Personal profile

Name Corales Jesus

Age 63 years old

Gender Male

Civil status Single

Birthdate feb/8/1995

Religion Catholic

Date of admission dec/30/1995

Diagnosis F200 Paranoid Schizophrenia

General date: Client is a male, he was active and alert and answering any

Question in English and was wearing the NCMH gown, his hygiene is good
and no sign of skin disorder noticed. He was a little bit quite person but he maintain good eye contact.

History of present illness: The client was doing well, he was in 3rd year high school student and he being
to go out with his school friends and start drinking alcohols every time and his mother noticed that he is
drinking with his friends because she noticed a new behaviour in him and she advised him not to drink
but he continues drinking and his mother decide to top him from going to school, after he stop going to
school his behaviour became good he helps his mother cleaning the houses and washing dishes, one day
his friends secretly called his and they start to drink again and little by little he start smoking at this time
he manifest a new behaviour he can’t sleep at night and he dance alone and talks alone he fells
irritable and he get admitted.

Medication

-Chlorpromazine

-Na Valproate

-Risperidone

-Biperiden

-Clozapine
Family history = HPN- Mother and Father

Orientation Phase
objectives:

1.To be able to gather information from the client.

2. To establish rapport in order to gain the patient’s trust from the client and for him
to cooperate.
3. To be able to know the condition of my patient.

Nurse patient Interaction

Student Nurse Analysis Patient’s verbal and ANALYSIS

Non-Verbal
Communication

Good Morning po Giving recognition ac Good morning The patient is

responsive

I am Abdisa form Giving information to Oww good The patient has

manila Adventist gain trust expressed his approval
college For discussion and
willing to answer
question
I am 3rd year student Giving information to Hmm very Good The patient has
nurse I will be here for 2 gain rapport and trust expressed his approval
weeks

Po Where are you from Seeking information From illocos norte The patient is aware of
his address prior to
confinement

PO can you tell me your Seeking information Jesus corales The patient is aware of
name him self

The date today is Presenting reality to Ow okayy The patient seems

Wednesday/ keep him oriented of confused that is not
feb/20/2019 the date. aware of the day but
didn’t not manifest any
reactions
How do you feel about Reflective to see if the Yes its fine, it’s good to The patient seems to
this interview patient is interested to talk to people I enjoy enjoy talking and
the interview talking. remind willing and
compliant

“What are the things Seeking information I like to exercise and The patient is
that you like to do when dance, before I used to responsive.
you are free?” play basketball, “smile “

What food do you like Seeking information Fish I like fish, and I Patient is responsive
to eat?” used to go fishing and seems enjoying the
before question

What food do you like Seeking information I like juice orange Giving information
to eat?”

Do you have children Seeking information Yes I have 4 buys and 2 He seems sad and
girls, 4 of them in uncomfortable
college 2 of them in
high school
Okay, Can you tell me Asking to client to Farmer Agree
about your work?” explain his work

Have you had visitors Seeking information No Looks uncomfortable

and sad

Okay sir , thank you for Closing conversation okay”( smile, stand up agree
time you spend with me and went back to ward)
and we will meet again
and have conversation
again for next day”

Reflective to see if he is Ow it’s so good I like it

still inserted no problem at all The patient looks happy
How do you find our enjoying the activity
activity

Working Phase
Goals: learn more about client’s strengths and weakness/like and dislike

Facilitate client through the prepare activities and therapies

Establish a therapeutic communication with client

 Encourage client to express self and socialize

STUDENT NURSE ANALYSIS Patient’s verbal and ANALYSIS

Non-Verbal
Communication
Good morning : Using his mane makes Good morning. Yes of Patient recalling of
Do you remember me him more valuable course I remember you previous meeting was
are abdisa from intact manifesting long
Adventist term memory

How was your day Seeking information It was good no problem Patient seems to be in
good mood and
responsive
okay sir, so we just have Start topic of Dancing” (rise hands client show interesting
activity right , so which conversation make some move) in dancing
activity do you like?”

About the our activity Asking clarification for “it’s my house”and I “it’s my house”(smile)
drawing , I saw you vague thought used to fish
draw a fish and house
,why did you come up
with that idea

Do u like the food Seeking information Yes its good agree

so how did you get here Seeking information Alcohol Responded

what do you think of Exploring Its good its okay no Seems happy with the
this place that you are problem place
staying right now
Do you like this place Asking clarification Its food Seems good with the
place

what do you think of Asking for information Its okay am fine Patient responded
yourself right now

okay sir , that’s it for End of conversation Okay thank you , stand responded with
today we will meet and smile walk to ward comfortable answer
again and than kyou for
your time “
Termination phase

Goal: help patient to establish networks of support

Help in coping with future problems.

STUDENT ALYNSIS Patient’s verbal and ALYNSIS

Non-Verbal
Communication
“good morning sir” -giving recognition “good morning “ -pt responded

“sir, this is the last day -giving information “okayyy ” -agree

of our conversation “

“So do you have -giving broad opening “…..”(smile) -pt unable to say
something you want to anything
talk about ?”

“how’s your day?” -seeking information It’s okay its fine Patient looks in good
mood

“Have you had similar -Comparison “no, I don’t know “ -denial

experience?”

“Okay sir , Do you -giving information “yes”(nodding) -agree aware of events

remember the activities
that we have since first
day we meet ?

“So among of all of that -asking for clarification “…. Dancing and singing -patient looks happy
activities which one do and food “ with the activities
you like ? Everything is good

“Did these activities -asking for clarification

make you happy”? Yes its good I like it -agree

“ So what did you learn -asking for information

from all of these “it’s okay” -patient responded
activity?”

Do you like this activity -asking for clarification “ yes , I like it “

to happen evey day ?” (nodding) -agree
“Sir , we going to have a -giving information and “okay”
program for tomorrow new topic -pt understand
like a party and we
going to sing and have
some food for
tomorrow “
“Are you looking -asking for clarification “……” (smile) pt seem to be happy
forward for tomorrow
program?”

“And tomorrow is our giving information Ow ok socialization Patient is aware about

last day and I just want the program
to remind you that we
won’t be here after
Friday “

So what do you think of Asking for clarification Nice and kind I like kind Patient responsive
us “ people and smile

thank you sir for today End of conversation Okay see you Patient to be happy and
and thank you for your tired
time and we will meet
again one last time for
tomorrow”