Foundation University COLLEGE OF NURSING Dumaguete City BEHAVIORAL ANALYSIS NURSING CARE MANAGEMENT (NCM 104)

Submitted to: Ms. Michelle B. Dales, RN Clinical instructor

Submitted by: Ms. Jhyne Christy Tubaing, SN Ms. Jennylyn R. Lim, SN

TABLE OF CONTENTS
I. II. III. IV. V. VI. VII. IX. X. XI. FU Mission, Vision and life purpose Objectives Acknowledgement Introduction Demographic profile Genogram Growth and Development Physical Assessment Predisposing and precipitating factors Anatomy and physiology -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

VIII. Psychiatric Assessment

XII. Review of related literature XIII. Process recording XIV. Psychopharmacology XV. Psychodynamics XVI. Nursing Theory XVII. Nursing Care Plan XVIII. Summary of Nursing Diagnosis XIX. Annotated Readings XX. Conclusion

XXI. Bibliography

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FOUNDATION UNIVERSITY COLLEGE OF NURSING Dumaguete City

VISION, MISSION AND LIFE PURPOSE

VISION:

Foundation University envisions itself as a progressive university that cultivates effective learning, generates creative ideas, responds to social needs, and offers equal opportunity to all.

MISSION:

In its quest for excellence in mind, body, and characteristics, and to the pursuit of truth and freedom, Foundation University commits: y y y y to develop in students a sound character and broad culture to prepare individual for definite career to imbue citizens with the spirit of universal brotherhood to advocate truth promotes justice and advance knowledge

LIFE PURPOSE:

The life purpose of Foundation University is to educate and develop individuals to become productive, creative, useful, and responsible citizens of society.

OBJECTIVES

Topic description:
This behavioral analysis deals with a mentally ill client who is suffering from depression. It also includes the analysis of her current manifestations, its relevance, and the medications for her.

Central Objectives:
At the end of this behavioral analysis, the learners shall gain adequate knowledge, develop appropriate skills and manifest desirable attitudes and values in the care of the client with depression.

Specific Objectives:
After the end of hours of case presentation, the learners shall:  Identify the demographic profile of the client,  Discuss and identify the developmental task of middle adult.  Trace the psychodynamics of depression.  Discuss the developmental milestone of the client,  Review the anatomy and physiology of Respiratory system, Integumentary System, Nuerologic system and musculoskeletal system  Enumerate the medical management used during the care of the client with corresponding rationale,  Enumerate the independent nursing interventions and their rationale during the care of client,  Evaluate the case presentation as a whole

ACKNOWLEDGEMENT
This behavioral analysis will not be possible without the supportive efforts of many people. First of all, we would like to thank the Lord for giving us a lot of opportunities and for everything that He has provided us with. He gave us countless blessings in order to let us know and feel His passion. Second, we would like to give our beloved parents, brothers, sisters and to our benefactors a big thanks you for your endless support and compassion. They never turned their backs on us. Third, we greatly honor our ever dearest and active Dean of the College of Nursing for motivating every student to fight and overcome the difficulties and trials that pass along each students way. Ever since our first year of stay here, Dean Nenita P. Tayko, never failed to share her experiences and to give us a few points to ponder. Fourth, we would like to give our heartfelt gratitude to the clinical coordinators sacrifices and efforts for allowing and every student to gain the necessary knowledge, skills and attitude so that they may become competent and responsible individuals in the future. On the other hand, we thank our clinical instructor Ms. Michelle B. Dales, BSN-RN for being a mentor and strict adviser because she taught us to work hard and to be flexible in many ways. And to our driver who work hard on waiting for us in every duty. Lastly, we thank our friends for giving us advises and love. Truly, they will always remain in our hearts and we will treasure every little thing and memories we shared together.

INTRODUCTION
Depression is a serious medical illness that involves the brain. It's more than just a feeling of being "down in the dumps" or "blue" for a few days. Depression may be described as feeling sad, blue, unhappy, or miserable. Most of us feel this way at one time or another for short periods. True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period of time. Depression often runs in families. This may due to your genes (inherited), learned behavior, or both. Even if your genes make you more likely to develop depression, a stressful or unhappy life event usually triggers the onset of a depressive episode. Depression may be brought on by; Alcohol or drug abuse, Childhood events like abuse or neglect, Chronic stress, Death of a friend or relative, Disappointment at home, work, or school (in teens, this may be breaking up with a boyfriend or girlfriend, failing a class, or parents divorcing), Drugs such as sedatives and high blood pressure medications, Medical conditions such as hypothyroidism (underactive thyroid), cancer, or hepatitis, Nutritional deficiencies (such as a lack of folate and omega-3 fatty acids), Overly negative thoughts about one's self and life, self blame, and ineffective social problem solving skills, Prolonged pain or having a major illness, Sleeping problems, Social isolation (common in the elderly) these are some other factors that triggers the onset depression to an individual. (Psychiatric metal health. 2nd edition, mood disorders)

DEMOGRAPHIC PROFILE
NAME: Nancy Jabier AGE: 37 y.o. SEX: Female CIVIL STATUS: single RELIGION: Roman Catholic BIRTHDATE: HOME ADDRESS: San Carlos City HISTORY OF PRESENT ILLNESS Patient claimed she experienced depression, low self- esteem, fatigue, not eating meals and feel hopelessness it is the reason Why she has been admitted to Talay rehabilitation center. GENERAL IMPRESSION: receive patient just woke up from afternoon sleep sitting on bed side, combing her curly black colored hair, conscious and coherent, oriented to time and date. With dry skin and visible rashes on arms, slouch gait arms are directed straightly downward palms directed backward fingers are spread. ADMITTING IMPRESSION: admitted this 37 years old female for the first time with following behavioral manifestation noted at home patient brought by city health nurse of San Carlos City: coherent oriented, with inappropriate behavior or complained claimed, Oral meds stated for further observation seen and examined at NOPH. DATE and TIME of ORIENATION: may 3, 2011 (1:30 pm) DATE and TIME of ADMISSION: November 26, 2010 (08:10 am) ROOM and BED #: Female ward ATTENDING PHYSICIAN: Dr. Arias

GENOGRAM

(Dri

83 y/o occasionally) W and A

80 y/o W and A

Ms. Nancy Javier 37 y.o.

36y/o

34 y/o

32 y/o

DEPRE IVE DI ORDER

LEGEND:

PATIENT ---- MALE -----FEMALE

GROWTH and DEVELOPMENT

Middle Adulthood: 35 to 55 or 65 Developmental task: Generativity vs. Self absorption or Stagnation Basic Strengths: Production and Care Erikson observed that middle-age is when person tend to be occupied with creative and meaningful work and with issues surrounding their family. Also, middle adulthood is when an individual can expect to "be in charge," the role of longer envied. The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when a person reach this stage he often fear inactivity and meaninglessness. As their children leave home, or their relationships or goals change, they may be faced with major life changesthe mid-life crisisand struggle with finding new meanings and purposes. If they don't get through this stage successfully, they can become self-absorbed and stagnate. Significant relationships are within the workplace, the community and the family.

Sigmund freuds theory of personality and development Genital Stage: develops sexual maturity and learns to establish satisfactory relationship with opposite sex. PIAGETS THEORY OF COGNITIVE DEVELOPMENT The way an individual learn and think that have roots similar to those of both Freud and Erickson and yet separate from each. Piaget defines four stages of cognitive development; within each stage are finer units or schemas. Each period is an advance over the previous one. To progress from one period to the next, a person recognizes his or her thinking processes. KOHLBERGS THEORY OF MORAL DEVELOPMENT Lawrence Kohlberg is a psychologist, studied the reasoning ability of an individual, and developed a theory on the way individual gain knowledge of right and wrong moral reasoning. Does right things only when obvious authority or set rules are present. Recognizing moral reasoning also helps determine whether individual can be depended on to carry out self-care activities such as administering their own medicines. Moral stages closely approximate cognitive stages of development, because individual must think abstractly before being able to understand hoe rules apply even when no one is there to enforce them.

Correlation to patient:

In our patients case she is still single at present, but what she usually shared to us was that she loves her family more than she love herself, she said she cant afford to see anyone of them being hurt by somebody else. Base on the data that we got from her during our therapeutic interview (working phase) in our everyday conversation she had never forgotten to mention memories mostly happy memories with her family typically the setting shes trying to emphasize was in their house where she described it to be just a small one that can accommodate all of them (six person) the only problem she had regarding her family relationship was with her brothers, she said shes furious with her brother for she has been physically battered by him. She did also shared about her life being a student, claimed that she was a silent type of person, all she wanted was to be alone, and she cant make any friends in school because she thinks that these people are just envied of her. She stated that she tries to apply for work when she ceased school due to financial problem she has been gone to distant places just to apply job but none of those accepted her, then she claimed that it did also contribute to her depressive disorder.

Psychiatric Assessment Checklists

OBSERVATION AS OF THE WORKING PHASE Check the manifestations/responses observed in your patient and write the other specific significant data on the column for comments COMMENTS

APPEARANCE AND PHYSICAL CONDITION

1. FACIAL EXPRESSION        Fatigue Fear Tension Happiness Indifference Sadness others  No manifestation of fatigue was observed on the patient during the course of communication and group therapy.  Patient was happy and smiling every time we visit her  There was no sign of tension or reluctance as patient interacted with student nurses and has communicated well.

2. POSTURE  Stand erect  Slouch  Drooping shoulders 

 Patient slouches the way she walks and sits.

3. PHYSICAL CLEANLINESS  Hair combed  Face washed

 The patient changes her clothes when we have interaction, but sometimes the next interaction she will not able to change her clothes and she smell bad. Every time we

    

Full bath body odor clothes change teeth brushed Environment

arrive at the facility, she is ready to interact or go about the day s activity... She also washes her own clothes.

4. MOVEMENTS  Inappropriate gestures or mannerisms  Slow  Moderate  Rapid  Restless 5. SKIN         Clean Clear Flushed Perspiring Scratched Blistered Dry Warm  The patient s movements were moderate to active at times as per observation during the working phase.

 No unusual skin ailments were observed as per interaction with the patient. But as we observe the skin of the patient is dry.

6. LEGS AND ANKLES  Swollen  Atrophied  Others  The patient doesn t have any complaints of pain or tenderness with regards to his ankles and legs. The patient s gait is normal.

7. COMPLAINTS OF PAIN  Specify

8. HABITS     Sleeping Drinking Smoking Elimination

 The patient has no complaints with rest, sleep and elimination pattern. Her rest period is regular with a minimum of 8-9 hours of sleep daily.

9. FOOD     Eats well Voracious Plucks on food Does not eat at all  The patient is not choosy when it comes to the food she eats.

EMOTIVE ASSESSMENT 1. CHARACTERISTICS OF AFFECT      Spontaneous Appropriate Flat Ambivalent Mood swings

2. PREDOMINANT AFFECTIVE

REACTION         Euphoric Resigned Anxious Overactive Depressed Withdrawn Resentful Irritable  The patients affect were appropriate all throughout the student nurse-patient interaction. He was also spontaneous in sharing personal experiences with student nurses.

3. APPROPRIATENESS OF AFFECT TO:  Speech  Behaviour  Immediate situation  Patient is very expressive.

4. REACTIONS TO BEING IN THE HOSPITAL     Treatment Medications Interviews Visitors  The patient s affect is in accordance to speech, behavior.

COGNITIVE ASSESSMENT

1. THOUGHT CONTENT      Flight of ideas Associated looseness Preoccupations Concerns Coherence

 The patient verbalized that she is the kind of person who can adapt well to any situation. She has adapted well and adjusted to his living condition in the institution. She misses her home for his parents have provided well all the comfort she needs during her stay in the institution.

2. THOUGHT DISTURBANCE        Delusions Hallucinations Obsessions Phobias Suicidal thoughts/ideas Ideas of reference Logical ways of thinking  Throughout all the interaction, the patient s line of thinking or thought content was coherent but inconsistent at times.

3. SENSORIUM  Degree of consciousness

 The patient is oriented to time, place, and person.

Physical assessment

POCEDURE
Observe the following: Physical development Behavior Mood

NORMAL FINDINGS

DEVIATIONS FROM NORMAL

Appears to be stated chronological age Cooperative attitude and behavior Mild anxiety or tension

Just appropriate for her age Manipulative behavior Pleasant mood, but when she started talking about her family background her facial expression shows sadness .

y y

y y

y y

Dress Gait

Dressed for occasion Erect posture, coordinated, smooth and steady gait

y y

Wear appropriate dress for occasion Kyphotic, slouch gait arms are directed straightly downward palms directed backward fingers are spread.

Body build
y

Bilateral, firm developed muscles

Appropriate size and height for her age. Tall woman

PREDISPOSING and PRECIPITATING FACTOR

Psychological factors Unresolved traumatic experiences, previous history of depression, Damage to body image, Fear of death, Frustration with memory loss, Difficulty adjusting to stressful or changing conditions and Substance use. Environmental factors Loneliness, isolation, retirement, Being unmarried, Recent bereavement, Lack of a supportive social network, Decreased mobility due to illness or loss of driving privileges Physical factors, including genetics Inherited tendencies toward depression, Co-occurring illness (e.g. stroke etc), cerebrovascular changes, B-12 deficiency, and Chronic or severe pain Personality characteristics Low self-esteem, Extreme dependency, and pessimism Medications Some pain medicines (eg codeine), Some drugs for high blood pressure (propanolol), Hormones (Oestrogen, progesterone, prednisone), Some heart medications (digoxin), Anticancer and immune suppressing agents (cyclosporin, tamoxifen), Some drugs for Parkinsons disease (levodopa), Some drugs for arthritis (indomethacin), Some tranquilizers/anti-anxiety drugs (diazepam), Alcohol Often health care workers will use a holistic approach, explicitly seeking to consider the biologic, psychologic and social predisposing and precipitating factors for the presentation.

