process recording ncmh

Chapter I

Personal Data

Name : Patient X

Sex : Female

Age : Unknown

Address : Emerald height Garden Villas Mambugan Antipolo City

Civil Status : Married

Birth date : Unknown

Birthplace : Bicol

Religion : Unknown

Nationality : Filipino

Date Admitted : October 07, 2004

Time Admitted : 4:15pm

Admitted Doctor : Dr. Tamano

Diagnosis : Undifferentiated Schizophrenia - unstable

General data : Marimar Josephine unknown her age, parents, and religion.

They stay at Emerald height Garden Villas Mambugan Antipolo City; her province in

Bicol. She has married and there are 3 children. She grew up in Bicol and work in

Antipolo City.

History of Present Illness:

An Unknown woman “Marimar”, female brought here in NCMH by her

guardian because of a “mentally ill” patient.

A case of Evangelina Marimar, was by guardian from Emerald height

Garden Villas Mambugan Antipolo City with complaint of shouting while walking at the

street seen in 1989.

Mental status examination: Seen and examined as an adult female, thinly built in

hospital gown. Mood was enthymic and blunted affect. Speech was hypo productive she

1 Process Recording (Karl Angel B. Fabe, SN-SJIT)

disclosed that she was not clad at home. Patient is with appropriate affect with restricted

facial expression. “Naalala ko mga anak ko sa Bicol” and her speech is

normoproductive, spontaneous, barely audible. She has no appropriate answers when

questioned. She denies having any visual/auditory hallucinations and the patient was

not capable of reasoning.

Neurologic Examination:

• Cranial Nerves

I. N/A

II. 2.3mm equally reactive to light

III. Intact EOM

IV.

V. (+) Corneal Reflex

VI. Intact EOM

VII. No facial assymetry

VIII. Can hear whisper word

IX. (+) gag reflex

X.

XI. Can shrug shoulder

XII. Tongue at midline


Motor System:

Limbs

Trunk 5/5 5/5

Stance

Gait 5/5 5/5

Rombergo

Reflexes

J.J

B.J H H

S.J

T.J H H

Plantar

Sensational

Pain & Touch

Temperature 100 100

Vibration

JPS 100 100

Two – point Descrimination


Chapter II

Process Recording No. 1

Orientation Phase

Description of Phase:

Problem defining phase

Starts when client meets nurse as stranger

Defining problem and deciding type of service needed

Client seeks assistance ,conveys needs ,asks questions, shares

preconceptions and expectations of past experiences

Nurse responds, explains roles to client, helps to identify problems and to use

available resources and services

I. Goal Interaction

To gain rapport of my patient.

Establish trust, acceptance, and open communication

To be able to become acquainted of my patient.

To understand the patient’s problems.

To demonstrate genuine care and understanding.

To mutually formulate a contract with the patient

II. General Objectives

To distinguish the sickness of the client thru the observation done.

To reduce the anxiety felt by the client towards the nurse.

To discuss the contract to my patient.

To explore patient’s thoughts, feelings, and actions

III. Short-term Objectives

To be able to introduce myself to my patient and getting to know one another.

To show interest and sincerity to my patient.

To gain trust from my patient.

To observe and assess my patient’s personality.


IV. Description of the Environment

The environment was calm and therapeutic aided with props to promote joyous

atmosphere. The breeze of the wind makes the patient feel comfortable and relaxing.

There is slight noise but tolerable.

Nurse-Patient Interaction (NPI) – Orientation Phase

NPI Inference Rationale

N: Magandang hapon sa iyoP: Magandang hapon poN: Ano po ba ang pangalan mo?P: Marimar po.

N: Ako nga pala po si Karl Angel Fabe. Isang student nurse ng Saint Joseph Institute of Technology po sa Butuan City. Simula po ngayon, araw-araw na tayon magkakasama at pag- uusapan natin ang iyong talambuhay.P: Ano po’ng gusto mong malaman?N: San ka po nakatira?P: Sa Bicol po.

N: Anung araw ngayon?P: Lunes po.N:May asawa ka ba?P:Opo Patay na N:Ano naalala mo?P: Yung anak ko sa BicolN: Masaya ka bas a taas?P: Oo.. Masaya kasi may mga nurse na nag-aalaga sa amin at saka may libreng pagkain dito.

N: Minsan ba nalulungkot ka?P: Hindi naman kasi marami kami dito at kayo pumupunta dito.

