Table of Contents I. Introduction -------------------------------------------------------------------------------------------------2 A. Background of the Study -----------------------------------------------------------------------------2 B.

Significance of the Study -----------------------------------------------------------------------------3

II. Psychiatric Nursing Assessment --------------------------------------------------------------------4 A. Patients Profile -----------------------------------------------------------------------------------------4 B. Chief Complaint -----------------------------------------------------------------------------------------4 C. History of Present Illness -----------------------------------------------------------------------------4 D. Past Medical History -----------------------------------------------------------------------------------4 E. Past Psychiatric History ------------------------------------------------------------------------------4 F. Familial History -----------------------------------------------------------------------------------------4 G. Personal History ----------------------------------------------------------------------------------------4 H. Mental Status Examination --------------------------------------------------------------------------5 I. Impression/Diagnosis ---------------------------------------------------------------------------------7

III. Clinical Discussion of the Disease-------------------------------------------------------------------8 A. Psychodynamics

---------------------------------------------------------------------------------------8

B. Psychopathophysiology------------------------------------------------------------------------------9

C. Laboratory and Diagnostic Examination

--------------------------------------------------------10

D. Drug Study
---------------------------------------------------------------------------------------------12

IV. Nursing Care Plan ---------------------------------------------------------------------------------------14 A. Problem List ---------------------------------------------------------------------------------------14 B. Nursing Care Plan -------------------------------------------------------------------------------15

V. Process Recording --------------------------------------------------------------------------------------17 VI. Psychotherapies -----------------------------------------------------------------------------------------38 VII.

Bibliography -----------------------------------------------------------------------------------------------41

APPENDICES ---------------------------------------------------------------------------------------------------42 Mental Status Examination ---------------------------------------------------------------------------------A Process Recording --------------------------------------------------------------------------------------------B Reflection ---------------------------------------------------------------------------------------------------------C

I. INTRODUCTION A. Background of the Study

Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood. Diagnosis is based

on the patient's self-reported experiences and observed behavior. No laboratory test for schizophrenia currently exists.

The symptoms of schizophrenia are categorized into two major categories, the positive or hard symptoms which include delusion, hallucinations, and grossly disorganized thinking, speech, and behavior, and negative or soft symptoms as flat affect, lack of volition, and social withdrawal or discomfort. There are 5 categories of schizophrenia: Catatonic, Disorganized, Paranoid, Residual, and Undifferentiated. Catatonic schizophrenia involves a disturbance in movement, voluntary movement for prolonged periods of time. Disorganized schizophrenia involves, a disorganized thought process emotionally, mentally and verbally. Paranoid schizophrenia is primarily characterized by hallucinations and delusions (perhaps about persecution or conspiracies directed against the sufferer). Residual schizophrenia is diagnosed when the patient isn't really displaying significant symptoms. The person is no longer in an acute schizophrenic phase, but may experience symptoms that are either less frequent or less severe than they were during the peak of the disorder. Undifferentiated schizophrenia is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. It is diagnosed when one doesn't have the full symptoms of one of the other subtypes. In this study, undifferentiated schizophrenia will be used for the case analysis.

Worldwide about 1 percent of the population is diagnosed with schizophrenia. About 1.5 million people will be diagnosed with schizophrenia this year around the world. (mentalhelp.net). Ninety-five percent (95%) suffer a lifetime; thirty-three percent (33%) of all homeless Americans suffer from schizophrenia; fifty percent (50%) experience serious side effects from medications; and ten percent (10%) kill themselves (Keltner, 2007). According to study done 697,543 out of 86,241,697 of Filipinos or approximately 0.8% are suffering from schizophrenia (cureresearch.com).

Undifferentiated Schizophrenia is manifested by pronounced delusions, hallucinations, and disorganized thought processes and behavior. The undifferentiated subtype is diagnosed when people have symptoms of schizophrenia that are not sufficiently formed or specific enough to permit classification of the illness into one of the other subtypes. Patients in this category have the characteristics of positive and negative symptoms of schizophrenia but do not meet the specific criteria for the paranoid, disorganized or 3

catatonic subtypes. Onset of symptoms typically occurs in young adulthood with around 1.5% prevalence of the population affected. The disorder is thought to mainly affect cognition, but it also usually contributes to chronic problems with behavior and emotion Undifferentiated schizophrenia is a difficult diagnosis to make with any confidence because it depends on establishing the slowly progressive development of the characteristic negative symptoms of schizophrenia without any history of hallucinations, delusions, or other manifestations of an earlier psychotic episode, and with significant changes in personal behavior, manifest as a marked loss of interest, idleness, and social withdrawal. It can be also based on the self-reported experiences of the person, and abnormalities in behavior reported by family members, friends, or coworkers, followed by a clinical assessment by a mental health professional. Diagnosis of undifferentiated subtype may best describe the mixed clinical syndrome.

B. Significance of the Study General Objective: The main objective of this case study is to be able to present an extensive and comprehensive case study of the chosen client that would present a comprehensive discussion of Schizophrenia, Undifferentiated to yield important information for this case analysis. Specific Objective: In order to meet the general objective, the group aims to:

Assess and interpret the pertinent data gathered from the patient Determine the etiology factors (precipitating and predisposing) of the mental disorder Evaluate the presence or absence of signs and symptoms seen in the patient in relation to the mental disorder Formulate effective, specific, measurable, attainable, realistic and time-bounded nursing care plans base on identified actual and potential nursing problems Provide appropriate nursing care directed towards not only to the clients psychological but also his physical well-being

II. PSYCHIATRIC NURSING ASSESSMENT A. Patients Profile Sir J is a 47 year old, male, Filipino and Roman Catholic. He is single and was born on April 4, 1963 in Occidental Mindoro. He lives at San Miguel Heights, Valenzuela City. His educational attainment is Vocational. The date of his admission is December 4, 4

2006 (Re-admission) with Schizophrenia, unstable. B. Chief Complaint

an

admitting

Diagnosis

of

F20.3

Undifferentiated

According to his sister in law, Di natutulog, ayaw uminom ng gamot, nagwawala at mainitin and ulo. C. History of Present Illness The patient has been mentally ill since 1990. He was readmitted on December 4, 2006 in National Center for Mental Health with the same diagnosis. He had an irregular check-up until his significant others noticed that he doesnt sleeps, doesnt want to take medicines, became short tempered and showed irrational behavior. D. Past Medical History He has no history of seizure. Prior to admission, the patient was non-diabetic, non-hypertensive, non-asthmatic. E. Past Psychiatric History He was mentally ill since the onset of attention of crisis during 1990s. He had an irregular check-up until he was observed to become non-functional at home and became distracted. Hence, his family readmits him in the same institution. F. Familial History His father is deceased. There were no histories of diabetes mellitus, or suicide attempts in the both side of his family. There is no trace of any mental disorders in the clients family. G. Personal History The patient is a vocational graduate. He smokes cigarette and drinks alcoholic beverage but with no use of illegal drugs. He has no suicidal and homicidal tendencies. According to the patient, he studied for 2 years and work as a seaman, radio operator, guard, imprinting shirts and a magtatabako. He was self-supporting student and he said that his family is famous in their place though he is poor and he is ill. H. Mental Status Examination

H.1 General Appearance and Behavior

The patient is tall and thin in terms of muscularity, with fair brown complexion, and has short black hair with strands of white. He has wounds and lesions on right and left elbow and has diabetic feet. On the first day of the nurse-patient interaction, he had his clothes kept not that clean and pleasant. However on the second day, he had taken a bath and his uniform was neatly pressed. He also shaved his beard. He has a hoarse, husky and rough voice and intonation. He walks slowly with a shuffling gait. He sits with his legs crossed and taps his one foot at times. When he hears his name, he looks to his side and see who is calling. At times, he leans forward while talking, still maintaining good and straight eye contact throughout the interaction. His eyes are dilated at times but respond to light. H.2 Affect The patient displayed a blunted or restricted affect during the first minutes of the interaction, and once in a while, showed generally appropriate affect. In an objective manner, he appears to be serious but he was able to smile for a second especially if he feels that way. H.3 Mood During the interview, he stated that he knows he has a problem and he is ill. He was worried about his feet and kept repeating that he needs bayabas. He is used to touch his head part and sometimes, his face. Objectively, he appears to be concern on his situation while looking at his feet. Once in a while, he smiles especially if the topic is worth smiling for.

