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Msa and Process Finished

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Republic of the Philippines

BATAAN PENINSULA STATE UNIVERSITY
Balanga Campus
Don M. Banzon Ave. Poblacion, City of Balanga, Bataan (047) 237 – 3003 (047) 237 – 5477

COLLEGE OF NURSING AND MIDWIFERY
09/09/10

Process Recording And Mental Status Assessment (Psychiatric Nursing)
Submitted by:

Mr. Leomar P. Gonzales
Group23 ThFS Submitted to:

Mrs. Irish Lee
Clinical Instructress

Our Vision A university of excellence acknowledge in the country and the Asia Pacific Region for quality graduates and knowledge responsive to socio – economic needs.

Our Mission Provide quality and relevant education that will develop highly qualified and competitive human resources responsive to the national and regional development

Process Recording

Date: Time: Therapies: Place: Phase:

September 1, 2010 (Wednesday) (Day 4) 9:10 am Photo language and Newspaper Therapy Mariveles Mental Hospita Working Phase

I. Personal Data: Name: Mr. A.G. Address: Florida Blanca, Pampanga (c/o Elizabeth Baybayon, MSWD) Age: 23 years old Gender: Male Date/ Place of birth: January 18, 1983, Manila, Philippines Religion: Iglesia Ni Cristo Place where the patient spent last 15yrs. of life: Jail according to the client but it was observed that the jail that was stated by the client is, his ward inside the hospital, and the client was admitted to the hospital 2 years ago. II. Objectives: A. Client-Centered Objectives 1. To gain and maintain client’s trust by using therapeutic communication. 2. To promote proper personal hygiene by means of daily grooming. 3. To facilitate newspaper and photo language therapy to boost or assess immediate, recent and remote memory. B. Nurse-Centered Objectives 1. To help client interact or communicate with others inside the group as socializing agent. 2. To create therapeutic environment by acting as a student nurse manager. 3. To present reality regarding recalling the events and situations in their lives. III. Description of Setting A. Describe the Set-up/Environment It was a sunny day; the temperature was warm, with the wind blowing softly. At around 9:10 in the morning, personal hygiene was rendered to the client at the pantry. After the grooming, selected therapy like Photo Language and Newspaper therapy was conducted at the BPSU center. The place is just enough to have therapy even though the place is quite messy.

B. Describe the Nature, Behavior, Affect and Mood of the client

It was around 9:10 in the morning, I received Mr. A.G. sitting on the chair in the ground of the Male Ward A wearing a blue uniform. Mr. A.G. looks mad at that time while having a conversation with me during the grooming session but then after gaining trust to me during the therapy, Mr. A.G.’s with a smile on his face. IV. Process Recording Nurse-Client Conversation (including non-verbal cues) ------Before Grooming----SN: Magandang umaga po, ako po si Leomar Gonzales, estudyante po galing sa BPSU, ako po ang magiging student nurse nyo simula po ngayong miyerkules, huwebes, biyernes ng umaga, para pos a ngayong linggo at hanggang sa susunod na linggo, parehong araw po, tuwing hapon naman po. Kayo po, anong pangalan nyo? Mang A:Mang A.G. SN: Ah ok po, ilang taon nap o kayo? Mang A: 23 SN: Taga saan po kayo? Mang A: Maynila, sa may mga building. SN: Ano po ang birthday nyo at san po kayo pinanganak? Mang A: Sa Maynila, January 18. Therapeutic communication technique used -------------------------------Giving information Analysis and Interpretation based on theories -------------------------------- According to King (1960), the stress in NPI will occur if more conflict is experienced. Hence it is important for the student nurse to identify their role in relation to the patient.

Using direct question

- Included in the 10 carative factor of jean Watson is the cultivation of sensitivity to one’s self and to others. Asking the said question will measure the client’s memory retention level.

SN: Mang A., nasaan po Placing event in time or kayo ng taong 1995, 15 sequence taon na pong nakakalipas at ano po ang ginagawa nyo ng mga panahong iyon? Mang A: Nasa kulungan…

To relate past event to the present just to gather data regarding his illness.

SN: Nasa kulungan po? Tama po ba ang aking narinig? Mang A: Oo, ayan yung kulungan oh!

Seeking clarification

Include in the 10 carative factors of Jean Watson (1970), is the cultivation of sensitivity to one’s self and to others. Verbalizing what is observed in the patient aids in validation and encourages situation. To gather data related to the client.

SN: Ah... ang tinutukoy nyo po ay ang inyong ward... Ilan taon na po ba kayong namamalagi sa inyong ward? Mang A: Mga 2 taon na... SN: Kung dalawang taon na po, ibig sabihin, wala pa po kayo dito ng 15 years ng nakakalipas.. ang tanong ko po Mang A., nasan po kayo 15 years na pong nakakalipas? Nung wala pa po kayo dito? Mang A: Ah... Nasa Maynila pa ako… nagtratrabaho. SN: Ganun po ba.. Tara po Mang A., maghilamos na po kayo.. Mang A: (Nodding)

Asking direct question

Placing event in time or sequence

To relate past event to the present just to gather data regarding his illness.

In voicing doubt

This therapeutic communication is used because there is no pertinent data was gathered including chart reading that will proved if the client statement is true or not. -------------------------------According to Peplau (1952), a nurse is stranger to the patient. It is therefore important to remind the patient who we are and be consistent with the information we are giving to him to gain their trust. -------------------------------According to Abraham

-----After Grooming-------- -------------------------------SN: Tapos na po ba Giving Recognition kayong magcologne? Ayan po Mang A., malinis at mabango na po kayong tignan. Tara na po sa BPSU center. Doon po tayo gagawa ng therapy. Mang A: (nodding) -----Newspaper therapy---- -------------------------------SN: Mang A., bago po Encouraging Decisions

tayo dumako sa ating therapy, may mga ilang katanungan lang po akong nais tanungin sa inyo. Ayo slang po ba? Mang A: (nodding) SN: Ano po ang petsa ngayon? Mang A: Di ko alam eh... Asking Direct Question

Maslows, all needs must meet to proceed to the next level. Respecting client’s decision will make client to meet the 3rd level which is love, belongingness and acceptance. In order for the nurse to know if the client is oriented to the date. According to King (1960), the stress in NPI will occur if more conflict is experienced. Hence it is important for the student nurse to identify their role in relation to the patient. According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. It is stated in Kings theory of Goal Attainment(1960), that if a nurse with special knowledge and skill to communicates the appropriate information to the client, mutual goal setting and goal attainment will occur

SN: Mang A., ang petsa po Giving Information/ ngayon ay September 1, asking direct question 2010. Mang A., Nasaan po kayo ngayon? Mang A: Dito sa Mariveles, sa hospital. SN: Tama po. Mang A., alam nyo po ba kung anong dahilan ng pakakapunta nyo ditto sa hospital? Mang A: Oo, Para magpagamot kasi baliw ako at may epilepsy. Exploring

SN: Ok po Mang A., Giving Information ngayon naman po, dumako na po ulit tayo sa inyong therapy. Akin lang po ipapaalala sa inyo ang mga parte n gating dyaryo. Ito po ang frontpage, editorial, entertainment, classified ads, obituary, at sports. Ang dyaryo po ay naglalaman ng iba’t- ibang mahahalagang balita patungkol sa ating bansa, ngayon po, ano po ba ang nais nyong basahin? Mang A: Ito, basketball. SN: Sige po basahin nyo na po. Mang A: (silence) SN: (silence)

SN: Mang A., napansin ko Stating observation pong hindi nyo po binabasa ang dyaryo, Tanong ko lang po, marunong po ba kayong bumasa? Mang A: Hindi eh, grade 1 lng natapos ko, may sakit kasi akong epilepsy kaya huminto ako. SN: Ah ganon po ba, sige po, kung gusto ninyo ako na po ang magbabasa para sa inyo, gusto nyo po ba? Mang A: (nodding) Offering self

Having observation will lead a nurse to explore client’s feelings and mood.

To gain client’s cooperation, you must gain first his trust by offering yourself. According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior.

