Centro Escolar University

College of Nursing
Mendiola, Manila

In partial fulfillment of the requirements

In

NCM 104

Special Institution
Sta. Ana Elementary School

“MR”
(Mental Retardation)
Submitted by:

Daez, Mark Steven R.

BSN 3A /Group 3A

Submitted to:

Mr. Jeffrey Castillo

Clinical Instructor
CHAPTER 1: OBJECTIVES

At the end of 16 hours of exposure, the student will be able to:

1. Assess the adaptive functioning of the client during the orientation

phase

2. Assess the developmental tasks of the client during the orientation

phase

3. Determine the different characteristics of the client.

4. Observe the different learning skills of the client.

5. Know and understand what are the different psychiatric disorders

especially mental retardation and autism

6. Integrate the significance of nurses’ role in caring for clients with

special needs

7. Develop insights in the related learning experience

8. Establish rapport with the mentally challenged client

9. Care for the mentally challenged client

10. Assist in the activities of daily living and in the program of the institution
during the working phase

11. Prepare for program culmination during the termination phase or the
socialization day

12. Be familiarizing with the set-up of the institution.

13. Integrate the 3 principles of nursing care to the mentally challenge
clients.

14. Make use of proper therapeutic communication with the clients.

CHAPTER 2: INTRODUCTION

DEFINITION

Mental Retardation
 defined by deficits in general intellectual functioning and adaptive functioning.
General intellectual functioning is measured by an individual’s performance on
intelligence quotient (IQ) tests. Adaptive functioning refers to the person’s ability
to adapt to the requirements of daily living and the expectations of his or her age
and cultural group.

 The DSM-IV-TR identifies criteria for mental retardation as IQ of 70 or below,

with deficits or impairments in communication, self-care, home living,
social/interpersonal skills, use of community resources, self-direction, functional
academic skills, work, leisure, health, and safety.

ETIOLOGY

Causes of mental retardation include heredity such as Tay-Sachs disease or

fragile X chromosome syndrome; early alterations in embryonic development such as
trisomy 21 or maternal alcohol intake that causes fetal alcohol syndrome; pregnancy or
perinatal problems such as fetal malnutrition, hypoxia, infections, and trauma; medical
conditions of infancy such as infection or lead poisoning; and environmental influences
such as deprivation of nurturing or stimulation.

CLASSIFICATION

The degrees, or levels, of mental retardation are expressed in various terms.

DSM-IV-TR presents four levels of mental retardation: mild, moderate, severe, and
profound.

Mild mental retardation (IQ range, 50 to 70) represents approximately 85

percent of persons with mental retardation.
Moderate mental retardation (IQ range, 35 to 50) represents about 10 percent
of persons with mental retardation
Severe mental retardation (IQ range, 20 to 35) comprises about 4 percent of
individuals with mental retardation.
Profound mental retardation (IQ range below 20) constitutes approximately 1
to 2 percent of persons with mental retardation.
MANIFESTATION

Prenatal causes: the configuration and the size of the head offer clues to a
variety of conditions, such as microcephaly, hydrocephalus, and Down
syndrome.
hypertelorism, a flat nasal bridge, prominent eyebrows, epicanthal folds, corneal
opacities, retinal changes, low-set and small or misshapen ears, a protruding
tongue, and a disturbance in dentition, a high-arched palate, uncommon ridge
patterns and flexion creases on the hand
other clinical manifestations of other disorders associated with mental retardation
like Down syndrome, phenylketonuria, fetal alcohol syndrome, etc.

BEHAVIOR

Surveys have identified several clinical features that occur with greater frequency
in persons who are mentally retarded than in the general population. These features,
which can occur in isolation or as part of a mental disorder, include hyperactivity, low
frustration tolerance, aggression, affective instability, repetitive and stereotypic motor
behaviors, and various self-injurious behaviors. Self-injurious behaviors seem to be
more frequent and more intense with increasingly severe mental retardation.

PLAY

INTERACTIVE PLAY
One of the most prevalent problems among persons who are mentally retarded is a
sense of social isolation and social skills deficits. Thus, improving the quantity and
quality of social competence is a critical part of their care.