H.4 Thought Processes

The patient speaks in a loud and spontaneous manner. He speaks Filipino all the time. His speech is sometimes unclear and there are words that are poorly articulated making it difficult to understand. His thoughts are generally logical, and answer the questions being asked to him by the student nurse. He also manifests looseness of association but he still manages to answer some questions. Sometimes, he also manifest blocking but returns to function immediately. He is quite circumstantial, answers questions but includes unnecessary details and skips one topic from another having flight of ideas, looseness of association, perseveration and tangential thinking.

H.5 Thought Content

The client believes that his family is famous and well known by other people. Moreover, he is also preoccupied with thought that he is infertile and he is not good on making love, thats why his past girlfriends left her. In addition, he feels unworthy of himself especially regarding the condition of his feet. He likewise said that his father is in Guam, when in fact his father already died. Furthermore, he is inconsistent in remembering real situations that happened to him. (About his occupation: he graduated on a vocational course). Other than that, there were no noted signs of hallucination or any illusion. H.6 Cognitive Evaluation

The patient is fully awake and alert throughout the interview and is oriented to time, place where he is, person who is with him, and date of the interaction. He was able to: spell the word Japan and Salamat, count 1 to 10 and count it backwards, and recite the alphabet completely from A to Z. On the first day, the meaning of Konnichiwa is interpreted to him. And on the second day, he was asked about its meaning again and he was able to remember it. Patient has a recent memory intact for 2/3 words (Langit, lupa, puno) given to him during the first minutes of interview. He forgot the last 7

word for two consecutive times. When he was asked about his favorite song, he said that he loves many songs but was unable to enumerate even one. He is also able to answer simple mathematical calculations such as addition. He was able to recite a poem entitled Tutubi and interpret a proverb in accordance to his understanding. And when he was already on his room, he was shouting the 3 words (Langit, lupa, puno) correctly and in sequence. In addition, he was not able to recall 4 historical events and forgot 1 past president in the Philippines.

H.7 Insight

Patient knows that he has problem that is why he was admitted at the hospital. He also thinks that the reason why he is not allowed to leave the hospital and go home is because the doctors there are studying him especially the condition of his feet. According to him, he always asks the nurse to give him bayabas so that it will heal immediately but he said that they always refuse. He knows that his wound is treated with the use of medicine instead of herbal. He also made mentioned that he is more like of a prisoner because he was in the hospital for 24 years already unlike the prisoner who suffers only on the jail for 10 years. He is already tired of complying with his medicines but he said that he needs to take his drugs everyday so that he can already go home. He is also able to identify the reason why he was admitted in the institution by saying Nambabastos daw ako sabi ng hipag ko kaya pinasok nila ako dito. He was able to cope up in his stay in the hospital but still desire to be with his family. H.8 Judgment

The patient has fair and sound decisions regarding his everyday activities in the hospital. He cooperates well with the therapies he is engaging too. He is ready to answer questions asked by the student nurse. He said that when he will be able to go back in his home, he will just take a rest and have fun. 8

I. Admitting Diagnosis: F20.3 Undifferentiated Schizophrenia, unstable III. CLINICAL DISCUSSION OF THE DISEASE

A. Psychodynamics

Psychodynamics evolved from the work of Bleuler and Freud. Their works indicate that schizophrenia developed because of the psychic alterations that occurred within a person. In addition, these alterations are contingent on the poor caregiving that is provided within the childs environment. However, they believed that the psychic alterations are somehow tied to the genetic or physiological changes that develop within the childs environment.

DIATHESIS STRESS THEORY in Patients with Schizophrenia:

Individuals develop Schizophrenia based on the interactions of a number of factors. Like in the case of our patient who was diagnosed to have Undifferentiated Schizophrenia, unstable. He was a known to be a smoker and an alcohol drinker. According to him, he started smoking during his younger years and use of alcohol but in a moderate amount. This is under the environmental factor that may contribute to the development of Schizophrenia. Another factor is his interpersonal relationship. The client was not able to form a strong support system which is very essential in maintaining an individuals mental health. Its a fact that a weak support system could result to trigger behaviors or psychological disorders. All these predisposition factors are in conjunction with the presence of stressors. This model suggests that mental disorders are the result of an interaction between nature and nurture. As for our patient another possible contributory factor is the lower socio economic status that can create an environment susceptible to stress formation leading to psychological dysfunction. First, comprehensive measures of life stress give more precise information about the particular stressful circumstances hypothesized to interact with diatheses. Second, the influence of the diathesis on a person's life is typically ignored, which results in several types of possible bias in the assessment of life stress. Finally, information is available on diatheses and stress for specific disorders to provide a foundation for more empirically based hypotheses about diathesis-stress interactions. 9

B.

Psychopathophysiology
Compensatory Factors: Age (20 year oldonset) Gender (Male)

Decompensatory Factors: Lower socio economic status Environmental Stressors Lifestyle: Alcohol beverage drinker and cigarette smoker Symptom triggers: Low selfconcept

10

C. Laboratory results
Diagnostic Exam FBS Cholesterol Triglycerides BUN Normal Values 3.5 to 5.5 mmol/L < less than 5.2 mmol/L < 2.21 mmol/L 2.80 6.40 mmol/L Significant Findings 4.37 6.98 1.21 4.37 Analysis/Interpretation Normal Increased due to congested in the liver Normal Normal

*** Caligayahan Medical Clinic and Laboratory (February 19, 2010)

Diagnostic Exam Cholesterol Triglycerides

Normal Values < less than 5.2 mmol/L 90-150 mol/dL

Significant Findings 2.9 81.6

Analysis/Interpretation Normal Decreased due to metabolic syndrome characterized by excess adipose or fatty tissues.

*** NCMH (August 13, 2007)

Diagnostic Exam FBS Cholesterol Triglycerides

Normal Values 3.5 to 5.5 mmol/L < less than 5.2 mmol/L 90-150 mol/dL

Significant Findings 4.21 7.04 150.0

Analysis/Interpretation Normal Normal Normal

*** NCMH (February 9, 2007) Diagnostic Exam BUN Uric acid Sodium Potassium Normal Values 2.80 6.40 mmol/L 155.00 428.00 umol/L 136.00 145. 00 mmol/L 3.50 5.10 mmol/L Significant Findings 5.35 356.9 umol/L 139.2 mmol/L 4.8 mmol/L Analysis/Interpretation Normal Normal Normal Normal

*** NCMH (February 5, 2007) Diagnostic Exam Hemoglobin Normal Values M: 135 160 g/L Significant Findings 132 Analysis/Interpretation Decreased due to

11

abnormality or disease. Erythrocytes M: 4.5 5.0 4.48 17.2 0.02 0.04 Decreased due to enriched cholesterol Increased due to infection Normal Normal

