Mindanao State University

Iligan Institute of Technology

DEPARTMENT OF NURSING

Name of Student: GROUP G Date: March 20, 2009 Clinical Instructor: Ma’am
Mae-Lanie Poblete

ASSESSMENT FORM

I. SOCIO-ECONOMIC PROFILE

Patient’s Name: Abraham Sereño Age: 28 Gender: Male

Address: Sitio, kawayan, B. Rodriguez Ext. Sambang II, Cebu City Religion: Roman
Catholic

Birthdate: November 4, 1980 Birthplace: Cebu City

Marital Status: Single Weight: not taken Height: 5’8”

Dominant Language Spoken: Cebuano

Diagnosis: Schizophrenia Paranoid Type

Family Genogram:

Abraham's Family Genogram

Mother Aunt
Father

1980 1982
27

Abraham Arman

LEGEND

Male Female

Affected w / Disease Mental Disorder

Close Relationship Hostile Relationship

Sister Brother

II. HISTORY OF PAST ILLNESS

 Year 1999, the client was 19 years old, he felt frustrated when he was a college student,
and this is triggered when he failed in some of his subjects. The client showed agitated
behaviors and increased nervousness, he even punched his father because of this. In his
school, h showed patterns of suspiciousness among people, he is unable to distinguish the
green color of the leaves and reports wilted or dried appearance, and vision is limited in a
straight path. His first admission was in Cebu Doctor’s Hospital, and was not diagnose of the
present disease. The doctor administered Risperidon and Thorazine for this following
admission.

Six months later, the client was admitted to Vicente Sotto Memorial Medical Center, Center
for Behavioral Sciences and was diagnosed with SCHIZOPHRENIA PARANOID type. He was
rehabilitated there for a long period. His schizophrenic symptoms were triggered by different
reasons. June of the same year, he got home and displayed agitation, feelings of tension,
anger, and hyper vigilance to their neighborhood; he even threw stones at them. The reason for
this behavior was because of the disease process.

The client was then admitted to the same hospital, VSMMC, with the same diagnosis, and
stayed there until the present.

III. HISTORY OF PRESENT ILLNESS

9 years PTA, patient was a working student, and started missing meals, “mukalit lang siya
panumbag ug masuko lang ug kalit, isog na kaayo siya, unya igkahuman maghinuktok, dili na
dayon ganahan mukaon, magsige na lag yawyaw”. Sought consultation with private physician,
given Risperidone, no improvement noted. Condition kept recurring. Had regular follow-up at
psychia OPD with no improvement noted.
6 months PTA, patient was readmitted due to episode of violent behaviors. There was
minimal improvement of patient’s condition still with forms of violent behaviors. 2 days PTA,
patient become violent thus, they’ve decided to admit the patient.

IV. FAMILY HISTORY

A case of 28 years old, male, Roman Catholic from Sitio Kawayan, B. Rodriguez Ext.
Sambang II, Cebu City was admitted at VSMMC Psychiatric Ward due to behavioral changes
(hostility, hyper vigilance, delusions and hallucinations).

Their family belongs to the middle class. His mother was at first an Avon dealer, but as of
now she doesn’t have any occupation. He was the eldest in the family. He has a younger
brother. His mother’s pregnancy had a normal cycle, no chronic illness were stated when his
mother was childbearing. With the normal cycle of pregnancy, the patient was delivered
normally (NSVD) at 9 months full term.

The patient was delivered properly without any complication and was completely
immunized. The patient has a mixed or combination of both breastfeeding and bottle feeding.
He only experienced fever, chicken pox, and dengue.

“Na-busy man gud ko sa akong trabaho sa Avon, nganong wala nako nabantayan katong
bata pa siya” claimed by the mother. Accordingly, he is closer with his mother and his younger
brother Arman than to his father. The patient sought attention from his parents and thus made
ways to attain this.

The patient was an intelligent person as claimed by his mother:”Honor siya katong
elementary ug highschool siya, best in math pud siya. Maayo pud siyamag-chess. Maayo man
pud siya nga bata kay kung naa siya’y sala sa amo kay mangayo ug pasailo. Katong grade 5
siya kay nakahithit na siya ug marijuana, gikulata ug hubuan siya ug paka-ulawan sa iyahang
mga silingan”. The patient was a working student and had good performance in his college
studies.
 According to the family’s genogram, the mental disorder that was traced begin at his aunt,
this becomes a risk factor for the succeeding generation. The patient was one of the family
members which is affected with a mental disorder which is schizophrenia.