NURSING INTERVENTION

1. Assess all children for signs of developmental delays.

2. Administer prescribed medications for associated problems such as anticonvulsants

for seizure disorders, and methylphenidate (Ritalin) for attention deficit hyperactivity
disorder.

3. Support the family at the time of initial diagnosis by actively listening to their feelings
and concerns and assessing their composite strengths.

4. Facilitate the child’s self-care abilities by encouraging the parents to enroll the child in
an early stimulation program, establishing a self-feeding program, initiating independent
toileting, and establishing an independent grooming program (all developmentally
appropriate).
5. Promote optimal development by encouraging self-care goals and emphasize the
universal needs of children, such as play, social interaction and parental limit setting.

6. Promote anticipatory guidance and problem solving by encouraging discussions

regarding physical maturation and sexual behaviors.

7. Assist the family in planning for the child’s future needs (e.g. Alternative to home
care, especially as the parents near old age); refer them to community agencies.

8. Provide child and family teaching

Identify normal developmental milestones and appropriate stimulating activities

including play and socialization.
Discuss the need for patience with the child’s slow attainment of developmental
milestones.
Inform parents about stimulation, safety and motivation.
Supply information regarding normal speech development and how to accentual
nonverbal cues, such as facial expression and body language, to help cue
speech development.
Explain the need for discipline that is simple, consistent and appropriate to the
child’s .
Review an adolescent’s need for simple, practical sexual information that
includes anatomy, physical development and conception.
Demonstrate ways to foster learning other than verbal explanation because the
child is better able to deal with concrete objects than abstract concepts.
Point out the importance of positive self-esteem, built by accomplishing small
successes in motivating the child to accomplish other tasks.

9. Encourage the prevention of mental retardation

Encourage early and regular prenatal care.

Provide support for high risk infants.
Administer immunizations, especially rubella immunization.
Encourage genetic counselling when needed.
Teach injury prevention – both intentional and unintentional

THERAPY

Certain skills are important to adaptive behavior, such as:

Daily living skills, such as getting dressed, using the bathroom, and feeding
oneself
Communication skills, such as understanding what is said and being able to
answer
Social skills with peers, family members, spouses, adults, and others
MEDICATION

If seizure disorder is present, antiseizure medications

DIAGNOSTIC PROCEDURE

An assessment of age-appropriate adaptive behaviors can be made using

developmental screening tests. The failure to achieve developmental milestones
suggests mental retardation.

The following may be signs of mental retardation:

 Abnormal Denver Developmental Screening Test (DDST)

Here in the Phils. (MMDST)
MMDST- is a test utilized in pediatric patients to determine their physical and mental
skills. the nurses will assist in developing motor skills among toddlers and young
patients

Purposes

Measures developmental delays

Evaluates 4 aspects of development
Aspects of development
Personal-social
Fine-motor adaptive
Language
Gross motor behavior
Adaptive behavior score below average
Development way below that of peers
Intelligence quotient (IQ) score below 70 on a standardized IQ test

Laboratory tests to help detect metabolic and genetic disorders. Imaging tests, such as
computed tomography (CT) or magnetic resonance imaging (MRI), may be performed
to look for structural problems within the brain. An electroencephalogram (EEG) records
the brain's electrical activity and is used to evaluate a child for possible seizures. A
chromosome analysis, urine and blood tests, and x-rays of bones can also help rule out
suspected causes of MR/ID.
CHAPTER 3: DEMOGRAPHIC DATA

Client is JC. He is 9 years old. He is now a Kindergarten under Special

Education Program in Sta. Ana Elementary School.

CHAPTER 4: THEORIES

DEVELOPMENTA MANIFESTATI ANALYSIS

THEORY
L TASK ON

Psychosexu Latent- -no obvious In relation with my

al Theory of 7-12 years development. client, his libido is
Sigmund - Child’s libido or concentrated in his
-he accepts
Freud energy is diverted activities rather than on
and can do all
to more concrete his genital. He is active
things given to
type of thinking in school by
him.
participating well in
class.

Psychosocial Industry vs.