ANATOMY AND PHYSIOLOGY OF AFFECTED SYSTEMS

1.) Nervous System 2.) Skeletal System 3.) Integumentary System

Anatomy and Physiology of the Brain

Introduction Brain, portion of the central nervous system contained within the skull. The brain is the control center for movement, sleep, hunger, thirst, and virtually every other vital activity necessary to survival. All human emotionsincluding love, hate, fear, anger, elation, and sadnessare controlled by the brain. It also receives and interprets the countless signals that are sent to it from other parts of the body and from the external environment. The brain makes us conscious, emotional, and intelligent. Anatomy The adult human brain is a 1.3-kg (3-lb) mass of pinkish-gray jellylike tissue made up of approximately 100 billion nerve cells, or neurons; neuroglia (supporting-tissue) cells; and vascular (blood-carrying) and other tissues. Between the brain and the craniumthe part of the skull that directly covers the brainare three protective membranes, or meninges. The outermost membrane, the dura mater, is the toughest and thickest. Below the dura mater is a middle membrane, called the arachnoid layer. The innermost membrane, the pia mater, consists mainly of small blood vessels and follows the contours of the surface of the brain. A clear liquid, the cerebrospinal fluid, bathes the entire brain and fills a series of four cavities, called ventricles, near the center of the brain. The cerebrospinal fluid protects the internal portion of the brain from varying pressures and transports chemical substances within the nervous system. From the outside, the brain appears as three distinct but connected parts: the cerebrum (the Latin word for brain)two large, almost symmetrical hemispheres; the cerebellum (little brain)two smaller hemispheres located at the back of the cerebrum; and the brain stema central core that gradually becomes the spinal cord, exiting the skull through an opening at its base called the foramen magnum. Two other major parts of the brain, the thalamus and the hypothalamus, lie in the midline above the brain stem underneath the cerebellum. The brain and the spinal cord together make up the central nervous system, which communicates with the rest of the body through the peripheral nervous system. The peripheral nervous system consists of 12 pairs of cranial nerves extending from the cerebrum and brain stem; a system of other nerves

branching throughout the body from the spinal cord; and the autonomic nervous system, which regulates vital functions not under conscious control, such as the activity of the heart muscle, smooth muscle (involuntary muscle found in the skin, blood vessels, and internal organs), and glands. A.Cerebrum Most high-level brain functions take place in the cerebrum. Its two large hemispheres make up approximately 85 percent of the brain's weight. The exterior surface of the cerebrum, the cerebral cortex, is a convoluted, or folded, grayish layer of cell bodies known as the gray matter. The gray matter covers an underlying mass of fibers called the white matter. The convolutions are made up of ridgelike bulges, known as gyri, separated by small grooves called sulci and larger grooves called fissures. Approximately twothirds of the cortical surface is hidden in the folds of the sulci. The extensive convolutions enable a very large surface area of brain cortexabout 1.5 m2 (16 ft2) in an adultto fit within the cranium. The pattern of these convolutions is similar, although not identical, in all humans. The two cerebral hemispheres are partially separated from each other by a deep fold known as the longitudinal fissure. Communication between the two hemispheres is through several concentrated bundles of axons, called commissures, the largest of which is the corpus callosum. Several major sulci divide the cortex into distinguishable regions. The central sulcus, or Rolandic fissure, runs from the middle of the top of each hemisphere downward, forward, and toward another major sulcus, the lateral (side), or Sylvian, sulcus. These and other sulci and gyri divide the cerebrum into five lobes: the frontal, parietal, temporal, and occipital lobes and the insula.

The frontal lobe is the largest of the five and consists of all the cortex in front of the central sulcus. Broca's area, a part of the cortex related to speech, is located in the frontal lobe. The parietal lobe consists of the cortex behind the central sulcus to a sulcus near the back of the cerebrum known as the parieto-occipital sulcus. The parieto-occipital sulcus, in turn, forms the front border of the occipital lobe, which is the rearmost part of the cerebrum. The temporal lobe is to the side of and below the lateral sulcus. Wernicke's area, a part of the cortex related to the understanding of language, is located in the temporal lobe. The insula lies deep within the folds of the lateral sulcus. The cerebrum receives information from all the sense organs and sends motor commands (signals that result in activity in the muscles or glands) to other parts of the brain and the rest of the body. Motor commands are transmitted by the motor cortex, a strip of cerebral cortex extending from side to side across the top of the cerebrum just in front of the central sulcus. The sensory cortex, a parallel strip of cerebral cortex just in back of the central sulcus, receives input from the sense organs. Many other areas of the cerebral cortex have also been mapped according to their specific functions, such as vision, hearing, speech, emotions, language, and other aspects of perceiving, thinking, and remembering. Cortical regions known as associative cortex are responsible for integrating multiple inputs, processing the information, and carrying out complex responses.

B.Cerebellum The cerebellum coordinates body movements. Located at the lower back of the brain beneath the occipital lobes, the cerebellum is divided into two lateral (side-by-side) lobes connected by a fingerlike bundle of white fibers called the vermis. The outer layer, or cortex, of the cerebellum consists of fine folds called folia. As in the cerebrum, the outer layer of cortical gray matter surrounds a deeper layer of white matter and nuclei (groups of nerve cells). Three fiber bundles called cerebellar peduncles connect the cerebellum to the three parts of the brain stem the midbrain, the pons, and the medulla oblongata. The cerebellum coordinates voluntary movements by fine-tuning commands from the motor cortex in the cerebrum. The cerebellum also maintains posture and balance by controlling muscle tone and sensing the position of the limbs. All motor activity, from hitting a baseball to fingering a violin, depends on the cerebellum. C.Thalamus and Hypothalamus

The thalamus and the hypothalamus lie underneath the cerebrum and connect it to the brain stem. The thalamus consists of two rounded masses of gray tissue lying within the middle of the brain, between the two cerebral hemispheres. The thalamus is the main relay station for incoming sensory signals to the cerebral cortex and for outgoing motor signals from it. All sensory input to the brain, except that of the sense of smell, connects to individual nuclei of the thalamus. The hypothalamus lies beneath the thalamus on the midline at the base of the brain. It regulates or is involved directly in the control of many of the body's vital drives and activities, such as eating, drinking, temperature regulation, sleep, emotional behavior, and sexual activity. It also controls the function of internal body organs by means of the autonomic nervous system, interacts closely with the pituitary gland, and helps coordinate activities of the brain stem.

D.Brain Stem The brain stem is evolutionarily the most primitive part of the brain and is responsible for sustaining the basic functions of life, such as breathing and blood pressure. It includes three main structures lying between and below the two cerebral hemispheresthe midbrain, pons, and medulla oblongata. D1.) Midbrain The topmost structure of the brain stem is the midbrain. It contains major relay stations for neurons transmitting signals to the cerebral cortex, as well as many reflex centerspathways carrying sensory (input) information and motor (output) commands. Relay and reflex centers for visual and auditory (hearing) functions are located in the top portion of the midbrain. A pair of nuclei called the superior colliculus control reflex actions of the eye, such as blinking, opening and closing the pupil, and focusing the lens. A second pair of nuclei, called the inferior colliculus, control auditory reflexes, such as adjusting the ear to the volume of sound. At the bottom of the midbrain are reflex and relay centers relating to pain, temperature, and touch, as well as several regions associated with the control of movement, such as the red nucleus and the substantia nigra. D2.) Pons

Continuous with and below the midbrain and directly in front of the cerebellum is a prominent bulge in the brain stem called the pons. The pons consists of large bundles of nerve fibers that connect the two halves of the cerebellum and also connect each side of the cerebellum with the opposite-side cerebral hemisphere. The pons serves mainly as a relay station linking the cerebral cortex and the medulla oblongata. D3.) Medulla Oblongata The long, stalklike lowermost portion of the brain stem is called the medulla oblongata. At the top, it is continuous with the pons and the midbrain; at the bottom, it makes a gradual transition into the spinal cord at the foramen magnum. Sensory and motor nerve fibers connecting the brain and the rest of the body cross over to the opposite side as they pass through the medulla. Thus, the left half of the brain communicates with the right half of the body, and the right half of the brain with the left half of the body. D4.) Reticular Formation Running up the brain stem from the medulla oblongata through the pons and the midbrain is a netlike formation of nuclei known as the reticular formation. The reticular formation controls respiration, cardiovascular function (see Heart), digestion, levels of alertness, and patterns of sleep. It also determines which parts of the constant flow of sensory information into the body are received by the cerebrum. E. Brain Cells There are two main types of brain cells: neurons and neuroglia. Neurons are responsible for the transmission and analysis of all electrochemical communication within the brain and other parts of the nervous system. Each neuron is composed of a cell body called a soma, a major fiber called an axon, and a system of branches called dendrites. Axons, also called nerve fibers, convey electrical signals away from the soma and can be up to 1 m (3.3 ft) in length. Most axons are covered with a protective sheath of myelin, a substance made of fats and protein, which insulates the axon. Myelinated axons conduct neuronal signals faster than do unmyelinated axons. Dendrites convey electrical signals toward the soma, are shorter than axons, and are usually multiple and branching. Neuroglial cells are twice as numerous as neurons and account for half of the brain's weight. Neuroglia (from glia, Greek for glue) provide structural support to the neurons. Neuroglial cells also form myelin, guide developing neurons, take up chemicals involved in cell-to-cell communication, and contribute to the maintenance of the environment around neurons. F. Cranial Nerves

Twelve pairs of cranial nerves arise symmetrically from the base of the brain and are numbered, from front to back, in the order in which they arise. They connect mainly with structures of the head and neck, such as the eyes, ears, nose, mouth, tongue, and throat. Some are motor nerves, controlling muscle movement; some are sensory nerves, conveying information from the sense organs; and others contain fibers for both sensory and motor impulses. The first and second pairs of cranial nervesthe olfactory (smell) nerve and the optic (vision) nervecarry sensory information from the nose and eyes, respectively, to the undersurface of the cerebral hemispheres. The other ten pairs of cranial nerves originate in or end in the brain stem. How the brain works: The brain functions by complex neuronal, or nerve cell, circuits (see Neurophysiology). Communication between neurons is both electrical and chemical and always travels from the dendrites of a neuron, through its soma, and out its axon to the dendrites of another neuron. Dendrites of one neuron receive signals from the axons of other neurons through chemicals known as neurotransmitters. The neurotransmitters set off electrical charges in the dendrites, which then carry the signals electrochemically to the soma. The soma integrates the information, which is then transmitted electrochemically down the axon to its tip. At the tip of the axon, small, bubblelike structures called vesicles release neurotransmitters that carry the signal across the synapse, or gap, between two neurons. There are many types of neurotransmitters, including norepinephrine, dopamine, and serotonin. Neurotransmitters can be excitatory (that is, they excite an electrochemical response in the dendrite receptors) or inhibitory (they block the response of the dendrite receptors). One neuron may communicate with thousands of other neurons, and many thousands of neurons are involved with even the simplest behavior. It is believed that these connections and their efficiency can be modified, or altered, by experience.

Scientists have used two primary approaches to studying how the brain works. One approach is to study brain function after parts of the brain have been damaged. Functions that disappear or that are no longer normal after injury to specific regions of the brain can often be associated with the damaged areas. The second approach is to study the response of the brain to direct stimulation or to stimulation of various sense organs. Neurons are grouped by function into collections of cells called nuclei. These nuclei are connected to form sensory, motor, and other systems. Scientists can study the function of somatosensory (pain and touch), motor, olfactory, visual, auditory, language, and other systems by measuring the physiological (physical and chemical) changes that occur in the brain when these senses are activated. For example, electroencephalography (EEG) measures the electrical activity of specific groups of neurons through electrodes attached to the surface of the skull. Electrodes inserted directly into the brain can give readings of individual neurons. Changes in blood flow, glucose (sugar), or oxygen consumption in groups of active cells can also be mapped. Although the brain appears symmetrical, how it functions is not. Each hemisphere is specialized and dominates the other in certain functions. Research has shown that hemispheric dominance is related to whether a person is predominantly right-handed or left-handed (see Handedness). In most right-handed people, the left hemisphere processes arithmetic, language, and speech. The right hemisphere interprets music, complex imagery, and spatial relationships and recognizes and expresses emotion. In left-handed people, the pattern of brain organization is more variable. Hemispheric specialization has traditionally been studied in people who have sustained damage to the connections between the two hemispheres, as may occur with stroke, an interruption of blood flow to an area of the brain that causes the death of nerve cells in that area. The division of functions between the two hemispheres has also been studied in people who have had to have the connection between the two hemispheres surgically cut in order to control severe epilepsy, a neurological disease characterized by convulsions and loss of consciousness. A.Vision The visual system of humans is one of the most advanced sensory systems in the body (see Vision). More information is conveyed visually than by any other means. In addition to the structures of the eye itself, several cortical regionscollectively called primary visual and visual associative cortexas well as the midbrain are involved in the visual system. Conscious processing of visual input occurs in the primary visual cortex, but reflexivethat is, immediate and unconsciousresponses occur at the superior colliculus in the midbrain. Associative cortical regions specialized regions that can associate, or integrate, multiple inputsin the parietal and frontal lobes along with parts of the temporal lobe are also involved in the processing of visual information and the establishment of visual memories. B.Language

Language involves specialized cortical regions in a complex interaction that allows the brain to comprehend and communicate abstract ideas. The motor cortex initiates impulses that travel through the brain stem to produce audible sounds. Neighboring regions of motor cortex, called the supplemental motor cortex, are involved in sequencing and coordinating sounds. Broca's area of the frontal lobe is responsible for the sequencing of language elements for output. The comprehension of language is dependent upon Wernicke's area of the temporal lobe. Other cortical circuits connect these areas. C. Memory Memory is usually considered a diffusely stored associative processthat is, it puts together information from many different sources. Although research has failed to identify specific sites in the brain as locations of individual memories, certain brain areas are critical for memory to function. Immediate recallthe ability to repeat short series of words or numbers immediately after hearing themis thought to be located in the auditory associative cortex. Short-term memorythe ability to retain a limited amount of information for up to an houris located in the deep temporal lobe. Long-term memory probably involves exchanges between the medial temporal lobe, various cortical regions, and the midbrain. D.Autonomic Brain System The autonomic nervous system regulates the life support systems of the body reflexivelythat is, without conscious direction. It automatically controls the muscles of the heart, digestive system, and lungs; certain glands; and homeostasisthat is, the equilibrium of the internal environment of the body (see Physiology). The autonomic nervous system itself is controlled by nerve centers in the spinal cord and brain stem and is fine-tuned by regions higher in the brain, such as the midbrain and cortex. Reactions such as blushing indicate that cognitive, or thinking, centers of the brain are also involved in autonomic responses.