Total WBC 5.0 10.0 10^ 9/L Monocytes 0.02 0.06 10^ 9/L Eosinophiles 0.01 0.050 10^ 9/L *** NCMH (February 2, 2007) ***NCMH (June 11, 2010) Diagnostic Exam Alkaline Phosphate SGOT SGPT Bilirubin, Total Bilirubin, Direct Normal Values 20-140 IU/L 10-34 IU/L 5-35 IU/L 0.2-1.3 mg/dL <0.3 mg/dL

Significant Findings 26.6 18.2 15.3 1.8 0.15

Analysis/Interpretation Normal Normal Normal Increased due to blockage of the bile ducts Increased due to blockage of the bile ducts

*** NCMH (December 6, 2006)

Skin Craping done on April 2, 2008 in NCMH: ROH (Preparation): (+) Fungal Elements

DIAGNOSTIC EXAMS: Radiological: (January 7, 2008) CHEST: Consider pulmonary arterial hypertension Pulmonary emphysema bilateral Fibriocalcific scarrings, bilateral old rib fracture (July 26, 2007) ECG: Non-specific ST wave changes (February 8, 2007)

D. Drug Study
12

Generic/ Mechani Brand/ sm Dosage/ of Action Classificati on Haloperi Blocks dopamine dol receptors (Haldol) in brain especially 10 g HS in limbic system/ block post antipsychoti synaptic D2 c dopamine

Indication

Contraindication

Side Effects

Nursing Responsibiliti es -Assess mental status (orientation, mood, behavior) prior to and periodically during therapy -Monitor for tardive dyskinesia (uncontrolled rhythmic movement of mouth, face, and extremities; lip smacking or puckering, puffing of cheeks; uncontrolled chewing, rapid or worm-like movements of tongue). Report immediately; may be irreversible. -Report increase in temperature, hypotension, muscle rigidity (NMS symptoms) -Ask patient to rise slowly to avoid orthostatic hypotension. 13

Acute and chronic psychotic disorders including: schizophren ia, druginduced psychoses. Also useful in managing aggressive or agitated patients.

Hypersensitivity Narrow glaucoma Bone marrow depression CNS depression

Seizures Extrapyrami dal reactions Confusion Drowsiness Restlessness Constipation Dry mouth

Generic/ Mechanis Indicatio Contraindication Brand/ m n Dosage/ of Action Classifica tion

Amlodipine 5 mg Calcium Channel Blocker Losartan Antihypertensive

Side Effects

Nursing Responsibilities

Aspirin 80 mg Analgesic

Antiinflammatory Ferrous Provides/ sulphate 1 tab replaces TID elemental iron, an essential 1 component in Iron formation of Preparation hemoglobin in red blood cell development

Inhibits influx Hyper-tension; Sick sinus Palpitations, of calcium ion chronic stable syndrome; 2nd or tachycardia, across cell angina; 3rd degree atrio- headache, membranes to vasospastic ventricular block, dizziness, produce angina. except with a fatigue relaxation of functioning coronary pacemaker. vascular smooth muscle Selectively Reduction in Patients who are Dizziness and blocks the the risk of hypersensitive to dose-related binding of cardio other orthostatic angiotensin II to vascular sulfonamidehypertension. receptor sites in morbidity and derived drugs. many tissues, mortality in especially the hyper-tensive vascular smooth patients muscles and adrenal glands. Relieves pain Treatment of Hyper-sensitivity EENT: and reduces mild-toto salicylates or dizziness; inflammation moderate pain. NSAIDS; tinnitus. GI: by inhibition of hemophilia. nausea; peripheral heartburn. prostaglandin synthesis. Dietary Hyper-sensitivity GI irritation, supplement of to any ingredient, anorexia, iron. hemosiderosis, nausea, hemolytic vomiting, diarrhea. Prevention andanemia. treatment of iron deficiency anemia.

Assess cardiorespiratory status: angina pain, B/P, pulse, respiration, ECG. Advise client to avoid getting up too fast from a sitting or lying position. Get up slowly and steady yourself to prevent a fall. Assess patients BP before starting therapy and regularly thereafter. Assess B/P and pulse. Monitor for adverse reactions.

Assess pain: character, location, intensity, ROM before and 1 hour after administration. Give with meals or after meal to avoid GI irritance. Monitor for adverse reaction: GI: nausea, epigastric pain, constipation, diarrhea, black stools, anorexia. Others: temporary teeth staining Caution patient to make position changes slowly to minimize orthostatic hypotension.

IV. NURSING CARE PLAN

A. LIST OF PRIORITIZED PSYCHIATRIC NURSING DIAGNOSIS

14

Cues Bakit ako kinuhanan noon? (BP and weight). May kaso ako? as verbalized by the patient. Buwan-buwan ako dinadalaw. Mga alas kwatro ng hapon. Sabi ng kapatid ko petition for Guam ang nanay ko. Ganoon din ang tatay, petition for Guam. as verbalized by the patient.

Diagnosis Disturbed Thought Processes related to disruption in cognitive and psychological process as manifested by ideas of delusions, altered attention span and disordered thought sequencing

Justification There was an obvious manifestation of the psychological problem of the patient that needs to be resolved for a progress in the rehabilitation of the client. According to him, his father is for petition in Guam, when in fact his father already died. In addition, he said that he was being visited monthly but the last time was still in the year of 2007.

24 years na akong ganito. Tingnan mo ang mga paa ko. Naluluto na. Makati siya, kinakamot ko na minsan. Naluluto na ang paa ko. Gusto ko ng bayabas para sa paa ko. as verbalized by the patient.

Impaired skin integrity related to presence of wounds on lower extremities as manifested by redness, numbness of affected area and presence of itching and pain at times.

The client was noted to have presence of a diabetic feet and this is a concern since it may possibly result to a further complication or infection. Rendering nursing interventions to the client is important to achieve timely wound healing.

ASSESSMENT Subjective cues: 24 years na akong ganito. Tingnan mo ang mga paa ko. Naluluto na.

DIAGNOSIS Impaired skin integrity related to presence of wounds on lower extremities as manifested by

PLANNING Short term: After 1 day of nursing interventions, the patient will verbalize the

IMPLEMENTATION Independent: Note changes in skin color, texture and turgor. Palpate skin lesions

RATIONALE

EVALUATION Short term:

To provide baseline data

Assessment

After 1 day of nursing interventions, the patient verbalized the

15

Makati siya, kinakamot ko na minsan. Naluluto na ang paa ko. Gusto ko ng bayabas para sa paa ko. as verbalized by the patient.

redness, numbness of affected area and presence of itching and pain at times.

willingness and ability to manage situation of cleaning his wounds.

for the size, shape, consistency and temperature and hydration. Inspect surrounding skin for erythema, induration and maceration. Keep the area clean/ dry, carefully clean the wounds with antiseptic solution. Encourage client to verbalize feelings and discuss how to manage wound cleaning on his own. Develop repositioning of the client and encourage early ambulation. Use appropriate padding devices

purposes to determine severity of skin integrity

willingness and ability to manage situation of cleaning his wounds.

Long term: Objective cues: >diabetic feet >numbness of affected area >presence of itching and pain at times >decreased self esteem After weeks of nursing interventions, the patient will display timely healing of skin lesion/wounds pressure sores without complication.

Long term: To prevent infection After weeks of nursing interventions, the patient still manifested presence of itching and redness on the affected area. Appearance of wound was still noted.

