PATIENT’S PROFILE

Name: Amelia B. Gonzales

Age: 29
Address: 108 Lansones, Extension Clarkview, Angeles City
Religion: Catholic
Status: Married
Final Diagnosis: Schizophrenia

ABC ASSESSMENT

APPEARANCE BEHAVIOR COMMUNICATION

-Well groomed -Hyperactive -Talkative ‘
-Good body shape -Aggressive -Disorganized speech
-Disorganized behavior -Flight of ideas
-Dramatic
-Non reality-reality-based
thinking
NURSING CARE PLAN

ASSESSMEN NURSING GOAL/PLA INTERVENTI RATIONAL EVALUATIO

T CUES DIAGNOSI N ON E N
S
SUBJECTIV Disturbed At the end of 1. Attempt to 1. Important
E CUES thought 8 hours understand the clues to
“Ang asawa process nursing significance of underlying
ko, niloloko related to intervention these beliefs to fears and
ako overwhelmi the patient the client at the issues can be
nagbabayad ng stressful will refrain time on their found in the
pala ng babae life events from acting presentation. client’s
sa Saudi as evidence on non- 2. Explain the seemingly
Arabia” as by reality-based procedures and illogical
verbalized by inappropriat thinking try to be sure the fantasies.
the px. e non- client understand 2. When
OBJECTIVE reality-based the procedures client has full
CUES: thinking before carrying knowledge
-Talkative them out of
-Disorganized 3. Do not touch procedures,
thinking the client; use he or she is
-Dramatic gestures less likely to
-Flight of carefully. feel tricked
Ideas by the staff.
-Disorganized 3. Suspicious
speech clients might
-Non reality misinterpret
based thinking touch as
either
aggressive or
sexual in
nature and
might
interpret it as
threatening

NURSE PATIENT INTERACTION
Nurse
“Good morning ma’am
Amelia, I am Nathaniel Paolo
A. Delos Santos your nurse
for today. Kamusta po kayo?
“Ilang taong gulang na po
kayo at saan kayo nakatira?”
“Okay naba ang iyong
pakiramdam ngayon?”
“Alam niyo po ang petsa
ngayon at kung saan kayo
ngayon?”
“Naiinom niyo ba ng gamot
niyo sa tamang oras?”
“Salamat sa inilahad niyong
oras para sa mga katanungan
ko babalik ako bukas Mrs.
Gonzales bye”
Patient
“Hello Paolo okay naman po
ako.”
“29 gulang na po ako at
nakatira sa 108 Lansones
Clark view Angeles City”
“Yes po sa awa ng Diyos”
“Sa pagkakaalam kop o
ngayong araw ay July 05,
2021 at kasalukuyang nasa
National Center for Mental
health”
“opo lagi ko chinicheck ang
orasan para po sa oras ako
iinom ng gamot”
“Salamat rin po nurse Paolo”
gesture.
Analysis
Introducing self to gain the
trust of the patient.
Seeking information from
the patient
Making sure patient is feeling
well
Reorienting patient to date
and place
Making sure patient takes
medication on time