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Published by Ynaffit Alteza

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Published by: Ynaffit Alteza on Oct 07, 2013
Copyright:Attribution Non-commercial


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27 years old
Civil Status:
August 16, 1981
Brgy. Tangub, Bacolod City
Chief Complaints:
Thought broadcasting, nervousness, agitation, sleeplessness/ insomnia
Medical Diagnosis:
T/C Schizophrenia
Nursing Diagnosis:
Ineffective individual coping related to inadequate support system asevidenced by disturbances on REM sleep
B.History of the Present Illness
Last October 2006, M.P. was brought to BCMHCC because of the event that he knifed bothof his arms. At first, he refused to take his medications. And on that the same year, heattempted to cut his mother’s arms with a knife and hit her at the back of her head.
I.General Appearance and Behavior
The patient is a young adult male, fair-skinned, with several cut marks on both armsdressed with the institution’s provided clothing. He is also well-groomed and nails areclean. Facial expressions depend on the patient’s way of conversing. He looks at the person he talks to as a direct eye contact. He was helpful during the putting of decorations during the occupational therapy activity. Though he always came late, itis of noticeable of preparing himself to be presentable and only after his everymorning ritual of eating breakfast and grooming. There were no problems with theway he walks. He was active in doing activities.
II.Characteristics of Speech
The patient is coherent and his words are easy to understand. And due to the reason thathe had been staying in Texas for years, he already had the American accent inspeaking English. He talks fast but can be understood easily. He talks in a moderatevolume enough to be heard each time of conversation.
III.Mood and Affect
The patient on the first day of interview was laughing whenever he hears jokes. He iseven familiarized with the songs playing and asked for its artist and title, sortremembering and organizing memories. He showed emotions of missing his family but then shows a stable mood that does not affect his daily activities almost akin toenthusiasm.
IV.Forms of Thought or Content of Thought
The patient answered to questions being asked and even admitted that he was confinedin a rehabilitation center in Manila. He gave a statement that he came from the statesand wanted to have “freedom”. He also admitted of having auditory and convincedhallucinations letting him hurt himself and others.
V.Sensorium Functions
The patient is oriented with the time, place, person, date, and even his personal situation.He has a good memory for he can even remember the date when he was brought intothe institution. He is very aware of the reasons why he was brought in BCMHCC andthat is of depression and anxiety.Khans 10 QuestionsANSWERS
What is the name of this place?BCMHCC
Where is it located?Paglaum, Bacolod
What day of the week is it?9
What is the month now?December 
What is the year now?2008
How old are you?27 years old
What month were you born?August
What year were you born?1981
Who is the president now?GMA
Who is the president before him/her?ERAP
Total Score:
10- No evidence of organic brain syndrome
VI.I nsight and Judgment
The patient was aware and understood his situation. He had a good compliance withmedications. He could talk what happened to him freely and with no signs of depressions. He was also giving a good judgment when asked what to do in asituation seeing his friends fighting one another. He said without hesitations that hewould stop the tiff and let his friends settle it with a talk.
The 80% of the data being collected were taken from the client during the interview. Theremaining 20% were taken from the patient’s chart.
VIII.P rognosis of the ClientPROGNOSISGOODBAD
Onset of illness
Good - below 20
Bad - above 40
 Educational Attainment 
Good -High School or College Graduate
Bad - Elementary Undergraduate or NoSchooling
Good – Female
Bad – Male
 History of Present Illness in the Family
Good – Negative
Bad – Positive
 History of Admission
Good – Acute
Bad – Chronic
 Socio-Economic Status
Good – Sufficient/ Adequate
Bad – Not S
Family Support 
Good – Yes
Bad – No
 Pre- Morbid Personality
Good – Extrovert
Bad – Introvert
Compliance to Medication
Good – Yes
Bad – No
XI. References
Patient’s Chart
Patient’s Family Interview
Patient’s Personal Interview
XII. Evaluation and Recommendation
The patient participated in the interview and was able to answer questions. Accordingto the prognosis of the clients, it shows a good result. As an observation, he just needsmore time to cope up with himself, his illness and self-issues that awaits him outsidethe institution.
IX.DRUG STUDYX.NURSE-PATIENT INTERACTIONDAY 1Nurse InteractionPatient InteractionNurse InterferencePatient Interference
“Good morning, akogali si Kamille, akoang student nurse mosubong asta saFriday.”“Good moring... ah...ok.”
- fothe patient to identifyme as her studentnurse at a certainlength of time.Patient smiled andwas looking up thestudent nurse.

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