By: Lukban, CherylA.

A4BB

Stayed at 13 days in the PGH and was forwaded to SW of Muntinlupa. 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. Objectives: Specific Objectives: . Tanod of Muntinlupa City. Bought to the Philippine General Hospital and operated. to be classified T/c Mental Retardation S/p Exploratory Laparoscopy Descending Limb Colostomy Admission notes: Found by the Brgy. Final Diagnosis: Psychosis 2˚ to seizure disorder s/p Exploratory Laparoscopy Descending Limb Colostomy II. along the railroad and side swiped by a running train.I. Gonzaga Admitting Diagnosis: Psychosis.

To know or gain information about what happened to the patient. His head started to move to the right and scratching his head. Assessment: The patient manifest the following symptoms of not having eye contact to the nurse. He was sitting still looking at me in the eyes with his hands intertwined. Ngayon po ay February 4. 4. III. 3.1. . ano po araw at petsa ngayon?” C:”2…2…2…. obeying single command.” P: “Maganda Umumaga rin. Staring at me smiling. there is delusion and word salad. stuttering and repetition of his own words (verbigeation). Techniques Giving recognition to indicate that you are aware of him Giving Information to tell the client who you are.” N:”Kuya. 2010 Inference Client was sitting and looking at me in the eye.21…. Clarification on what the client knew of the date today. To understand the patient’s problems. Establish rapport. General Objectives To distinguish the sickness of the client thru the observation done. Presenting Reality to know that what really is true.” N:”Ako po si Cheryl and nurse niyo ngayon” P:”Ako-ako-ako na man si Felipe” N:”Kuya. doesn’t remember the day. 2. To know the symptoms manifested. Recording: Nurse-Patient N: “Maganda Umaga po. 5. IV. there is disorganized speech. To reduce the anxiety felt by the client towards the nurse. 2010… Feb… feb… February.

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 how old the client is. He started to point at the room. His eyes started to roam around. Pakiulit po.21…21 yrs na ako dito sa lugar. His eyes looked straight.a…. outside and the chairs. Ilan taon na po kayo” P:”Ako… ako…. Giving information to know the name of .a…. Tapos upo pag pagod” N:”Anu-ano pa ng mga ginagawa ninyo ditto?” P:”Ano…. Dun sa labas ikot ikot lakad pag mainit ditto loob upo… kinig ng music” N:”Ano pangalan ng magulang ninyo” P:” A…. Exercise…. N:”19 yrs old na po ako.39 yrs old” N:”Sigurado po” P:”Oo… 21. Kain… lakad… upo…. Giving information to know the name of the client’s partner.” N:”May asawa po His head started to go left to right as he answered. He started to make hand actions that correspond on what he was saying.. Validation the client’s answer. Eyes started to wander around. 21… 21 yrs na ako dito…” N:”Kuya.. Restating to know what the client said and to repeat the sentence.Thursday.” C:” 4 Feb… February 2010 thu… thu… thurdays. Gawa ng lakad tapos pahinga… Ulit gawa araw-araw ” N:”Anu po yun Kuya? Naglalakad?” P:”Lakad lakad sa tabi-tabi…. Ilan taon na po kayo” P:”3…3…. Tapos lakd pulot ng basura…. Clarification to make the client understand the question Validation to confirm if the client said is true. He was making hand gestures and his eyes just looked straight. Sila patay na.3….

He’s shaking his head that he agree as he stand up Suggesting Collaboration to the client to participate on the excerise. Dala pagkain tapos usap.” N:”Kuya. ikaw po ba may asawa?” P:”Oo… asawa… mga kapatid ko may asawa. Giving information to know the who are the people visiting him. Giving information to know if the client’s is being visited. kuha siya doon…. He stared straight then his head turn right. meyroon?” P:”Oo…. Anak ko…. Anak ng tatay ko… mga anak rin ng kapatid ko. .” N:”May dumadala po ba sayo ditto?” P:”Dalaw…. the client’s children. He was making hand gestures and his eyes just looked straight. Pati kapatid… magulang dito dalaw sa akin…. Dami dami….kayo?” P:”Oo…. Noon dugo lit ako tigil kamot.” N:”Mga anak Kuya. His head gestures up and down as he point on his arm. Ako kamot tapos dugo ulit…. tayo muna tayo at mageexercise” P:”Sige… sige…. Oo…” N:”Sino-sino po?” P:”Mga anak ok….” N:”Kuya… ano po nagyari diyan sa sugat ninyo?” P:”Ito’y…. Tapos bigla siya dugo…. Noon na tuyo…. Exploring to know what happened to his wound. Yun tatay ko may asawa. Kami araw-araw exercise sa loob” Head turns to the left and stared.” N:”Kuya.

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

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