PERSONAL DATA: Name: Manuel Sy Age: 55 years old Gender: Male Civil status: Single Address: Binondo Tondo,

Divisoria Date of Birth: March 21,1955 Person to Notify: Catalina Sy (Sister) Religion: Roman Catholic Educational Attainment: first year high school Date of Admission: July 3, 1984 at 4:30 pm Admission notes: Case of 29 years old male, single Chinese Mestizo residing at 2227, Pampanga St. Rizal Ave. brought by her sister because he could not be prevented for going out of the house and going too far places. Patient is an adult; very dirty in appearance seems in deep thoughts. Perform only with much nodding. Diagnosis: Schizophrenia,undifferentiated ,Chronic

History of illness: This is a case of Mr. Manuel Sy, Male 5o years old, single , Roman Catholic residing at Rizal was readmitted on July 3, 1984 due to relapse of psychotic behavior. History revealed that patient was readmitted because he could not be prevented by going out of the house, going too far places and neglects personal hygiene at present. Patient is well behaved; follows command and do the chore well. Medication being maintained as Chlorpromazine 200mg HS.

MSE: Seen and examined a 50 years old male, well groomed, well kept, cooperative, good eye contact, erythmic mood with appropriate affect, normoproductive speech denies any hallucinations, delusions/ morbid ideation, good thought content and process good judgment, intact recent memory, oriented to person, place, good insight of illness.

At the end of the rotation, this process recording will help the students nurse knowledge about the clients condition. This will give the student nurse the opportunity to know and give therapeutic therapy. General Objectives: To distinguish the sickness of the client through the observation done. Specific: - To build a therapeutic nurse-patient relationship To know the clients history To be to make the client verbalize his own feeling To be able to construct interaction therapeutically To formulate effective nursing intervention

Assessment: The patient is behaved with good eye contact. Speech is relevant, a bit slurred but relatively coherent. Appropriate affect, no mood swings. He denies hallucinations, delusion nor suicidal ideation. He claims to feel well in eating and sleeping. He desires to go home since he claims that he have been here for a long time. He further state that he will grow healthier at home since he will be able to change of view.

Nurse Patient Interaction: Nurse Patient Interaction Nurse: Magandang umaga po. Kamusta po kayo? Patient: Mabuti naman ako. Nurse: Ako nga po pala si Nurse Joyce Supnet mula sa Perpetual Help College of Manila, student nurse mo ako ngayon. Magkikita at mag-uusap tayo simula lunes hanggang Miyerkules, Inference My patient interacts accordingly Technique Used Acknowledging

He was sitting still looking at me in the eyes.

Offering self

mula alas-siyete hanggang als tres ng hapon. Maguusap tayo ulit bukas ha? Patient: (smiles) Opo. Opo. ( with nodding) Nurse: Pwede ko po bang malaman ang iyong pangalan? Patient: Ako po si Manuel Sy. Nurse: Ahh. Ano po ulit pangalan ko? Patient: Joyce Supnet Nurse: Ilan taon na po ba kayo? Patient: fifty-five (smiles) Nurse: Tatay Manuel, kayo po ay 55 years old sabi nyo, eh kelan po ang birthday nyo? Patient: March 21 Nurse: March 21... Anong taon po? Patient: March 21 1955. Nurse: Eh tatay, ano po ang natapos niyo? Patient: (stares at me) Natapos? Ha? Nurse: Opo tatay, ano po ang natapos niyo sa pagaaral? Patient: Ha? (looks around) Ang natapos ko ay college. Second year college. Nurse: ah, first year college. Anong kurso ang kinuha nyo nun? Patient: Engineering, kaso tumigil ako.

Patient is comprehending

Exploring

My patient answers my question correct and focused My patient answer my question correct and focused. He can focused into what he will say and answers it correctly.

Restating and Validating Clarifying

Focusing

Hes sure into his answer. He s not focused

Clarifying Using Broad Openings

Hes not paying attention to my question and his answer was not right because according to the chart he only finished first year high school Hes focused and confident into what she is saying.