SN: Ang balitang ito po ay Giving information/ patungkol sa labanan ng Exploring dalawang kuponan sa basketball, ang USA at ang Brazil, na kung saan po ay muntikan ng matalo ng Brazil ang USA sa iskor na 80-78. Ang USA po ay isang malakas na kuponan pagdating sa larong basketball. Mang A., ngayon po, ang aking katanungan ay, ano po bang dahilan at napili nyo poi tong balitang ito? Mang A:Ah, kasi mahilig akong maglaro ng basketball simula noong bata pa ako. SN: Ganon po ba, naglalaro din po ba kayo ng ibang laro? Mang A: Naglalaro din, computer, tatsing, pero paborito ko basketball. SN: Ano po ang dahilan at mas napili nyo po ang larong basketball kaysa sa ibang laro? Mang A: Masaya kasama ko mga kaibigan ko, Asking Question

To gather info regarding his favorite sports from his past life.

Encouraging Comparison

According to Abdellah, nurses must help individual in developing a comprehensive plan. In the comprehensive nursing, it is stated that nurses can

nanalo kami tapos ililibre kami ng softdrinks. SN: Sino naman po ang Exploring nagturo sa inyo? Tatay nyo po ba? Mang A: Hindi, bata pa lang ako, namatay na sya, kaibigan ko lang nagturo sa akin. SN: Nabanggit nyo pong namatay ang tatay nyo, tama po ba ang aking narinig? Mang A: Oo SN: Ganun po ba, eh ang nanay nyo po, nasan na? Mang A: Wala na, bata pa lang ako iniwan na nya ako. Seeking clarification

help direct the works of others. According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. Helps the client to clarify their own thoughts and maximize mutual understanding between the nurse and the client. To gather data from his past life regarding his family

Asking Question

SN: Ganon po ba, sige po General leads magkwento pa po kayo patungkol sa inyong buhay. Mang A: Grade 1 lang natapos ko, kasi may epilepsy ako, tapos, iniwan din ako ng nanay ko, mga 5 yrs/old ako namatay ang tatay ko kaya inampon ako ng amo nya. Taga linis ako ng bus at tumutolong din ako sa pagmemekaniko. Natuto din ako magrugby kasi tinuruan ako ng mga kaibigan ko. Kaya doon na rin ako nagsimulang masiraan ng ulo. SN: Nabanggit noy po na Identifying participants iniwan kayo ng inyong ina, and relationship Ano po ang naramdaman ninyo? Mang A: Medyo galit, naiinggit din ako sa ibang bata kasi nag-aaral sila.

It helps nurse to explore client’s feeling and it allows client to verbalize his feelings.

To explore if his significant others has contribution to his illness

SN: Ganon po ba, sige po, malapit na kasing maggroup dynamics, pwede nyo po bang ibuod ang ating mga napagusapan? Mang A: basketball at saka buhay ko.

Summarization

It is stated by Orlando (1980), that individuals have their own subjective perceptions and feeling that may not be observed directly. Therefore, it is important to set the client know their perception are accepted and heard to encourage verbalization of thoughts. -------------------------------According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior.

-----Photo Language-------SN: Mang a, nakapilina po ba kayo ng larawan? Tara po, upo po tayo doon. SN: Mang A, maaari nyo po bang sabihin kung ano po ang nais sabihin ng inyong napiling larawan? Mang A: Ito baskeball, at saka ito mga tao, nagbubuhat ng bahay. SN: Maari nyo po bang sabihin ang dahilan ng inyong pagpili sa larawang iyan? Mang A: Ito kasi mahilig ako sa basketball, Masaya kasi kasama ko mga kaibigan ko. Ito naman, gusto ko kasi magtayo ng bahay ko sa maynila.

-------------------------------Exploring/ encouraging evaluation

Encouraging expression

To explore client’s feeling why he chooses the two pictures, whether it has significant relation regarding his life.

Encouraging comparison SN: Ganon po ba, kung papapiliin kayo sa dalawang larawan nay an, ano po ang mas pipiliin ninyo? Mang A: Itong bahay, kasi gusto ko din magtayo ng bahay. SN: Ok po, may gusto po ba kayong sabihin tungkol sa larawang inyong napili? Mang A: Itong bahay, may mga taong nagbubuhat, Encouraging description of perception

According to Abdellah, nurses must help individual in developing a comprehensive plan. In the comprehensive nursing, it is stated that nurses can help direct the works of others. To explore whether client’s has a abstract thinking about the picture.

sumisilong sila. Asking Direct question SN: Alam nyo po ba ang tawag sa ganyan? Mang A: Hindo ko alam. Giving information SN: Bayanihan po ang tawag dyan. May mga taong tumutulong upang mailipat ang isang bahay. Pinapakita po nayn ang pagagakaibigan. Mang A: (silence) Summarization SN: Ngayon po mang A., Maari nyo po bang ibuod ang ating napagusapan? Mang A: Basketball at bahay. To know if the client knows that thing in the picture. It is stated in Kings theory of Goal Attainment(1960), that if a nurse with special knowledge and skill to communicates the appropriate information to the client, mutual goal setting and goal attainment will occur It is stated by Orlando (1980), that individuals have their own subjective perceptions and feeling that may not be observed directly. Therefore, it is important to set the client know their perception are accepted and heard to encourage verbalization of thoughts. As Stated in the domain concepts of Orlando, one goal of nursing is improvement in client’s behavior. Feedback encourage client to pursue positive behavior.

Reinforcement SN: Maraming salamat Mang A., bukas po ulit, gagawin naman po natin ang creative arts therapy. Babalik na po tayo sa inyong ward… salamat po. Mang A: Salamat din. V.1 Theme Identification

A. Content Theme- The focus of the 1st conversation is all about newspaper therapy where we talked about his favorite sports and we also talked about his past life. We also talked about the photo language therapy, where the client interprets his feelings regarding to the picture. B. Interaction Theme- At first, there are some resistance between our conversations where I can’t get his cooperation. But then, afterwards, after the client gain trust, he opens a lot to me making our conversation more productively, where he answer my entire question relevant.

C. Mood Theme- At first, as what I’ve observed to my client, clients looks mad while I’m talking to him. But then, during the therapy, I observed that patient looks happy where I think he gain trust to me. V.2 Nursing Diagnosis - Risk for loneliness r/t loss of family VI. Nursing Interventions Ernestine Wrendenbeck (1964) stated that nursing skills are made up of a variety of actions and characterized by harmony of movement, precision, and effective use of self. It is important to let the client know that the nurse is available for the client and is willing to listen. The effective use of self lessens the feeling of loneliness or being alone and at the same time; it allows the nurse to identify possible harm the client may do to himself due to situation. It also give nurses a great opportunity to gain client’s cooperation during the whole course of the treatment by letting him understand that the health care team’s action are carried out to achieves a specific clients-centered purpose rather than completion of skills itself being end goal. Aside from therapeutic use of self, we can also identify strategies to expand the world isolated. There may be special gathering in the hospital or there may be activity programs like therapies. VII. Summary and Evaluation Around 9 o’clock in the morning, I received Mr. A.G. from male ward A, where I assist him in terms of grooming at grooming area. We start a conversation talking about his personal profile while walking. At the BPSU center, we started our therapy. The group dynamics was lead by our facilitator which is our co-student nurse. After that, we started our first therapy, the “newspaper therapy”. Mr. A.G. selects some news at the newspaper which is all about basketball. Our conversation focus on that game and some of his past experience. After that therapy, another group dynamics was held. Then the second therapy, which is the Photo Language therapy, was started. Mr. A.G. picks two pictures where I get some data regarding his life. Around 11am, the therapy was finished. Lastly, Mr. A.G. returns to his ward. VIII. References -Psychiatric Nursing Handouts -Psychiatric-Mental Health Nursing fifth edition by Videbeck -NANDA

Psychotherapy I. Newspaper therapy - Types of therapy where the psychiatric nursing uses newspaper as a material just for the nurse to assess client’s immediate memory also including his comprehensive ability. *Purpose of the Therapy* 1. Assess client’s comprehensive ability. 2. Assess client’s immediate memory. 3. To inform client recent news. *Procedures* 1. There will be a group dynamics where the facilitator will discussed some information about the therapy. 2. After the group dynamics, each student nurse will pick their clients for 1 on 1 conversation about the newspaper. 3. After reading the newspaper by the client, there will be a conversation for the evaluation. 4. After the therapy, the client will return in the group dynamics for further assessment.

*Analysis and Interpretation* Mr. A.G. chooses the sports page especially the news that talks about basketball. Mr. A.G. tells that he likes basketball especially if he is with his friends. By this statement, we can says that Mr. A.G. does not want to be alone, based on him, his father died and his mother left him alone making him to find friends. Mr. A.G. has no knowledge or skills in terms of reading.