Theory of Inferiority In relation with my client,
- the client can
Erik Erickson 7-12 yrs child shows competency
do things well as evidenced by
- child learns how
in his own participating well in the
to do things well class as his teacher called
ways. him to read or answer in
front of his classmates but
not as good compared
with his other classmates
because sometimes, he
needs supervision or help
of his classmates in
answering some question
of his teacher. He is also
not confident in answering
some question of his
teacher that leads to
guidance, supervision at
dependency of the child.
But if we talk about
classroom works, he is
responsible in a way that
he’s the one who dispose
the garbage of the
classroom every end of
their class.

Cognitive Concrete
Theory of Operational
- he can count
Jean Piaget thought up to 100 and Some of the
(7-12 years) cite the developmental task in
alphabet. this theory was not fully
 Able to find
achieved by the client
solution to -needs
everyday guidance in
problems which some areas of
systematic
learning like
reasoning.
comparison
 have concept of and reasoning.
reversibility-
cause and
effect

 Have concept of
longer situation
– constancy
despite of
transformation.

-- Social One of the task on this

subordination - obey stage of Sullivan theory
Interpersona parental-like authority The client has was social subordination
or obeying parental-like
l Theory of -extends from the a good authority. In relation with
Harry patterning of relationship my client, he can obey
commands by authorities
Sullivan preferred genital with his
like his teacher and older
activity through classmate and age that him by reading
to his mentors. for participation in the
unnumbered
class, and following
educative and He can take instructions like the
drawing activity that the
deductive steps to good care of
CEU students and other
the establishment himself. activities during the
of a fully human or socialization. He also has
a good interaction with his
mature repertory of classmates because he
interpersonal can easily mingle with
them and he also has a
relations, as
good interaction with
permitted by them.
available
opportunity,
personal
and cultural
 -The main focus as a
juvenile is the need
for playmates and
the beginning of
healthy socialization.

CHAPTER 5: ADAPTIVE FUNCTIONING:

a. Communication- The client blurts out inappropriate comments, show his

emotions without restraint, and act without regard for consequences. He
doesn’t seem listening when spoken to and lacks eye contact during
conversation.. He uses simple words when communicating. He speaks and
understands simple English. He uses Filipino as a medium of communication.

b. Self-care- the client is well groomed upon observation.

c. Social interaction- he often interrupts conversations or others' activities. He

is friendly and has good interaction with others.

d. Self direction- He has difficulty processing information as quickly and

accurately as others and struggles to follow instructions. The client is easily
distracted, miss details, forget things, and frequently switch from one activity
to another.

e. Functional academic skills-. He has trouble completing or turning in

homework assignments alone and needs supervision. He has hard time
answering his teacher’s question when asked. But excels in doing school
projects and works.

f. Work- the client has difficulty focusing on one thing. He easily becomes
bored with a task after only a few minutes, unless he does something
enjoyable. He also has difficulty focusing attention on organizing and
completing a task or learning something new. But accepts tasks given to him.

g. Leisure- He likes to watch television and play computer games.

h. Health- The client seems to be too skinny. Most likely, he is in below normal
weight. He is neat. He also likes to eat fruits. He practices good hygiene.
i. Safety- Patient manifest some slight hyperactivity. He dashes around,
touching or playing with anything and everything in sight. He has slight
uncoordinated movements which can lead to injury to the child.

CHAPTER 6

A. CLINICAL MANIFESTATIONS:

CHARACTERISTICS OBSERVED NOT OBSERVED

Affect isolation ∕
Unrelatedness to others ∕
Twiddling behaviour ∕
Inconsistent
developmental maturity
∕
Self destructive
behaviour
∕
Temper tantrums/
anxiety
∕
I/you apparent
confusion
∕
Concrete thinking ∕
Perceptual
inconsistencies
∕
Immediate and delayed
echolalia
∕
Orderliness ∕
Physical uncoordination ∕
Language ∕
Excessive activity ∕

CHAPTER 7

Physical Description
 Patient is in small frame body built. He has a smooth rhythmic gait,
appropriately dressed and no malodorous scent noted. No obvious physical
deformities. Skin is in normal racial tone and nails are long and dirty. Hair is black
in color. Ears are aligned on the patient’s eyebrows and no deviations found.
Eyes are straight normal. He has a flat nose bridge. No other deformities found

CHAPTER 8: NURSE-PATIENT INTERACTION

ORIENTATION PHASE

Definition: It is during the orientation phase that the nurse and the patient
meet. The tasks in this phase of the relationship are to establish a climate of
trust, understanding, acceptance, and open communication and formulate a
contract with the client.

