Personal Data
Name
Sex
Age
Address
Civil Status
Birth date
Birthplace
Religion
Nationality
Date Admitted
Time Admitted
Admitted Doctor
Diagnosis
General data
Cranial Nerves
I.
II.
III.. so on and so on
Motor System:
Limbs
Trunk
5/5
5/5
5/5
5/5
Stance
Gait
Rombergo
Reflexes
J.J
B.J
S.J
T.J
Plantar
Sensational
Pain & Touch
Temperature
100
100
100
100
Vibration
JPS
Two point Descrimination
Chapter II
2
Inference
Rationale
Broad Opening
To establish openended
communication
Giving Information
Offering Self
To accommodate her
thoughts and giving a
free expression of
thoughts and feeling
Exploring
To have an idea on
her present illness
and help analyze her
situation
Recognition
To build confidence
and increase her
self-esteem
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.
was a presence of slight noise coming from other schools 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
Use Name
Help to orient
Marimar?
Rationale
Using a person's name
makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.
Illness and hospitalization
can be very disorienting for
patients.
P: Kran po!
N: Carl ako
P: Carl
N: Kumusta kana Marimar?
P: Okey lang p
N: Anung araw ngayun po
ate marimar?
P: Martes po.
N: Nag-almusal ka na?
P: Opo.. kumain ako ng
Tinapay, nagligo at
Nagtoothbrush
Broad Opening
To establish open-ended
communication
N: Galing, Masarap ba
yun?
P: Oo.. kani-kanina lang..
Accepting
To prevent negative
feedbacks and thoughts on
her mind
Exploring
N: Kalimutan mo na po un..
P: Medyo nakalimutan ko
na..
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.
Presenting Reality
To promote easy
understanding on the
problem
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.
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
Inference
Use Name
Help to orient
Marimar?
P: Kran po!
N: Carl ako
P: Carl
N: Kumusta kana Marimar?
P: Okey lang p
N: Anung araw ngayun po
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
pinag-usapan natin po?
P: Ah.. yung tungkol sa
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
autos ng nurse at doctor
dito.. nang sa ganun
makalabas ka.
P: okey po.
N: Eto na po pala ang huli
nating pagkikita..
magpakabait po kayo
dito ha? Tandaan mo
lagi yung mga itinuro
naming sayo araw-araw.
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Rationale
Using a person's name
makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.
Illness and hospitalization
can be very disorienting for
patients.
Broad Opening
To establish open-ended
communication
Exploring
Presenting Reality
To promote easy
understanding on the
problem
Chapter III
Music Appreciation and Interpretation Approach
A. Happy Songs
Black depression and anxiety
Red dominating behavior
Single Drawing represents selfish motives
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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
12
RANK
RATIONALE
Impaired Verbal
Communication related to
impaired cognitive abilities as
evidenced by loose association
of ideas
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