To increase independence and concern on his condition

Promotes circulation

To reduce pressure and enhance circulation

Dependent: Administer antibiotic for prophylaxis as prescribed by the physician To prevent infection

Capitol Medical Center Colleges

#4 Sto. Domingo Ave., Quezon City

V. PROCESS RECORDING
16

NPI # 1 (Orientation Phase)

Date: August 17, 2010; Tuesday Time: 12:45-1:10 pm Setting: Hallway Name: Sir J Age: 47 years old Educational Attainment: Vocational Date of Admission: December 4, 2006 Diagnosis: F20.3 Undifferentiated Diagnosis Unstable Description of patient: The client is a tall and thin man, wearing his uniform, not that neatly pressed. He is fully awake, conscious, alert and cooperative. He has a fair brown complexion. Hair is short and color black with strands of white hair. He has a mustache. His eyes are color black and have a good eye contact. He sits with legs crossed and taps his foot. There was no untoward behavior experienced during the nursing-patient interaction. Description of environment: Sir J is in the pavilion 21. During the first minutes, the NPI happened at the hallway outside the ward because there was no space inside due to other affiliated schools activity. It was a rainy and windy day. The surrounding is slightly noisy because there are other students who are present outside the area. Objectives:

1. To establish rapport and trust

2. To orient the client 3. To form contract with the client 4. To assess clients strengths and weaknesses 5. To help the client communicate

NURSE Magandang hapon Joven. Ako si Diana Ortiz, student nurse ng Capitol Medical Center. Ako ang magiging nurse mo ngayong araw, bukas at next week, Lunes at Martes. Ano ang gusto mong itawag ko sayo? Joven. Nagagalak akong makilala ka. Ako ang makakasama mo hanggang

Therapeutic Technique Establish rapport Giving information

Patient Joven. Hoven.

Analysis The patient answered the question of the student nurse.

Acknowleding

Gusto ko malaman ang pagaaral.

The patient chose a topic of conversation.

17

mamaya 3 pm. May mga inihanda kaming activities para sa inyo. Ano ang gusto mong pagusapan natin ngayon? Pag-aaral. Kaninong pagaaral? Ah. Gusto mong malaman ang pagaaral ko? Fourth Year na ako. Ikaw naman ang gusto kong makilala. Ano nga pala ang nagdala sa iyo dito? Ano ang nangyari?

Providing general leads Syempre sayo. Pagaaral mo, Oo. Dinala ako ng kapatid kong babae dito noong 2006. Use of openended question Sabe hindi daw ako makausap ng maayos at ayaw ko daw uminom ng gamot. Nagwawala din ako minsan. Seeking clarification Oo. Nagsawa na ako. 24 years na akong umiinom ng gamot. Pero wala naming nangyayari, Nandito na ako noong 1994 tapos umalis ulit tapos bumalik nitong 2006 lang. Silence Pabalik-balik na lang ako lage. 47 years old na ako. Ganoon pa din. May sakit pa din ako. He continued verbalization of what he feels and stating how old he is. He had remembered the date when he was brought to the institution but it was not his sister who accompanied him. He still knew why he was brought to the hospital. The client was able to clarify what he wants to talk about.

Seeking clarification

Ang ibig mong sabihin hindi ka umiinom ng gamot?

He verbalized his feelings about the situation.

He manifested circumstantiality.

Ano ang ibig mong sabihin na may sakit ka? Ibig?

Providing general leads

May sakit ako, sabi ng doctor, baog daw ako eh. Hindi daw ako ibig. Iibig. Baog daw ako sabe ng mga doctor. Hindi daw ako marunong makipag sex.

Self-depreciation

18

Sinabi nila iyon?

Seeking clarification

Oo. Ganoon siguro talaga pag dukha. At pinagkaitan ng Maykapal. Okay naman. (Silence) Ang mga doctor dito pinagaaralan nila ang mga tao. Ayaw ko na nga uminom ng gamot eh pero kailangan para uwi na.

Self-depreciation

Ano ang nararamdaman mo ngayon?

Providing general leads

Flight of Ideas

Parang hindi ka naniniwala sa mga doctor na tumitingin sayo?

Focusing

24 years na akong ganito. Tingnan mo ang mga paa ko, naluluto na. Naluluto na. Makati siya. Kinakamot ko na minsan. Naluluto na ang paa ko. Gusto ko ng bayabas para sa paa ko. Oo. May problema kasi talaga ako. Di daw kasi ako marunong mag-sex eh. Sabi din naman ng mga naging girlfriend ko. Ilan taon ka na ba? Ah ganoon. Oo.

From his words, it only showed that he was anxious about his feet.

Nakikita ko na masyadong kang nag-aalala sa iyong kalagayan.

Being tentative rather than absolute

Looseness of Association

19 years old. Mamaya pala Joven may mga activities tayo na inaasahan ko na magiging cooperative ka. Tara doon tayo sa loob magpatuloy mag-usap. Anong pinagkakaabalahan mo bago ka nagpunta dito?

Use of openended question

Nag-aral ako dati. 2 years. Self- supporting ako, naging radio operator sa La Union. Nag-imprinta ng damit. Nag stay din ako sa Oriental Mindoro. Seaman, dati interland, ngayon international. Katulad ng tatay ko pero patay na siya

Somatic delusion

19

ngayon. Lahat ng binanggit mo ay naging trabaho mo? Silence Nga pala, may alam ka bang ibang salita? Seeking clarification Oo. Silence Meron. Arigato. He was able to remember the true meaning of the word taught to him.

Ano ibig sabihin nun? May isa pa akong alam. Konnichiwa. Konnichiwa. Ibig sabihin, magandang hapon. Kanina ay nabanggit mo yung tungkol sa tatay mo. Nasaan naman ang nanay mo?

Seeking clarification

Salamat. Ano yun?

Giving information

Ah. Magandang hapon pala. Di ko alam. Wala na akong balita sa kanya eh. Sabi ng kapatid kong babae, hindi daw niya alam. Kaya gusto ko talaga kamustahin. Buwan-buwan ako dinadalaw. Mga alas kwatro ng hapon. Sabi ng kapatid ko petition for Guam ang nanay ko. Ganoon din ang tatay, petition for Guam. Teka lang, iihi muna ako.

He accepted new information from the student-nurse. He was able to answer the question.

Providing general leads

Kailan ka ba huling dinalaw ng kapatid mo?

Closed-ended question

He was inconsistent about what he knows about his father.

(Tatayo sana ako para samahan siya)

Diyan ka na lang. Maupo ka na. Ako na lang mag-isa pupunta ng banyo. Offering Self Sige.

He showed a manipulative behavior.

Hindi sasamahan na lang kita. Kahit dyan lang bago lumabas. Malapit na tayo magsimula sa mga activities. Madami na din tayong napagusapan sa

Summarizing and Planning

Sige, Diana.

The client accepted the notion about what the student nurse told him.

20

kalahating oras. Bukas naman ay mas palalawakin pa natin ang mga topic natin ha? Upo ka na. Salamat.

Evaluation and remarks:

The student nurse was able to establish rapport in order to gain the trust of the client. After introducing, orienting and forming contract, the student nurse was able to gather some information about the client especially how was he feeling by that time. He was ready to answer the questions though there is some inconsistency in his thoughts. He manifested circumstantiality, flight of ideas, looseness of association and self-depreciation. There is no evidence of other thought disorders. The goals are met.