SOCIAL & PESONAL HISTORY

Client is an occasional alcohol drinker; numbers of bottle vary depending on the occasion.
He is not a tobacco user. Mother stated that he has been using marijuana, and was not trace
when he stopped. The client is so close with his mother and with his younger brother when he
was still mentally healthy.

V. Mental State

A. General Description

> Appearance

Grooming: Patient’s grooming is not well-fitted. He takes a bath but does not use
soap, just the water; he doesn’t scrub his body, leading to retained dirt and when he
scratches any part of his body, black debris can be noticed, especially in the neck and
inguinal area. He rarely changes clothes but if he does, he prefers the white t-shirt
paired with the green pajamas.

Hygiene: He has unkempt hair because he doesn’t comb it; he also has long,
untrimmed and dirty nails on both hands and feet; he has dried, orange like sebum
located near the opening of his left and right ears. He has missing teeth, with
cavities on the front teeth and left 2nd molar; food particles can be found surrounding
the mouth because he doesn’t brush his teeth.

Eye Contact: Patient is observed to have good eye contact to topics not sensitive for
him. However, if certain topics such as about his father, he refuses to maintain the eye
contact and prefers to bow down.

Posture: Patient has a straight forward posture and has a steady gait.

Identifying features: Patient has a wound on his left buttock, which is in its scar
formation stage. He has no birthmarks, tattoos, and any more scars in his body.

Appearance over stated age: As observed, the patient appears to be younger than
his stated age.

Overall Appearance: Generally, self-care deficit can be noted due to neglect to

needs.

> Behavior

Patient tends to resist talking about familial topics and manifests this hesitation
through walking out from the student nurse during interaction. The patient displays an
inappropriate expression of emotions as manifested by the giddy laughter for no
apparent reason.

Sometimes, he can be observed to have anhedonia and depressed for a while and
conversely, he displays a behavior of being elated especially during episodes of
psychosis. And also, he suddenly becomes agitated, nervous, and tense and frequently
scans people around him, like being a suspicious person.

He has been observed to have short attention span as evidenced by his no

participation to any therapies.

When his mother visits him, he acts like a child in front of her, as if clinging to him
and student observed that when his mother is not talking to him, he attempts to get his
mother’s attention back by turning her face towards his direction.

Patient has no tics, no tremors, no catatonias, no rigidity, no akathisia and no

unusual facial movements like jaw/ lip smacking.
 Patient becomes angry when not granted what he asked for such as food and
scriptures. He is suspicious and guarded about disclosing personal information.

> Communication

Articulation is slurred but can be understood. The pace of conversation is slowed,

pressured speech noted with moderate tone of voice. He can speak Cebuano fluently.
He is manifesting perseveration and is sometimes hesitant to answer questions that are
sensitive such as those relating to his family specifically to his father. He sometimes
talks in a hushed and secretive tones.

VI. Emotional State

> Mood

The patient also becomes irritable if asked by the usual question like, “how are you?”
and when student cannot provide what he likes such as chocolates and scriptures of
Jesus.

> Affect

Overall, the patient Sometimes, patient displays no facial expression (flat affect)
during interaction. And some other times, the patient shows only a few expressions
(blunted affect). The patient also displays an inappropriate expression of emotions as
manifested by the giddy laughter for no apparent reason.

> Perceptions

The patient has visual hallucination of a guy named Adrian, whom he says is his
best friend, and that Adrian just passes into the walls. Pt. often tells his student nurse that
they must not talk too much so that Adrian will not get jealous.

The patient has auditory hallucinations of someone telling him or commanding him
to do something violent towards others.

Aside from hallucinations, patient displays no other perceptual disturbances.

> Thought Content

Patient has persecutory delusions. He thinks that the “NPA” are planning to harm
and kill him. He also shows religious delusions. He often thinks that Jesus is talking to Him
or communicates directly to him. Other than that, he shows no other type of delusions.

Patient also has suicidal thoughts, as stated by his mother and has also attempted
suicide before hospitalization. He also has homicidal thoughts toward a guy named
“Jason”, whom was described by the patient’s mother as one of their neighbors who
humiliated his son before.

The patient’s paranoia is that he suspects that the people around him are talking
about him and starts to become threatened and nervous.

He also has obsessions about the scriptures of Jesus and English prayers as
evidenced by his full memorization of them.

Other than that, he has no phobias and no magical thinking.