MUSCULOSKELETAL SYSTEM
Skeletal System serves many important functions; it provides the shape and form for our bodies in addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing minerals. Functions Its 206 bones form a rigid framework to which the softer tissues and organs of the body are attached. Vital organs are protected by the skeletal system. The brain is protected by the surrounding skull as the heart and lungs are encased by the sternum and rib cage. Bodily movement is carried out by the interaction of the muscular and skeletal systems. For this reason, they are often grouped together as the musculo-skeletal system. Muscles are connected to bones by tendons. Bones are connected to each other by ligaments. Where bones meet one another is typically called a joint. Muscles which cause movement of a joint are connected to two different bones and contract to pull them together. An example would be the contraction of the biceps and a relaxation of the triceps. This produces a bend at the elbow. The contraction of the triceps and relaxation of the biceps produces the effect of straightening the arm. Blood cells are produced by the marrow located in some bones. An average of 2.6 million red blood cells are produced each second by the bone marrow to replace those worn out and destroyed by the liver.

supply of these minerals within the blood is low, it will be withdrawn from the bones to replenish the supply. Divisions of the Skeleton The human skeleton is divided into two distinct parts: The axial skeleton consists of bones that form the axis of the body and support and protect the organs of the head, neck, and trunk. The Skull the Sternum the Ribs the Vertebral Column The appendicular skeleton is composed of bones that anchor the appendages to the axial skeleton. The Upper Extremities the Lower Extremities the Shoulder Girdle the Pelvic Girdle--(the sacrum and coccyx are considered part of the vertebral column) Types of Bone The bones of the body fall into four general categories: long bones, short bones, flat bones, and irregular bones. Long bones are longer than they are wide and work as levers. The bones of the upper and lower extremities (ex. humerus, tibia, femur, ulna, metacarpals, etc.) are of this type. Short bones are short, cube-shaped, and found in the wrists and ankles. Flat bones have broad surfaces for protection of organs and attachment of muscles (ex. ribs, cranial bones, bones of shoulder girdle). Irregular bones are all others that do not fall into the previous categories. They have varied shapes, sizes, and surfaces features and include the bones of the vertebrae and a few in the skull. Bone Composition Bones are composed of tissue that may take one of two forms. Compact, or dense bone, and spongy, or cancellous, bone. Most bones contain both types. Compact bone is dense, hard, and forms the protective exterior portion of all bones. Spongy bone is inside the compact bone and is very

porous (full of tiny holes). Spongy bone occurs in most bones. The bone tissue is composed of several types of bone cells embedded in a web of inorganic salts (mostly calcium and phosphorus) to give the bone strength, and collagenous fibers and ground substance to give the bone flexibility Joints A joint, or articulation, is the place where two bones come together. There are three types of joints classified by the amount of movement they allow: immovable, slightly movable, and freely movable. Immovable joints are synarthroses. In this type of joint, the bones are in very close contact and are separated only by a thin layer of fibrous connective tissue. An example of a synarthrosis is the suture in the skull between skull bones. Slightly movable joints are called amphiarthroses. This type of joint is characterized by bones that are connected by hyaline cartilage (fibro cartilage). The ribs that connect to the sternum are an example of an amphiarthrosis joint. Most of the joints in the adult human body are freely movable joints. This type of joint is called a diarthrosis joint. There are six types of diarthroses joints. These are: Ball-and-Socket: The ball-shaped end of one bone fits into a cup shaped socket on the other bone allowing the widest range of motion including rotation. Examples include the shoulder and hip. Condyloid: Oval shaped condyle fits into elliptical cavity of another allowing angular motion but not rotation. This occurs between the metacarpals (bones in the palm of the hand) and phalanges (fingers) and between the metatarsals (foot bones excluding heel) and phalanges (toes). Saddle: This type of joint occurs when the touching surfaces of two bones have both concave and convex regions with the shapes of the two bones complementing one other and allowing a wide range of movement. The only saddle joint in the body is in the thumb. Pivot: Rounded or conical surfaces of one bone fit into a ring of one or tendon allowing rotation. An example is the joint between the axis and atlas in the neck. Hinge: A convex projection on one bone fits into a concave depression in another permitting only flexion and extension as in the elbow joints.

Gliding: Flat or slightly flat surfaces move against each other allowing sliding or twisting without any circular movement. This happens in the carpals in the wrist and the tarsals in the ankle. The Skull The skull is the bony framework of the head. It is comprised of the eight cranial and fourteen facial bones. Cranial Bones The cranial bones makeup the protective frame of bone around the brain. The cranial bones are:
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The frontal forms part of the cranial cavity as well as the forehead, the brow ridges and the nasal cavity. The left and right parietal forms much of the superior and lateral portions of the cranium. The left and right temporal form the lateral walls of the cranium as well as housing the external ear. The occipital forms the posterior and inferior portions of the cranium. Many neck muscles attach here as this is the point of articulation with the neck. The sphenoid forms part of the eye orbit and helps to form the floor of the cranium. The ethmoid forms the medial portions of the orbits and the roof of the nasal cavity.

The joints between bones of the skull are immovable and called sutures. The parietal bones are joined by the sagittal suture. Where the parietal bones meet the frontal is referred to as the coronal suture. The parietals and the occipital meet at the lambdoidal suture. The suture between the parietals and the temporal bone is referred to as the squamous suture. These sites are the common location of fontanelles or "soft spots" on a babys head. Facial Bones The facial bones makeup the upper and lower jaw and other facial structures. The facial bones are:
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The mandible is the lower jawbone. It articulates with the temporal bones at the temporomandibular joints. This forms the only freely moveable joint in the head. It provides the chewing motion.

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The left and right maxilla are the upper jaw bones. They form part of the nose, orbits, and roof of the mouth. The left and right palatine form a portion of the nasal cavity and the posterior portion of the roof of the mouth. The left and right zygomatic are the cheek bones. They form portions of the orbits as well. The left and right nasal form the superior portion of the bridge of the nose. The left and right lacrimal help to form the orbits. The vomer forms part of the nasal septum (the divider between the nostrils).

The left and right inferior turbinate forms the lateral walls of the nose and increase the surface area of the nasal cavity. The Sternum The sternum is a flat, dagger shaped bone located in the middle of the chest. Along with the ribs, the sternum forms the rib cage that protects the heart, lungs, and major blood vessels from damage. The sternum is composed of three parts: The manubrim, also called the "handle", is located at the top of the sternum and moves slightly. It is connected to the first two ribs. The body, also called the "blade" or the "gladiolus", is located in the middle of the sternum and connects the third to seventh ribs directly and the eighth through tenth ribs indirectly.
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The mandible is the lower jawbone. It articulates with the temporal bones at the temporomandibular joints. This forms the only freely moveable joint in the head. It provides the chewing motion. The left and right maxilla are the upper jaw bones. They form part of the nose, orbits, and roof of the mouth. The left and right palatine form a portion of the nasal cavity and the posterior portion of the roof of the mouth. The left and right zygomatic are the cheek bones. They form portions of the orbits as well. The left and right nasal form the superior portion of the bridge of the nose. The left and right lacrimal help to form the orbits. The vomer forms part of the nasal septum (the divider between the nostrils).

The left and right inferior turbinate forms the lateral walls of the nose and increase the surface area of the nasal cavity.

The Sternum The sternum is a flat, dagger shaped bone located in the middle of the chest. Along with the ribs, the sternum forms the rib cage that protects the heart, lungs, and major blood vessels from damage. The sternum is composed of three parts: The manubrim, also called the "handle", is located at the top of the sternum and moves slightly. It is connected to the first two ribs. The body, also called the "blade" or the "gladiolus", is located in the middle of the sternum and connects the third to seventh ribs directly and the eighth through tenth ribs indirectly. The ribs serve several important purposes. They protect the heart and lungs from injuries and shocks that might damage them. Ribs also protect parts of the stomach, spleen, and kidneys. The ribs help you to breathe. As you inhale, the muscles in between the ribs lift the rib cage up, allowing the lungs to expand. When you exhale, the rib cage moves down again, squeezing the air out of your lungs. The Vertebral Column The vertebral column (also called the backbone, spine, or spinal column) consists of a series of 33 irregularly shaped bones, called vertebrae. These 33 bones are divided into five categories depending on where they are located in the backbone. The first seven vertebrae are called the cervical vertebrae. Located at the top of the spinal column, these bones form a flexible framework for the neck and support the head. The first cervical vertebrae is called the atlas and the second is called the axis. The atlas' shape allows the head to nod "yes" and the axis' shape allows the head to shake "no". The next twelve vertebrae are called the thoracic vertebrae. These bones move with the ribs to form the rear anchor of the rib cage. Thoracic vertebrae are larger than cervical vertebrae and increase in size from top to bottom. After the thoracic vertebrae, come the lumbar vertebrae. These five bones are the largest vertebrae in the spinal column. These vertebrae support most of the body's weight and are attached to many of the back muscles.

The sacrum is a triangular bone located just below the lumbar vertebrae. It consists of four or five sacral vertebrae in a child,which become fused into a single bone after age 26. The sacrum forms the back wall of the pelvic girdle and moves with it. The bottom of the spinal column is called the coccyx or tailbone. It consists of 3-5 bones that are fused together in an adult. Many muscles connect to the coccyx. These bones compose the vertebral column, resulting in a total of 26 movable parts in an adult. In between the vertebrae are intervertebral discs made of fibrous cartilage that act as shock absorbers and allow the back to move. As a person ages, these discs compress and shrink, resulting in a distinct loss of height (generally between 0.5 and 2.0cm) between the ages of 50 and 55. When looked at from the side, the spine forms four curves. These curves are called the cervical, thoracic, lumbar, and pelvic curves. The cervical curve is located at the top of the spine and is composed of cervical vertebrae. Next come the thoracic and lumbar curves composed of thoracic and lumbar vertebrae respectively. The final curve called the pelvic or sacral curve is formed by the sacrum and coccyx. These curves allow human beings to stand upright and help to maintain the balance of the upper body. The cervical and lumbar curves are not present in an infant. The cervical curves forms around the age of 3 months when an infant begins to hold its head up and the lumbar curve develops when a child begins to walk. In addition to allowing humans to stand upright and maintain their balance, the vertebral column serves several other important functions. It helps to support the head and arms, while permitting freedom of movement. It also provides attachment for many muscles, the ribs, and some of the organs and protects the spinal cord, which controls most bodily functions. The Upper Extremities The upper extremity consists of three parts: the arm, the forearm, and the hand. The Arm The arm, or brachium, is technically only the region between the shoulder and elbow. It consists of a single long bone called the humerus. The humerus is the longest bone in the upper extremity. The top, or head, is large, smooth, and rounded and fits into the scapula in the shoulder. On the bottom of the humerus, are two depressions where the humerus connects to the ulna and radius of the forearm. The radius is connected on the side away from the body (lateral side) and the ulna is connected on the side towards the body (medial side) when standing in the anatomical position.

Together, the humerus and the ulna make up the elbow. The bottom of the humerus protects the ulnar nerve and is commonly known as the "funny bone" because striking the elbow on a hard surface stimulates the ulnar nerve and produces a tingling sensation. The Forearm The forearm is the region between the elbow and the wrist. It is formed by the radius on the lateral side and the ulna on the medial side when the forearm is viewed in the anatomical position. The ulna is longer than the radius and connected more firmly to the humerus. The radius, however, contributes more to the movement of the wrist and hand than the ulna. When the hand is turned over so that the palm is facing downwards, the radius crosses over the ulna. The top of each bone connects to the humerus of the arm and the bottom of each connects to the bones of the hand. The Hand The hand consists of three parts (the wrist, palm, and five fingers) and 27 bones. The wrist, or carpus, consists of 8 small bones called the carpal bones that are tightly bound by ligaments. These bone are arranged in two rows of four bones each. The top row (the row closest to the forearm) from the lateral (thumb) side to the medial side contains the scaphoid, lunate, triquetral, and pisiform bones. The second row from lateral to medial contains the trapezium, trapezoid, capitate, and hamate. The scaphoid and lunate connect to the bottom of the radius. The palm or metacarpus consists of five metacarpal bones, one aligned with each of the fingers. The metacarpal bones are not named but are numbered I to V starting with the thumb. The bases of the metacarpal bones are connected to the wrist bones and the heads are connected to the bones of the fingers. The heads of the metacarpals form the knuckles of a clenched fist. The fingers are made up of 14 bones called phalanges. A single finger bone is called a phalanx. The phalanges are arranged in three rows. The first row (the closest to the metacarpals) is called the proximal row, the second row is the middle row, and the farthest row is called the distal row. Each finger has a proximal phalanx, a middle phalanx, and a distal phalanx, except the thumb (also called the pollex) which does not have a middle phalanx. The digits are also numbered I to V starting from the thumb. The Lower Extremities The lower extremity is composed of the bones of the thigh, leg, foot, and the patella (commonly known as the kneecap).

The Thigh The thigh is the region between the hip and the knee and is composed of a single bone called the femur or thighbone. The femur is the longest, largest and strongest bone in the body. The Femur The Leg The leg is technically only the region from the knee to the ankle. It is formed by the fibula on side away from the body (lateral side) and the tibia, also called the shin bone, on the side nearest the body (medial side). The tibia connects to the femur to form the knee joint and T Femur and Patella

with the talus, a foot bone, to allow the ankle to flex and extend. The tibia is larger than the fibula because it bears most of the weight, while the fibula serves as an area for muscle attachment. The Femur and Patella The Foot The foot, or pes, contains the 26 bones of the ankle, instep, and the five toes. The ankle, or tarsus, is composed of the 7 tarsal bones which correspond to the carpals in the wrist. The largest tarsal bone is called the calcaneus or heel bone. The talus rests on top of the calcaneus and is connected to the tibia. Directly in front of the talus is the navicular bone. The remaining bones from medial to lateral are the medial, intermediate, the lateral cuneiform bones, and the cuboid bone. The metatarsal and phalanges bones of the foot are similar in number and position to the metacarpal and phalanges bones of the hand. The five metatarsal bones are numbered I to V starting on the medial side with the big toe. The first metatarsal bone is larger than the others because it plays a major role in supporting the body's weight. The 14 phalanges of the foot, as with the hand, are arranged in a proximal row, a middle row, and a distal row, with the big toe, or hallux, having only a proximal and distal phalanx. The foot's two arches are formed by the structure and arrangement of the bones and are maintained by tendons and ligaments. The arches give when weight is placed on the foot and spring back when the weight is lifted off of the foot. The arches may fall due to a weakening of the ligaments and tendons in the foot.