Objectives: After the orientation phase, the student nurse will be able to:

 Establish trust and rapport with the client;

 Establish a contract with the client;
 Initially identify problems of the client that are needed to
intervene;
 Explore patient’s feeling, perceptions, thoughts, and actions;
and
 Define mutual, specific goals with the patient.

Date: January 20, 2011

Time: 9:30 a.m.

Venue: Sta. Ana Elementary School

Nurse Patient Rationale of the Nurse’s

Communication
Techniques

Giving Recognition: This is to

provide acknowledgment and
Nurse:Magandang Patient: (patient
awareness. Greeting the
umaga sayo smiles)
client shows that the
patient’s presence is felt by
 the nurse.

Giving information: To give

details that the patient needs
Nurse: Ako si kuya Mark Patient: J.C.
to know in order to gain
Steven Daez. student
patient’s trust and
nurse po ng Centro
cooperation. The nurse also
Escolar University sa
sets the time frame of
Mendiola. Eto ang unang
working with the client.
araw naming ditto sa
school niyo. Hanggang
dito kami bukas. Anu
naman ang pangalan
mo?

Nurse: Pakiulit nga po Patient: Kuya Mark!

ang pangalan ko?

Nurse: Ikaw si J.C. ? Patient: (blocking.....) Restating: This restatement

Ilang taon ka na? 8 po. lets the client know that he
communicated the idea
effectively. This encourages
the client to continue.

Questioning: To gain basic

information about the client.

Nurse: 8 years old ka Patient: (shows 8 Restating: This restatement

na? Ilan yung sa kamay? digits on hands) lets the client know that he
Pakita mo nga? communicated the idea
effectively. This encourages
the client to continue.
Nurse: Wow. Very good.
Patient: Dun sa amin.
Saan ka naman
nakatira?

Questioning: To gain basic

 information about the client.

Nurse: Saan dun? Patient : Sa bahay Exploring: To examine the

namin. issue more fully.

Nurse : okay

Questioning: To gain basic

information about the client.
Nurse: Nasaan mga Patient: Nasa bahay
pamilya mo? po naming.

Nurse:May kapatid ka Patient: Pumasok po Exploring: To examine the

ba? Eh yung mga sila. issue more fully.
kapatid mo? Asan sila?

Nurse: Ilan kayong

Patient: 3 po kami. Exploring: To examine the
magkakapatid?
issue more fully.

Questioning: To gain basic

Nurse: ahh. 3 kayo? information about the client.
Pang ilan ka? Ikaw ba Patient: opo.
yung bunso?

Nurse: Ikaw ba ung

Patient: Hindi po.
drinowing sa sa papel
Bunso namin yun.
kanina?

Nurse: Sabi mo ikaw

yung bunso ? Patient : Hindi po. si
( cite a name) po ang
buso namin
Nurse: okay

Restating: This restatement

Nurse: Eh si tatay? Patient: Pumasok din lets the client know that he
Nasaan? po. communicated the idea
effectively. This encourages
the client to continue.
Nurse: Pumapasok din si Patient: Nasa bahay
Questioning: To gain basic
tatay? Eh si nanay? mo kasama niya lola
information about the client.
ko po.
Exploring: To examine the
issue more fully.

(patient goes out the Giving recognition-

room and dispose
acknowledging, indicating
garbage can)
awareness
Patient: (big grin
Nurse: Wow! Ansipag
smile)
mo naman. Questioning: To gain basic
information about the client.

Patient: Opo. kase Exploring: To examine the

Nurse: Lagi mo bang
ako lang po ang may issue more fully.
ginagawa yan?
gusto nito. Ayaw ng
mga classmates ko.

Nurse: Okay. Yun lang

muna sa araw na to. Oh,
Bukas ah? Andito kami
ulit. May mga Patient: Okay po!!! Accepting: To indicate the
nakahandang mga nurse has heard and
surpresa sa inyo para followed the train of thought.
bukas. Okay ba un?

Nurse: So dapat bukas, Patient: opo!!

papasok ka ah? Wag
kang aabsent ah ?. Restating: This restatement
lets the client know that he
communicated the idea
Nurse : o sige JC. Anu effectively. This encourages
na nga pala ulit Patient : (blocking). the client to continue.
pangalan ko ? Miguel !
Questioning: To gain basic
information about the client.