II. Photo Language Therapy - Technique of psychotherapy that uses photos to help client express their feelings that they cannot express. It also assesses client perception regarding the pictures. *Purpose* 1. To help client express their feelings by use of photos. 2. To encourage client to verbalize thoughts and experienced related to their selected photos. 3. To provide a diversion activity to the client who cannot verbalize their feelings. *Procedure* 1. There will be a group dynamics where the facilitator will discussed some information about the therapy. 2. After the group dynamics, each student nurse will pick their clients for 1 on 1 conversation about the Photo Language therapy. 3. The client will choose two pictures and they will talk about it together with his student nurse. 4. After the conversation, the client will return to the group dynamics for the summarization.

*Analysis and Interpretation* Mr. A.G. chose 2 pictures; one is playing basketball and the other is “bayanihan”. Client chose basketball because that is his favorite sports and he want to have friends. He also chose “bayanihan” because he wants to build his own house someday together with his family.

Date and time: Therapy: Place: Phase:

September 2, 2010; 9:00am; Thursday (Day 5) Expressive Arts Therapy Mariveles Mental Hospital Working Phase

I. Client’s Name: Mr. A.G. II. Objectives: A. Client-Centered Objectives 1. To discover client’s ability in terms of creativeness. 2. for the client to express his feelings through expressive arts therapy. 3. for the client to recall his past life as what he designs to the therapy. 4. To maintain his trust to his Student Nurse. B. Nurse-Centered Objectives 1. To interpret output made by the client. 2. To explore client’s feelings regarding the therapy. 3. To maintain client’s trust to his student nurse. III. Description of Setting A. Describe the Set-up/ Environment September 2, Thursday morning, it was a rainy day making the set-up or place empty (no people walking around inside the hospital). The therapy was conducted at BPSU center. The three groups were combined to conduct the expressive arts therapy making the place or set-up crowded and not enough to conduct good therapy. B. Describe the Nature, Behavior, Affect and Mood of the client Around 9 o’clock in the morning, I received Mr. A.G. at the male ward A, wearing his blue uniform well groomed. I observed that Mr. A.G. is not in good mood which is evidenced by his mad face. But then, during the therapy, he smiles at me showing that he is enjoying the activity. IV. Process Recording Nurse-Client Conversation SN: Magandang umaga po Mang A., naaalala nyo pa po ba ako? Mang A: Hindi Therapeutic Communication Giving Recognition Analysis and Interpretation According to Peplau (1952), a nurse is stranger to the patient. It is therefore important to remind the patient who we are and be consistent with the information we are giving to him to gain their trust.

SN: Ganun po ba. Ako po Giving information Si leomar Gonzales, yung student nurse nyo kahapon, noong umaga po. Mang A: (silence)

According to king (1960), stress in NPI will occur if conflicts are experienced. Hence it is important for the student nurses to identify their more in relation to the client. Include in the 10 carative factors of Jean Watson (1970), is the cultivation of sensitivity to one’s self and to others. Verbalizing what is observed in the patient aids in validation and encourages situation. --------------------------------It is stated in Kings theory of Goal Attainment(1960), that if a nurse with special knowledge and skill to communicates the appropriate information to the client, mutual goal setting and goal attainment will occur

SN: Mukhang bagong ligo po kayo ah… Nagtoothbrush nap o ba kayo? Mang A: Hindi Pa SN: Tara po mang A., Magtoothbrush po muna kayo. ----After Grooming-------SN: Pagkatapos nyo pong magpulbos, pupunta nap o tayo sa BPSU center upang isagawa ang Expressive therapy. Ang therapy po na iyon ay ginagawa gamit ang palito ng posporo kung saan ay ididikit nyo poi to sa isang papel. Mang A: (nodding) SN: Tara na po. ----During therapy--------SN: Ito po ang papel, pandikit at palito ng posporo, dyan nyo po ididikit ang palito para po gumawa ng kahit anong maisipan nyo. Mang A: (nodding) SN: Pakidikit na po…

Stating Observation

-------------------------------Giving information

-------------------------------Giving information

--------------------------------For the client to be oriented on how to do the therapy.

---After therapy------------- -------------------------------SN: Ayan po.. ang ganda Giving recognition naman po ng inyong binuo… Mang A: (smile)

--------------------------------Peplau identified the basic nature of nursing as an interpersonal process noting efforts of the client has made shows that the nurse recognize the client as a person

SN: Maaari nyo po bang Encouraging sabihin sa akin ang inyong collaboration ginawa? Mang A: Ah ito bahay, ito bundok, ito puno ng niyog, at ito naman araw. SN: Mang A., maaari nyo po bang sabihin ang dahilan kung bakit iyan po ang inyong nabuo? Mang A: Iyan kasi lagi kong nakikita. Ayun yung bundok oh.. ayun din yung bahay… SN: yun lang po ba dahilan? Pagpatuloy nyo pa po.. Mang A: Oo. SN: Hindi nyo po ba naaalala ang inyong pamilya habang binubuo po yang bahay? Mang A: Hindi. Exploring

For the client to explain his work more abstractly

According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. For the client to expound his thoughts

General Leads

Asking close-ended question

Included in the 10 carative factor of jean Watson is the cultivation of sensitivity to one’s self and to others. Asking the said question will measure the client’s memory retention level. Based on Watson theory there is independency and integration of the parts and elements of thoughts and behavior that make up the system, hence it is important to help the client identify his own thoughts and feelings to gain better understanding of him. Include in the 10 carative factors of Jean Watson (1970), is the cultivation of sensitivity to one’s self and to others. Verbalizing what is observed in the patient aids in validation and encourages situation. According to abdellah, one

SN: oh sige po, tanong ko lang po sa inyo, saan nyo po ba gusto magtayo ng bahay? Mang A: Sa may syudad, sa may maraming building.

Focusing

SN: Mang A., napansin kop o kanina na ang inyong bahay na ginawa ay malapit sa bundok. Tama po ba? Mang A: Oo..

Stating Observation/ Seeking Clarification

SN: Eh sabi nyo po na Exploring mas gusto nyong tumira sa syudad, eh ano pong dahilan at malapit poi to sa bundok? Mang A: wala lang, mas gusto ko talaga sa syudad, lagi ko lang kasi nakikita yung bundok at saka mahirap gumawa ng building eh… SN: Ganun po ba? Eh sino naman po gusto nyo isama sa binuo nyong bahay? Mang A: Wala, ako lang… Exploring

step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior.

According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. According to Abraham Maslows, all needs must meet to proceed to the next level. Respecting client’s decision will make client to meet the 3rd level which is love, belongingness and acceptance. Included in the 10 carative factors of Jean Watson is the cultivation of sensitivity to one’s self and to others. Asking the said question will measure the client’s memory retention level. Asking the meaning or important of something may lead to self disclosure. Thus identifying the problems of the client. According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior.

SN: Ayaw nyo po bang isama ang pamilya nyo o magulang? O kaya asawa? Mang A: Wala na sila, patay na.. asawa? Pwedi rin kung mayaman na siguro ako. SN: Ganon po ba, matanong ko lang po, may asawa na po ba kayo o nanligaw na po ba kayo? Mang A: Hindi pa

Encouraging Decisions

Asking Close-ended Question

SN: Ganon po ba, ahm.. noong nagagawa po kayo ng ating therapy, ano po ang inyong naramdaman? Mang A: Masaya. SN: Sa anong kadahilanan po? Mang A: Wala kasi ito yung mga nakikita ko ditto sa hospital.

Encouraging Expression

Exploring

SN: Kung papapiliin po kayo, gusto nyo pa po bang bumalik sa inyong tahanan o ditto na lang mamalagi? Mang A: Sa dati, kaso hindi na ako pwedi bumalik doon, baliw kasi ako. SN: Ano po ang nararamdaman ninyo sa tuwing maaalala nyo po ang dati nyong tirahan? Mang A: Malungkot SN: Sa ano pong kadahilanan. Mang A: Wala, basta.

Encouraging Comaprison

According to Abdellah, nurses must help individual in developing a comprehensive plan. In the comprehensive nursing, it is stated that nurses can help direct the works of others. Through this question, I will explore or know if the client wants to go back in his home. According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. This aid having in depth understanding of client’s thoughts of feelings. As stated by Levine (1989), human being must be aware and must be able to contemplate objects, condition and situation. Reviewing the main points of discussions and making appropriate conclusions will help the client remember what was discussed and its significance. As Stated in the domain concepts of Orlando, one goal of nursing is improvement in client’s behavior. Feedback encourage client to pursue positive behavior.