Capitol Medical Center Colleges

#4 Sto. Domingo Ave., Quezon City
NPI # 2 (Working Phase) Date: August 18, 2010; Wednesday Time: 11:05-11:35 am Setting: Under the tree; and beside the ward, under the roof Name: Sir J Age: 47 years old

21

Educational Attainment: Vocational Date of Admission: December 4, 2006 Diagnosis: F20.3 Undifferentiated Diagnosis Unstable Description of patient: The patient has a shuffling gait. He is alert and cooperative. His complexion is brown. He has a good hygiene this time. His clothes are well-kept. He has shaved his mustache and his hair was short. His eyes are color black and have a good eye contact. Nails are short and clean. He sits with legs crossed and taps his foot. Once in a while, he leans forward while talking. He sometimes scratches his head and crumples his face. Description of environment: The working phase of the nurse-patient interaction happened under the tree after doing the different therapies. Drops of rain are felt that made us transfer to another area where a roof can protect us from the scattered rain shower. The area was conducive. Objectives: 1. Promote positive self-concept 2. Realistic goal-setting 3. Encourage client to verbalize feelings and explore self 4. Develop positive coping behaviors 5. Take action to meet the goals set with the client NURSE Magandang araw sayo Joven! Ang galing mo kanina sa mga activities natin. Nakita kong nagparticipate ka talaga. Bago ang lahat, may ibibigay akong 3 salita tapos tandaan mo ito, mamaya ipapaulit ko muli sayo. Langit, Lupa, Puno. Ulitin mo nga. Magaling. Magkwentuhan ulit tayo. Ano nga ulit yung natapos mong kurso? Ah. At pagkatapos, anong pinasukan mong trabaho? Being specific Therapeutic Technique Establish rapport by greetings Patient Oh. Oo. Analysis

Oo. Talaga. Acknowledging

MSE Component

Sige. Ano yun?

He agreed to what the student nurse asked him to do.

Langit, Lupa, Puno. Langit, Lupa, Puno Radio operator. Nag-aral ako sa Samson. Sa Recto. Sa Maynila. 2 taon akong nag-aral. Seaman, sa dagat. Nagtatabako. Nag-iimprinta ng damit. Guard.

He was able to repeat the 3 words given to him. He had answered the question with details about his school days. He had a false belief about his work of being a seaman.

Validating data from previous conversation.

22

Lahat yan naging trabaho mo? Ano ginagawa mo noong bata ka pa?

Seeking clarification Using openended question

Oo, madami akong pinagkaabalahan noon. Nung bata ako, mahilig akong maglaro ng kard. Pusoy dos. Baraha. At nagjojolen din ako kasama ng aking mga kaibigan. Oo. Kasama ko mga kapatid ko at mga pinsan na naglalaro. Mga kapatid ko. 7 kaming magkakapatid lahat. Nasa Guam ang 4 kong kapatid. Si Ilinoy, Dalisay, Angelito at Anastacio. Yung 3, sina Danilo, at A, Joven. Dito sa Maynila. Pang-apat. He stated the names of his siblings and where they reside. He was able to answer the question.

Naging masaya ba childhood days mo? Sino ang mga kasama niyo sa bahay?

Close-ended question Using openended question

Pang ilan ka ba sa magkakapatid? Ano yung masasayang araw or memories mo na kasama mo sila? Ha? Ang ibig mong sabihin ay masaya ka kapag may patay? Anong nagagawa ng pakiramdam mong yan sa iyo? Joven, ano nga pala date ngayon?

Clarifying relationship status Using openended question Perception seeking/ Restating Using openended question to explore feelings Evaluating if the client is oriented to date.

Kapag may patay.

Hindi! Syempre kumpleto kaming pamilya. Lahat kami kumpleto pag bumibisita. Masaya nga.

He was able to clarify his feelings.

He did not further elaborate his response. He was able to answer the question correctly.

August 18.

2000 ano? Eh anong araw? Saan ka nga pala pinanganak? Kailan pala birthday mo? Saan ka nakatira? Anong mga pagkain Exploring clients important

2010. Miyerkules. Mindoro. April 4, 1963. 47 na ako. Maynila. Hotdog. Longganisa. Hotdog. He was able to answer the question correctly showing that hes aware and capable to remember events in his life. He is comprehensible. He stated his favorite

23

yung paborito mo? Anong kanta naman yung gusto mo? Katulad ng?

thoughts about his life

Longganisa. Longganisa. Madami akong gusto. Basta madami.

foods.

He was not able to enumerate the title of some of his favorite songs. He verbalized his feelings about his relationship with other his past girlfriends.

Ilan na nga ulit naging girlfriend mo?

Close-ended question

Madami na pero lahat sila iniwan ako dahil nga hindi daw ako marunong makipag sex. Ah. Ganoon.

Ah. Joven, umaambon. Lipat tayo dun sa may bubong. Ayan. Di na tayo mauulanan. Sabihin mo nga ulit yung pangalan ko. Nakita mo ata sa name plate ko eh! Laugh Joven sabihin mo nga ulit yung 3 salita na sinabi ko sayo kanina. Langit, lupa, puno. Kailan ka pala napunta dito?

Showing Concern Oo. Diana. Testing Oo nabasa ko. Smile Langit. Lupa. (pause) Bundok. MSE Component Langit, lupa, puno. Evaluating if he still remembers when he was brought to the hospital August 3, 1987 ako una nandito. Tapos umalis. Tapos bumalik ulit. Noong 2006. December 6, 2006. 2010 na ngayon diba? He forgot the last word given to him. He repeated the same words given to him. He had a false belief of the date when he was first admitted in the institution. It was 1990 and it was December 4, 2006 for his readmission.

Oo. Bakit? Ano bang nanyari at bumalik ka dito?

Probing Using openended question

24 years na pala no. Tagal ko ng nandito. Nambabastos daw ako sabi ng hipag ko. Nanggugulo. Nakikipag away. He was able to recall the reason why he was admitted and who brought him to the

24

hospital. Silence Eh alak? Exploring Naninigarilyo din ako bata pa lang. Alak onti lang. Pag dumadaan ako sa may sa amin, bigyan nila ako ng 1shot. Isa lang talaga tapos uwi na ko. Si Tess nga. Noong katapusan. Dinalaw ako ng pamangkin ko. Misperception of when he was visited by his loved one. The last visitation was 2007 by his brother.

He remembered his lifestyle when it comes to vices.

Ganoon ba. Anong pangalan ng hipag mo? Ah. Kailan ka huling dinalaw ng mahal mo sa buhay?

Exploring clients important thoughts about his life

Ganon. Mahal mo ba mga magulang mo? Nasaan magulang mo ngayon? May kakaiba ka bang naririnig o nakikita dati at ngayon? Nasaan ka ba ngayon? Sino mga kaibigan mo dito? Ano ginagawa mo dito sa ward? Tumutulong ka ba? Joven, tawag tayo sa loob. Kuhanan ka daw ng BP. Silence. Aso? Seeking clarification Exploring clients ideas and thoughts

Oo. Nasa Guam sila. Wala naman.

Sa Mental. Lahat sila. Madami. Wala. Sabe hindi daw pwede umalis kaya di ako makauwi. Oo. Silence.

He knew where he was.

May kaso ba ako? Bat ako kinuhanan nun? (pertaining to BP and weight) May kaso ako? Ah. Akala ko kasi meron akong kaso. Sabi kasi nila may kaso daw ako.

Ah. Kaso. (Laugh). Wala. Tiningnan lang natin BP at timbang mo para makita kung mataas ba

Giving

He thought that he had done something wrong thats why his BP and height was obtained.

25

ang presyon mo sa dugo at kung ano timbang mo. Ano daw kaso mo?

information Seeking clarification Agreeing Hindi ko alam. Sabi kasi ni Elsi kalimutan ko na lang at wag isipin kaya di ko alam kaso ko. Oo, wag daw isipin eh. Kalimutan na lang. Dahil sa swimming, trabaho ko. Gamot. May binibigay na gamot. Gamot eh. Gusto ko nga bayabas para gumaling na. Ayaw naman ako bigyan. Oo. Pero pinagaaralan nila ang paa ko. Ayaw ata pagalingin. Pero alam ko gagaling pa yung paa ko. Oo. Presenting reality Ah ganoon pala yon. He agreed to what the student nurse explained. He was aware that he has medicine for his feet to be healed. He used to believe in herbal medicine to restore his feet. He thought that doctors dont want him to be healed because he was being studied.