Nurse : Miguel ba Patient: Kuya……. Exploring: To examine the

pangalan ko ? Ano na (blocking) issue more fully.
nga ulit pangalan ko?
Kuya ?..

Patient: (repeats)
Nurse: Kuya Mark!?
Kuya Mark!

Nurse: Yes. Sige

Patient : Salamat din
salamat sayo JC. Inggat
po !
ka sa pag uwi.

WORKING AND TERMINATION PHASE

Working Phase

Definition: This is the right time to gather all the data you need. It is the time

when the client must have trust to the nurse. This is the phase in which the client

actively participates to all the activities.

Objectives: After the working phase, the student nurse will be able to:

 Establish more trust and rapport with the client;

 Encourage the client to joining all the activities;

 Explore relevant stressors of the client;

 Develop their coping mechanism; and

 Identify existing psychiatric nursing problems.

Termination Phase
Definition: This is the last day of the therapeutic relationship. This is the time

to remove all the attachment and let them reflect for all the activities that was

done.

Objectives: After the termination phase, the student nurse will be able to:

 Establish reality of separation; and

 Evaluate goals if they are met.

Date: January 21, 2011

Time: 10:00 a.m.

Venue: Sta. Ana Elementary School

Nurse Patient Rationale of the Nurse’s

Communication
Techniques

Giving Recognition: This is

to provide acknowledgment
Nurse: Hi JC. Magandang Patient: hello kuya!
and awareness. Greeting
umaga sa iyo. Magandang umaga
the client shows that the
din.
patient’s presence is felt by
the nurse.

Nurse: Andito nanaman Giving information: To give

ako para makipaglaro details that the patient
Patient: Opo!
sayo. Ayos ba sayo yon? needs to know in order to
Nurse: Tyrone Aquino. gain patient’s trust and
cooperation. The nurse also
Nurse: Pero bago tayo sets the time frame of
maglaro mamaya sa Patient: Opo. working with the client.
socialization, may mga
tanong ulit ako sayo ah?

Accepting: To indicate the

nurse has heard and
 Patient: Kuya, followed the train of thought.
Magtatapon po ulit
Nurse: Oo naman.
tayo ng basura
mamaya ah?

Nurse: May mga kaibigan Patient: Meron po. Accepting: To indicate the
ka ba dito? Sila Daniel, Mac nurse has heard and
Arthur, at Rafael followed the train of thought.

Questioning: To gain basic

Nurse: Pala kaibigan ka
information about the client.
pala. Patient: opo (smile)

Questioning: To gain basic

information about the client.
Nurse: Anong gusto Patient: Maging pulis
mong maging paglaki po. Kasama ko Focusing: To encourage the
mo? Rafael, Daniel at Mac client to concentrate his
Arthur. energies on a single point.

Giving Recognition: This is

Nurse: Bakit gusto mong
to provide acknowledgment
maging pulis? Patient: Para po di po
and awareness. Greeting
maging traffic sa
the client shows that the
kalsada.
patient’s presence is felt by
Nurse: Wow!. Ang galing
the nurse.
mo naman.
Patient : (smile)

Nurse: Naaalala mo pa Questioning: To gain basic

ba drinowing mo information about the client.
Patient: Opo.
kahapon?
Exploring: Delving further to
a subject or idea.

Questioning: To gain basic

information about the client.
Nurse: Kung naalala mo, Patient: (Blocking...) Exploring: Delving further to
ano yung pinadrawing (stared blankly and a subject or idea.
namin? slient)
Questioning: To gain basic
information about the client.

or idea.

Nurse: Hindi mo na ba Patient: ayy. Oo nga Questioning: To gain basic

maalala? Diba, bahay at pala. Opo yun po. information about the client.
pamilya mo yung
drinowing mo kahapon?
Yun nga ba?

(showed the art work of Questioning: To gain basic

the client) information about the client.
Patient: (smile)
Nurse: Di ba eto yung
drinowing mo kahapon?

Nurse: di ba pinapasulat Patient: Opo. Exploring: Delving further to

ko sayo dito sa drawing a subject or idea.
mo ang pangalan mo?