Encouraging description of perception

Exploring

SN: Ok po, ano po ang inyong natutunan sa ating ginawang therapy? Mang A: natutong magdikit at gumawa ng bahay.

Encouraging Evaluation

SN: Ok po, bago po natin Summarizing tapusin ang ating therapy, maaati nyo po bang ibuod ang ating pinagusapan? Mang A: Ayun, tungkol sa ginawa ko, sa bahay. SN: Tama po. Ngayon po ay babalik na po tayo sa ating grupo at pagkatapos po nun ay babalik na po kayo sa inyong ward. Nawa po ay natuwa po sayo sa ating ginawa, Reinforcement

magkikita po ulit tayo bukas ng umaga. Salamat po sa inyong kooperasyon. Mang A: Salamat din. V.1 Theme Identification A. Content Theme- The focus of our conversation is all about the expressive art therapy. We talked about his output, his feelings towards to our activity and his reasons why did the client do that thing which I can relate it to his past life. B. Interaction Theme- Mr. A.G. interacts to me well and logically even though that there are some things that he didn’t want to open with me. He answers all my questions with his concrete thinking, meaning to say that, his work doesn’t have meaning to him; instead it’s only an observation to his surroundings. C. Mood Theme- The client feels mad when I received him. Maybe because he is tired to what he is doing before I received him. But then, doing his therapy, he feels happy, maybe because of what he’s doing. He smiles while doing hi activity. V.2 Nursing Diagnosis - Risk for injury r/t deficit on support measure as evidence by bare feet walking. VI. Nursing Interventions According to Sullivan (1953), the goal of treatment as the establishment of satisfying interpersonal relationships. The therapist provides a corrective interpersonal relationship for the client. Sullivan coined the term participant observer for the therapist’s role, meaning that the therapist both participates in and observes the progress of the relationships. In order for the nurse to gain patient’s trust and cooperation for the progressive therapy, he must use therapeutic communication. VII. Summary and Evaluation After receiving Mr. A.G. at around 9 o’clock in the morning, we start our expressive art therapy. Mr. A.G made a house, sun, tree and mountain using matchstick where he explained that he made that things because that is his observation to his surroundings. Mr. A.G.’s work is not correlated to his past life, instead, its focus to his environment inside the hospital. While doing his activity, Mr. A.G. Seems happy in what he is doing. VIII. References - Psychiatric-Mental Health Nursing by Videbeck - Psychiatric Nursing Handouts - NANDa

Psychotherapy I. Expressive Arts Therapy - Technique use to evaluate client’s ability in terms of arts and to assess client’s feelings and perception towards the activity. This therapy is done using a matchstick as a material. *Materials* Matchstick Glue A4 Bond paper *Goals* 1. Evaluate client’s ability in terms of arts 2. Assess client’s feelings and perception towards the activity. *Procedure* 1. There will be a group dynamics that will lead by facilitator to explain the therapy. 2. The student will give the necessary equipments needed for the therapy and will instruct the client about the procedure. 3. After the activity, the student nurse will have conversation with his client. 4. The nurse will get the output of his client and record all the necessary data regarding to his client.

*Evaluation* Mr. A.G. made a house, sun, mountain and coconut tree because these things are based on his observation to his environment. This therapy shows that client’s output has no significant relation to his past life, instead, it focus on his present life inside the hospital.

Date and time: Therapy: Place: Phase: I. Client’s Name: II. Objectives:

September 3, 2010; 9:00am; Friday (Day 6) Role Play Therapy Mariveles Mental Hospital Working Phase Mr. A.G.

A. Client-Centered Objectives: 1. for the client to develop abstract thinking from concrete thinking 2. for the client to recognize the difference between fiction and reality 3. for the client to gain moral values 4. To maintain his trust from his student nurse B. Nurse-Centered Objectives: 1. for the nurse to assess client’s cognitive ability 2. for the nurse to maintain trust of his client 3. for the nurse to gain skills in assessing client using MSA. III. Description of Setting A. Describe the Set-up/ Environment September 3, 2010, Friday, at around 9 o’clock in the morning, role therapy was conducted at BPSU center, near the coconut tree. It was a fair and sunny day were it can boost the energy of each client to do therapy more effectively.

play

B. Describe the nature, behavior, affect and mood of the client Around 9 o’clock in the morning, I received Mr. A.G. sitting on the chair I n the male ward. During the grooming and the role play therapy, I’ve observed that Mr. A.G.’s mood is in good mood with a smile on his face. I was amazed that Mr. A.G. remembers my name because last past 2 days, Mr. A.G. didn’t recognize my name. IV. Process Recording Nurse- client relationship SN: Magandang umaga po Mang A., ako po yung student nurse nyo kahapon. Makakasama nyo pa po ako sa susunod na linggo, sa araw po ulit ng miyerkules, huwebes at biyernes, tuwing hapon poi yon. SN: Naalala nyo pa po ba Therapeutic communication used Giving Information Analysis and Interpretation According to Imogene King (1960), nursing is a process of action, reaction and interaction whereby nurse –client share information about their perception in the nursing action situation. According to Peplau

Giving Recognition

ako? Mang A: Oo, (smiled) kaw si Mar.

(1952), a nurse is a stranger to the patient. It is therefore, important to remind the client who we are and be consistent with the information we are giving them to gain their trust. Giving Recognition According to Peplau (1952), he identified the basic nature of nursing as an interpersonal process noting efforts to the client has made shows that the nurse recognizes the client as a person. Thus rapport is built by demonstrating acceptance. --------------------------------Include in the 10 carative factors of Jean Watson (1970), is the cultivation of sensitivity to one’s self and to others. Verbalizing what is observed in the patient aids in validation and encourages situation. It is stated in Kings theory of Goal Attainment(1960), that if a nurse with special knowledge and skill to communicates the appropriate information to the client, mutual goal setting and goal attainment will occur --------------------------------Asking questions about the therapy will assess patient’s ability in terms of memory including his immediate recall.

SN: Ako po ay nagagalak at naaalala nyo pa po ang aking pangalan Mang A: (smiled)

-------After Grooming-----

--------------------------------

SN: Mang A., napansin Making observation kop o na nakangiti po kayo ngayon. Ano po ang dahilan ng inyong pagngiti? Mang A: Masaya ako, kasi may gagawin ulit tayong therapy. SN: Tama po kayo, ang gagawin po nating therapy ngayon ay role play therapy na kung saan makikinig po kayo ng gagawin naming dula dulaan, tapos po may ilan po akong itatanong sa inyo pagkatapos ng therapy. Mang A: (nodding) -------After Role Play-----Giving Information

--------------------------------

SN: Ngayon pong tapos na Asking Direct Question ang ating therapy, maaari nyo po bang sabihin kung ano po ang pamagat ng aming ginawang duladulaan?

Mang A: Ampalaya SN: A ng buong pamagat Encouraging decisions po ay “Alamat ng Ampalaya”, Ngayon po, sa lahat po ng gumanap na gulay, sino po ang pinaka nagging paborito nyo? Mang A: Si ampalaya. SN: Sa ano pong kadahilanan at napili nyo si ampalaya? Mang A: mapait kasi sya. Encouraging Evaluation According to Abraham Maslows, all needs must meet to proceed to the next level. Respecting client’s decision will make client to meet the 3rd level which is love, belongingness and acceptance. This aid having in depth understanding of client’s thoughts of feelings. As stated by Levine (1989), human being must be aware and must be able to contemplate objects, condition and situation. To encourage client to express his feelings toward to the object and to explore more of his reasons.

SN: Sige po, sabihin nyo pa po kung ano pong dahilan at ampalaya ang napili nyo. Mang A: Mapait at sinasama sa ulam. SN: Mang A., maaari nyo po bang maikumpara ang nagging buhay nyo sa isang ampalaya? Mang A: Ahm.. Masarap saya, mapait, masarap igulay.