Ganoon? Oo nga wag mo na lang gaano isipin. Ano nangyari diyan sa paa mo? Ano ginagawa mo para gumaling? Anong gamot ginagamit mo? Sinabi mo ba sa doctor na gusto mo bayabas ang gamitin? Yan ang paniniwala mo? Alam mo ba na ang mga doctor, ginagamot nila ang mga may sakit. At ang mga nurse tinutulungan nila ang doctor sa mga gawain nito at syempre tinutulungan din nila ang may sakit. Oo. Namimiss mo na ba ang pamilya mo?

Using open ended question

Giving information

Close ended question

Oo. Alam mo ba sikat ang pamilya ko sa amin. Ang mga magulang ko. Ang tito ko, sikat sa probinsiya. He believes that his family is famous and known by many people in their province.

Silence

Silence Mas grabe pa ako sa nakakulong. Sawa na ko dito. 24 years na.

He verbalized his feelings of being tired

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Ano ang ibig mong sabihin?

Seeking clarification

Di ba ang mga nakakulong 10 taon lang sila sa kulungan pero ako, sobra pa sa 10 taon ako nandito. Hindi pwede lumabas. Nakakulong din ako. Walang Kalayaan. Ah ganoon pala. Depende sa kaso.

staying in the hospital comparing it to people who are in jail. He likewise said that hes more of a prisoner, no freedom.

Sa pagkakaalam ko kasi, depende sa kaso na nagawa ng isang tao kung gaano siya makukulong eh. Oo. Kung grabe ang nagawa ng isang tao, katulad na lang kung nakapatay siya na sinasadya at planado, pwede siyang makulong habang buhay. Joven, banggitin mo nga ulit yung 3 salita na sinabi ko sayo kanina. Langit, lupa, puno. Ayan. Recite mo naman un letters ng alphabet. Galing! Ngayon, magbilang ka naman mula 1 to 10. Tama! Spell mo nga yung word na Japan. Eh un tagalog word na salamat. Hmm. 6+3? 7+6? 2+5? Magaling! Naaalala mo pa ba kahapon yung tinuro ko sayong salita? Yung Konnichiwa. Anong ibig sabihin nun?

Presenting reality

Agreeing to the student nurse Ah. Ganoon pala yun.

Giving information

Langit, lupa, dagat.

He still forgot the last word given to him a while ago.

Langit, lupa, puno. MSE Component A-B-C-D-E-F-G-H-I-J-K-L-M-NO-P-Q-R-S-T-U-V-W-X-Y-Z

1-2-3- 4-5-6-7-8-9-10 J-A-P-A-N S-A-L-A-M-A-T 9 13 7 MSE Component Ano dun? He was able to answer the questions correctly to evaluate his cognitive ability.

Magandang Hapon.

He remembered the meaning of the word

27

given to him yesterday. Tama. Kapag pinayagan ka ng umalis dito, anong gagawin mo pag nasa labas ka na? Ah talaga? 11:30. Bakit? Exploring ideas Magpapahinga ako paglabas, enjoy. Punta ko sa look. Dun ako magpapahinga. Anong oras na ba? Tapos na ba interview? Pasok na tayo. 11:30 na pala. Ah ganon. Sige. Summarizing and Planning Verbalization of feelings.

He asked about the time and requesting that he will already go inside.

Ganoon ba. Sige. Joven, magkita tayo ulit next week ha. Sa Martes na Socialization day natin. Tara, pasok na tayo.

Evaluation and Remarks: The client was able to answer the questions being asked to him though in some cases there were still some inconsistencies in his ideas/thoughts and misperception of the real situation. Some of his answers are different from his answers during the orientation phase. He had manifested circumstantiality and looseness of association. There is no evidence of hallucination or illusion. He had also difficulty in remembering the 3 words given to him to evaluate his short term memory. He was cooperative during the nurse-patient interaction. He had maintained a good eye contact and showed no untoward behavior. The goals are met.

28

Capitol Medical Center Colleges

#4 Sto. Domingo Ave., Quezon City

NPI # 3 (continuation of Working Phase) Date: August 23, 2010; Monday Time: 1:10-1:30 pm Setting: Tree house Name: Sir J Age: 47 years old Educational Attainment: Vocational Date of Admission: December 4, 2006 Diagnosis: F20.3 Undifferentiated Diagnosis Unstable Description of patient: The patient has a shuffling gait. He is alert and cooperative. His complexion is brown. His eyes are color black and have a good eye contact. He sits with legs crossed and taps his foot. Once in a while, he leans forward while talking. He sometimes scratches his head and crumples his face. Description of environment: The continuation of the working phase of the nurse-patient interaction happened in the tree house in the afternoon after he had eaten his lunch. The environment was conducive, quiet and comfortable. Objectives: 1. Promote positive self-concept 2. Encourage client to verbalize feelings and explore self 3. Develop positive coping behaviors 4. Take action to meet the goals set with the client

29

NURSE Hi. Kamusta Joven?

Therapeutic Technique Establish rapport Using openended question

Patient Mabuti naman. Ano gagawin naten? Magdadrawing?

Analysis He asked about the activity.

Hindi. Mag NPI tayo at pagkatapos mag games. Pinoy Henyo. Oo. Last day na naming ngayon. Bukas socialization na natin. O anong gusto mong food natin? Ah. Anong kinain mo sa tanghalian? Masarap ba? Describe mo naman sa akin famly mo. Nasaan magulang mo? Anong dahilan bakit hindi mo sila kasama? Anong dahilan bakit hindi mo sila kasama? Ano ba rason bakit andito ka?

Giving information

Ah ganoon ba.

Kahit ano. Using openended question He was able to answer the question of the student nurse. Baboy. Paksiw. Oo. Nasa Guam nanay at tatay ko. Petition for United States. Sa London din. Andon din mga kapatid ko. Nasa US sila. Tatay ko patay na. Nanay ko Petition. Andito ko sa loob eh. Paano ako sasama? Nakikipag-away nga. Tsaka sabi ng nanay at kapatid ko nagsasalita daw ako ng walang kausap. Mabilis daw ako magsalita. Walang kausap. Kaya dinala nila ako ditto. Noong una, sila. Tapos yung hipag ko nagdala sa akin. Wala nga. Mental nga diba. Noong katapusan. Ng kapatid ko. Ayoko na dito. He manifested delusion. He was last visited 2007. He was able to verbalize his thoughts. He manifested delusion. His father already died. Inconsistent thought.

Focusing and Using openended question

Sino ba kinakausap mo? Ano.. Kailan ka huling dinalaw dito? Anong nararamdaman

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mo noong pinasok ka nila dito? Joven, iinom ka daw ulit ng gamot. *He took his medicine. Buti at ininom mo pa din ang gamot mo. Ayoko na. Sawa na ako. 24 years na ako umiinom ng gamot. Hindi naman ako gumagaling. Sawa na ako. Ang tagal-tagal na eh. Dito na ako sa mental matagal. May sakit ako. Kaya nga pinasok ako dito eh. May kapansanan ako. May kapansanan ako. Kaya nandito ako. Kaya nga nasa Crossings eh. Sa Mandaluyong. Seeking clarification Oo mental nga. Ano ba naman ito. Oo. Validation of the congruency of his past answers to present Sa Mindoro nga. Ano ba naman ito. Look. Oo. Taga Maynila ka ba? Nag stay din ako sa Maynila. Grade 3 pa lang ako. Paraphrasing Hindi. Namamasyal lang ako sa Maynila. Edi pamilya ko.Magulang. Mga kapatid. Namamasya. Nagpupunta sa mga kapitbahay. Kung saansaan,. Pero ayoko dito sa Maynila. Ayoko dito sa Maynila. He was able to answer the question and he verbalized his thoughts and feelings. He was slightly annoyed of repeated question asked. He manifested tangential thinking, circumstantiality. Gamot ulit. Lagi na lang gamot. Nagsasawa na ako. He was able to verbalize his feelings. He doesnt want to take his medicines anymore but still, he complies to take it. He is concerned about his health.