The Patella The patella or kneecap is a large, triangular sesamoid bone between the femur and the tibia. It is formed in response to the strain in the tendon that forms the knee. The patella protects the knee joint and strengthens the tendon that forms the knee. The bones of the lower extremities are the heaviest, largest, and strongest bones in the body because they must bear the entire weight of the body when a person is standing in the upright position. The Shoulder Girdle The Shoulder Girdle, also called the Pectoral Girdle, is composed of four bones: two clavicles and two scapulae . The clavicle, commonly called the collarbone, is a slender S-shaped bone that connects the upper arm to the trunk of the body and holds the shoulder joint away from the body to allow for greater freedom of movement. One end of the clavicle is connected to the sternum and one end is connected to the scapula. Thescapula is a large, triangular, flat bone on the back side of the rib cage commonly called the shoulder blade. It overlays the second through seventh rib and serves as an attachment for several muscles. It has a shallow depression called the glenoid cavity that the head of the humerus (upper arm bone) fits into. Usually, a "girdle" refers to something that encircles or is a complete ring. However, the shoulder girdle is an incomplete ring. In the front, the clavicles are separated by the sternum. In the back, there is a gap between the two scapulae. The primary function of the pectoral girdle is to provide an attachment point for the numerous muscles that allow the shoulder and elbow joints to move. It also provides the connection between the upper extremities (the arms) and the axial skeleton. The Pelvic Girdle The Pelvic Girdle, also called the hip girdle, is composed to two coxal (hip) bones. The coxal bones are also called the ossa coxae or innominate bones. During childhood, each coxal bone consists of three separate parts: the ilium (denoted in purple above), the ischium (denoted in red above),

and the pubis (denoted in blue above). In an adult, these three bones are firmly fused into a single bone. In the picture above, the coxal bone on the left side has been divided into its component pieces while the right side has been preserved. In the back, these two bones meet on either side of the sacrum. In the front, they are connected by a muscle called the pubic symphysis (denoted in green above). The pelvic girdle serves several important functions in the body. It supports the weight of the body from the vertebral column. It also protects and supports the lower organs, including the urinary bladder, the reproductive organs, and the developing fetus in a pregnant woman. The pelvic girdle differs between men and woman. In a man, the pelvis is more massive and the iliac crests are closer together. In a woman, the pelvis is more delicate and the iliac crests are farther apart. These differences reflect the woman's role in pregnancy and delivery of children. When a child is born, it must pass through its mother's pelvis. If the opening is too small, a cesarean section may be necessary. Bone Cells There are five main types of bone cells in bone tissue. Osteogenic cells respond to traumas, such as fractures, by giving rise to bone-forming cells and bone-destroying cells. Osteoblasts (bone-forming cells) synthesize and secrete unmineralized ground substance and are found in areas of high metabolism within the bone. Osteocytes are mature bone cells made from osteoblasts that have made bone tissue around themselves. These cells maintain healthy bone tissue by secreting enzymes and controlling the bone mineral content; they also control the calcium release from the bone tissue to the blood. Osteoclasts are large cells that break down bone tissue. They are very important to bone growth, healing, and remodeling. The last type of cells are bone-lining cells. These are made from osteoblasts along the surface of most bones in an adult. Bone-lining cells are thought to regulate the movement of calcium and phosphate into and out of the bone.

A.The skull - is the bone of your head. Itprotects the brain and other sensoryorgans from harm. It is one of thestrongest bones in your body. The skull isnot a single bone; it is composed of 26 bones fused together to protect the structure of the head.. B.Vertebrae -The vertebrae are small but thick bones that comprise the spine or thebackbone. The structure of the vertebrae allows a greater range of motion to the trunk of the body. The vertebrae protect the spinal cord. C. Ribs- Twelve pairs of ribs are attached to the sternum or breastplate to form the ribcage. The ribcage protects the vital organs of the body such as the heart,lungs, and liver. D. Pelvis - is made up of several thick and wide bones that protect the organs of the reproductive and urinary systems. The structure of t he pelvis

greatly affects the outcome of a pregnancy. Wider pelvises in women allow the passage of the baby at birth. E. Humerus - The humerus is the bone of the upperarm. The humerus makes arm movements possible. F. Femur - The femur is the bone of the upper leg.It is the longest bone in the body and it greatly contributes to your height. G. Phalanges - The phalanges are the bones of It supports the clavicle, articulates directly with the first seven pairs of ribs and comprises the manubrium, the gladiolus (body) and the xiphoid process H. Scapula -is the technical name for the shoulder blade. It is a flat, triangular bone that lies over the back of the upper ribs. The rear surface can be felt of the arm, neck, chest and back and aids in the movements of the arm and shoulder. It is well padded with muscle so that great force is required to fracture it. I. The Patella The patella or kneecap is a large, triangular sesamoid bone between the femur and the tibia. It is formed in response to the strain in the tendon that forms the knee. The patella protects the knee joint and strengthens the tendon that forms the knee.The bones of the lower extremities are the heaviest, largest, and strongest bones in the body because they must bear the entire weight of the body when a person is standing in the upright positionMuscle Cell Types There are three types of muscle tissue 1. skeletal (or voluntary/striated) muscle, the most abundant tissue in the human body, producing movement. Each skeletal-muscle fiber is roughly cylindrical, contains many nuclei, and is crossed by alternating light and dark bands called striations. Fibers bind together, via connective tissue, into bundles; and these bundles, in turn, bind together to form muscles. Thus, skeletal muscles are composite structures composed of many muscle fibers, nerves, blood vessels, and connective tissue. Skeletal muscles are controlled by the somatic nervous system (SNS). 2. smooth (or visceral) muscle, forming the muscle layers in the walls of the digestive tract, bladder, various ducts, arteries and veins, and other internal organs. Smooth- muscle cells are elongated and thin, not striated, have only one nucleus, and interlace to form sheets rather than bundles of muscles. Smooth muscle is controlled by the autonomic nervous system (ANS). 3. cardiac (or heart) muscle, a cross between the smooth and striated muscles, comprising the heart tissue. Like smooth muscle, it is innervated by the autonomic nervous system (ANS). Musculoskeletal System The musculoskeletal system consists of the skeletal system -- bones and joints (union of two or more bones) -- and the skeletal muscle system (voluntary or striated muscles). These two systems work together to provide basic functions that are essential to life, including:
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Protection: protects the brain and internal organs

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Support: maintains upright posture Blood cell formation: hematopoiesis Mineral homeostasis Storage: stores fat and minerals. Leverage: A lever is a simple machine that magnifies speed of movement or force. The levers are mainly the long bones of the body and the axes are the joints where the bones meet.

Tissues There are 5 basic tissues comprising the musculoskeletal system: 1. 2. 3. 4. bones, ligaments (attaching bone to bone) cartilage (protective gel-like subtance lining the joints and intervertebral discs), skeletal muscles, and tendons (attaching muscle to bone).

Each of these contains various combinations of 4 connective tissue building blocks:

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fibroblasts - the "mother" cell, producing the other 3 connective tissue components. collagen - the principal protein manufactured by the fibroblast. Organized into various configurations, these long, thin fibers intertwine to form very strong fibers which do NOT stretch. elastic fibers - highly elastic fibers, unlike collagen, particularly abundant in the walls of arteries. proteoglycans - the "ground substance," or "matrix," in which fibroblasts, collagen, and elastic fibers reside.

How We Move Skeletal muscles, attached to bone by tendons, produce movement by bending the skeleton at movable joints. The connecting tendon closest to the

body or head is called the proximal attachment: this is termed the origin of the muscle. The other end, the distal attachment, is called the insertion. During contraction, the origin remains stationary and the insertion moves. The force producing the bending is always exerted as a pull by contraction, thus making the muscle shorter: Muscles cannot actively push. Reversing the direction in which a joint bends is produced by contracting a different set of muscles. For example, when one group of muscles contracts, an antagonistic group stretches, exerting an opposing pull, ready to reverse the direction of movement. The contracting unit is the muscle fiber. Muscle fibers consist of two main protein strands - actin and myosin. Where the strands overlap, the fiber appears dark. Where they do not overlap, the fiber appears light. These alternating bands of light and dark give skeletal muscle its characterisitc striated appearance. The trigger which starts contraction comes from the motor nerve attached to each muscle fiber at the motor end plate.

Acetylcholine is released at the motor end plate when the electrical impulse reaches the muscle fiber. As it binds to receptors on the surface of the muscle cells, it causes the electrical impulse to be transmitted in both directions along the fiber, activating the actin and myosin strands. The strands slide past each other to flex, or to shorten, the fiber, thus producing contraction. Muscles by Function Each muscle has its own special name. Muscles, however, are also described by their function. Muscles that bend a limb are flexors;

those which straighten a limb are extensors (e.g. elbow flexors and elbow extensors.) Muscles which move a limb to the side, away from the body, are abductors; those which move a limb sideways toward the body are adductors (e.g. hip abductors and hip adductors.) Other functional groups are elevators, depressors, rotators, doriflexors, planar flexors, and palmar flexors.

What Are the Bones and What Do They Do? The human skeleton has 206 bones. Our bones begin to develop before birth. When the skeleton first forms, it is made of flexible cartilage, but within a few weeks it begins the process of ossification (pronounced: ah-suh-fuh-kay-shun). Ossification is when the cartilage is replaced by hard deposits of calcium phosphate and stretchy collagen, the two main components of bone. It takes about 20 years for this process to be completed. The bones of kids and young teens are smaller than those of adults and contain "growing zones" called growth plates. These plates consist of columns of multiplying cartilage cells that grow in length, and then change into hard, mineralized bone. These growth plates are easy to spot on an X-ray. Because girls mature at an earlier age than boys, their growth plates change into hard bone at an earlier age. Bone building continues throughout your life, as your body constantly renews and reshapes the bones' living tissue. Bone contains three types of cells: osteoblasts (pronounced: ahs-tee-uh-blastz), which make new bone and help repair damage; osteocytes (pronounced: ahs-tee-o-sites), which carry nutrients and waste products to and from blood vessels in the bone; and osteoclasts (pronounced: ahs-tee-o-klasts), which break down bone and help to sculpt and shape it. Osteoclasts are very active in kids and teens, working on bone as it is remodeled during growth. They also play an important role in the repair of fractures. Bones are made up of calcium, phosphorus, sodium, and other minerals, as well as the protein collagen. Calcium is needed to make bones hard, which allows them to support your weight. Bones also store calcium and release some into the bloodstream when it's needed by other parts of the body. The amounts of certain vitamins and minerals that you eat, especially vitamin D and calcium, directly affect how much calcium is stored in the bones. The soft bone marrow inside many of our bones is where most of the blood cells flowing through our bodies are made. The bone marrow contains special cells called stem cells, which produce the body's red blood cells and platelets. Red blood cells carry oxygen to the body's tissues, and platelets help with blood clotting when a person has a cut or wound. Bones are made up of two types of material compact bone and cancellous bone. Compact bone is the solid, hard outside part of the bone. It looks like ivory and is extremely strong. Holes and channels run through it, carrying blood vessels and nerves from the periosteum, the bone's membrane

covering, to its inner parts. Cancellous (pronounced: kan-suh-lus) bone, which looks like a sponge, is inside the compact bone. It is made up of a mesh-like network of tiny pieces of bone called trabeculae (pronounced: truh-beh-kyoo-lee). The spaces in this network are filled with red marrow, found mainly at the ends of bones, and yellow marrow, which is mostly fat. Bones are fastened to other bones by long, fibrous straps called ligaments (pronounced: lih-guh-mentz). Cartilage (pronounced: kar-tul-ij), a flexible, rubbery substance in our joints, supports bones and protects them where they rub against each other. What Are the Muscles and What Do They Do? Bones don't work alone they need help from the muscles and joints. Muscles pull on the joints, allowing us to move. They also help the body perform other functions so we can grow and remain strong, such as chewing food and then moving it through the digestive system. The human body has more than 650 muscles, which make up half of a person's body weight. They are connected to bones by tough, cord-like tissues called tendons, which allow the muscles to pull on bones. If you wiggle your fingers, you can see the tendons on the back of your hand move as they do their work. Humans have three different kinds of muscle:
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Skeletal muscle is attached to bone, mostly in the legs, arms, abdomen, chest, neck, and face. Skeletal muscles are called striated (pronounced: stry-ay-ted) because they are made up of fibers that have horizontal stripes when viewed under a microscope. These muscles hold the skeleton together, give the body shape, and help it with everyday movements (they are known as voluntary muscles because you can control their movement). They can contract (shorten or tighten) quickly and powerfully, but they tire easily and have to rest between workouts. Smooth, or involuntary, muscle is also made of fibers, but this type of muscle looks smooth, not striated. Generally, we can't consciously control our smooth muscles; rather, they're controlled by the nervous system automatically (which is why they are also called involuntary). Examples of smooth muscles are the walls of the stomach and intestines, which help break up food and move it through the digestive system.

Smooth muscle is also found in the walls of blood vessels, where it squeezes the stream of blood flowing through the vessels to help maintain blood pressure. Smooth muscles take longer to contract than skeletal muscles do, but they can stay contracted for a long time because they don't tire easily.
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Cardiac (pronounced: kar-dee-ak) muscle is found in the heart. The walls of the heart's chambers are composed almost entirely of muscle fibers. Cardiac muscle is also an involuntary type of muscle. Its rhythmic, powerful contractions force blood out of the heart as it beats.

Even when you sit perfectly still, there are muscles throughout your body that are constantly moving. Muscles enable your heart to beat, your chest to rise and fall as you breathe, and your blood vessels to help regulate the pressure and flow of blood through your body. When we smile and talk, muscles are helping us communicate, and when we exercise, they help us stay physically fit and healthy. The movements your muscles make are coordinated and controlled by the brain and nervous system. The involuntary muscles are controlled by structures deep within the brain and the upper part of the spinal cord called the brain stem. The voluntary muscles are regulated by the parts of the brain known as the cerebral motor cortex and the cerebellum. When you decide to move, the motor cortex sends an electrical signal through the spinal cord and peripheral nerves to the muscles, causing them to contract. The motor cortex on the right side of the brain controls the muscles on the left side of the body and vice versa. The cerebellum (pronounced: ser-uh-beh-lum) coordinates the muscle movements ordered by the motor cortex. Sensors in the muscles and joints send messages back through peripheral nerves to tell the cerebellum and other parts of the brain where and how the arm or leg is moving and what position it's in. This feedback results in smooth, coordinated motion. If you want to lift your arm, your brain sends a message to the muscles in your arm and you move it. When you run, the messages to the brain are more involved, because many muscles have to work in rhythm. Muscles move body parts by contracting and then relaxing. Your muscles can pull bones, but they can't push them back to their original position. So they work in pairs of flexors and extensors. The flexor contracts to bend a limb at a joint. Then, when you've completed the movement, the flexor relaxes and the extensor contracts to extend or straighten the limb at the same joint. For example, the biceps muscle, in the front of the upper arm, is a flexor, and the triceps, at the back of the upper arm, is an extensor. When you bend at your elbow, the biceps contracts. Then the biceps relaxes and the triceps contracts to straighten the elbow. What Are the Joints and What Do They Do? Joints allow our bodies to move in many ways. Some joints open and close like a hinge (such as knees and elbows), whereas others allow for more complicated movement a shoulder or hip joint, for example, allows for backward, forward, sideways, and rotating movement. Joints are classified by their range of movement. Immovable, or fibrous, joints don't move. The dome of the skull, for example, is made of bony plates, which must be immovable to protect the brain. Between the edges of these plates are links, or joints, of fibrous tissue. Fibrous joints also hold the teeth in the jawbone. Partially movable, or cartilaginous (pronounced: kar-tuh-lah-juh-nus), joints move a little. They are linked by cartilage, as in the spine. Each of the vertebrae in the spine moves in relation to the one above and below it, and together these movements give the spine its flexibility.