General Leads

Encouraging Comparison

According to Abdellah (1965), nurses must help the individual in developing a comprehensive plan in the comprehensive nursing skills, it is stated that nurses can help direct the work of others. According to Abdellah (1965), nurses must help the individual in developing a comprehensive plan in the comprehensive nursing skills, it is stated that nurses can help direct the work of others. Helps the client clarify their own thoughts and

SN: Hindi po iyon ang Encouraging tanong ko, ang sabi kop o, Comparison paano nyo maikukumpara ang sarili nyo sa isang ampalaya? Naging mainggitin din po ba kayo dati? Mang A: Hindi naman ako nagging maiingitin. SN: Mang A., sabi nyo po sa akin na hindi po kayo Seeking Clarification

nagging mainggitin, tama po ba ang aking narinig? Mang A: Oo. SN: Sabi nyo po dib a sa akin dati, namatay ang tatay nyo at iniwan kayo ng inyong nanay, nakaramdam po ba kayo ng inggit sa ibang bata dahil sa nangyari? Mang A: Nakaramdam din, Pero hindi na ngayon. SN: Pag-usapan po natin ang inyong ina, Galit pa po ba kayo sa kanya? Mang A: hindi naman, nagtatampo lang ako. Encouraging Expression

maximize mutual understanding between the nurse and the client. According to Abdellah (1965), one of the steps in identifying the client’s problem is to continue observing and evaluating the patient to identify attitude and cues affecting his behavior. As stated by Watson, there is interdependency and integration of the parts and elements of thoughts and behavior that make up the system. Hence, it is important to help the client identify his thoughts to gain better understanding of himself. According to Abraham Maslows, all needs must meet to proceed to the next level. Respecting client’s decision will make client to meet the 3rd level which is love, belongingness and acceptance. It is stated by Orlando (1980), that individuals have their own subjective perceptions and feeling that may not be observed directly. Therefore, it is important to set the client know their perception are accepted and heard to encourage verbalization of thoughts. As stated in the domain concept of Orlando (1980), one goal of nursing is improvement in client’s

Focusing

SN: Ganon po ba Mang A., gusto nyo pa po bang Makita at makasama ang inyong ina kung bibigyan kayo ng pagkakataon? Mang A: Hindi na, nasa malayo na yung mga yun ngayon. SN: Ngayon po Mang A., malapit na pong matapos ang ating pag-uusap, maaari nyo po bang sabihin kun ano ano ang ating napag-usapan? Mang A: Si ampalaya at si nanay ko.

Encouraging Decisions

Summarizing

SN: Tama po Mang A., Salamat po sa inyong kooperasyon. Magkikita po ulit tayo next week.

Reinforcement

Miyerkules po ng Hapon. Mang A: Salamat din

behavior. Feedback encourage client to pursue or continue positive behavior.

V.1 Theme Identification A. Content Theme- the focus of conversation between me and Mr. A.G. is all about the role play therapy which is all about the “legend of the Bitter gourd.” We talked about if he can compare himself to the said vegetable. We also talked about his mother. B. Interaction Theme- Mr. A.G. answers some of my questions illogically by answering me not related to our topic. But then, some of my questions were answered correctly. C. Mood Theme- Mr. A.G. seems happy since I received him from his ward up to the last part of our conversation. He enjoys watching our role play. V.2 Nursing Diagnosis - Risk for injury r/t absence of foot wear as evidence by bare feet. VI. Nursing Interventions Nursing skills is made up of variety of actions and characterized by harmony of movement, precision and effective use of self as what Ernestine Wredenback (1964), stated. It is important for the client to know that someone is willing to listen to all his concern about himself. Someone he can trust on and can solve regarding his feeling of loneliness, etc. By gaining client’s trust, nurse will also gain his cooperation to perform all therapy well that can help client to decrease his anxiety and for the nurse to assess client’s psychophysiologic aspects. It is also stated by Orem’s Self Care Deficit Theory that, we as nurses should assist others in provision and management of self care to maintain or improve human functioning at home level of effectiveness. Through instructing them to their activities of daily living well, we can improve them for a better one. VII. Summary and Evaluation Around 9 o’clock in the morning, I received Mr. A.G. starting his day with grooming. Then we proceed to the BPSU center to do his role play therapy. Through that therapy, I assess and evaluate his cognitive ability showing a result that Mr. A.G. has concrete and sometimes illogical thinking than in abstract or logical ones. VIII. Reference: -Psychiatric Nursing handouts - Psychiatric –Mental Health Nursing, Fifth edition by Videveck.

Psychotherapy I. Role Play Therapy - technique which the nurses will prepare a role playing to evaluate client’s cognitive thinking ability towards the said therapy and to test their memory especially immediate recall. *Goals* 1. Assess client’s cognitive thinking ability 2. To test their memory especially immediate recall 3. To relate the role play to their past life. 4. To give differentiation between fiction and reality *Procedure* 1. Through a group dynamics, the facilitator will give information about the therapy. 2. The nurse will perform role play. 3. Afterwards, clients will go their respective student nurses for further assessment. 4. Lastly, they will go back to a group dynamics. Evaluation: Mr. A.G. enjoys watching the role play that was presented by the student nurses. He choose “Ampalaya” as his favorite vegetables and character in the reason that it is bitter but then, Mr. A.G. didn’t show any abstract thinking regarding that character and cannot relate the characteristic of the said vegetables to his life. As our conversation regarding the bitter gourd goes by, there is a point where we talked about his mother if he feels some bitterness towards his mother, then he answer me that he is not bitter and angry anymore against his mother.

Date and time: Therapy: Place: Phase:

September 8, 2010; 2:30pm; Wednesday (Day 7) Dance Therapy Mariveles Mental Hospital Working and Pre-termination phase

I. Client’s Name: Mr. A.G. II. Objectives A. Client-Centered Objectives 1. Maintain client’s trust to his student nurse. 2. for the client to discover his talent in dancing. 3. For the client to gain skill in terms of following procedure especially those steps that he will learn from his student nurse. B. Nurse-Centered Objectives 1. To gain skills in handling mental ill patient especially in teaching steps in dance therapy. 2. To maintain client’s trust for better result of the therapy. 3. To assess client’s perception about the dance therapy. III. Description of Setting A. Describe the Set-up/ Environment September 8, at around 2:30pm where I received Mr. A.G. from his ward. The environment seems wet and slippery just because it was a cloudy day with slightly rain. The set up of the therapy was conducted at BPSU center where it seems conducive for the dance therapy. B. Describe the Nature, Behavior, Affect and Mood of the Client I received Mr. A.G. at around 2:30pm at male ward. I observed that Mr. A.G. is in good mood which is evidence by a big smile on his face, maybe because of the near event which is the grand socialization day. IV. Process Recording Nurse-Client Conversation SN: Magandang hapon po Mang A., naaalala nyo pa po ba ako? Mang A: Oo,.. ahm… kaw si Mar. Therapeutic Communication Giving Recognition Analysis and Interpretation According to Peplau (1952), a nurse is stranger to the patient. It is therefore important to remind the client who we are and be consistent with the information we are giving to them to gain their trust. According to abdellah, one

SN: Tama po, Mang A.,

Stating Observation/

napansin kop o na Masaya kayo ngayon, ano po ba ang dahilan? Mang A: Wala lang, malapit na kasi ang grand socialization natin.

exploring

step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. According to King (1960), stress in NPI will occur if conflict is experienced nurses to identify the more on relation to the patient.

SN: Tama po Mang A., Giving information/ malapit na ang grand Setting Limits socialization natin, at dahil po doon, hanggang bukas nyo na lang po kami makakasama, sa susunod po na linggo, iba nap o ang hahawak sa inyo, hindi nap o ako, pero BPSU pa rin po. Mang A: Oo nga eh, nasabi na rin yan ng student nurse ko kaninang umaga. SN: Mang A., tanong ko lang po, alam nyo po ba ang gagawin nating therapy ngayong hapon? Mang A: Oo, dance therapy. Asking close-ended question

Included in the 10 carative factors of Jean Watson is the cultivation of sensitivity to one’s self and to others. Asking the said question will measure the client’s memory retention level. -------------------------------By giving client an information, the client will be aware to what he is been going to do and by asking question related to his feelings regarding the therapy is use to explore his feelings.