Kailangan mo pa din uminom ng gamot mo para gumaling ka.

Anong kapansanan mo?

Crossings? Ah. Crossings sa Mandaluyong. Pasensya Saan ka nga ulit nakatira? Saan sa Mindoro? Probinsya yon? Oo. Bakit? Ibig mong sabihin grade 3 ka pa lang, nag-aral ka na dito sa Maynila? Sino kasama mo? Anong ginagawa niyo pag nandito kayo sa Maynila? Sa anong dahilan?

Focusing and Using open

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May mga naging karanasan ka ba habang nasa Maynila ka pa? Kamusta naman pagkabinata mo? Naaalala mo si Kaye? Mukhang ayaw mo at nagsasawa ka na talaga uminom ng gamot ha. Pero kailangan mong uminom ng gamot mo. Para sa ikabubuti mo din yan. Sino ba ang doctor mo? Kailan ka huling chineckup? May mga bisyo ka ba? Ano? Nagyoyosi ka? Saan mo nakuha yung yosi mo? Sinong kasama? Wala daw batas na bawal mag yosi dito? Masama iyan sa kalusugan mo. May peklat ka ba diyan sa ulo mo? Ganoon ba. Magbigay ka nga Joven ng 5 naging presidente ng Pilipinas. 5 mga mahahalagang nangyari naman sa Pilipinas. Yung naaalala mo sa history? Ah. Explain mo naman sa akin yung salawikain

ended question

Wala. He manifested perseveration. Okay lang. May sakit pa din. Ayoko na ng gamot. Oo. Ayoko ng gamot. Ang tagal-tagal na eh. 24 years na.

Focusing

Using open ended question

Si Dr. Tamayo. Si Dr. Ho. Si Dr. Kaligayahan. Matagal na. Oo. Nagyoyosi. Kanina yosi.

Clarifying Focusing and Using open ended question

Hindi bawal. Walang batas. Nagyosi. Dito din sa mga kasama ko. Bigay. Sila. Binibigay lang. Walang batas. Pwede. Nagyoyosi. Hindi. Yosi lang. Wala. Wala no. Manuel Roxas. Manuel Quezon. Ninoy Aquino. Corazon Aquino. (pause) Manuel Quezon. He repeated Manuel Quezon. He manifested delusion.

MSE Component

(pause) Wala. Wala akong alam. (pause) Noong dumating ang mga kastila. Yon lang. Ang biyaya. Ang biyaya ay hindi dadating pag hindi

He was not able to recall historical events in the Philippines. He interpreted the

32

na Ang palay ay hindi kusang lalapit sa manok. Magaling. O Joven, magsimula na daw ang Pinoy Henyo. Sali ka ah. Babye Joven. Bukas ulit ha. Socialization na. Huling araw na natin. Anong Code? Ah. Yung powder? Sige. Planning

pinaghihirapan. Dapat maghirap para magkaroon ng biyaya. Oo.

proverbs given to him.

Ganoon ba. Dalhan mo ako Alaska. Code. Alaska. Code. Basta. Yung Pulbo. Oo. Damihan mo ha. Kaw na bahala. Sige Diana.

He demanded something for tomorrows Socialization day and termination phase.

Sige Joven. Babye ulit.

Evaluation and Remarks: For the continuation of the Working Phase, still, the client was able to answer the questions being asked to him though in some cases there were still some inconsistencies in his ideas/thoughts and misperception of the real situation. Some of his answers are different from his answers during the orientation and first part of the working phase. He had manifested delusion, circumstantiality, looseness of association, perseveration and tangential thinking. There is no evidence of hallucination or illusion. He had also difficulty in remembering historical events in the Philippines and was not able to complete 5 Past Presidents of our country for his cognitive evaluation. He was cooperative during the nurse-patient interaction. He had maintained a good eye contact and showed no untoward behavior. The goals are met.

33

Capitol Medical Center Colleges

#4 Sto. Domingo Ave., Quezon City

NPI # 4 (Termination Phase) Date: August 24, 2010; Tuesday Time: 12:45-12:55 pm Setting: Outdoor, under the tree Name: Sir J Age: 47 years old Educational Attainment: Vocational Date of Admission: December 4, 2006 Diagnosis: F20.3 Undifferentiated Diagnosis Unstable Description of patient: The patient is happy and excited upon seeing the token of appreciation. He is alert and cooperative. He is relaxed and feels comfortable. Still, he maintains a good eye contact. He leans forward while talking. Description of environment: The termination phase of the nurse-patient interaction happened under the tree immediately after the socialization day. The environment was in high spirit and comfortable. Other patients and student-nurses are beside us. Objectives: 1. Promote self-care 2. Recognize increasing anxiety 3. Increase independence 4. Demonstrate emotional stability 5. Evaluate goals achieved by the patient NURSE Hi. Kamusta ka Joven? Therapeutic Technique Establish rapport Using openended question Salamat sayo kanina ha. Nagparticipate ka talaga Dapat magparticipate. Client was able to interpret and verbalize Patient Okay naman. Analysis

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sa mga inihanda namin. Tapos na socialization day natin. Ano pakiramdam mo ngayon? Talaga? Buti naman. Kasi ako nag-enjoy din ako. Eto pala yung pinapabili mo sa akin. Request mo. Welcome. Okay lang yun na naka uniform ka. Yun naman talaga dapat suotin dito diba. Naging Masaya ako na nakasama ko kayo. Ha? Hindi ah. Wag ka maniwala sa kanya. Hindi ako mayaman. Hindi Joven, hindi ako mayaman. Market? Clarifying Acknowledging Providing general lead Ayun. Salamat. Madami ha. Salamat. Nakauniform ako, Sorry. Naka uniform eh. Enjoy. Masaya ako.

his feelings and thoughts about the situation.

Ah. Masaya. Mayaman ka ba?

Presenting reality Verbalization of feeling Sabi niya, mayaman ka daw eh. Mayaman ka pala. Client was asking the student nurse and verbalized his observations.

Edi may shoe mart kayo? Shoemart.

Ah, shoemart. Wala ha. Di ako mayaman. Ako? Hindi ko alam. Haha. Hindi naman. O ikaw, ano bago sayo? Talaga? Saan ka pupunta? Kailan? Sino nag sabi sayo? Ah, ganoon ba. Aalis na din ako mamaya. Huling araw na namin ngayon diba? Reminds client that termination is near

Ah, iibigin ka no? Oo iibigin ka eh. Lalabas na ako eh. Using openended question Aalis na. Lalabas na daw ako eh. Sa katapusan. Aalis na ako. Aalis na nga ako. Ah ganoon ba. Oo. He thought the he will already leave the institution.

35

Gusto ko magpasalamat sayo kasi dami ko natutunan sayo eh.

Ako din. Dapat magparticipate talaga tayo. Para Masaya.

He recognized his responsibility. He thanked the student nurse.