Freely movable, or synovial (pronounced: sih-no-vee-ul), joints move in many directions. The main joints of the body found at the hip, shoulders, elbows, knees, wrists, and ankles are freely movable. They are filled with synovial fluid, which acts as a lubricant to help the joints move easily. There are three kinds of freely movable joints that play a big part in voluntary movement:
y y y

Hinge joints allow movement in one direction, as seen in the knees and elbows. Pivot joints allow a rotating or twisting motion, like that of the head moving from side to side. Ball-and-socket joints allow the greatest freedom of movement. The hips and shoulders have this type of joint, in which the round end of a long bone fits into the hollow of another bone.

Things That Can Go Wrong With the Bones, Muscles, and Joints As strong as bones are, they can break. Muscles can weaken, and joints (as well as tendons, ligaments, and cartilage) can be damaged by injury or disease. The following are problems that can affect the bones, muscles, and joints in teens:

Arthritis. Arthritis (pronounced: ar-threye-tus) is the inflammation of a joint, and people who have it experience swelling, warmth, pain, and often have trouble moving. Although we often think of arthritis as a condition that affects only older people, arthritis can also occur in children and teens. Health problems that involve arthritis in kids and teens include juvenile rheumatoid arthritis (JRA), lupus, Lyme disease, and septic arthritis (a bacterial infection of a joint). Fracture. A fracture occurs when a bone breaks; it may crack, snap, or shatter. After a bone fracture, new bone cells fill the gap and repair the break. Applying a strong plaster cast, which keeps the bone in the correct position until it heals, is the usual treatment. If the fracture is complicated, metal pins and plates can be placed to better stabilize the fracture while the bone heals. Muscular dystrophy. Muscular dystrophy (pronounced: mus-kyoo-lur dis-truh-fee) is an inherited group of diseases that affect the muscles, causing them to weaken and break down over time. The most common form in childhood is called Duchenne muscular dystrophy, and it most often affects boys. Osgood-Schlatter disease (OSD). Osgood-Schlatter disease is an inflammation (pain and swelling) of the bone, cartilage, and/or tendon at the top of the shinbone, where the tendon from the kneecap attaches. OSD usually strikes active teens around the beginning of their growth spurts, the approximately 2-year period during which they grow most rapidly.

Osteomyelitis. Osteomyelitis (pronounced: os-tee-oh-my-uh-lie-tus) is a bone infection that is often caused by Staphylococcus aureus (pronounced: sta-fuh-low-kah-kus are-ee-us) bacteria, though other types of bacteria can cause it, too. In kids and teens, osteomyelitis usually affects the long bones of the arms and legs. Osteomyelitis often develops after an injury or trauma. Osteoporosis. In osteoporosis (pronounced: ahs-tee-o-puh-row-sus), bone tissue becomes brittle, thin, and spongy. Bones break easily, and the spine sometimes begins to crumble and collapse. Although the condition usually affects older people, girls with female athlete triad and teens with eating disorders can get the condition. Exercising regularly and getting plenty of calcium when you're a kid and teen can prevent or delay you from getting osteoporosis later in life. Repetitive stress injuries. Repetitive stress injuries (RSIs) are a group of injuries that happen when too much stress is placed on a part of the body, resulting in inflammation (pain and swelling), muscle strain, or tissue damage. This stress generally occurs from repeating the same movements over and over again. RSIs are becoming more common in kids and teens because they spend more time than ever using computers. Playing sports like tennis that involve repetitive motions can also lead to RSIs. Kids and teens who spend a lot of time playing musical instruments or video games are also at risk for RSIs. Scoliosis. Every person's spine curves a little bit; a certain amount of curvature is necessary for people to move and walk properly. But three to five people out of 1,000 have a condition called scoliosis (pronounced: sko-lee-o-sus), which causes the spine to curve too much. The condition can be hereditary, so a person who has scoliosis often has family members who have it. Strains and sprains. Strains occur when a muscle or tendon is overstretched. Sprains are an overstretching or a partial tear of the ligaments. Strains usually happen when a person takes part in a strenuous activity when the muscles haven't properly warmed up or the muscle is not used to the activity (such as a new sport or playing a familiar sport after a long break). Sprains, on the other hand, are usually the result of an injury, such as twisting an ankle or knee. Both strains and sprains are common in teens because they're active and still growing. Tendinitis. Tendinitis (pronounced: ten-duh-ny-tus) is a common sports injury that usually happens after overexercising a muscle. The tendon and tendon sheath become inflamed, which can be painful. Resting the muscles and taking anti-inflammatory medication can help to relieve this condition.

INTEGUMENTARY SYSTEM

The integumentary system consists of the skin and accessory structures such as hair, nails and glands.

Skin

Functions Skin is extremely important to normal physiologic function secondary to the roles that it plays in maintaining homeostasis. The seven chief functions of the skin are as follow: 1. Regulation of body temperature 2. Protection

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3. Sensation 4. Excretion 5. Immunity 6. Blood reservoir 7. Synthesis of vitamin D

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Structure
o

Skin is the largest organ of the body. In adults, the skin covers an area of approximately 2 square meters and accounts for nearly 20% of one's body weight. Its thickness varies from 0.3-4.0 mm depending on the location on the body.

The skin is composed of three principal parts:



Epidermis


The epidermis is composed of stratified squamous epithelium and is separated from the dermis by a thin basement membrane.

The epidermis is not as thick as the dermis and varies in thickness from approximately 0.3 mm on the eyelids to 1.5 mm on the palms of the hands and soles of the feet.

The epidermis is an avascular structure. Therefore, all gases, nutrients and waste products must diffuse to & from the capillaries located in the dermis.

Dermis

  

The dermis is composed of dense, irregular connective tissue. The dermis varies in its thickness from less than 1 to 4 mm thick. Blood vessels, nerve endings, hair follicles, smooth muscle, glands and lymphatic vessels all extend into the dermis.

Hypodermis


The hypodermis which is also known as the subcutaneous tissue attaches the skin to underlying bones and muscles and also supplies it with blood vessels and nerves.

 

The hypodermis consist mostly of connective tissue and adipose cells. As much as one half of the body's stored fat is located in the hypodermis

Hair

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Hair develops from the embryonic epidermis. The primary function of hair is protection.

Nails Nail Structure Nails are plates of hard, tightly packed keratinized cells of epidermis. Nails are composed of three principal parts: 1. Nail body- The visible portion of the nail. 2. Free edge- The aspect of the nail that may extend past the distal end of the digit. 3. Nail root- The aspect of the nail that is buried underneath a fold of skin.

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Other structures associated with the nail include: 1. Lunula- The whitish semilunar area of the proximal end of the nail body. 2. Eponychium- Also known as the cuticle. This is a narrow band of epidermis which extends from the lateral border of the nail wall. 3. Nail matrix- Epithelial tissue deep to the nail root where actual nail growth occurs.

Nail Function Functionally, nails allow us to grasp and manipulate small objects. In addition, nails also provide protection against trauma to the distal ends of the digits.

Glands

The two major glands of the skin are the sebaceous and sweat glands. Sebaceous glands
 

Sebaceous glands are located in the dermis and are usually connected to hair follicles. These glands produce an oily, white substance known as sebum which oils the hair and skin and thus prevents drying and also provides protection against some bacteria.

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Sebaceous glands are located on the lips, on the eyelids and on the genitalia.

Sweat glands


There are approximately 3 to 4 million sweat glands in the human body.

Sweat glands are typically divided into two types, eccrine & apocrine, based on their structure and location.


Eccrine Sweat Glands Eccrine sweat glands, also known as merocrine sweat glands, are the most common type of sweat glands. These sweat glands are composed of simple coiled tubular glands that opens directly onto the surface of the skin through sweat pores.  Eccrine glands are most numerous on the palms of the hands & the soles of the feet. Apocrine Sweat Glands
   

Apocrine sweat glands are composed of compound coiled tubular glands that usually opens into hair follicles superficial to the opening of sebaceous glands. These glands are typically found in the axillae, genitalia and around the anus.

Blood Supply Blood supply to the skin is limited to the capillary plexus of the dermis & hypodermis. A subcapillary network of veins drains the capillary system. Lymphatic vessels of the skin arise in the dermis and drain into larger hypodermic branches.

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Please cite sources

REVIEW OF RELATED LITERATURE

NURSING HISTORY History of Present Illness  Patient claimed she experienced depression, low self- esteem, fatigue, not eating meals and feel hopelessness it is the reason why she has been admitted to Talay rehabilitation center. Past Health History  Patient was never been hospitalized before with certain diseases. Patient was admitted since Nov 20, 2011.

Psychosocial History:  She is a Roman Catholic. She was not able to finish her college level because she was depress she failed the entrance exam in nursing course. She is a loner person, silent and they are six in the family including her mother and father, has one brother and 2 sisters. She is the eldest among the four of them. General Impression of Client:  The clients appeared clean but with slight odor, dry skin. Client is respectful and cooperative. During our first meeting and interaction, the client has problem communicating his concerns and thoughts. The client was able to maintain eye contact during the conversation, she able to share what is the reason why she is admitted in Talay rehabilitation center.

PROCESS RECORDING
SN1- jhyne cristy tubaing SN2- Jennylyn R. lim P- Patient

Conversation FIRST DAY ORIENTATION PHASE (May 3, 2011) SN 1 & SN 2: Maayong hapon maam! P: maayong hapon pud! Mag unsa di-ay mo ron diri? SN2: ai kami di ay taga foundation nga mga estudyante. SN1: ug ako diay si jhyne. Ug akong kauban si jenny P: Ahhhh! Jhyne jenny, SN1: unsai ganahan nimong etawag namo nimo maam, manang o maam nancy? P: maam ra. SN2: maam pwede mi makig esturya nimu? P: taysa ha hulat sa mo kadyut dai. (patient puts on face powder and combed her hair) SN1: ok ra ka maam diri rata mag estuyahanai? P: oh SN1: maam naa assign mi nimo mag duty mi diri kada hapon gikan

Technique Used

Analysis

Therapeutic: Establish rapport

Establishing rapport is very important so that our client would trust us and may not limit every conversation.

Asking permission

This shows respect to client and little by little getting the clients trust.

Therapeutic: contract setting

Contract setting is used in order for the patient to be informed of the inclusive dates of duty of the student nurses and they will be aware of the activities to be done.

Monday to Friday pero dili pa nya siya permamente kay basin mausob-usob pa and schedule, kutob sa may 20, 2011, naa ta pagabuhaton na mga activity usa ana ang exercise, art therapy kana galing magdrawing-drawing maam, ug uban pa.pabal-on raka namu maam. P: apil d i ko ana? pwede ko makagawas diri? SN2: oo maam apil ka maam. mananghid sa mi sa nurse maam ha if ok lang ba. SN1: maam ang amo di ayng culmination activity karon di ayng May 19, 2011. P: ok dai, kato na siyang mura ug program dai sa? SN2: oo maam mao na siya maam naa tai program pagabuhaton maam.TMRC compound (underneath the tree on the first bench from the right) SN1: gwapa kaayu ka maam P: thank you (smiley) SN1: unsai rason maam nga ania ka diri? P: daghan jud kaayong rason dai nga na anhi q diri. Ga sugod sa highschool katong 1989 ni take ko ug nursing entrance exam sa nursing didto sa La Salle Ika duha ni take nalng ko og BS bio na course. Dayon ni balhin na pod ko ug eskwelahan sa San Augustine ni kuha ko ug curso na medtech dayon human ato ni Therapeutic: questioning Questioning is used appropriately this time because by using this technique we can gain information from our client. Therapeutic: broad opening and questioning Broad opening is used in order to start a conversation between us and the patient.

take napod q ug exam sa nursing kato nakapasar nako apang wala nq gi dawwat kay naulahi na q sa enrolment. Sukad ato na dedpress na ko, din q katulog irritable, sentsitive, ill mannered dayun sige nag yaw-yaw. SN2: kinsai gadala di ay nimu diri maam? P: ela raman ko g engnan na manlakaw mi unya dal-on di ay ko nila diri si sir nonoy Solidarios ang gadala nako. Lisod kaayu sa Bacolod dai kai ang bording house mahal kaayu then mahal pod ang tuition fee sa La Salle, nya wla biya kwarta kai gamai ra ihatag. SN2: pila di ay mo ka managsuon maam? P: upat mi ka managsuon dai ako kamagulangan usa ka laki tulo mi na baye, maglakaw-lakaw raman ko ako ra usa maglakaw ra jud ko dai kai wala man koy e plite.paengon sa balai sa akong lolo ug lola. SN2: mag unza pod ka sa ka lolo ug lola nimu maam? P: mag tiner lang gud didto dai, anhion gali ko nla usahay dai.sa akong papa. SN1: ah. (nodding) anhianhion pod ka sa imo pamilya di ay diri maam, nya mag unsa pod mo maam ug mo anhi sila. P: nakaanhi man akong papa katong sa December ug akong bayaw bana gali sa akong igsoun.(silence)

Therapeutic: clarification

Clarification was used appropriately in order for us to clarify what the patient really means.

Therapeutic: restating

Restating is repeating the words the client states. It used appropriately since we understand what our client means when she say checkpoint.

Therapeutic: acknowledging

Acknowledging this time is appropriate because it makes client feel that she is useful and enhances self-esteem.