> Thought Process

Patient’s thought process is disordered and the continuity of thoughts and

information processing are disrupted. He answers questions being asked but sometimes
gives unrelated answers and never leading into the original question. He also has tendency to
stop talking suddenly in the middle of the conversation and jumping into another topic
such as when asked to talk about his father he suddenly stops talking and interestingly
shares his belief about Jesus. He is also manifesting flight of ideas and perseveration.
VII. SENSORY AND COGNITION

> Level of Consciousness

Patient is awake/ readily aroused, fully aware of external stimuli and responds to stimuli,
ex. When asked by the student he answers appropriately. Patient is oriented to person and
place, but sometimes when the patients displays inappropriate mood, he doesn’t answer the
SN appropriately. The patient was unable to name the SN but can identify by appearance.
However, he is disoriented to time because he was not able to answer the question, “what date
is today?” accurately.

> Memory

The client was able to remember the things asked by the SN. This indicates that recent
memory is intact and well functioning. For the remote memory, the SN assessed this by asking
questions about past events, he is able to recall past events but some parts of these events
were repressed by the patient and avoids answering them.

> Level of Concentration and Calculation

The patient was able to answer the calculation but doesn’t continues to answer, the SN
asked him to spell the word “world” backwards and he was able to spell it properly. The client
has short attention and is easily distracted, this is evidenced by non-participating in any
therapies. His concentration is decreased due to auditory hallucinations which he manifest.

VIII. PSYCHODYNAMICS
A.GENETICS:

According to Videbeck, chapter 14 pages 278-279, genetics played a significant role in

the acquisition of schizophrenia. Most studies focused on relationship on parents, siblings and
off springs. The closer the relationship is the greater the risk of developing it. Twins have 50%
of getting the same illness and siblings have 15% of doing so. Children with one biologic parent
with schizophrenia have also 15% of risk, and the risk rises to 35% if both biologic parents
have schizophrenia. In the case of the patient, her parents are not schizophrenic, but on her
mother side, her mother’s sister had mental illness. This may have predisposed the patient to
develop schizophrenia.

B. NEUROCHEMICAL

Dopamine is an excitatory neurotransmitter which controls complex movements,

motivation, cognition, and regulates emotional response. Alteration of this neurotransmitter, in
which the neuronal networks that transmit information by electrical signals from a nerve cell
through its axon and across synapses to postsynaptic receptors on other nerve cells seem to
malfunction, is implicated in Schizophrenia and other psychoses because the transmission of
the signal across the synapse requires a complex series of biochemical events,and thus the
increase of dopamine causes schizophrenia.

Serotonin is an inhibitory neurotransmitter which controls food intake, sleep and

wakefulness, temperature regulation, pain control, sexual behaviors and regulation of
emotions. It is one of the leading neurochemical factors affecting schizophrenia. It suggests
that serotonin modulates and helps to control excess dopamine. Thus the excess of serotonin
itself contributes to the development of schizophrenia. It has been found to contribute to the
delusions, hallucinations, and withdrawn behavior seen in schizophrenia.

C. INTRAPSYCHIC
 The patient and patient’s family belongs to the religion, Roman Catholic. Although they
live in a rural setting, they don’t have superstitious beliefs. The patient’s religion believes in one
God with a triune person; they also believe in saints. It also nurtures friendship and brotherly
love for one another.

Within patient’s self, he has a struggle between trust and mistrust. Before the onset of
recent illness, the patient started to build a positive intrapsychic condition by acquiring social
contact with churchmates.

D. PSYCHOSOCIAL:

Infancy: - Mistrust

According to Erikson as sited in Wikipedia, the concept of trust vs. mistrust is present
throughout a person’s life. Therefore, if it is not handled carefully, it may come up anytime
during adulthood. According to S.O., the patient was breastfed, but was not carefully nurtured
as a child. The pt’s S.O. admitted that they constantly neglected their son as a child because of
the reason that they needed to work to provide their children’s needs the best they could.
Because of that, the pt would always find a way to get attention from his parents. He grew up to
be a very obedient young boy, smart and talented in his own way. He was a chess player, an
achiever, and a good guitarist. He was also very religious, and would be the one who
convinces his family to go to church and attend mass. He was very loving towards his family,
and would always say sorry every time he did something wrong.

However, his bad luck started when he was in the fifth grade of elementary. Their
neighbors would always tease him and make him do things against his will. They would bare
him naked in the streets, and in front of others. The worst thing was, they made him use
prohibited drugs. It continued until college, when another thing came up. The patient failed in
his accountancy subject for the reason that he was unable to focus during the examination
because he was already abusing drugs. That was when he got very embarrassed and had an
outburst of behavior. “Nagwild na siya. Iyang gisumbag iyang papa,” according to pt’s mother.
Still, he continued attending classes, but since then, he became very suspicious and mistrustful
of others. “ Musulti na siya sa ako nga paminaw daw niya kay ginalantaw siya sa tanan. Dayon,
straight ra iya makita. Mahugaw gud na siya usahay kay maabot man siya sa kanal ug lakaw,”
according to pt’s mother.