------After Grooming-----SN: Mang A., ngayon po ay sasayaw tayo, susundan nyo po muna kaming sumayaw, tapos po, mamaya, sabay-sabay nap o tayong sasayaw kasama nap o ang musika. Mang A., sabik nap o ba kayong sumayaw? Mang A: Medyo… -----After therapy----------SN: Mang A., Mukha pong pinagpapawisan kayo, nag-enjoy po ba kayo sa ating ginawang therapy? Mang A: Medyo, kaso

-------------------------------Giving information/asking direct question

-------------------------------Stating observation/ Asking question

-------------------------------Through the use of this two therapeutic communication, I can explore client’s feelings toward the therapy.

mahirap, kaw din pinagpapawisan. SN: Mang A, dib a po, kaninang umaga ay kumanta po kayo kasama ng inyong student nurses, ano po ba mas gusto nyo, sumayaw o kumanta? Mang A: kumanta kasi mas madali. According to Abdellah, nurses must help individual in developing a comprehensive plan. In the comprehensive nursing, it is stated that nurses can help direct the works of others. Helps the client to clarify their own thoughts and maximize mutual understanding between the nurse and the client. It helps client to recall all songs that he knows from his past life.

Encouraging Comparison

SN: Sinabi nyo pong mas gusto nyo kumanta, tama po ba ang aking narinig? Mang A: Oo, mahirap kasi Seeking Clarification yung step ng sayaw eh… SN: Ok po, anu-ano naman po mga alam nyong kanta? Mang A: “Bakit nga ba Asking Question ang puso” SN: Ah, “kung mula sa puso” ang title po ng kantang iyan. Ano pa po? Ituloy nyo pa po. Mang A: yung “Halik”

For the client to expound his thoughts. General Leads Reviewing the main points of discussions and making appropriate conclusions will help the client remember what was discussed and its significance.

SN: Mukha pong marami kayong alam na kanta ah.. Mang A., malapit na pong matapos ang ating Summarization paguusap. Maaari nyo po bang ibuod ang ating mga napagusapan? Mang A: Ah yung kanta at sayaw. Pati na rin yung grand socialization. ---After Group DynamicsSN: Mang A., babalik nap o kayo sa inyong ward, nawa po ay natuwa kayo sa ating ginawa, magkikita pa po ulit tayo bukas sa ating grand socialization ng umaga. Mang A: Ok salamat din

-------------------------------Reinforcement

-------------------------------As Stated in the domain concepts of Orlando, one goal of nursing is improvement in client’s behavior. Feedback encourage client to pursue positive behavior.

sayo. V.1 Theme Identification A. Content Theme- Our discussion was focused on the therapy that we’ve done. Mr. A.G. stated that he loves to sing than to than to dance, because of the reason that dancing is more difficult than singing. The therapy that was conducted is the dance therapy. B. Interaction Theme- Mr. A.G. interacts with me in a good manner, where he can recall his past favorite songs. He also answers all my questions correctly. C. Mood Theme- Within our conversation, Mr. A.G. shows a good mood which is evidenced by a smile on his face. He enjoys dancing even though that he like to sing than to dance. V.2 Nursing Diagnosis - Risk for deficient fluid volume r/t over perspiration. VI. Nursing Interventions Based on Virginia Henderson’s definition of the unique function of nursing, she defines nursing as “Assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery.” Based on this statement, we nurses must assist our client in doing such a thing in the sense that our client should not be dependent on us. Another is that, According to Peplau, we must used therapeutic communication just to gain their trust and cooperation in doing such thing like conducting a group therapy. VII. Summary and Evaluation Around 2:30 in the afternoon, I received Mr. A.G. in male ward. We conducted dance therapy. Mr. A.G. shows interest in dancing well in fact, he loves to sing than to dance as he stated in our conversation. Mr. A.G. didn’t follow the steps correctly but then I observed that he tries his best to the therapy. We also talked about his favorite songs when he was an adolescent. VIII. Reference -Scribd.com -Psychiatric Nursing Handouts -NANDA -Psychiatric- Mental Health Nursing by: Videbeck

Psychotherapy I. Dance Therapy - It is a group therapy where the client will mimic or follow steps from their student nurses with music. *Goal* 1. Assess if the client can follow direction through copying some steps from their student nurses. 2. It serves as recreation for the client for them to recall if they do dance in their past life. Procedure: 1. The facilitator will inform the entire client regarding the procedure in dance therapy. 2. All students will teach their client about the step with out music. 3. After the rehearsal, all nursing students together with their client will dance with music. 4. After the dance therapy, the client will go to his student nurse to have a talked about the therapy and for summarization. 5. Lastly, there will be a group dynamics again for the whole evaluation. Evaluation: While doing the therapy, I observed that Mr. A.G. enjoys dancing. He states to me that those steps that we teach to him are hard for him to follow, but then he enjoys it. He said that he loves to sing than to dance because singing is more easy than dancing. He also recalls some of his favorite songs in his past life.

Date and time: Therapy: Place: Phase: I. Client’s Name: II. Objectives:

September 9, 2010; 9:00am; Thursday; Day 8 Grand Socialization Mariveles Mental Hospital Termination Phase Mr. A.G.

A. Client-Centered Objectives 1. Maintain client’s trust. 2. The client will verbalize his feelings regarding Grand Socialization 3. The client will be inform that this is the last day that he will be handle by his student nurse. B. Nurse-Centered Objectives 1. The nurse will assess client’s feelings regarding Grand Socialization. 2. The nurse will inform client regarding termination phase. 3. The nurse will demonstrate how to socialize with others to his client. III. Description of Setting A. Describe the Set-up/Environment September 8, 2010, Thursday, around 9 o’clock in the morning, grand socialization was conducted at the ruins. It was a fair and sunny day where it can boost the energy of each client to cooperate in the grand socialization. B. Describe the Nature, Behavior, Affect and Mood of the Client Around 9 o’clock in the morning, Mr. A.G. was bought by his 2 other student nurses in the ruins for grand socialization. While having a snack, I talked to Mr. A.G. to assess his feelings towards the grand socialization and informed him about the termination phase. I observed that Mr. A.G. is in good mood, and happy because he cooperates well in our event. IV. Process Recording Nurse- client relationship --Having Snack in Grand Soc---------------------------SN: Mang A., magandang umaga po, kamusta po kayo? Natatandaan nyo pa po ba ako? Mang A: Oo, kaw si Mar. Therapeutic communication used -------------------------------Giving Recognition Analysis and Interpretation -------------------------------According to Peplau (1952), a nurse is a stranger to the patient. It is therefore, important to remind the client who we are and be consistent with the information we are giving them to gain their trust.

SN: Ako po ay natutuwa at Giving Recognition naaalala nyo pa po ako hanggang sa last day kop o ditto sa Mental hospital bilang student nurse nyo. Mang A: (smiled)

According to Peplau (1952), he identified the basic nature of nursing as an interpersonal process noting efforts to the client has made shows that the nurse recognizes the client as a person. Thus rapport is built by demonstrating acceptance. Include in the 10 carative factors of Jean Watson (1970), is the cultivation of sensitivity to one’s self and to others. Verbalizing what is observed in the patient aids in validation and encourages situation. To assess if the client is aware regarding the date and time. It is stated in Kings theory of Goal Attainment(1960), that if a nurse with special knowledge and skill to communicates the appropriate information to the client, mutual goal setting and goal attainment will occur

SN: Napansin kop o Stating Observation kanina na Masaya kayo habang naglalaro kayo sa ating grand soc. Ano po ba ang dahilan? Mang A: Masaya, kasi grand soc ngaun, sumali ako sa maraming laro kahit 1 beses lang ako nanalo. SN: Alam nyo po ba kung anong araw ngayon? Mang A: Hindi eh. SN: Ngayon po ay huwebes, September 8, 2010, at ngayon po ang huling araw na ihahandle kop o kayo ditto sa Mental Hospital. Iba na po ang hahawak sa inyo sa susunod na linggo, pero BPSU students pa rin po sila. Mang A: Ah… SN: Mang A., masarap po ba ang pagkain na inihanda naming sa inyo? Mang A: Oo, masarap. Asking Direct Question

Giving Information/Setting Limits

Encouraging Evaluation

According to abdellah, one step in identifying the client’s problem is to continue observing and evaluation the patient to identify attitude and cues affecting his behavior. Reviewing the main points of discussions and making appropriate conclusions will help the client remember what was

SN: Mang A., pagkatapos po ng grand soc., ako po ang maghahatid sa inyo sa inyong ward, bago po ang lahat, nais ko pong

Summarization

ipabuod sa inyo ang ating napag-usapan. Mang A: Grand soc., at saka yung huling araw nyo rito. -------After------------------SN: Mang A., maraming salamat po sa inyong cooperasyon at tiwala, nawa po ay nagenjoy kayo sa ilang linggong kasama nyo po ako, ingat po! Mang A: Salamat din. -------------------------------Reinforcement

discussed and its significance.

