Chapter I

Personal Data
Name Sex Age Address Civil Status Birth date Birthplace Religion Nationality Date Admitted Time Admitted Admitted Doctor Diagnosis General data : Patient X : Female : Unknown : Emerald height Garden Villas Mambugan Antipolo City : Married : Unknown : Bicol : Unknown : Filipino : October 07, 2004 : 4:15pm : Dr. Tamano : Undifferentiated Schizophrenia - unstable : 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

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. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Can shrug shoulder Tongue at midline (+) Corneal Reflex Intact EOM No facial assymetry Can hear whisper word (+) gag reflex N/A 2.3mm equally reactive to light Intact EOM

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

Motor System: Limbs Trunk Stance Gait Rombergo 5/5 5/5 5/5 5/5

Reflexes J.J B.J S.J T.J Plantar H H H H

Sensational Pain & Touch Temperature Vibration JPS Two point Descrimination 100 100 100 100

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

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 patients 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 patients 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 patients personality.

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

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 N: Magandang hapon sa iyo P: Magandang hapon po N: 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 paguusapan natin ang iyong talambuhay. P: Ano pong 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 Bicol N: 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. Inference Broad Opening Rationale To establish openended communication

Giving Information

To gain rapport and trust

Offering Self

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

Exploring

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

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

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.

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

Process Recording No. 2 Working Phase

Description of Phase: At this point, the clients problems are identified and solutions are explored, applied and evaluated. The focus of the assessment and of the relationship is the clients behavior and the focus of the interaction is the clients feelings. VI. Goal Interaction To establish confidence upon interaction To promote patients 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 days activity. There was a presence of slight noise coming from other schools session. The weather was

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

hot but then tolerable. The environment was therapeutic as evidenced by the patient understanding during the interaction. Nurse-Patient Interaction (NPI) Working Phase NPI N: Magandang umaga po Sa yo ate Marimar! Inference Use Name Rationale 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.

N: Ano ulit ang pangalan ko Marimar? P: Kran po! N: Carl ako P: Carl N: Kumusta kana Marimar? P: Okey lang p N: 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 Bicol N: Napanu po sila ate Marimar? P: Namatay lang, Hindi ko alam kung bakit

Help to orient

Broad Opening

To establish open-ended communication

Accepting

To prevent negative feedbacks and thoughts on her mind To have an idea on her present illness and help analyze her situation

Exploring

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

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. X. Evaluation of Interaction

Presenting Reality

To promote easy understanding on the problem

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.

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

Process Recording No. 3 Termination Phase

Description of 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 patients 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

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

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 NPI N: Magandang umaga po Sa yo ate Marimar! Inference Use Name Rationale 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.

N: Ano ulit ang pangalan ko Marimar? P: Kran po! N: Carl ako P: Carl N: Kumusta kana Marimar? P: Okey lang p N: 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 autos ng nurse at doctor dito.. nang sa ganun makalabas ka.

Help to orient

Broad Opening

To establish open-ended communication

Exploring

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

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

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.. XV. Evaluation of Interaction

Presenting Reality

To promote easy understanding on the problem

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 wont lapse every single word that she wants to clarify.

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

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

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

List of Prioritized Psychiatric Nursing Diagnosis NURSING DIAGNOSIS RANK RATIONALE 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. According to Karen Horneys 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. According to Sullivans 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.

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

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

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

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

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

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

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.

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