Clarifying

Using broad openings

Nurse: Ano pong dahilan

He can answer my question

Clarifying

ng pagtigil nyo sa pagaaral? Patient: Tinatamad na ksi ako. Saka wala na kami negosyo. (smiles then looked around) Nurse: wala na negosyo? Ibig sabihin may negosyo kayo? Ano negosyo nyo? Patient: (smiles then looks around) Ha? Nurse: Tatay, sabi nyo po may negosyo kayo? Ano po ulit ung negosyo nyo? Patient: (stares at me)... oo may negosyo kame sa palengke. Basta negosyo. Nagbubuhat ako ng balding tubig. (Laughing) Nurse: ano dahilan ng pagtawa mo? May nakakatawa ka bang naalala? Patient: ( stares at me and smiles) Nurse: ano ung tinatawanan mo? Patient: (smiles) yung ilaw. Nurse: ano nakakatawa sa ilaw? Patient: Yung asawa ko nasa hospital. Nurse: Nasa hospital iyong asawa niyo? Anung dahilan? Patient: Dahil sa ilaw. Nurse: May anak po ba kayo? Patient: Oo may anak kame, dalawa. Babae tsaka lalake.

but then he is thinking of something else. Then he smiles every now and then.

He wasn't able to answer me back.

Validation

He shares what he wants to say and this time we have an eye to eye contact

Restating

He keeps on smiling

Encouraging Description

His answer is not appropriate to my question. He doesnt answer me

Validation

Clarification

His answer is inappropriate to my questions.

Validation

He becomes serious.

Using Broad Openings

Nurse:........... Patient: ung panganay ko eh babae, 16 year old tapos ung bunso 12 year old. Nurse: Asan yung mga anak mo ngaun? Patient: (looks around and thinking). Nasa Binondo. Nurse: hindi mo ba sila namimiss? Patient: (smiles) Hindi, malapit lang ang Binondo. Nurse: ang malapit po eh ung tipong pwedeng lakarin lang. Eh ung Binondo po eh 30 minutes mula dito. Malayo un. Patient: (stares at me) Nurse: Tatay ano nga po ulit ang pangalan ko? Patient: Nurse Joyce Supnet Perpetual Help college of Manila Nurse: Magaling po. May mga kapatid po kayo? Patient: (smiles) meron. Nurse: ilan po kayong magkakapatid?at pang ilan kayo? Patient: 12. Ako ang pangapat. Nurse: ah pang-apat kayo? Ilang taon na po yung panganay Patient: 64 (confuse) Nurse: Eh tatay gano kana katagal ditto? Patient: 52 years na.

His answer was not right because according to the chart he is single. He appears to be confuse

Silence

Validation

Not oriented

Offering General Leads

He doesnt answer me and instead just stares at me

Presenting reality

My patient interacts accordingly

Clarification

He answer me with good eye contact.

clarification

My patient interacts accordingly

Using Broad Openings

My patient interacts accordingly but hes thinking of something else

Using Broad Openings

Not oriented

Validation

Nurse:Sino po ang nagdala sa inyo dito? Patient: ung ate ko. Nurse: Ano po yung dahilan, paano po kayo dinala ng ate nyo dito?? Patient: ate ko nagdala sakin ditto eh. Galit kasi siya sakin. Nurse: Ganun po ba. Ano ang dahilan at galit sayo ang ate mo? Patient: Hindi kasi ako nagtratrabaho sa bahay. Nurse: Anong dahilan ng hindi mo pagtratrabaho sa bahay? Patient: sabi kasi ng tatay ko wag daw ako magtratrabaho Nurse:Mukha po yatang malungkot po kayo ngayon? Patient: Ha? ( looks around) Nurse: kung malungkot po kayo ngayon? Patient: Hindi Masaya ako. Nurse: Pero parang malungkot naman po kayo? Patient: ( stares at me)

He can answer my question but then her answer was not that appropriate. he can answer my question but it is appropriate and seems that he is thinking of something else

Using Broad Openings

Focusing

Good eye contact

Exploring

He answers my question

Using Broad Openings

Hes not focused

Making Observation

His answer does not appear Restating on her facial appearance he doesnt answer me Translating Into Feelings

Nurse: ano po ang paborito My patient interacts ninyong kainin? accordingly Patient: Mahilig ako sa friedchicken. Nurse: Ah ganun po ba. Eh My patient interacts

Using Broad Opening

Exploring

ano naman po ang kinahihiligan ninyong gawin? Patient: Nagbubuhat ng tubig at naglalaba. Nurse: Maraming salamat po sa inyong oras. Tayo na po ay magmemeryenda. Patient: ( stares at me and smiles)Sige. Day 2: Nurse Patient Interaction Nurse: Magandang umaga po. Kumusta na po? Kilala niyo pa ba ako? Patient: (Stares at me) Magandang umaga din naman. Ikaw si Joyce.