Nashare mo din sa akin mga experiences and mga nararamdaman mo diba? And sana natulungan din kita kahit papaano. Salamat ha. O tawag na tayo sa loob. O ingatan mo sarili mo habang nandito ka ah. Pakabait ka sa susunod na makakasama mo dito.

Evaluate goal achievement

Oo. Salamat din. *Silence.

Tell him responsibility for his care; Achieve smooth transition to other caregiver; Expresses thought about termination phase

Oo. Iingat ako.

He recognized his responsibility.

Ikaw din Diana. Kumain ka ng masusustansyang pagkain. Oo, Uminom ka din ng gatas gabi-gabi para lumusog ka. Oo. Gamitin ko yan.

He gave some reminders to the student nurse.

Oo naman. Ikaw din dapat. Hehe. Sige. Ikaw din ha, yung gatas na binigay ko sayo, gamitin mo. Ingat ka Joven. Oo. Salamat sa mga paalala mo sa akin. Babye Joven.

He thanked the student nurse.

Mag-ingat ka din. Sige Diana. Babye. Salamat sayo ha. Sige pasok na. Salamat.

Evaluation and Remarks: During the termination phase, He had manifested circumstantiality, looseness of association, delusion. There is no evidence of hallucination or illusion. He was alert and cooperative during the nurse-patient interaction. He had maintained a good eye contact and showed no untoward behavior. He seemed to be happy and contented with the token of appreciated he had. He 36

even gave reminders to the student-nurse. There was no increase anxiety level on the part of the client during the termination phase. The goals are met.

VI. PSYCHOTHERAPIES
THERAPY
Calisthenic/ Exercise therapy

DEFINITION
A free body exercise performed with varying degrees of intensity & rhythm, employ motions It is a treatment modality as an energizer and enable patient to enjoy.

PURPOSE
To energize the client and to revitalizes the patients interest & helps him to be relaxed & be refreshed

TECHNIQUE
Use of different motions such bending, stretching, jumping, hand shaking, head and ankle rotation with a background sound of Solo and Eye of the Tiger Asked the patients to make a cheer prior to game. Employed different questions that enhanced their memory. (Sa Bughaw, Sa Dilaw) With the use of manila paper, the client sang Wont last a day without you and Umagang Kay Ganda

ANALYSIS
Sir J was able to do simple steps like hand shaking, head rotation and stretching. However, he has a slower movement when it comes to jumping and ankle rotation. Probably he takes extra effort in handling his lower extremities due to his diabetic feet. The client was able to actively participate in the games, raising the colored card to answer questions. He was asked to enumerate 3 kinds of food that has a soup, he itemize the ff: Sinigang na baboy, Sinigang na isda and Sinigang na baka.

Play therapy

Provides a change from the patients usual routine and enable patient to experience intense emotion in a safe environment To learn a new song that will revitalizes patients interest & helps him to be relaxed & be refreshed (Music) To change human behavior so that the individual affected will be able to function as worthwhile person. (Arts) Use of music to aid relaxation.

Singing therapy

It is a recreational therapy that allow patient to sing and read lyrics with rhythm (Music) Use of unique properties & potential of music in a therapeutic situation.

The client was able to follow the lyrics of the songs that were taught to the group. He was focusing on the reading rather on singing.

Music & Arts (Fast & Slow Instrumental Song )

(Arts) A Creative/

The client was given a bond paper. He wrote his name above it and while playing the background music, he was asked to draw what is in his mind. The student nurse let him choose the color he wants to use. The fast music was

For the fast song, he had drawn a circle with trees around it. He used a brown color in outlining the circle and green for trees. On the right side, he draw 3 candles using an orange color and wrote on the center, corona. Based on his interpretation, he said that Halloween is near thats why he drawn candles symbolizing his family members who already died and left him. The corona

37

Expressive art therapy that encourages a person to express & understand emotions through artistic expression & through creative process.

Helps in reconciling emotional conflicts as well as promoting self-awareness & growth.

played first followed by the slow instrumental song.

signifies the gift he is offering to his deceased loved ones. And in addition, he said that when it is near to Christmas, he will draw a different thing again. For the slow song, he has drawn a stick man playing inside a basketball court using only one color, green. He said that he was playing those younger years. The drawing for the fast song showed that he thinks more of the occasions he experiences yearly specifically the times when he and his family reunites during visitation of the deceased members of his family while for the slow song, it can be interpreted that he misses the times when he was able to play basketball during the years when he was outside the hospital.

Biblio-therapy (Story Telling)

Use of printed words in modifying or stimulating emotions and awareness

To improve the attention span of the individual with power of concentration, and to stimulate the imagination & ideas of the patient

The story was entitled Ang Tipaklong at ang Langgam. It was presented with the use of puppets, art works, drawing & voice dubbing while the student nurses are behind the cloth.

After the story telling, when the patient was asked what he understood of the story, he was able to verbalize that Dapat nag-iipon ng pagkain para hindi magugutom. It shows that he was attentively listening to the story presented and he understands that the ant became cautious in gathering his food so that it will not get hungry in the future.

Biblio-therapy (Proverbs Interpretation)

Use of printed picture to identify characters in the story that will modify or stimulate emotions and understanding.

Reading may help lift a depressed patient. To facilitate expression

Sir J was asked to read the proverb written on a bond paper, Sa Panahon ng Kagipitan, makikilala ang Tunay na Kaibigan.

He explained that Kapag magkaibigan, dapat nagtutulungan. Halimbawa sa paggawa ng bahay, dapat madaming tao ang gumawa para mas matibay at maganda ang maging bahay. He had expressed his understanding of what he read. According to him, friends should help one another to make work easier though the real meaning of the proverb is

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one will be able to recognize his true friends in times of downfall. Remotivation therapy Technique of a simple group therapy that uses a poem and a drawing which aims to bridge the fantasy world of the psychotics to the real world. To stimulate patients to be fellow explorer of the real world. To develop their ability to communicate & share ideas & experiences with the other people. To promote group harmony & identification. . Help clients to reach their maximum level of function and independence in all aspects of daily life. Patient is seated in a U-formation. The facilitator provided a poem and a picture about a mountain. The student-nurse asked stimulating questions leading to the topic and asked to relate it in his experiences in life. Patient was able to cooperate in the group therapy though he goes to the comfort room twice during the therapy. When he was asked about the relation of the mountain to his experiences, he said, Kumukuha kami noon ng ibatibang prutas sa bundok. May okra, kopra, apple, orange, patatas. Namimitas kami dati sa bundok. When asked about the message of the poem, he said, Dapat natin pangalagaan ang kalikasan, bundok. Bigay ito sa atin ng Panginoon. Dapat alagaan at ingatan. The clients response to the activity is good. He appreciated the occupational therapy done. He was participative while the facilitator explains the procedure.

Occupational Therapy ( Banana Split )

Treatment of physical and psychiatric conditions by encouraging patients to undertake specific selected activities

The clients are provided with the materials and ingredients needed for making a banana split. Student nurses are beside them to assist and help them while doing the therapy. Steps are written in a manila paper while the facilitator explains the procedure.

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VII. BIBLIOGRAPHY Psychiatric Nursing Biological and Behavioral Concepts. Second Edition. Deborah Antai-Otong. 2008 Nurses Pocket Guide 11th Edition by Doenges, etc. http://psychcentral.com/lib/2006/undifferentiated-schizophrenia/. Retrieved August 07, 2010 www.wikipedia.com http://psychcentral.com/lib/2006/undifferentiated-schizophrenia/ http://aids.about.com/od/nutrition/qt/choltri.htm http://www.scribd.com/doc/27589683/Undifferentiated-Schizophrenia

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