions, the patient was able to manifest an optimum mobility level as evidenced by: demonstrating techniques that enable resumption of activities maintaining position of function performing activities of daily living (ADLs) and desired activities maintaining skin integrity

-Provides opportunity for release of energy which refocuses attention, enhances patients sense of selfcontrol/self-worth, and aids in reducing social isolation. -Allowing the patient to participate in self-care promotes independence and feelings of self-control.

-Encourage the patient to perform ADLs (as tolerated) and to participate in decisions about self-care. -Reposition periodically and encourage coughing/deep- breathing exercises.

-Early mobility reduces complications of bed rest (e.g., phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety. -Useful in creating individualized activity/exercise program. Patient may require longterm assistance with movement, strengthening, and weight-bearing activities, pickup sticks/teachers; special eating utensils. Ambulation promotes feelings of independence and increases the likelihood that the patient will socialize and engage in age-appropriate activities. Such activities promote normal development and mobility.

-Encourage the patient to socialize by ambulating (assistance is necessary).

-Provide the patient with age-appropriate activities, such as television and reading materials, other recreational activities possible.

Dependent: -Administer antipsychotic (such as Risperidone) and other drugs as ordered. .

-Anti-psychotic drugs affect neurotransmitters that allow communication between nerve cells. Giving medications promptly helps ensure that the patient's thought processes are decreased. Risperdal is a monoaminergic antagonist of D2 and 5-HT2 postsynaptic. It is indicated for the management of the manifestations of psychotic disorders. In this case, this medication may reduce the clients stupor state.

ASSESSMENT Subjective: - Client did not want to join any activity that was provided. Client did not want to go outside. The staff mentioned that the client just goes out for food. When the client was asked about his family, client did not respond and became teary eyed. Wala na, as verbalized by the client when asked about his family. Objective: - Client sitting on bed, hands clasped together - Hands shake when moved - Inactivity - Disorientation - Mute when not asked - Reduced emotional expression, - In a stare - Blank facial expression - No eye contact when conversed with - Social isolation

NURSING DIAGNOSIS Social isolation r/t altered mental status as evidenced by inability to engage in personal relationships, uncommunicativeness and inadequate emotional responses.

RATIONALE The client experiences aloneness. He states that his family is gone and he doesnt know where they are anymore.

OBJECTIVES After 6 hours of nursing interventions, the patient will be able to develop basic social skills as evidenced by: Answering questions with appropriate answers

NURSING INTERVENTIONS Independent: -Monitor vital signs. -Provide emotional support, positive reinforcement.

RATIONALE -For continuous monitoring of clients status. -Providing support and encouragement during the experience increases the patients sense of security and control. Positive reinforcement enhances selfesteem. -Your presence may help improve client's perception of self as a worthwhile person. Physical presence is reality. Being emotionally present and authentic fosters growth in relationships and decreases isolation -Presence, acceptance and conveyance of positive regard enhance the clients feelings of self-worth.

EVALUATION After 6 hours of nursing interventions, the patient was able to develop basic social skills as evidenced by: Answering questions with appropriate answers

-Spend time with client; sit in silence for a while.

-Develop a therapeutic nurse-client relationship through frequent, brief contacts and an accepting attitude. Show unconditional positive regard. -Encourage client to verbalize feelings.

-Verbalization of feelings in a nonthreatening environment may help client come to terms with long unresolved issues.

Dependent: -Administer antipsychotic (such as Risperidone) and other drugs as ordered.

-Anti-psychotic drugs affect neurotransmitters that allow communication between nerve cells. Giving medications promptly helps ensure that the patient's thought processes are decreased. Risperdal is a monoaminergic antagonist of D2 and 5-HT2 postsynaptic. It is indicated for the management of the manifestations of psychotic disorders. In this case, this medication may reduce the clients stupor state which is a factor in social isolation.