Chapter I

Personal Data

Name : Patient X
Sex : Female
Age : Unknown
Address : Emerald height Garden Villas Mambugan Antipolo City
Civil Status : Married
Birth date : Unknown
Birthplace : Bicol
Religion : Unknown
Nationality : Filipino
Date Admitted : October 07, 2004
Time Admitted : 4:15pm
Admitted Doctor : Dr. Tamano
Diagnosis : Undifferentiated Schizophrenia - unstable
General data : Marimar Josephine unknown her age, parents, and religion.
They stay at Emerald height Garden Villas Mambugan Antipolo City; her province in
Bicol. She has married and there are 3 children. She grew up in Bicol and work in
Antipolo City.

History of Present Illness:

An Unknown woman “Marimar”, female brought here in NCMH by her

guardian because of a “mentally ill” patient.
A case of Evangelina Marimar, was by guardian from Emerald height
Garden Villas Mambugan Antipolo City with complaint of shouting while walking at the
street seen in 1989.

Mental status examination: Seen and examined as an adult female, thinly built in
hospital gown. Mood was enthymic and blunted affect. Speech was hypo productive she

Process Recording (Karl Angel B. Fabe, SN-SJIT)

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disclosed that she was not clad at home. Patient is with appropriate affect with restricted
facial expression. “Naalala ko mga anak ko sa Bicol” and her speech is
normoproductive, spontaneous, barely audible. She has no appropriate answers when
questioned. She denies having any visual/auditory hallucinations and the patient was
not capable of reasoning.

Neurologic Examination:

• Cranial Nerves

I. N/A

II. 2.3mm equally reactive to light

III. Intact EOM

IV.

V. (+) Corneal Reflex

VI. Intact EOM

VII. No facial assymetry

VIII. Can hear whisper word

IX. (+) gag reflex

X.

XI. Can shrug shoulder

XII. Tongue at midline

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 Motor System:

Limbs

Trunk 5/5 5/5

Stance

Gait 5/5 5/5

Rombergo

 Reflexes

J.J

B.J H H

S.J

T.J H H

Plantar

 Sensational
Pain & Touch
Temperature 100 100
Vibration
JPS 100 100
Two – point Descrimination

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 Chapter II
Process Recording No. 1
Orientation Phase
Description of Phase:

 Problem defining phase

 Starts when client meets nurse as stranger
 Defining problem and deciding type of service needed
 Client seeks assistance ,conveys needs ,asks questions, shares
preconceptions and expectations of past experiences
 Nurse responds, explains roles to client, helps to identify problems and to use
available resources and services

I. Goal Interaction
 To gain rapport of my patient.
 Establish trust, acceptance, and open communication
 To be able to become acquainted of my patient.
 To understand the patient’s problems.
 To demonstrate genuine care and understanding.
 To mutually formulate a contract with the patient

II. General Objectives

 To distinguish the sickness of the client thru the observation done.
 To reduce the anxiety felt by the client towards the nurse.
 To discuss the contract to my patient.
 To explore patient’s thoughts, feelings, and actions

III. Short-term Objectives

 To be able to introduce myself to my patient and getting to know one another.
 To show interest and sincerity to my patient.
 To gain trust from my patient.
 To observe and assess my patient’s personality.

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IV. Description of the Environment
The environment was calm and therapeutic aided with props to promote joyous
atmosphere. The breeze of the wind makes the patient feel comfortable and relaxing.
There is slight noise but tolerable.
Nurse-Patient Interaction (NPI) – Orientation Phase

NPI Inference Rationale

N: Magandang hapon sa iyo Broad Opening To establish open-

P: Magandang hapon po ended
N: Ano po ba ang pangalan mo? communication
P: Marimar po.

N: Ako nga pala po si Karl Angel Giving Information To gain rapport and
Fabe. Isang student nurse ng trust
Saint Joseph Institute of
Technology po sa Butuan City.
Simula po ngayon, araw-araw
na tayon magkakasama at pag-
uusapan
natin ang iyong talambuhay.
P: Ano po’ng gusto mong
malaman?
N: San ka po nakatira?
P: Sa Bicol po.

N: Anung araw ngayon?

P: Lunes po.
N:May asawa ka ba? Offering Self To accommodate her
P:Opo Patay na thoughts and giving
N:Ano naalala mo? a free expression of
P: Yung anak ko sa Bicol thoughts and feeling
N: Masaya ka bas a taas?
P: Oo.. Masaya kasi may mga
nurse na nag-aalaga sa amin
at saka may libreng pagkain
dito.

N: Minsan ba nalulungkot ka? Exploring To have an idea on

P: Hindi naman kasi marami kami her present illness
dito at kayo pumupunta dito. and help analyze her
situation

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 N: Salamat po sa iyong tiwala sa Recognition To build confidence
paglahad ng mga bagaybagay.. and increase her
P: Walang anuman po… self-esteem
N: Pagod ka na ba ate?
P: Opo.
N: Okay sige. Pahinga ka
na ate Marimar. Hintayin
lana muna natin ang iba
na matapos ha.
P: Opo.

