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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
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 N: “Maganda Umaga po.” P: “Maganda Umumaga rin.” N:”Ako po si Cheryl and nurse niyo ngayon” P:”Ako-ako-ako na man si Felipe” N:”Kuya, ano po araw at petsa ngayon?” C:”2…2…2….21…. 2010… Feb… feb… February.” N:”Kuya, Ngayon po ay February 4, 2010 Inference Client was sitting and looking at me in the eye. He was sitting still looking at me in the eyes with his hands intertwined. Staring at me smiling. Techniques Giving recognition to indicate that you are aware of him Giving Information to tell the client who you are.
Clarification on what the client knew of the date today. Presenting Reality to know that what really is true.
His head started to move to the right and scratching his head.
Thursday. Pakiulit po.” C:” 4 Feb… February 2010 thu… thu… thurdays. N:”19 yrs old na po ako. Ilan taon na po kayo” P:”Ako… ako…. 21… 21 yrs na ako dito…” N:”Kuya, Ilan taon na po kayo” P:”3…3….3…..39 yrs old” N:”Sigurado po” P:”Oo… 21..21…21 yrs na ako dito sa lugar, Gawa ng lakad tapos pahinga… Ulit gawa araw-araw ” N:”Anu po yun Kuya? Naglalakad?” P:”Lakad lakad sa tabi-tabi…. Exercise…. Tapos upo pag pagod” N:”Anu-ano pa ng mga ginagawa ninyo ditto?” P:”Ano…. Kain… lakad… upo…. Tapos lakd pulot ng basura…. Dun sa labas ikot ikot lakad pag mainit ditto loob upo… kinig ng music” N:”Ano pangalan ng magulang ninyo” P:” A….a….a…. Sila patay na.” N:”May asawa po
His head started to go left to right as he answered.
Giving Information to know how old the client is. Clarification to make the client understand the question Validation to confirm if the client said is true.
His eyes looked straight.
His eyes started to roam around. Restating to know what the client said and to repeat the sentence.
He started to point at the room, outside and the chairs.
He started to make hand actions that correspond on what he was saying.
Using broad openings to introduce a topic
He started to looked around again.
Giving information to know the names of the client’s parents. Giving information to know the name of the client’s partner. Validation the client’s answer.
He was making hand gestures and his eyes just looked straight. Eyes started to wander around.
Giving information to know the name of
kayo?” P:”Oo…. Yun tatay ko may asawa.” N:”Kuya, ikaw po ba may asawa?” P:”Oo… asawa… mga kapatid ko may asawa.” N:”Mga anak Kuya, meyroon?” P:”Oo…. Dami dami…. Anak ng tatay ko… mga anak rin ng kapatid ko.” N:”May dumadala po ba sayo ditto?” P:”Dalaw…. Oo…” N:”Sino-sino po?” P:”Mga anak ok…. Anak ko…. Pati kapatid… magulang dito dalaw sa akin…. Dala pagkain tapos usap.” N:”Kuya… ano po 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”
Head turns to the left and stared.
the client’s children.
He stared straight then his head turn right. He was making hand gestures and his eyes just looked straight.
Giving information to know if the client’s is being visited. Giving information to know the who are the people visiting him.
His head gestures up and down as he point on his arm.
Exploring to know what happened to his wound.
He’s shaking his head that he agree as he stand up
Suggesting Collaboration to the client to participate on the excerise.
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.