Therapeutic: questioning Questioning the client in order to further emphasize some information

that we can get from the client. SN2: kumosta man ang imong pag puyo dire maam? P: ok raman diri dako kaau ang bayad 4000 a month dala na tambal ug pag kaon, atong una mingawon jud q sa amo maghilak ko, mag wild ko apan karon nagpasalamat ko kai medyo ok2 na ko. (patient suggested to transfer to another place where we are going to continue our conversation.) P: igang kaau diri dai, dai pwede nya ko mgayo niyu ug daang sinina ug short bisan usa-usa ra,kanang galing relief gali dai kana pong magamit dai baraton ra man na sya dais a? Dayon shampoo pod ug colgate. Pero kon wala dai ok ra makasabot raman ko. SN2: lantawon ra namo maam pero dili ra mi mo promise nimo. P: sige dai segi thank you ha. SN1 : diri nalang to maam kai naay electric fan Non- therapeutic: changing the topic Changing the topic directly is rude for the patient, but we think that using this technique is appropriate this time because the patient is no longer responding this time.

P: (patient looks tired) gi kapoi naman ko esturya mo agto sa ko didto mo balik ra unya ko diri.

SN1and SN2: cge maam kai magkupya sa mi sa imong chart.maam P: sige (smiling again before leaving)

Therapeutic: bidding goodbye.

Bidding goodbye means showing respect that the conversation is already done.

..left the patient..

SECOND DAY INTERACTION (May 4, 2011) (WORKING PHASE)

SN1 & 2: maayong hapon maam! P: Maayong hapon pud ninyo.(smiling)

Giving Recognition Greeting client, indicating awareness Indicates awareness of change of change, or noting effort the client and personal efforts. Does not imply good or bad, or right or has made all show that the nurse wrong. recognizes the client as a person, as individual. Informing the client of facts increase of her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client. Giving Recognition Indicates awareness of change and personal efforts. Does not imply good or bad, or right or wrong. Giving information Observing the facial expression and gestures of the patient helps us to be aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion. Informing the client of facts increase her knowledge about a topic or lets

SN2: Jenny ug si jhyne maam katong gahapon. P: Oh.. (prolong oh..)nanglaba ko dai. SN1: ok ra maam.

Asking permission Provide proper way introducing a certain activity

SN2: Naa ra mi isulti maam, ugma mag art therapy ta maam, kanang y mag drawing2x maam. P: Oh.. (prolong oh..) tagae niya ko shapoo, sabon panglaba, pahumot ug

sanina ninyo ha SN1: unyang May 19, 2011 maam naa me culmination activity, usa anah maam naa me mga premyo na sabon, shampoo, ug sanina. Kinahanglan cooperate ta sa activity para makadawat ug premyo. Giving information P: oh... (Prolong oh..) apil ko anah, sa May 19 sah? Dugay pa manah. Manglaba sah ko ha. SN1 &2: Sige maam adto sah me didto. P: sige bye. left the patient. y Therapeutic: bidding goodbye. y

the client knows what to expect.

Making Observation Commenting what is seen and heard to encourage discussion

Giving information also build trust to client.

Bidding goodbye means showing respect that the conversation is already done.

THIRD DAY INTERACTION (WORKING PHASE) May 5, 2011

Therapeutic technique: Greeting and broad opening The techniques used were appropriate so that we can open up communication with our client .

SN2: mayong hapon maam! P: Oh (prolong oh with smile) SN2: Maaoyong hapon maam P: Hello.. mayong hapon pud (smiling ). Hulat sah ha.

(patient o inside the FM and fix her clothes and after she fix it, she change her dress and put some powder in her face after she come out the FM) P: Tala..! SN2: Asa man imung ganahan maam kanang comfortable ka. P: Bisan asa dai. (simling) SN1: Didto dapit sa may chapel maam, naa man lamisa didto para comfortable pud ka. P: sige2x didto ta.. (smiling)
Therapeutic technique: setting goals and giving information Setting goals is used so that our client will know on what we will do the next day. Giving information was also used so that she will know what physical assessment is all about.

(we walk together with the patient going in the chapel) SN1: diri ta maam kay naa lamisa.

P: sige2x diri ta.

(patient sit on a long chair)

SN1: Maam maayong hapon balik nimu! Musta naman ka maam?

P: Ok ra ko day
Therapeutic technique: Instructing Instructing was used so that our client will know on what to do during the procedure. Non verbal cues was seen, client seems bored and tired during the procedure

SN1: karon maam naa ta therapy katong among giingon nimu gahapon na art therapy. Magdrwaing2x ta karon maam gamit aning crayon ug papel, bago ta magsugud maam kaning crayons 8 colors ni siya nia pud ang papel para imung drwingan, tagaan ka namu ug 15 minito ani magdrawing maam bisan unsa imung ganahan na mahuhunaan nimu drawingon pwede. Human anah maam mangutanah kami unsa imung ka storya sa imung gidrawing.

P: Oh
Therapeutic technique: giving Giving information to the client was appropriate so that she will know on what to do during the therapy. Questioning was also used so that information and questioning

SN1: human nimu magdrwaing maam pwede raba namu hulaman imung gidrawing amu ra pud uli ugma.. amu ra suhiron para naa

pud me copy sa imung drawing. Ug human nimu drawing pud maam amo pud kuhaon ang color balik maam.

P: sige day ai SN2: sige maam ang oras diri karon sa akoa maam 2: 45 pagka 3:00 lantawon nato imung drawing maam. Kung wala paka nahuman tagaan ka namu extension time 2 minutos. Placing event in time sequence Putting events in proper sequence helps both the nurse and client to see them in perspective.

P: sige2x

SN1: sige maam Nancy mag starat nata. Nia ang color ug ang papel.

P: sige salamat dai.

(patient start get the activity) Making Observation Observing the facial expression and Commenting what is seen and gestures of the patient helps us to be aware as to the limitation of a certain heard encourage discussion activity to be conducted and encourages soft flow of discussion.

SN1: patient remove the colors in the box and put it on the table besides her paper and she arrange it. SN2: maam nancy, magsulat ra me while ga drawing ka ha. y

P: oh dai sige2x.

(PATIENT CONTINUE THE ACTIVITY)

SN1 & SN2: client first arrange the things for the activity and she stop and thinlk what color she will be use: the first color she use is brown, she draw a branch of a tree, 2nd color she is green, she draw a tree, she is so serious while doing the activity, her facial expression is like she is angry then sometimes she smile while she draw. The 3rd color she use is red she draw an apple in the tree that she draw then she draw a house using the blue color and she also draw a flower, sun and a fence. Making observation Observing the facial expression and gestures of the patient helps us to be aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion.

P: hala day nabali.!

SN1: ok ra maam nancy padaun ra ok ranah.

SN2; maam Nancy 2 minutes nalang ang time, hapit naka human maam o nahan ka extension ta ug 2 minutes.

Therapeutic : setting time

Informing the client time so that they are aware if they stillhave time or they can ask a extension time in their work.

P: oh

SN1: sige maam dugangan nato ug 2 minotos

( AFTER THE TWO MINUTES)

P: human na ko day
Therapeutic technique: questioning and acknowledging Questioning and acknowledging was also used well so that well know if our client has eaten already, and acknowledging her will make her happy.

SN1 &2: WOW..! tsada kaayo imung drawing maam nancy.

P: tsada ra day. Amu man nah balay.

SN1: ah ok maam tsda au maam nancy. Naa rame pangutana ma;am kabahin sa imung drawing. Unsa man imung masulti kabahin ani imung na drawing maam.

P: Amung balay nah day sauna, sa margarita village, kanah siya day housing loan nah among balay, dugay2x day anah na closed siya na for sale human nahalin.

SN1: pila man imung edad anh maam? P: 17years old ako ato day, daghan kaau me tanum anah day human daku among lugar dai.
Therapeutic technique: Broad opening and Questioning Broad opening is used in order to start a conversation between us and the patient

SN2: unsa man inyong mga tanum didto maam sauna? P: mga bulak day, ako mama man day gabaligya siya ug tanum, retired man siya ug police. Two stairs pud nah among balay dai cement sa ubos human sa taas kahoy ang gamit.

SN1: unsa paman imung masulti nga lan sa imung drawing maam, kay whle ga drawing ka na obserbahan namu murag seryosa kaau ka nag drawing. General leads Encourage the client to continue or express her feeling or thought about P: sauna dai naglalis na ang akong papa ug ang contractor sa gagama sa among balay, nahadluk jud ko ato day. Human ato day wala nahuman among balay: ang kusina, kwarto kulangan ug rooms. the activity.

SN2: pila man mo kapuyo sa inyong balay maam?

Therapeutic technique: Broad opening and Questioning Broad opening is used in order to start a conversation between us and the patient

P: lima me kabuok day akong papa,mama ug igsuon na ko. 3 man me mag igsuon.

SN2: mubalik ta sa imung gingon maam na naglalis imung papa ug ang contractor. Unsda man imong gibuhat katng nahadlok ka?

P: nahadlok ko day kay ganahan man katng contractor na kuhaon ang among balay. Human nag kaso2x sila n papa katong contractor nahadlok. Niadto sa lain lugar. Wala niya nakuha ang balay namu. General leads Help the client to express her feeling about the outcome of her therapy.

SN1: ah mubalik ta imung drawing maam . nganu man kaning mga color imung gipili?

P: wala ra day ganahan ra ko kana nga mga color. Help the client to express her feeling about the outcome of her therapy.

SN1: kani maam mga bulak sa imung drawing, mahuilig ka ug mag tanum2x? P: mga ornamental plants day among tanum. Mga flowers, pine tree, naa pud me avocado na tanum , san Francisco na flowers. Usahay pud day mu mag bunlay2x ko, suguon ko sa akong mama ug silhig.

General leads

SN1: ah makalingaw pud mag bunlay2x ka maam sa human tanum2x ka.

P: Oh day.

(PATIENT SILENCE AND GET THE SMALL NOTE OF MS.TUBAING AND SHE OBSERVE THE PICTURE) SN1: nahan ka anah mickey mouse maam. Making observation Observing the facial expression and gestures of the patient helps us to be aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion

P: diman day tsada lang siya. Lantaw ra ko ani picture.

(she return the small note to ms. Tubaing.)

SN2: maam uslan namu ning imung drawing ha. Amu ra uli sa imuha pag anhi namu diri ugma.

Asking permeation

To ask permission to the client that we will borrow her drawing and give it back to her the next day.

P: sige day ibalik ramn nimu ugma pud. Ok lang. (pt. smiling)

SN2: maam nancy naa di I ta eating therapy karon snack para ninyo tanan.

Giving information

Teeling what the next activity so that the patient is aware.

P: oh

(pt. ask if she can go to FW)

P: adto sah ko didto day.

SN1: kapoy ka maam. Ganahan sah ka magpahuway.

P: oh day. SN2: sige maam hatod ka namu didto balik. Ingnun raka namu if snack time na.

P: sige day, ayaw ra ko hatod. Adto sah ko dai ha. Bidding goodbye means showing respect that the conversation is already done (PATIENT LEAVE US IN THE CHAPEL AND WENT TO HER ROOM FEMALE WARD.)

SN1 &2: sige maam.

Therapeutic binding

Fourth day interaction (May 6, 2011)

SN 1 and SN 2: maayong hapon maam P: maayong hapon sad ninyo dai mag esturyahanai nata dai? y Giving Recognition Indicates awareness of change and personal efforts. Does not Greeting client, indicating awareness imply good or bad, or right or of change, or noting effort the client wrong. has made all show that the nurse recognizes the client as a person, as SN 1: karon nang tiod-tiod maam agtuon raka namo ron didto sa imo Giponduhan maam. P: ah.. okey dai maghulat rako didto dai ha..? SN1 and SN2: ok maam magkita rata ron maam. (preconference with CI and first group for the preparation of music and exercise therapy) (SN1 and SN2 looking for the patient) SN2: Maam naa na pod mi ron maam para sa atong gi sabutan na therapy gahapon maam kahinomdom paka maam? P: oo dai katong music ug exercise to dai sa? SN1: oo maam mao na ang mga therapy na atong buhaton ron maam SN2 : maam pwede ko mangutana if nakasulay naka ani sauna na mga klasing therapy? y Making Observation Commenting what is seen and Observing the facial expression and heard to encourage discussion gestures of the patient helps us to be aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion. Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client. individual. Giving information

P: oo dai kanang music therapy dai ang mga student man to nanganta ato dai, kanang exercise dai ganahan kaayu ko ana. SN1: sige maam kai karon mag exercise sad ta maam. (smile)

Giving information Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to

P : unsa man atong unahon dai? SN2: mag music therapy sat a una maam dayon mag snack ka dayon e sunod nato and exercise maam, P: ok dai gahan ko ana dai. SN1: asa man ka gahan mo lingcod maam? P: anha rata sa atobangan dai. SN1 and SN2: ok maam anha ta dinhi naman ka sa tunga namo maam.Patient: ok dai. SN2: ai maam di a di ay ag imong drawing gahapon maam amo nang e uli salamat sa pagpahulam maam, chada kaau ng imong drawing maam oi. P : Salamat dai, (stare at her drawing) kaning among balay dai memorable kaayu nko ni dai (looking back and forth to SN1 and SN2)Dai no? kai akong papa ug ang contructor ani dai kana galling ga pa gama ani dai nag away sila dai. Nya hadlok kayo ko ato dai. y

Therapuetic : conversation

client. Builds student nurses and clients therapeutic relationship and enhances trust.

Making Observation Observing the facial expression and Commenting what is seen and gestures of the patient helps us to be heard encourage discussion aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion.