Toddler: - Autonomy

According to Erikson, during the toddler stage, a child must be allowed to explore and
be trained for bowel and bladder training. If this is mastered, autonomy will develop. In the
case of the patient, he was allowed to explore things he wanted, he was given choices. He was
taught bowel and bladder training in a not strict and not laxed manner. He was able to master
complete bowel and bladder training at the age of one and a half years old. Because of this,
the patient developed independence, generosity, ability to delay gratification, self-control and
cooperativeness. In this area, patient is successful.

Preschooler: - Guilt

According to Erikson, in the preschooler stage, the child begins to learn things around
him. He may learn basic skills, count and speak with ease. Thus, it is very important that a child
should be given gender-specific toys and plays with same-gender children for him to be fully
aware of his environment, and of himself. However, guilt is a new emotion that will arise and
this may confuse the child. He may feel guilty over things he should not be. In the case of the
patient, he was not able to rule out which actions should he be guilty of and which he should
not. According to his mother, pt would always find a way to get attention. He was jealous of his
younger brother when they were still small. Pt also gets very excited when given a new toy to
play with. “ Dili na siya katulog basta naay bag-ong dulaan”, according to mother. Pt feels guilty
when he did something wrong and unacceptable, and he would readily ask for forgiveness
from his parents. Pt also experienced much embarrassment when he failed his subject. In
addition to that, he became reluctant to show his emotions to others and avoids activities for
pleasure.

School Age: - Industry

In this stage, children are becoming more aware of themselves as individuals. They
work hard at being responsible, being good and doing right. In the case of the patient, during
her elementary days, the patient worked hard to study, to do well. The patient learned reading,
writing, telling time. All these efforts were supported by his parents. He was encouraged to
learn more. Thus, the patient developed industry. According to parents, pt is an achiever. He is
also good at playing chess, and guitar. He is obedient and not rebellious.

Adolescence: - Identity

According to Erikson, during the stage of adolescence, a person would seek to develop
fixed sexual identity. The question “who am I?” must be clearly answered. The person’s search
for identity is manifested by patient’s choice of career. In the case of the patient, he was able to
make decisions for himself. He was also able to know who he is and what he is. He was also
able to choose his own career. All his efforts to pass this stage was supported, thus identity
was developed.

Young Adulthood:

According to Erikson, the stage of young adulthood is the stage where young adults
form loving relationships and meaningful attachments to others especially to the opposite sex.
In the case of the patient, he was not able to form long lasting relationships with the opposite
sex. According to his mother, pt was a “chick boy” during his adolescent years. Pt also claimed
of having twelve girlfriends in the past.

However, later in the year 1999, pt fell in love with someone very special to him. This
was, according to his mother, the one he treated seriously. The relationship lasted for a while,
but soon came to an end because the girl went to Hongkong to live with her family. That was
his very first real heartbreak. Pt did not have any intimate relationship after that. It was, along
with other stressors of his life, may be one of the reasons for his present condition.

E. PSYCHOSEXUAL:

Oral Stage:

During this stage, the focus of gratification is on the mouth and pleasure is the result of
proper nursing; also, because of exploration of the surroundings as infants tend to put objects
in their mouths. In the case of the patient, he was breastfed as a child but did not receive
consistent maternal care. As a result, the patient demonstrated fixation in this stage- paranoia.
The student nurses conduct that this has developed because even though he was breastfed, pt
was not properly taken care of as a child. He was also abused by their neighbors. This might
be the reason why he found it hard to trust others, and have intimate relationships with the
opposite sex. This is also congruent to Erickson’s theory that the conflict trust vs. mistrust
continues throughout a person’s life.

Anal Stage:

The major experience during this stage is toilet training and the area of gratification is
the anus. This conflict must be resolved gradually; not strict so that patient will not develop
OCD, nor lax so patient will not develop passive aggressive personality disorder, nor
dysfunctional so patient will not develop borderline personality disorder. In the case of the
patient, his toilet training was moderate, gradual and non-traumatic. According to mother, the
patient was asked to voice out need for bowel/bladder release and he would be assisted to do
so. Complete bladder/bowel training without assistance was achieved when he was one and a
half years old. Thus, pt was able to achieve gratification at this stage.

Phallic Stage:

This stage is focused on the genitals as the main area of gratification. Although the
genitals are the area of gratification, this does not refer to the sexual relationship adults have.
Stimulation of the genitals is welcomed as pleasurable. In this stage also, children seek
attachment by trying to find out who among their parents carry the same genitals like them.