V. Evaluation of Interaction

At the end of the conversation, the patient held smile and was confident to

confess a part of her life in summary. The patient used healthy words in mind easily

understandable by healthy mental state. She did said her favorite songs and artist as

well as her work before she was admitted at the said institution. She was responsive

and accommodating with frequent praise on physical looks on her nurse. In addition, the

patient lapses often on some topics which are not good in mental state.

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 Process Recording No. 2
Working Phase
Description of Phase:

At this point, the client’s problems are identified and solutions are
explored, applied and evaluated. The focus of the assessment and of the relationship is
the client’s behavior and the focus of the interaction is the client’s feelings.

VI. Goal Interaction

 To establish confidence upon interaction
 To promote patient’s self-esteem
 To provide high level of trust
 To promote self enhancement through life confession experience
 To gain working trust and relationship

VII. General Objectives

 To readily apply the therapeutic activities for self enhancement
 To help them understand their current mental health status
 To promote mind set for easy recovery
 To reduce the level of anxiety
 To prevent them from harming their self

VIII. Short-term Objectives

 To make her realize that there is hope in life
 To promote self-actualization
 To reduce the level of fear
 To provide physical cleaning
 To create a good therapeutic binding

 To overcome resistance behavior

IX. Description of the Environment

The working atmosphere was good. Everyone is active on their respective
activities. The patient did verbalized that she was excited on that day’s activity. There
Process Recording (Karl Angel B. Fabe, SN-SJIT)
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was a presence of slight noise coming from other school’s session. The weather was
hot but then tolerable. The environment was therapeutic as evidenced by the patient
understanding during the interaction.

Nurse-Patient Interaction (NPI) – Working Phase

NPI
N: Magandang umaga po
Sa yo ate Marimar!
Inference Rationale
Use Name Using a person's name
makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.

N: Ano ulit ang pangalan ko Help to orient Illness and hospitalization

can be very disorienting for
Marimar?
patients.
P: Kran po!
N: Carl ako
P: Carl

N: Kumusta kana Marimar? Broad Opening To establish open-ended

P: Okey lang p communication
N: Anung araw ngayun po
ate marimar?
P: Martes po.
N: Nag-almusal ka na?
P: Opo.. kumain ako ng
Tinapay, nagligo at
Nagtoothbrush

N: Galing, Masarap ba Accepting To prevent negative

yun? feedbacks and thoughts on
P: Oo.. kani-kanina lang.. her mind

N: May gusto ka bang Exploring To have an idea on her

sabihin sa akin? present illness and help
P: Yung ano lang.. yung analyze her situation
tungkol sa asawa ko.
N: Anong tungkol kay
asawa mo?
P: Namatay siya pati anak
kung tatlo sa Bicol
N: Napanu po sila ate
Marimar?
P: Namatay lang, Hindi ko
alam kung bakit
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 N: Kalimutan mo na po un.. To promote easy
P: Medyo nakalimutan ko Presenting Reality understanding on the
na.. problem
N: Ganyan po ate Marimar!
Pagod ka na ba ate?
P: Opo.
N: Okay sige. Pahinga ka
na ate Marimar. Hintayin
lana muna natin ang iba
na matapos ha.
P: Opo.

X. Evaluation of Interaction
At the end of the working phase interaction, the patient was confident in herself
as evidenced by sharing her thoughts which are unlikely in the previous interactions.
She also added that she learned a lot during remotivation. In this phase, the patient
expresses her thoughts freely without fear. Furthermore, she sing and dance graciously
without anxiety.

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 Process Recording No. 3
Termination Phase
Description of Phase:

The nurse terminates the relationship when the mutually agreed goals are met,
the patient is discharged or transferred or the rotation is finished. The focus of this stage
is the growth that has occurred in the client and the nurse helps the patient to become
independent and responsible in making his own decisions. The relationship and the
growth or change that has occurred in both the nurse and the patient is summarized.

XI. Goal Interaction

 To evaluate the patient’s readiness of oneself
 To develop independent care
 To gain self-awareness and self-care
 To prevent interdependency of the patient to the nurse
 To relieve discomfort on understanding others

XII. General Objectives

 To protect patient from harming herself
 To stabilize her good mental health or state of mind
 To increase her level of independence
 To establish a hopeful life outside the institution
 To regain self respect

 Establish reality of separation

 Mutually explore feelings of rejection, loss, sadness, and anger and related
behaviors

XIII. Short-term Objectives

 To make her realize that there is hope in life
 To promote self-actualization
 To reduce the level of fear
 To provide physical cleaning

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  To create a good therapeutic bonding

XIV. Description of the Environment

The weather was calm and sunny. The termination phase was quite more joyous
and active since it is the last time to interact with them. Every patient cooperated and
tried their best to achieve the goals in that particular activity. At the end, they are quite
sad on that farewell but then as they verbalize that they are thankful that we had them.
Nurse-Patient Interaction (NPI) – Termination Phase
NPI Inference Rationale
N: Magandang umaga po Use Name Using a person's name
Sa yo ate Marimar! makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.
N: Ano ulit ang pangalan ko Help to orient Illness and hospitalization
Marimar? can be very disorienting for
patients.
P: Kran po!
N: Carl ako
P: Carl

N: Kumusta kana Marimar?

