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By:

Lukban, CherylA.

A4BB
I. PERSONAL DATA:

Name: “UM” Felipe Valencia

Age: about 42 years old

Gender: Male

Civil status: Unknown

Address: Unknown

Date of Birth: Unknown

Place of Birth: Unknown

Person to Notify: Annalyn Aguda (Escort)

Date of Admission: September 6, 1995 at 7:20

Admitting Doctor: Dr. Gonzaga

Admitting Diagnosis: Psychosis, to be classified

T/c Mental Retardation

S/p Exploratory Laparoscopy Descending Limb


Colostomy

Admission notes: Found by the Brgy. Tanod of Muntinlupa City,


along the railroad and side swiped by a running
train.

Bought to the Philippine General Hospital and


operated.

Stayed at 13 days in the PGH and was forwaded to


SW of Muntinlupa.

Final Diagnosis: Psychosis 2˚ to seizure disorder s/p Exploratory


Laparoscopy Descending Limb Colostomy

II. Objectives:

Specific Objectives:
1. Establish rapport.

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

3. To know or gain information about what happened to the


patient.

4. To understand the patient’s problems.

5. To know the symptoms manifested.

General Objectives

To distinguish the sickness of the client thru the observation


done.

III. Assessment:

The patient manifest the following symptoms of not having eye


contact to the nurse, there is disorganized speech, stuttering and repetition
of his own words (verbigeation), obeying single command, doesn’t
remember the day, there is delusion and word salad.

IV. Recording:

Nurse-Patient Inference Techniques

N: “Maganda Umaga Client was sitting and Giving recognition to


po.” looking at me in the indicate that you are
P: “Maganda Um- eye. aware of him
umaga rin.”
Giving Information to
He was sitting still tell the client who
N:”Ako po si Cheryl looking at me in the you are.
and nurse niyo eyes with his hands
ngayon” intertwined.
P:”Ako-ako-ako na
man si Felipe” Clarification on what
Staring at me smiling. the client knew of
N:”Kuya, ano po the date today.
araw at petsa
ngayon?”
C:”2…2…2….21…. Presenting Reality to
2010… His head started to know that what
Feb… feb… move to the right and really is true.
February.” scratching his head.

N:”Kuya, Ngayon po
ay February 4, 2010
Thursday. Pakiulit Giving Information to
po.” His head started to go know how old the
C:” 4 Feb… February left to right as he client is.
2010 thu… thu… answered.
thurdays.
Clarification to make
N:”19 yrs old na po the client understand
ako. Ilan taon na po His eyes looked the question
kayo” straight.
P:”Ako… ako…. 21… Validation to confirm
21 yrs na ako dito…” if the client said is
true.
N:”Kuya, Ilan taon na His eyes started to
po kayo” roam around.
P:”3…3….3…..39 yrs
old”
Restating to know
N:”Sigurado po” what the client said
P:”Oo… 21..21…21 He started to point at and to repeat the
yrs na ako dito sa the room, outside and sentence.
lugar, Gawa ng lakad the chairs.
tapos pahinga… Ulit
gawa araw-araw ”
Using broad
N:”Anu po yun Kuya? openings to
Naglalakad?” He started to make introduce a topic
P:”Lakad lakad sa hand actions that
tabi-tabi…. correspond on what he
Exercise…. Tapos upo was saying.
pag pagod”

N:”Anu-ano pa ng
mga ginagawa ninyo Giving information to
ditto?” know the names of
P:”Ano…. Kain… He started to looked the client’s parents.
lakad… upo…. Tapos around again.
lakd pulot ng
basura…. Dun sa Giving information to
labas ikot ikot lakad know the name of
pag mainit ditto loob He was making hand the client’s partner.
upo… kinig ng music” gestures and his eyes
just looked straight. Validation the
N:”Ano pangalan ng client’s answer.
magulang ninyo” Eyes started to wander
P:” A….a….a…. Sila around.
patay na.”
Giving information to
N:”May asawa po know the name of
kayo?” Head turns to the left the client’s children.
P:”Oo…. Yun tatay ko and stared.
may asawa.”

N:”Kuya, ikaw po ba
may asawa?” Giving information to
P:”Oo… asawa… mga know if the client’s is
kapatid ko may He stared straight then being visited.
asawa.” his head turn right.
Giving information to
N:”Mga anak Kuya, know the who are
meyroon?” He was making hand the people visiting
P:”Oo…. Dami gestures and his eyes him.
dami…. Anak ng just looked straight.
tatay ko… mga anak
rin ng kapatid ko.”

Exploring to know
N:”May dumadala po His head gestures up what happened to
ba sayo ditto?” and down as he point his wound.
P:”Dalaw…. Oo…” on his arm.

N:”Sino-sino po?”
P:”Mga anak ok….
Anak ko…. Pati
kapatid… magulang
dito dalaw sa akin….
Dala pagkain tapos Suggesting
usap.” He’s shaking his head Collaboration to the
that he agree as he client to participate
N:”Kuya… ano po stand up on the excerise.
nagyari diyan sa
sugat ninyo?”
P:”Ito’y…. kuha siya
doon…. Tapos bigla
siya dugo…. Noon na
tuyo…. Ako kamot
tapos dugo ulit….
Noon dugo lit ako tigil
kamot.”

N:”Kuya, tayo muna


tayo at
mageexercise”
P:”Sige… sige….
Kami araw-araw
exercise sa loob”
V. Evaluation:

The goals of the objectives are partially unmet because I was not
able to know what happened to the client. Due to the client not
remembering things on what happened before he was bought inside
the hospital.