-------------------------------As Stated in the domain concepts of Orlando, one goal of nursing is improvement in client’s behavior. Feedback encourage client to pursue positive behavior.

V.1 Theme Identification A. Content Theme- The focus of our conversation is all about the grand socialization and termination phase. We talked about his feelings regarding the event and also I informed him that this is the last time that I will handle him. He shows his cooperation to the event making him to enjoy the grand soc. B. Interaction Phase- Mr. A.G. answerws all my questions relevant to the topic. C. Mood Theme- Mr. A.G. seems happy since I was received him up to the point that I accompanied him going to his ward. He enjoys playing with his co-client in the grand soc. V.2 Nursing Diagnosis - Risk for loneliness r/t termination phase VI. Nursing Intervention According to Peplau’s Interpersonal theory, in termination phase, the nurse must inform his client regarding that this is the last time that he will handle the client. By the use of therapeutic communication while having a conversation, the client will accept that he will not see anymore his nurse and another nurse will handle him. Through acceptance, the client will be no longer experience loneliness regarding of that event. VII. Summary and Evaluation Around 9 o’clock in the morning, Grand Socialization was conducted at the ruins. Mr. A.G. came with his two other student nurses. Mr. A.G. cooperates in almost all games in that event. He won 1 times out of 4 games but then he feels happy. Mang A., verbalized his feelings regarding the grand soc, and he shows acceptance regarding termination phase.

VIII. Reference - Psychiatric Nursing Handouts -Psychiatric-Mental Health nursing, Fifth edition by Videbeck -NANDA

Psychotherapy I. Grand Socialization- is event conducted as a part of termination phase where all clients will group as one to have an entertainment that will lead by the nurses. *Goals* 1. Teach client how to socialize with others. 2. To give entertainment. 3. To inform client about the termination phase. *Procedure* 1. The grand soc will be lead by the student nurses of different committee and there will be two MC to give entertainment to the client. 2. The different committee will do therir assigned task; food committee; games; aftercare; invitation and program; sounds; and decoration. 3. After the event, there will be a conversation between the student nurse and the client for the termination phase. 4. The client will return to their ward accompanied by the student nurse. Evaluation Mr. A.G. shows energy in the grand soc. He cooperates to different games winning 1 game out of 4 games. But then eventhough he loses to other games, still, he is happy. Mr. A.G. shows acceptance regarding the termination phase.

MENTAL STATUS ASSESSMENT Legend: Δ- Has, or oriented, possesses Ω-Has no, not oriented, or do not possesses Name: Age: Orientation: Day 1 Person Place Date Time Situation Analysis and Interpretation: Day4: Mr. A.G. is oriented in terms of person, place, and situation. He answers me correctly when I asked him about the person, place and situation but then, Mr. A.G. is not oriented in date and time. Day 5: Mr. A.G. is oriented in terms of place, and situation. He answers me correctly when I asked him about the place and situation but then, Mr. A.G. is not oriented in person, date and time. He didn’t recognized me when I asked him who am i. Day 6: Mr. A.G. is oriented in terms of person, place, and situation. He answers me correctly when I asked him about the person, place and situation but then, Mr. A.G. is not oriented in date and time. Day 7: Mr. A.G. is oriented in terms of person, place, and situation. He answers me correctly when I asked him about the person, place and situation but then, Mr. A.G. is not oriented in date and time. Day8: Mr. A.G. is oriented in terms of person, place, and situation. He answers me correctly when I asked him about the person, place and situation but then, Mr. A.G. is not oriented in date and time. Theories: -According to Hildegard Peplau’s Interpersonal theory, one of the signs that aclient gain trust to his nurse is by recognizing and remembering the name of his nurse which is caused by a good Nurse-Client interaction. -It is also stated in Pschoanalytic theory coined by Sigmund Freud that if a person over used his defense mechanism just to protect his ego will result in forgetting other Day 2 Day 3 Day 4 Δ Δ Ω Ω Δ Day 5 Ω Δ Ω Ω Δ Day 6 Δ Δ Ω Ω Δ Day 7 Δ Δ Ω Ω Δ Day 8 Δ Δ Ω Ω Δ Day 9 Mr. A.G. Male Ward A

things which can decrease his level of awareness like Mang A. which are not oriented to the date and time. -According to Martha Roger’s concept of science of unitary human beings, and principles of homeodynamics, nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the individual and redirect human and environmentak patterns or organization to achieve maximum health. And one of the sign the a client return to his maximum health is to be oriented in person, place, time, situation and date as a part of psychological aspects.

Defense Mechanism: Day 1 a. Repression b. Suppression c. Regression d. Fixation e. Denial f. Displacement g. Conversation h. Identification i. Intellectualization j. Introjections k. Projection l. Rationalization m. Sublimation n. Substitution o. Symbolism p. Undoing q. Reaction Formation r. Fantasy Analysis and Interpretation: Day 4: Mr. A.G. was observed having repression, fixation, denial and rationalization as his defense mechanism to protect his ego. Repression was used by Mr. A., just to protect his emotion and by forgetting the bad things happen to him when he was in adolescence and childhood days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation where he was fixate to the time when he was 5 years old which he is with his father. Denial was also used because he said that he is not angry to his mother who is contradicted to his facial expression. He also used rationalization by giving me some reasons telling that he is not angry to his mother Day 5: Mr. A.G. was observed having repression, fixation, denial and rationalization as his defense mechanism to protect his ego. Repression was used by Mr. A., just to protect his emotion and by forgetting the bad things happen to him when he was in adolescence and childhood days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation where he was fixate to the time when he was 5 years old which he is with his father. Denial was also used because he said that he is not angry to his mother who is contradicted to his facial expression. He also used rationalization by giving me some reasons telling that he is not angry to his mother Day 6: Mr. A.G. was observed having repression, fixation, denial and rationalization as his defense mechanism to protect his ego. Day 2 Day 3 Day 4 Δ Ω Ω Δ Ω Ω Ω Ω Ω Ω Ω Δ Ω Ω Ω Ω Ω Ω Day 5 Δ Ω Ω Δ Ω Ω Ω Ω Ω Ω Ω Δ Ω Ω Ω Ω Ω Ω Day 6 Δ Ω Ω Δ Ω Ω Ω Ω Ω Ω Ω Δ Ω Ω Ω Ω Ω Ω Day 7 Δ Ω Ω Δ Ω Ω Ω Ω Ω Ω Ω Δ Ω Ω Ω Ω Ω Ω Day 8 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Day 9

Repression was used by Mr. A., just to protect his emotion and by forgetting the bad things happen to him when he was in adolescence and childhood days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation where he was fixate to the time when he was 5 years old which he is with his father. Denial was also used because he said that he is not angry to his mother who is contradicted to his facial expression. He also used rationalization by giving me some reasons telling that he is not angry to his mother Day 7: Mr. A.G. was observed having repression, fixation, denial and rationalization as his defense mechanism to protect his ego. Repression was used by Mr. A., just to protect his emotion and by forgetting the bad things happen to him when he was in adolescence and childhood days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation where he was fixate to the time when he was 5 years old which he is with his father. Denial was also used because he said that he is not angry to his mother who is contradicted to his facial expression. He also used rationalization by giving me some reasons telling that he is not angry to his mother Day 8: Mr. A was observed negative to all items listed above. Theories -According to Sigmund Freud, defense mechanism is used by an individual to protect their ego and just to decrease their anxiety. -According to Han Seyle’s Stress theory, to cope up with the stress, there are some mechanisms that a person must use like defense mechanisms. -According to Callista Roy’s Adaptation theory, he viewed humans as biopsycholosocial beings constantly interacting with changing environment and who cope with their environment through biopsychosocial adaptation mechanism

Extrapyramidal Symptoms: Day 1 Pseudoparkinsonism 1. Masklike face 2. No swinging of arms 3. Hesitancy of speech 4. Decreased muscle strength 5. Shuffling gait 6. Drooling 7. Fine intention tremors Acute Dystonic Reaction 1. Muscle spasm of jaw, tongue, neck, eyes 2. Laryngeal spasm Akathisia 1. Restlessness 2. Tenseness 3. Inability to sit still 4. Rocking back and forth on feet 5. Crossing leg frequently 6. Inability to relax Tardive Dyskinesia 1. Involuntary movements of mouth, tongue, face, may extend to fingers, arms and trunk Analysis and Interpretation:

Day Day Day Day Day Day 2 3 4 5 6 7 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 8 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 9

Ω Ω Ω

Day 4: Mr. A.G. was observed negative to all items listed above. Day 5: Mr. A.G. was observed negative to all items listed above. Day 6: Mr. A.G. was observed negative to all items listed above. Day 7: Mr. A.G. was observed negative to all items listed above. Day 8: Mr. A.G. was observed negative to all items listed above.