In this stage, the conflicts Oedipus and Electra conflicts arise. The ego resolves this by
repression, and identifying one’s genitals with the parents. In the case of the patient, he
underwent stage of stimulating genitals for pleasure. Fortunately, the patient did not fixate in
this stage because he was able to identify himself with his father. However, pt is not close with
his father for some reasons pt did not disclose.

Latency Stage:

Latency stage is the stage of dormant sexual feelings. In this stage, the child’s attention
is diverted to play. This is the result of the resolution of Electra and Oedipus complexes through
the repression of the phallic stage. In the case of the patient, he was able to divert his energy
to play. According to his parents, the patient is an achiever. He is also good at playing chess,
and guitar. Children during this stage do not usually develop fixation; however if they do, it is
because of inadequate repression of the ego of the premature sexual thoughts. As a result,
they become extremely sexually unfulfilled. In the case of the patient, fixation in this stage
cannot be assessed because patient did no have any sexual relationships with his girlfriends.

Genital Stage:

This is the last stage of psychosexual development which starts on the 12 th year of age
and continues until development stops which is approximately 21st year of age. The major task
in this stage is detachment from parents and forming love relationships. In this stage, sexual
drives return but is expressed in adult sexuality. In the case of the patient, he is now 28 years
old but he still lives with his family, and was able to commit to intimate relationships with the
opposite sex but not to sexual relationships.

F. COGNITIVE THEORY OF DEVELOPMENT

Sensory Motor:

Infants are born with set of congenital reflexes. According to Piaget, the sensory motor
stage is the stage where reflexes are modified into coordinated movements and where habits
are formed. This is also the stage where a child learns object permanence. In the case of the
patient, he was able to pass successfully into this stage. He learned to walk when he was 8
months old. Pt learned to play every waking time and cry to get attention of people around him.
He was able to recognize his family even though he’s not seeing them. He knows he has
parents even when they’re not around, and he would always find them. In the later part of this
stage, the patient was able to say single words such as mama and papa.

Preoperational:

The preoperational stage is the stage when children develop their language skills. They
begin representing things with words and symbols. They also begin attributing emotions to
inanimate objects and they are fond of bedtime stories. In the case of the patient, the patient
developed full language skills at the age of 4 and learned to count at the age of 5. However,
pt’s active imagination and intuition were not fully recognized because his parents were not
always there to supervise him.

Concrete Operational:

This stage proceeds from pre-logical to concrete thoughts. The child learns the
concepts of conservation, reversibility, classification, and inductive reasoning, as well as
concepts of morality, numbers, and spatial relationships. In the case of the patient, he,
according to his mother, is very good in academics. He is also very religious, obedient, and has
a high regards for moral values. The student nurses therefore conclude that the pt passed this
stage successfully.

Formal Operational:

This is the last and final stage of cognitive development. The student nurses conclude
that the patient does not have problem in this area because he was able to acquire ability to
think abstractly, reason logically, use critical thinking, and draw conclusions from careful
investigation of things.

G. ENVIRONMENTAL FACTORS:

According to Wikipedia, environmental factors such as social adversity, urbanicityand

failed close relationships cannot cause but can precipitate schizophrenia. In the case of the
patient, experiences like inattention from parents, social embarrassment from persons in their
community who belittle him, failure in academics, and heartbreak from intimate relationship
precipitated the development of paranoid schizophrenia. The patient started to be suspicious
of others; he became very mistrustful of people and environment, thinking that they are trying
to persecute him. He became anxious when he is in public places, giving rationalization to his
being socially isolated.

The patient’s signs and symptoms of schizophrenia were controlled by medicines. The
patient was in and out of the mental institution because his psychotic episodes are intermittent,
until recently, when he constantly displayed violent behavior towards other people, and he can
not be controlled by his parents anymore. Thus, pt was admitted permanently in the mental
institution, staying for treatment and rehabilitation up to the present.

PREMORBID TRAITS

After asks for forgiveness

Excel at class (best in math) always on the top 10
Good in playing chess (was featured at magazine as a “player to watch”.
Respectful
Helpful
Religious
Chick-boy
Not into groups
Good in playing guitar
Obedient
Protective
Hard working
High regards for privacy
Loving
Attention-seeker

PRECIPITATING FACTORS

DEFENSE MECHANISM

MALADAPTIVE BEHAVIORS

SCIZHOPHRENIA PARANOID TYPE

POSITIVE/HARD Sx:
NEGATIVE/Soft Sx

DESCRIPTION