P: Okey lang p Broad Opening To establish open-ended
N: Anung araw ngayun po communication
ate marimar?
P: Merkules po.
N: Nag-almusal ka na?
P: Opo.. kumain ako ng
Tinapay, nagligo at
Nagtoothbrush

N: Naalala mo pa yung
mga Exploring To have an idea on her
pinag-usapan natin po? present illness and help
P: Ah.. yung tungkol sa analyze her situation
buhay ko?
N: May gusto ka pa bang
ilahad sa akin?
P: Oo.. gusto ko sa nang
umuwi na sa amin..
N: Magpagaling ka po..
sundin mo lang mg
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 autos ng nurse at doctor
dito.. nang sa ganun
makalabas ka.

P: okey po. Presenting Reality To promote easy

N: Eto na po pala ang huli understanding on the
nating pagkikita.. problem
magpakabait po kayo
dito ha? Tandaan mo
lagi yung mga itinuro
naming sayo araw-araw.
P: Opo.. tatandaan ko po..

XV. Evaluation of Interaction

At the end of the termination phase, the patient understand her current situation
and wants to improve as verbalized by “gusto ko nang umuwi at magsimula ulit”. She
freely expresses her thoughts and feelings. The patient was seldom on crying and
expressing negative thoughts. During the interaction the patient won’t lapse every single
word that she wants to clarify.

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 Chapter III
Music Appreciation and Interpretation Approach

A. Happy Songs
 Black – depression and anxiety
 Red – dominating behavior
 Single Drawing – represents selfish motives
 Indecisive line – insecurity and selfishness
 Huge Head – open seen in grandiose paranoid evidence of aggressiveness, high
fantasy, high level of self-esteem which is usually associated with chronic
alcoholism
 Two Shapes Put Together – represents dependency to someone

B. Sad Songs
 Red – dominating behavior
 Single Drawing – represents selfish motives
 Indecisive Line – insecurity and selfishness
 Huge Head – open seen in grandiose paranoid evidence of aggressiveness, high
fantasy, high level of self-esteem which is usually associated with chronic
alcoholism

- Attached Drawing…

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List of Prioritized Psychiatric Nursing Diagnosis
NURSING DIAGNOSIS
Disturbed Thought Processes
related to developmental
delay of cognition as
evidenced by cognitive
dissonance
Impaired Verbal
Communication related to
impaired cognitive abilities as
evidenced by loose
association of ideas
Impaired Social Interaction
related to impaired thought
processes as evidenced by
dysfunctional interaction with
others
14
RANK RATIONALE
Based on Carl Jung's Theory of
Psychological Types, perception involves
all the ways of becoming aware of
things, people, happenings, or ideas.
Judgment involves all the ways of
coming to conclusions about what has
1
been perceived. If people differ
systematically in what they perceive and
in how they reach conclusions, then it is
only reasonable for them to differ
correspondingly in their interests,
reactions, values, motivations, and skills.
According to Karen Horney’s Theory on
Personality, moving away from people:
The final possible consequence of a
neurotic is a personality style filled with a
social behavior and an almost
indifference to others. If they don't get
2
involved with others, they can't be hurt
by them. While it protects them from
emotional pain of relationships, it also
keeps away all positive aspects of
relationships. It leaves them feeling
alone and empty.
According to Sullivan’s Interpersonal
Theory, the need for friendship and need
for sexual expression get combined
during late adolescence. In this stage a
long term relationship becomes the
3 primary focus. Conflicts between
parental control and self-expression are
commonplace and the overuse of
selective inattention in previous stages
can result in a skewed perception of the
self and the world.
Process Recording (Karl Angel B. Fabe, SN-SJIT)

Self-Care Deficit, Bathing and
Hygiene related to mental
4 required because of the inability to
delay as evidenced by
inability to bathe himself
Risk for Injury related to
5
delayed developmental age
15
Dorothea E. Orem's Self-Care Deficit
Nursing Theory states that nursing is
perform self-care as the result of
limitations.
Self-harm is listed in the Diagnostic and
Statistical Manual of Mental Disorders
(DSM-IV-TR) as a symptom of borderline
personality disorder and depressive
disorders.
Because of a delay on the gross and fine
motor skills, as well as how the patient
perceives things and events, the patient
is at great risk of physical injury.
Process Recording (Karl Angel B. Fabe, SN-SJIT)