Broad Opening

Giving Information

Offering Self

Exploring

To establish open-ended communication

To gain rapport and trust

To accommodate her thoughts and giving a free expression of thoughts and feeling

To have an idea on her present illness and help analyze her situation


N: Salamat po sa iyong tiwala sa paglahad ng mga bagaybagay..P: Walang anuman po…N: Pagod ka na ba ate?P: Opo.N: Okay sige. Pahinga ka na ate Marimar. Hintayin lana muna natin ang iba na matapos ha.P: Opo.

Recognition To build confidence and increase her self-esteem

V. Evaluation of Interaction

At the end of the conversation, the patient held smile and was confident to

confess a part of her life in summary. The patient used healthy words in mind easily

understandable by healthy mental state. She did said her favorite songs and artist as

well as her work before she was admitted at the said institution. She was responsive

and accommodating with frequent praise on physical looks on her nurse. In addition, the

patient lapses often on some topics which are not good in mental state.



Working Phase


At this point, the client’s problems are identified and solutions are

explored, applied and evaluated. The focus of the assessment and of the relationship is

the client’s behavior and the focus of the interaction is the client’s feelings.

VI. Goal Interaction

To establish confidence upon interaction

To promote patient’s self-esteem

To provide high level of trust

To promote self enhancement through life confession experience

To gain working trust and relationship

VII. General Objectives

To readily apply the therapeutic activities for self enhancement

To help them understand their current mental health status

To promote mind set for easy recovery

To reduce the level of anxiety

To prevent them from harming their self

VIII. Short-term Objectives

To make her realize that there is hope in life

To promote self-actualization

To reduce the level of fear

To provide physical cleaning

To create a good therapeutic binding

To overcome resistance behavior

IX. Description of the Environment

The working atmosphere was good. Everyone is active on their respective activities. The patient did verbalized that she was excited on that day’s activity. There


was a presence of slight noise coming from other school’s session. The weather was hot but then tolerable. The environment was therapeutic as evidenced by the patient understanding during the interaction.

Nurse-Patient Interaction (NPI) – Working Phase


N: Magandang umaga po Sa yo ate Marimar!

N: Ano ulit ang pangalan ko

Marimar?

P: Kran po!N: Carl akoP: Carl

N: Kumusta kana Marimar? P: Okey lang pN: Anung araw ngayun po ate marimar?P: Martes po.N: Nag-almusal ka na?P: Opo.. kumain ako ng Tinapay, nagligo at Nagtoothbrush

N: Galing, Masarap ba yun? P: Oo.. kani-kanina lang..

N: May gusto ka bang sabihin sa akin?P: Yung ano lang.. yung tungkol sa asawa ko.N: Anong tungkol kay asawa mo?P: Namatay siya pati anak kung tatlo sa BicolN: Napanu po sila ate Marimar?P: Namatay lang, Hindi ko

Use Name

Help to orient

Broad Opening

Accepting

Exploring

Using a person's name makes her feel more valued, and introducing yourself is a basic step in establishing a therapeutic interaction.

Illness and hospitalization can be very disorienting for patients.


To prevent negative feedbacks and thoughts on her mind



alam kung bakit

N: Kalimutan mo na po un..P: Medyo nakalimutan ko na..N: Ganyan po ate Marimar! Pagod ka na ba ate?P: Opo.N: Okay sige. Pahinga ka na ate Marimar. Hintayin lana muna natin ang iba na matapos ha.P: Opo.

Presenting Reality To promote easy understanding on the problem

X. Evaluation of Interaction

At the end of the working phase interaction, the patient was confident in herself

as evidenced by sharing her thoughts which are unlikely in the previous interactions.

She also added that she learned a lot during remotivation. In this phase, the patient

expresses her thoughts freely without fear. Furthermore, she sing and dance graciously

without anxiety.



Termination Phase


The nurse terminates the relationship when the mutually agreed goals are met,

the patient is discharged or transferred or the rotation is finished. The focus of this stage

is the growth that has occurred in the client and the nurse helps the patient to become

independent and responsible in making his own decisions. The relationship and the

growth or change that has occurred in both the nurse and the patient is summarized.

XI. Goal Interaction

To evaluate the patient’s readiness of oneself

To develop independent care

To gain self-awareness and self-care

To prevent interdependency of the patient to the nurse

To relieve discomfort on understanding others

XII. General Objectives

To protect patient from harming herself

To stabilize her good mental health or state of mind

To increase her level of independence

To establish a hopeful life outside the institution

To regain self respect

Establish reality of separation

Mutually explore feelings of rejection, loss, sadness, and anger and related

behaviors

XIII. Short-term Objectives

To make her realize that there is hope in life

To promote self-actualization

To reduce the level of fear

To provide physical cleaning


To create a good therapeutic bonding

XIV. Description of the Environment

The weather was calm and sunny. The termination phase was quite more joyous

and active since it is the last time to interact with them. Every patient cooperated and

tried their best to achieve the goals in that particular activity. At the end, they are quite

sad on that farewell but then as they verbalize that they are thankful that we had them.