Nurse: di ba. Ang

Questioning: To gain basic
pangalan mo ay J.C.? Patient: (smiling and
information about the client.
Bakit mga letrang staring blankly at the
JOIYYPOA ang sinulat drawing)
mo?

Nurse: Ganito mo ba
Patient: Hindi po.
isulat ang pangalan mo?

Patient: (smiles again)

Nurse: Eh bakit, eto ang
mga sinulat mong letra?

Nurse: Nahihirapan ka Suggesting collaboration:

bang isulat ang pangalan offering to share, to strive,
to work together with the
mo? Sige tutulungan kita client for his benefit.

(client followed)

Nurse: Gayahin mo tong

mga letrang ito ah?.

(taught how to write the

client’s name)

Patient: Opo! Salamat

Nurse: Ngayon, alam mo
po!
na kung paano isaluat
pangalan mo ah?

Nurse: welcome!!

Nurse: So dito na Patient: yehey!! Giving information: making

nagtatapos ang pag- available the facts that the
uusap natin. Kaya gaya client needs to know.
ng pinangako ko kanina,
maglalaro tayo.

Suggesting collaboration:
Nurse: kaya mamayang
Patient: opo! offering to share, to strive,
socialization, sasali ka
to work together with the
ah? Okay ba yon?
client for his benefit.
Nurse: Apir tayo! Patient: Apir!

CHAPTER 9: RELATED LITERATURE

Exercising With Mental Retardation: Prescription

for Health
American College of Sports Medicine
Posted: 04/13/2010
Introduction

The benefits of regular physical activity for individuals with mental retardation are
numerous, including increased strength and endurance, better weight
maintenance and reduced risk of many diseases. Heart disease is a common co-
morbidity in persons with mental retardation, so health care providers need to
make efforts to reduce the common risk factors for heart disease in their patients
with mental retardation. The key to maximizing the benefits of exercise is to help
the individual follow a well-designed program that accommodates his or her
specific needs and limitations.

Getting Started

 Talk with the individual's health care provider before starting an exercise
program and ask for specific concerns about the patient doing exercise.
 The primary goal of exercise training is to find activities that the individual
enjoys and that is within his or her functional capabilities. Additional goals
include body fat and weight loss and improved muscle strength and
aerobic capacity.
 If the individual's fitness level is low, start with shorter sessions (10 to 15
minutes) and gradually build up to 30 minutes of aerobic activity, 5 days
per week.
 Recommended activities include swimming, walking and indoor cycling.
 Strength may have important ramifications for vocational productivity and
independence. A twice-per-week strength-training program using
machines with one to three sets of exercises for the major muscle groups,
with 10 to 15 repetitions, is recommended.
 Help create a structured environment by following a standard routine that
is consistent and rewarding for the individual. Reward systems and
positive reinforcement are particularly effective for helping the individual
adhere to the program.
 Activities set to music increase adherence and are particularly effective,
as are community-based exercise programs.

Exercise Cautions

 Exercise should always be supervised.

 While strength-training gains may be apparent within 10 to 12 weeks, it
may take considerably longer (four to six months) to observe
improvements in cardiorespiratory endurance.

 Reaction

Your exercise program should be designed to maximize the

benefits with the fewest risks of aggravating your health or physical
condition. Consider contacting a certified health and fitness professional*
who can work with you and your health care provider to establish realistic
 goals and design a safe and effective program that addresses your
specific needs.

If your health care provider has not cleared you for independent
physical activity and would like you to be monitored in a hospital setting or
a medical fitness facility, you should exercise only under the supervision of
a certified professional. 

CHAPTER 10: LEARNING INSIGHTS

Special children must be treated so special.

Mentally incapacitated individuals are not to be afraid of or someone to

make laugh and fun of. We must treat them as normal individuals instead.
Special education is of great help for those mentally challenged people. It
enhances the way they interact with the people around them. I would like to
recommend to those parents with those who have a child of the same cases to
send their child into special institutions that has the capacity to enhance their
child’s potential and the correct way of dealing, handling their situation and
teaching them. As a registered nurse hopeful, teachers on that institution really
opened my heart and my mind to be dedicated to my duty and serve the Filipino
people with all my heart first.