Accordingly

He just stare at me and smiling

acknowledging

Inference Responsive

Technique Used Acknowledging

Nurse: kamusta kana? Kumain na kayo? Patient: Mabuti naman . oo. Nurse: Ano po ulit yung kinain niyo? Patient: Kape at pandesal Nurse:nabusog ka naman? Patient: (smiles) oo

My patient interacts accordingly

Validation

My patient interacts accordingly

Exploring

My patient interacts accordingly

Clarifying

Nurse: nag-enjoy naman po ba kayo sa exercise

My patient interacts

validating

natin kanina? Patient: (Smiles) oo nag enjoy Nurse: Masayang Masaya? Patient: Oo Masaya Nurse: Okay naman po yung ginawa natin kanina? Patient: (smiles) Nurse: maupo muna tayo ha Patient: Smiles

accordingly

My patient interacts accordingly He just smile

Translating into feelings

Exploring

Smiling

Offering Self

Nurse: may papakinggan po kayong music tas magdrawing po tayo Patient: ............................ (stares at me) Patient: Nurse tapos na to Nurse: sige po upo lang kayo Patient: ( smiles and thinking) Nurse: kamusta naman po ang , ang pakikinig niyon ng music? Patient: mabuti naman Nurse: ngayon po ay kakain naman tayo. Patient: (Smiles)

No response at all

Presenting Reality

While he was doing the music and art therapy it seems that he can think of something else

Offering General Leads

he is paying attention seriously

Using Broad Openings

Presenting Reality

Nurse: masarap po ba ung pagkain? Patient: masarap

He is always smiling

validating

Nurse: ayan tapos na po tayo, sa susunod na lingo ulit ha? Paalam. Maraming salamat! 3RD day Nurse: Magandang umaga po tatay. Patient:magandang umaga din (stares at me) Nurse: kamusta naman ang tulog mo? Patient: Mabuti naman Nurse: may tanong ako sayo. Kamusta naman kayo ng mama mo? Patient: nanay ko? Matagal ng patay nanay ko. Nurse: Anu ikinamatay niya? Patient: May cancer siya Nurse : Ang ikinamatay ng nanay mo ay cancer? Patient: Oo around) (looks

My patient interacts accordingly

Reflecting

He appears happy

Acknowledging

Interacts accordingly.

Clarification

My patient interacts accordingly

exploring

My patient interacts accordingly

Validation

My patient interacts accordingly

Restating

Nurse: close ka ba kayo ng

He interacts accordingly

Exploring

nanay mo Patient: oo mabait un eh, palagi nya ako binibigyan ng pagkain

Nurse: tatay , kamusta ka naman ditto sa pavilion? Patient: Mabuti naman Nurse: pano mo nasabing mabuti? Patient: Kasi nagtratrabaho ako dito, isa akong helper ditto. Nurse: ano nakakapagpasaya sayo ditto? Patient: Sa tuwing inuutusan ako may limang piso ako, pinambibili ko ng kape.

He smiles

Offering General Leads

With good eye contact

Focusing

He Interacts accordingly

Using Broad Openings

Nurse: may friends ka ba dito? Patient: meron si William

My patient interacts accordingly

Focusing

Nurse: mabait ba si William? My patient interacts accordingly Patient: Oo , tabi lagi. Nurse: Sa inyo po ba sa binondo may mga kaibigan ka din? Patient: Oo madami (looks around) My patient interacts accordingly

validating

Validating

Nurse: ah Patient: (smiles) ............................... Nurse: ano religion mo? Patient: Roman Catholic

He just smile and no response at all

Focusing

My patient interacts accordingly

Validating

Nurse: Ako naman Baptist. Patient: (Smiles) Nurse: Luch break na pop ala. Bukas socialization na natin. Maraming salamat sa oras mo, at sa kooperasyon mo. God bless! Patient: Salamat din!

My patient appears happy

Exploring

He looks happy

Acknowledging

Evaluation: The goals of the objectives are partially met because I was able to get some information about what happened to the client and the data that I collect, I compared the information that is written in the chart.

PROCESS RECORDING

Submitted By: Supnet, Joyce Anne A. A4AB

Submitted to: Maam Carol De Lunas