SN1: sa asa man na part ato maam na hadlok kaayu ka? P: katong ga away na silang papa ug and contructor dai dayon mahadlok sab ko basin naa hilabtan unya mi sa contructor dai, pero wala na man pod to dai na human raman to dai kai nakuha man jud namo ang balay namo dai, gamai raman ning among baly dai pinobre ra gud dai. (patient stares at SN1 and touches her knee) ikaw ba dai bot-an gud ka kaayu dai (stares at SN2) ikaw pod dai bot-an gud mo kaayu. SN1 and SN2: ikaw pod maam bot an pod ka kaayu. (music therapy started Beethovens classical music patient listens carefully)Patient: ganahan kaau ko aron kantaha dai naka. SN2: unsa man imong gi bati maam samtang naminaw ka sa kanta maam? P: joy sa akong kasing-kasing dai. Na relax ko dai mingaw kaayu ang music. Lami d I nang malisuan dai.(Moment of silence) SN1: kai nganu maam na nakaana man kang lami nang malisuan? P: kai daghan man kong butang na wala pa experience dai ug diri lang nako na experience aning lugara dai. SN2: sama sa unsang mga butanga maam? P: kaning music therapy dai. SN1: ganahan d I kaayu ka ug music therapy maam.? Sauna maam y Making Observation Commenting what is seen and Observing the facial expression and gestures of the patient helps us to be heard encourage discussion aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion. Therapuetic: questionning Questioning the client in order to further emphasize some information that we can get from the client. Therapuetic: complement Recognizes patients good behavior from what is observe by student nrses.

katong naa pa ka sa inyu maam unsay mga kasagaran nimong buhaton maam? P: maninaw ug news dai dayun maminaw ug music kanang love song gali dai di man ko ganahan mamnaw uga drama dai.nya inig wala gali ko buhaton dai maminaw jud ko ug music usahay dai nanang manilhig ko pod. (second music theme song of boys over flowers movie is about to be played) Patient: mo balhin ta ato unahan dai. SN1 and SN2: ok maam asa man ka ganahan molingkod maam? P: Diri ra sa unahan gamaidai.(SN1, Patient and SN2 seated) (second music introduction and after wards it was played) P: strange kaayu ang music dai no murag nay tawo ga piano. SN1: oo maam sakto jud ka maam usa sa instrument g gamit ani na kanta mao ang piano na gina patukar ug usa ka tawo. P: (pointing the laptop) unsa na siya dai computer na dai mahal kaayu na dai sa? SN2: oo maam computer na siya maam pero wala man mi kabalo pila jud ang presyu ana maam kai sa amo manang classmate maam. P: dai tagae nya ko ninyu ug picture ni mama merry dai or dili Giving information Giving an idea or knowledge of a certain thing that client is asking for. Accepting Accepting respond indicates that the nurse has heard and followed the train of thoughts. Setting the time and sequence Chose were the client is comfortable and place during interaction.

kato gaing prayer booklet dai o kato bang brown na kulintas na naa picture ni mama merry dai ha. Kai continue ra jud ko ga ampo niya dai para maayu ko. SN2: sige maam among paningkamotan hatagan ka namo ana maam pero dili namo ma promise nimo amo mahatag tanan maam. P: ok ra dai. Bisag kanang karaan ningyong picture ni mama merry sa inyu o kanang sa kalendaryu gali dai. SN1: sige maam pangitaan ka namo ug picture ni mama merry maam. (snack time, about ten minutes after snack prepation for exercised therapy ) SN2: maam adto nata dapit sa ward C maam adto ta didto mag exercise therapy maam. Patient: ok dai. SN1: maam diri ka sa among likod ni SN2 ha dayon imo ming sundon sa action nato maam. P: ok dai (music played) P: (after the exercise) gi paningot jud ko maam (talking towards Clnical instructor) makayu sa circulation ang exercise. SN1 and SN2: thank you kaayu sa imong cooperation maam P: salamat pod ninyu dai. SN2: maam unya na pod pohon sa martes mi mo balik. P : sa martes dai? SN2: oo maam sa martes na pod maam unya pohon bo balik mi Therapeutic: bidding goodbye. Bidding goodbye means showing respect that the conversation is already done. Settting the place Inform the client where will the activity be done.

maam. P: ok dais a martes ha. SN1 and SN2: bidding goodbye

Fifth day interaction

SN1 &2: maayong hapon maam1 P: maayong hapon pud! SN1: musta naman ka maam? P: ok raman ko. Mag storia nata? SN2: kung pwede ra maam. Ditto ta dapit sa may payag. P: tala day. SN2: maam naa me exercise therapy karon. Muapil niya ta ha. P: sige maam kung dili ra mag lain akong paminaw. SN1: naganu man di I maam unsa imung gibati? P: lain akong paminaw day mura ko kasukahon na kalipungon. SN1: Inga na niya me maam nahan ka pahuwal ha. Basin gikapoy ka. Giging information. Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client. Giving recognition Greeting client, indicating awareness of change, or noting effort the client has made all show that the nurse recognizes the client as a person, as individual.

P: oh day musulti ra niya ko. SN1: sige maam P: day pwede ko dili ra mu apil sa exercise? SN2: galain na imung paminaw maam nancy. P: oh day. pwede ko pahuway sah ko. Matulog ko. Labad akong ulo. SN1: sige maam ai katulog sa h basin kapoy raka anah. Kulang lang pahuway. P: sige day. SN2: sige maam hatdan raka namu ug mag hatag na kami ug snacks after sa excrcise therapy. P: sige day SN1: hatod ka namu maam. P: tala day. Observing the facial expression and gestures of the patient helps us to be aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion.

(patient go inside the Fm ward and lie down in her bed and take a rest.)

Sixth day Interaction ( May 11, 2011)

SN1 and SN2: maayung hapon maam P: maayung hapon sab ninyu jen ug jhyne,ag esturyahanai ta ron? Giving recognition Greeting client, indicating awareness of change, or noting effort the client has made all show that the nurse

SN1: oo maam mag esturyahanai ta ron maam, kon homan naa tai dyutaing oras maam kai naa man ga culmination ang ABC maam. P: oo gali jen ug jhyne mo apil sa q nila ha. SN1 and SN2: ok maam sige maam apil sa nila maam. Mo pabalo lang mi daan nimo maam na naa di ay tai clay therapy ug ma maam. P: sige jen ug jhyne ha ari sa ko diri. Mo apil ko ana dai. SN2: sige maam kai ugaling dili pa mahoman ang ABC ron maam nans napabalo na ka namo daan maam nanz. SN1 and SN2: bidding goodbye Therapeutic binding Giving information.

recognizes the client as a person, as individual. Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client.

Bidding goodbye means showing respect that the conversation is already done.

Seventh day May 12, 2011

SN1 & SN2: maayong hapon maam!

P: hello, maayong hapon pud ninyo jhyne and jenny! (pt. smiling while she greet us). Mag storia nata jhyne ug jen? SN1: ok raba nimu maam nancy? P: ok ra jhyne. Asa man ta dapit?

Giving Recognition Greeting client, indicating awareness Indicates awareness of change and personal efforts. Does not of change, or noting effort the client imply good or bad, or right or has made all show that the nurse wrong. recognizes the client as a person, as individual. Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to clien

SN2: asa man imung ganahan maam kanang comfortable ka? P: bisan asa jen.

Therapeutic: contract setting

SN2: sige maam nancy diha ta dapit sa may hagdan dapit sa payag. Ok ra nimu?

Therapeutic: questioning

Contract setting is used in order for the patient to be informed of the inclusive dates of duty of the student

P: diha? Sige2x. (pt. smile and walk through the stairs beside the payag.) SN2: kuha sah ko ug chairs maam ha. P: sige jen. SN1: diri ta maam nancy. Diri ka lingcod maam nance. P: salamat jhyne. (smiling while she is looking at jhyne) SN2: diri me dapit lingcod maam nancy. Para atbanganay ta. Asking permission

nurses and they will be aware of the activities to be done.

Show respect .

P: SILENCE AND SMILING.. Giving Recognition Indicates awareness of change and personal efforts. Does not imply good or bad, or right or wrong. Greeting client, indicating awareness of change, or noting effort the client has made all show that the nurse recognizes the client as a person, as individual.

SN1: maayong hapon balik nimu maam nancy!musta naman imung gibati karon maam?

P: nalipay ko kay nia namu. (smiling while looking to us) Kay naa napud ko ka storia. SN1: nganu di I maam dili di I ka makig storia sa uban nia diri? P: storia man. Malipay ra ko na nia mo duha ni jen.
Therapeutic: broad opening and questioning Broad opening is used in order to start a conversation between us and the patient.

SN1: salamat maam nancy1 kami pud malipay na naa pud ka na ni

trust pud ka namu ni jenny. P: salamat pud ninyo daya ako inyong napili nga patient.

Therapeutic technique: Broad opening and Questioning

This is our third exposure to our client and basing on her reaction when she saw us, I know that she is happy to see us. And broad opening and questioning was used correctly this time so that we can further assess what the client fel

SN1: gaunsa di I ka ganiha buntag maam nancy?

P:nag music therapy man ang taga st. paul. Nakatolog ko ato human pag mata na ko human na sila ug music therapy. Gitagaan na ko nila ug snack. SN1: unsa man imu nabati sa music therapy maam nancy?
Therapeutic: broad opening and questioning Broad opening is used in order to start a conversation between us and the patient

P: nalagsik ko day. Nalipay ko (smiling) SN2: maam nancy karon hapon naa pud ta clay therapy. Katong among giingon namu nimu gahapon..
Therapeutic technique: Broad opening and Questioning

Broad opening is used in order to start a conversation between us and the patient

P: ohprolong oh. Giving information SN1:kaning clay therapy maam nancy. Mau ni siya kanang Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client.

magporma ka ug unsa imung ganahan nga porma gamit aning clay.

P: OH..SILENCE SN2: tagaan ka namu ani mga clay maam nancy human porma ka unsa imung ganahan nga porma na ma huna2x an. Giving information Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client.

P: bisan unsa jen? SN2: Bisan unsa maam nancy. Nahan ka mga fruits. Hilig man ka fruits . nahan pud ka lain pwede pud. Kanang ganhan ka eporma bisan unsa. Placing event in time sequence

Putting events in proper sequence helps both the nurse and client to see them in perspective.

P: fruits nalang. Para dali. SN1; kaw bahala maam nancy unsa imung ganahan nga promahon. Putting events in proper sequence helps both the nurse and client to see them in perspective.

SN1: sige maam tagaan ka namu oras na 15 mins if di pa mahuman ingana ra mi para dugangan natro ang time nimu P: tagae ra ko day na taas na time lisuran man ko ani. SN1: sige maam taas2x nato ang oras. Sugod ta maam.

Placing event in time sequence

P: sige day.

SN1: mau ni imung clay maam nancy.

(patient get te clay materials out in the plastic with the help of student nurse ad start the therapy)

SN2: maam nancy while ga porma ka mananaghid me kung pwede ra mi magsulat sa notebook.

P: sige2x day.. (smiling and go back to the activity) Making Observation Observing the facial expression and Commenting what is seen and gestures of the patient helps us to be aware as to the limitation of a certain heard to encourage discussion activity to be conducted and encourages soft flow of discussion

OBSERVATION DURING THE ACTIVITY: SN1& 2: patient get the red clay and form an apple. She is so serious in forming the clay. y

P: mau ni apple jhyne?

SN1: yes maam apple. Unsa man next imung pormahon maam? P: fruits ra tanan. Therapeutic: Accepting and questioning SN1: ok maam. Pwede nah nimu tunga2x on maam nancy. An accepting response indicates the nurse heard and followed the train of thought. Broad opening is used in order
to start a conversation between us and the patient

P: ah pwede di i. mabalik ra siya.

SN1: yes maam nancy pwede. Mabalik ranah siya. (pt. back to her clay forming) Giving information The nurse functioning as a resource person.

SN1& 2: the next clay color she chose is the green she form a mango, next is the violet, she form a small round like a grapes. y Making Observation Observing the facial expression and Commenting what is seen and gestures of the patient helps us to be heard to encourage discussion aware as to the limitation of a certain activity to be conducted and encourages soft flow of discussion

P: unsa pa jhyne ako porma nga fruit.

SN1: kaw maam unsa paman imung ganahan eporma? General leads Encourage the client to continue. P: ah sige kaning orange porma ko ug orange.

SN1: sige maam nancy. (after the given time patient finis her clay therapy she form different kinds of fruits using the clay) Accepting Indicates the nurse heard and followed the train of thoughts.

P: human na day. Sn1 & 2: wow, maam nancy nice imung gi porma.
Therapeutic technique: questioning and acknowledging Questioning and acknowledging was also used well so that well know if our client has eaten already, and acknowledging her will make her happy.

SN1: nganu man mga fruits imung gi porma maam nancy?

P: hilig ko ug mga fruits jhyne, kanang apple, orange, manga,

grapes ug uban pa. SN1: sige ka kaon anah maam?

Therapeutic technique: Broad opening and Questioning Broad opening is used in order to start a conversation between us and the patient

P: dili. Tagae niya ko ninyo ug mga fruits ha?

SN2: ah sa tong sunod na therapy maam nancy, naa man ta na gitawag na cookigntherapy, sa atong therapy naa ta mga different fruits kay mag halo2x man ta anah. Giving information Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect. Giving information also build trust to client.
Therapeutic technique: Broad opening and Questioning Broad opening is used in order to start a conversation between us and the patient

P: sige2x jen. Dagahan apple diri sa ato.

SN1: daghan ka baligya maam pero dili matanuman atong lugar diri ug apple. P: ah. Lami kaon sige apple, orange ug grapes.

SN1:sige ka kaon anah sauna maam nanacy? P: akong mama mag gama man siya ug kanang fruits salad sauna. Pag Christmas.
Therapeutic technique: Broad opening and Questioning Broad opening is used in order to start a conversation between us and the patient

SN1: tabang pud ka gama maam sa imung mama. Kanang ma mix sa fruits.

Therapeutic technique: Broad opening and Questioning

Broad opening is used in order to start a conversation between us and the

P: dili day mag tan aw ra ko ni mama. Human anah tagaan ra ko nila kung human na sila ug gama.

patient

SN1: nganu man maam dili ka ganahan anah ma mix2x sa mga fruits?

Therapeutic technique: Broad opening and Questioning

Broad opening is used in order to start a conversation between us and the patient

P: ganahan man ko day. nilantaw ra ko nila ato nga time. Nag observe ko. (smiling) SN1: ah nag observe ka para sunod kabalo naka unsaon pag gama sa fruits salad.

P: oh. Encourage perception of perception

SN2: unsa man imung gibati maam nancy sa imung na porma na mga fruits.

Encourage the client to describe ideas fully may relieve the tension the client is feeling.

P: nalipay ko na nakaporma ko ani mga fruits. Salamat ninyo.

SN2: salamat pud sa imung pag participate maam. Maam naa di ta exercise therapy after ani. Didto rata dapit sa isolation A.

P: sige day apil niya ko.

SN1: maam nancy nahan ka taguan ani imung clay o kami ra ani ang magtago.

P: ako nalang para naa napud ko remabrance ninyo duha.

SN1 &2: sige maam nancy.