Thinking and Communication: Day 1 Looseness of Association a. Neologism b. Word salad c. Echolalia d. Echopraxia e. Clang Association f. Illogical thinking Alogia Concrete thinking Lack of insight Aphasia Apraxia Agnosia Flight of Ideas Analysis and Interpretation: Day 4: Mr. A. was observed having lack of insight and having a concrete thinking. These things was evident during our conversation when he answered all my questions illogically and cannot give me an abstract reason to our topic, instead, he answered me in a concrete thinking. Day 5: Mr. A. was observed having lack of insight and having a concrete thinking. These things was evident during our conversation when he answered all my questions illogically and cannot give me an abstract reason to our topic, instead, he answered me in a concrete thinking. Day 6: Mr. A. was observed having illogical thinking, lack of insight and having a concrete thinking. These things was evident during our conversation when he answered all my questions illogically and cannot give me an abstract reason to our topic, instead, he answered me in a concrete thinking. Day 7: Mr. A. was observed having lack of insight and having a concrete thinking. These things was evident during our conversation when he answered all my questions illogically and cannot give me an abstract reason to our topic, instead, he answered me in a concrete thinking. Day 8: Mr. A. was observed having illogical thinking, lack of insight and having a concrete thinking. These things was evident during our conversation when he answered all my questions illogically and cannot give me an abstract reason to our topic, instead, he answered me in a concrete thinking. Day 2 Day 3 Day 4 Day Day 5 6 Day 7 Day 8 Day 9

Ω Ω Ω Ω Ω Ω Ω Δ Δ Ω Ω Ω Ω

Ω Ω Ω Ω Ω Ω Ω Δ Δ Ω Ω Ω Ω

Ω Ω Ω Ω Ω Δ Ω Δ Δ Ω Ω Ω Ω

Ω Ω Ω Ω Ω Ω Ω Δ Δ Ω Ω Ω Ω

Ω Ω Ω Ω Ω Ω Ω Δ Δ Ω Ω Ω Ω

Theories: -Based on Jean Piaget’s Cognitive theory, by the age of 12-15 years old, an individual should developed his abstract reasoning, logical thinking and achieve cognitive maturity. In this case, Mr. A. didn’t achieve his maturity which is caused by different factors of his past life. - It is also stated in the neurochemicals theory that if a person is under the substance abuse state, in will affect different neurotransmitter that can cause brain cells death that may affect thinking. -According to Psychosocial theory of Eric Erickson, if an individual didn’t attain or achieve his important task in each stage, there will be a fixation affecting his thinking ability

Perceiving and Interpreting: Day 1 Delusions 1. Reference 2. Persecution 3. External influence 4. Somatic 5. Grandiose Hallucinations Illusions Depersonalization Attending to irrelevant stimuli Poor reality testing Attending to relevant stimuli Poor reality testing Analysis and Interpretation:

Day Day Day Day Day 2 3 4 5 6 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 7 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 8 Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 9

Day 4: Mr. A.G. was observed negative to all items listed above. Day 5: Mr. A.G. was observed negative to all items listed above. Day 6: Mr. A.G. was observed negative to all items listed above. Day 7: Mr. A.G. was observed negative to all items listed above. Day 8: Mr. A.G. was observed negative to all items listed above.

Feelings and Affect: Day 1 Flat Blunted Inappropriate Lability Analysis and Interpretation: Day 4: Mr. A.G. was observed negative to all items listed above. Day 5: Mr. A.G. was observed negative to all items listed above. Day 6: Mr. A.G. was observed negative to all items listed above. Day 7: Mr. A.G. was observed negative to all items listed above. Day 8: Mr. A.G. was observed negative to all items listed above. Day 2 Day 3 Day 4 Ω Ω Ω Ω Day 5 Ω Ω Ω Ω Day 6 Ω Ω Ω Ω Day 7 Ω Ω Ω Ω Day 8 Ω Ω Ω Ω Day 9

Behaving and Interacting: Day 1 Withdrawal Motor Hyperactivity Motor Hypoactivity Ambivalence Anhedonia Avolition Poor Personal Hygiene Impulsive Paranoia Analysis and Interpretation:

Day 2

Day 3

Day 4 Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 5 Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 6 Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 7 Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 8 Ω Ω Ω Ω Ω Ω Ω Ω Ω

Day 9

Day 4: Mr. A.G. was observed negative to all items listed above. Day 5: Mr. A.G. was observed negative to all items listed above. Day 6: Mr. A.G. was observed negative to all items listed above. Day 7: Mr. A.G. was observed negative to all items listed above. Day 8: Mr. A.G. was observed negative to all items listed above.

Negative Cognition: Day 1 Overgeneralization All or nothing thinking Should statements Labeling Mind reading Fortune telling Analysis and interpretation: Day 4: Mr. A.G. was observed negative to all items listed above. Day 5: Mr. A.G. was observed negative to all items listed above. Day 6: Mr. A.G. was observed negative to all items listed above. Day 7: Mr. A.G. was observed negative to all items listed above. Day 8: Mr. A.G. was observed negative to all items listed above. Day 2 Day 3 Day 4 Ω Ω Ω Ω Ω Ω Day 5 Ω Ω Ω Ω Ω Ω Day 6 Ω Ω Ω Ω Ω Ω Day 7 Ω Ω Ω Ω Ω Ω Day 8 Ω Ω Ω Ω Ω Ω Day 9

Others: Day 1 Amnesia Fugue Depersonalization Phobias Memory 1. remote(long term) 2.recent(early am) 3.recent part(current events 4.immediate memory(short term) 5.immediate recall Analysis and Interpretation: Day 4: Mr. A. was observed having amnesia but then some of his memory was intact to his mind. He can remember his past life especially when he was 5 years old, and he can enumerate all events that happen from his past days. But then there are some memories that he can’t remember especially when he was in adolescene stage either intentionall or not, just to forget some bad memories. Day 5: Mr. A. was observed having amnesia but then some of his memory was intact to his mind. He can remember his past life especially when he was 5 years old, and he can enumerate all events that happen from his past days. But then there are some memories that he can’t remember especially when he was in adolescene stage either intentionall or not, just to forget some bad memories. Day 6: Mr. A. was observed having amnesia but then some of his memory was intact to his mind. He can remember his past life especially when he was 5 years old, and he can enumerate all events that happen from his past days. But then there are some memories that he can’t remember especially when he was in adolescene stage either intentionall or not, just to forget some bad memories. Day 7: Mr. A. was observed having amnesia but then some of his memory was intact to his mind. He can remember his past life especially when he was 5 years old, and he can enumerate all events that happen from his past days. But then there are some memories that he can’t remember especially when he was in adolescene stage either intentionall or not, just to forget some bad memories. Day 8: Mr. A. was observed having amnesia but then some of his memory was intact to his mind. He can remember his past life especially when he was 5 years old, and he can enumerate all events that happen from his past days. But then there are some Day 2 Day 3 Day 4 Δ Ω Ω Ω Δ Δ Δ Δ Δ Day 5 Δ Ω Ω Ω Δ Δ Δ Δ Δ Day 6 Δ Ω Ω Ω Δ Δ Δ Δ Δ Δ Day 7 Δ Ω Ω Ω Δ Δ Δ Δ Day 8 Δ Ω Ω Ω Ω Δ Δ Δ Δ Δ Day 9

memories that he can’t remember especially when he was in adolescene stage either intentionall or not, just to forget some bad memories. Theories -According to Sigmund Freud, forgetting something intentionally or not, it is under the defense mechanism that was used to decrease their anxiety. -According to biological theory, there are some factors that can affect the memory of a person, either accident, disease or affected by some chemicals. Based on the his tory of Mr. A., he is inhaling rugby, taking alcohol in his past life affecting his brain cells responsible for memory. -According to Han Seyle’s stress theory, there are two effects of stress, the eustress and distress; recovery and exhaustion. Under the exhaustion, it can result from prolonged exposure to stress and adaptive mechanisms can no longer persist, which can affect a lot of things including memory as a result of over use of defense mechanism.

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