Nurse-Patient Interaction (NPI) – Termination Phase


N: Magandang umaga po Sa yo ate Marimar!

N: Ano ulit ang pangalan ko

Marimar?

P: Kran po!N: Carl akoP: Carl

N: Kumusta kana Marimar? P: Okey lang pN: Anung araw ngayun po ate marimar?P: Merkules po.N: Nag-almusal ka na?P: Opo.. kumain ako ng Tinapay, nagligo at Nagtoothbrush

N: Naalala mo pa yung mga pinag-usapan natin po?P: Ah.. yung tungkol sa buhay ko?N: May gusto ka pa bang ilahad sa akin? P: Oo.. gusto ko sa nang umuwi na sa amin..N: Magpagaling ka po.. sundin mo lang mg

Use Name

Help to orient

Broad Opening

Exploring

Using a person's name makes her feel more valued, and introducing yourself is a basic step in establishing a therapeutic interaction.

Illness and hospitalization can be very disorienting for patients.




autos ng nurse at doctor dito.. nang sa ganun makalabas ka.

P: okey po.N: Eto na po pala ang huli nating pagkikita.. magpakabait po kayo dito ha? Tandaan mo lagi yung mga itinuro naming sayo araw-araw. P: Opo.. tatandaan ko po..

Presenting Reality

To promote easy understanding on the problem

XV. Evaluation of Interaction

At the end of the termination phase, the patient understand her current situation

and wants to improve as verbalized by “gusto ko nang umuwi at magsimula ulit”. She

freely expresses her thoughts and feelings. The patient was seldom on crying and

expressing negative thoughts. During the interaction the patient won’t lapse every single

word that she wants to clarify.


Chapter III

Music Appreciation and Interpretation Approach

A. Happy Songs

Black – depression and anxiety

Red – dominating behavior

Single Drawing – represents selfish motives

Indecisive line – insecurity and selfishness

Huge Head – open seen in grandiose paranoid evidence of aggressiveness, high

fantasy, high level of self-esteem which is usually associated with chronic

alcoholism

Two Shapes Put Together – represents dependency to someone

B. Sad Songs

Red – dominating behavior

Single Drawing – represents selfish motives

Indecisive Line – insecurity and selfishness

Huge Head – open seen in grandiose paranoid evidence of aggressiveness, high

fantasy, high level of self-esteem which is usually associated with chronic

alcoholism

- Attached Drawing…


List of Prioritized Psychiatric Nursing Diagnosis

NURSING DIAGNOSIS RANK RATIONALE

Disturbed Thought Processes related to developmental delay of cognition as evidenced by cognitive dissonance

1

Based on Carl Jung's Theory of Psychological Types, perception involves all the ways of becoming aware of things, people, happenings, or ideas. Judgment involves all the ways of coming to conclusions about what has been perceived. If people differ systematically in what they perceive and in how they reach conclusions, then it is only reasonable for them to differ correspondingly in their interests, reactions, values, motivations, and skills.

Impaired Verbal Communication related to impaired cognitive abilities as evidenced by loose association of ideas

2

According to Karen Horney’s Theory on Personality, moving away from people: The final possible consequence of a neurotic is a personality style filled with a social behavior and an almost indifference to others. If they don't get involved with others, they can't be hurt by them. While it protects them from emotional pain of relationships, it also keeps away all positive aspects of relationships. It leaves them feeling alone and empty.

Impaired Social Interaction related to impaired thought processes as evidenced by dysfunctional interaction with others

3

According to Sullivan’s Interpersonal Theory, the need for friendship and need for sexual expression get combined during late adolescence. In this stage a long term relationship becomes the primary focus. Conflicts between parental control and self-expression are commonplace and the overuse of selective inattention in previous stages can result in a skewed perception of the self and the world.


Self-Care Deficit, Bathing and Hygiene related to mental delay as evidenced by inability to bathe himself

4

Dorothea E. Orem's Self-Care Deficit Nursing Theory states that nursing is required because of the inability to perform self-care as the result of limitations.

Risk for Injury related to delayed developmental age

5

Self-harm is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a symptom of borderline personality disorder and depressive disorders.

Because of a delay on the gross and fine motor skills, as well as how the patient perceives things and events, the patient is at great risk of physical injury.


process recording ncmh

Documents

grandiose paranoid evidence

almusal ka na

kumusta kana marimar

provide physical cleaning

promote easy understanding

kran po

presenting reality

ended communication