P: pwede na ko ni tago sa. Butang na ko sa kwarto. SN1: sige maam nancy P: balik sa nako ang uban sa plastic.

SN1: kami ra anah himus sa uban maam nancy.

Offering self Making oneself available

P: kamu ra. Sige salamat ha. Taguan sah an ko ni. SN1: sige maam hatod ka namu didto. P: sige tala. Didto sa ko sa akong kwarto ha. (Patient go inside the female ward and look at and she smile. P: sige jhyne, jenny. Salamat ha. SN1 &2: salamat pud maam. Therapeutic: bidding goodbye

It is important that this offer is unconditional. That is, the client does not have to respond verbally yo get the burse attention.

Bidding goodbye means showing respect that the conversation is already done.

Eight day interaction ( May 13, 2011)

SN1 and SN2: maayung hapon maam nancy. P: maayung hapon sab ninyu jen ug jhyne. y Giving Recognition Greeting client, indicating awareness Indicates awareness of change of change, or noting effort the client and personal efforts. Does not imply good or bad, or right or has made all show that the nurse wrong. recognizes the client as a person, as individual. SN1: maam nancy adona na pod tai laing therapy karon maam P: unsa man nga therapy dai? SN2: mag dance therapy, mag exercise ug mag snack mo pagkahoman maam. P: ok jen ganahan kaayu ko mo apil anang exercise ug dance therapy dai. SN1: sige maam nancy apil jud ka ron ani maam ha, mintras nag andam pa ang among mga kauban maam mag esturya sat a maam, ok ra ba nimu maam. P: ok ra jhyne General leads Encopurage the client to join the activity. Giving information Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect.

SN2: ok lang nimu maam mag sulat mi samtang ga esturya ka maam? P: ok ra dai, imong e sulat akong e sulte dai. SN2: oo maam ok ra nimu maam?amo lang ni e apil sa among documentation maam sa among therapy nimu maam. P: aw oh ok ra dai. SN1: kumosta naman imong pamati ron maam? P: ok raman ko dai kong mag nerbyus ko dai kai usahai na laman. SN2: nganung nerbyuson man dyapon ka usahai maam? P: kai makahinumdom man dyapon lko sa nahitabo ni papa ug katong awai nila sa contructor sa among balai dai gud dayun ug mo inum ko ug kape pod dai mag nerbyus pod ko. Nya kana galing mag nerbyus ko dai kai ma imagine man gud nako tong nahitabo sauna gud dai nya mao man to makadugang sa akong ka kuyaw deep inside gud dai. SN1: unsa man na mga panghitabo ang makapahinumdom nimo sa nahitabo ni papa nimo ug sa contructor maam? P: kanang naay mag awai dai labi na kong naa sa akong atubangan. SN2: unsa pd imong buhaton maam kon naa mag awai o maglalis sa imong atubangan maam? P: mo layu nalang ko daan dai haron malikayan nako ang

Asking permition

Ask the permission of the client if she want document what you observe of see in her.

Therapuetic: questionning .

Questioning the client in order to further emphasize some information that we can get from the client.

Therapeutic technique: Broad opening and Questioning

Broad opening is used in order to start a conversation between us and the patient

Therapuetic: questionning

Questioning the client in order to further emphasize some information that we can get from the client.

pagjhinumdom sa mga panghitabo dai. Dai mo pahowai nako ha? SN1 AND SN2: Ok maam sige maam salamat maam. SN1: Ay maam ugma wala di ai mi duty, mmo balik mi pohon maam martes na then naa na pod unya tai therapy ana maam mag bibliotherapy or dili excersize thearapy ta ana pohon maam. Sultehan ra ka namo maam kon unsa ang una buhaton unya pohon maam. P: ok jen ug jhyne martes ha. Sige babye. SN1 and SN2: oo ma am martes pohon mi mobalik, bye2x maam. Therapeutic: bidding goodbye. Bidding goodbye means showing respect that the conversation is already done. Giving information Informing the client of facts increase her knowledge about a topic or lets the client knows what to expect.

Tenth day interaction (May 18, 2011)

SN1 and SN2: maayung hapon maam nancy. P: maayung hapon sab ninyu jen ug jhyne. y Greeting client, indicating awareness Giving Recognition of change, or noting effort the client Indicates awareness of change and personal efforts. Does not has made all show that the nurse imply good or bad, or right or recognizes the client as a person, as wrong. individual. Giving information Inform the client of what therapy will be done on that day.

SN1: maam nancy adona na pod tai laing therapy karon maam P: unsa man nga therapy dai? SN2: karon maam mag cooking therapy ta maam last na ni natong therapy maam kai last na sad namu ning duty karon na adlaw maam. P: maao lagi jhyne ug jen mingawon jud ko ninyu jen ug jhyne dili jud ko malimot ninyu. SN1: kami pod maam nancy dili pod mi malimot nimu. (preparing for cooking therapy patient with 2 student nurses washes their hands) P: (after the therapy) salamat kaau ninyung duha jhyne ug jen ha. SN2: salamat pod kaau nimu maam nancy imo mi gi welcome sa imong kinabuhi maam. P: mingawon jud ko ninyung duha oi, SN2: kami pd maam, maam mangutana lang unta mi maam ug unsai

imong nakat unan sa atong mga nangaging therapy.? P: daghan kaau kong nakat unan ningyu dai katong atong exercise makapaabtic sa lawas, katong drawing therapy kabalo na di ay ko ran jhyne ug jen kon maguol ko mag drawing2 na laman ko para makuhaan pod ang akong kaguol. Katong music therapy ganahan kaau kong maminaw ato kai relaxing kaau. SN1: wow! Maam haapy kaau mi na nakadungog sa imong gi esturya maam na adona kai daghang nakat unan sa atong pagkauban bisan sa kadyut lang na panahon. P: ako pod dai malipayun kaayu na ni abot mo sa akong kinabuhi unta dili ko ninyu kalimtan. SN2: dili mi malimot nimo maam nancy oi e ampo ka namu cge maam na unta magpadayun ang imong progress maam. P: salamat dai kamu pod e pray pod naqko mo always na mahoman jud mo sa ingyung school ug makapasar sa board exam. SN1: salamat kaau maam nancy, maam nans dako kaayung pasamat namu na imo ming gisaligan sa mga events na nahitabo sa imong kinabuhi ug selbe among e ilis sa imong pagsalig maam mao ang pag keep atong mga information sa sa ato lang tulo maam salamat kaau ug dako maam. (Final saying goobye) (giving of gift away

PSYCHOPHARMACOLOGY

GENERIC NAME: Fluphenazine decanoate TRADE NAME: Prolixin decanoate CLASSIFICATION: Antipsyhcotic, phenothiazine PHARMACODYNAMICS High incidence of extrapryamidal symptoms and a low incidence of sedation, anticholinergic effects, antiemetic effects, and orthostatis hypotension. The decanoate esther dramatically increases the duration of action. Fluphinazine hydrochloride can be cautiously administered to clients with known hypersensitivity to other phenothiazines. USES 1. 2. Psychotic disorders Decanoate for prolonged and parenteral neuroleptic therapy (e.g.chronic schizophrenics)

NURSING CONSIDERATIONS: Administration/Storage y In poor risk clients (i.e. phenothiazine hypersensitivity or with disorders that predisposes to untoward reactions) start PO or parenteral drug cautiously. y y y Protect all forms of medication from light. Store at room temperature and avoid freezing the elixir. Color of parenteral solution may vary from colorless to light amber. Do not use solutions that are darker than light amber.

Do not mix the hydrochloride concentrate with any beverage containing caffeine, tannates (e.g. tea), or pectins (e.g. apple juice) due to a physical compatibility.

Give the short-acting form when beginning phenothiazine therapy. Consider the decanoate form after the response to the drug has been evaluated and for those who demonstrate compliance problems.

An approximate conversion is 20mg of the hydrochloride to 25mg of the decanoate.

Asessment y y y Document indications for therapy, onset and characteristics of signs and symptoms, other therapies trialed, and the outcome. Obtain baseline labs and monitor periodically during prolonged therapy, LFTs, CBC, and eye exams. Note age, mental status, and physical condition. Elderly and debilitated clients are at increased risk for acute extrapyramidal symptoms.

Client/Family Teaching y y y y y y y y Review administration times; determine if client able to assume responsibility for self-medication. Avoid activities that require mental alertness until drug effects realized. Review written guidelines concerning side effects that should be reported and when to return follow-up. In hot weather, avoid strenuous activity, keep cool as heat stroke may occur. Do not stop abruptly. Change positions slowly to avoid low BP effects. Report any sore throat, bleeding, mouth sores, unusual fatigue or fever, need CBC an drug withdrawn. Wear sunscreen to prevent sunburns, increase fluids to prevent constipation and for dry mouth effects. Avoid alcohol, CNS depressants, and OTC drugs or cough remedies. Report any unusual or intolerable side effects.

GENERIC NAME Chlorpromazine hydrochloride TRADE NAME Thorazine, novochlorpromazine CLASSIFICATION Cns agents, psychotherapeutic, antipsychotic PHARMACODYNAMICS Phenothiazine derivative with actions at all levels of CNs. Mechanism that produces stron antipsychotic effects is unclear, but thought to be related to blockade of postsynaptic dopamine receptors in the brain. Actions on hypothalamus reticular formation produce strong sedation, hypotension, and depressed temperature regulation. Has strong alpha-adrenergic blocking action and weak anticholinergic effects. Inhibitory effect on dopamine reuptake, may be the basis for moderate extrapyramidal symptoms. They are sometimes called neuroleptics because they tend to reduce initiative and interest in environment, decrease display emotions or affect, suppress spontaneous movements and complex behavior. USES To control manic phase of manic-depressive illness, for symptomatic management of psychotic disorders, including schizophrenia, in management of severe nausea and vomiting, to control excessive anxiety and agitation. NURSING CONSIDERATIONS: y Watch to see that oral drug is swallowed and not horded. Suicide attempt is constant possibility in depressed patients, particularly when they are improving. y Chlorpromazine concentrate should be mixed just before administration in at least glass juice, milk, water, coffee, tea, carbonated beverage, or with semisolid food. y Maintenance therapy is usually administered as a single dose at bedtime.

PSYCHODYNAMICS

Predisposing Factors

BIOLOGICAL Depression runs in families.Genes may influe nce depression by causing abnormal activity in the brain. Studies have shown that certain brain chemicals called neurotransmitters play an important role in regulating moods and emotions. Neurotransmitters involved in depression include norepinephrine, dopamine, and serotonin. An imbalance of hormones may also play a role in depression. Many depressed people have higher than normal levels of hydrocortisone (cortisol), a hormone secreted by the adrenal gland in response to stress. In addition, an underactive or overactive thyroid gland can lead to depression.  no thorough information gathered from our patient  patients chart does not have good information from her biological status  Our client verbalized that the reason why she was admitted because of too much consumption of coffee 5 to 6 tall cups.

PSYCHOLOGICAL Psychological theories of depression focus on the way people think and behave. In a 1917 essay, Austrian psychoanalyst Sigmund Freud explained melancholia, or major depression, as a response to losseither real loss, such as the death of a spouse, or symbolic loss, such as the failure to achieve an important goal. Freud believed that a persons unconscious anger over loss weakens the ego, resulting in self-hate and self-destructive behavior. Cognitive theories of depression emphasize the role of irrational thought processes. American psychiatrist Aaron Beck proposed that depressed people tend to view themselves, their environment, and the future in a negative light because of errors in thinking. These errors include focusing on the negative aspects of any situation, misinterpreting facts in negative ways, and blaming themselves for any misfortune/adversities in their lives.  Claimed that she misses her family  Claimed that she was not able to work and earn money for no one will accept her.  Claimed that had witness trauma with her fathers fight against the constructor of their house.  Claimed that fighting between her and her brother often happen at their house.  Claimed that no one likes her in their school because of her being silent type person.

SOCIOCULTURAL Some theorists proposed that poverty, society, and cultural cacophony could cause depression or major depression. Little data is available regarding depression in persons from different ethnic, racial, or cultural groups, yet is known that persons from certain groups may manifest some depressive symptoms differently.  She claimed that she came from a poor family  Income of the family depends only in farming and some stuffs that her mother can trade on the market.  Has not finish attending school due to financial problem.

Precipitating Factors

Stressors  Suffering from poverty  Farming is the only source of income  Unemployed  Lacks sleep  Traumatic event  Too much consumption of coffee.

Coping Resources/Support System  Has three other siblings but she said that they were not close with the third one.  The love and care from her parents  Family visits her seldom  She only wants to be alone and walk al the time

   

Coping Mechanisms when shes under stress she will sleep or do some chores in Talay sit by her own wash her clothing do rituals like prayer

triggering symptoms Poverty Poor nutrition Lack of sleep Fatigue Social isolation Lack of social support

Experiences and develops crisis and traumatic event

Failure to cope with crisis and traumatic event which causes disequilibrium and post traumatic disorder

Maladaptive Responses  Subjective symptoms - Alterations of affect y Anger y Anxiety y Denial of feelings y Helplessness y Hopelessness y Low self esteem y Sadness - Alterations of cognition y Ambivalence and indecision y Confusion y Loss of interest y Self blame y Loss of motivation - Alterations of physical nature y Physiological disorders include pain, fatigue, anorexia, chest pain, menstrual changes, headache and nausea and vomiting Alteration of Perception y Delusion and hallucination

 Objective symptoms - Alterations in activity y Psychomotor agitation y Psychomotor retardation y General hyperactive behavior Altered social interaction y Poor social skills y Poor thinking skills y Easily distracted y Saddened facial expression, & drooping posture

DYSTHYMIA

Management

Therapies o o o o o Art Therapy Occupational Therapy Exercise Therapy Dance therapy Play therapy -

Medications for depression Chlorpromazine hydrochloride Fluphenazine decanuate

Side effect: muscle tremors

NURSING THEORY
LYDIA E. HALL CARE, CORE, CURE

THE PERSON

THE BODY

THE CORE

THE DISEASE

THE CARE

THE CURE

According to Lydia E. Hall, behavior is everything that is said or done. Nursing can and should be professional. Hall stipulated that patients should be cared for only by professional registered nurses who can take total responsibility for the care and teaching of their patients. Halls theory consists of three major tenets. The three circles are (1.) the patients body, (2.) the disease affecting the body, and (3.) the Person of the patient which is being affected by the circles. Nursing operates in all three circles, but it shares them with other professions to different degrees. Halls theory closely resembles the nursing model of primary care. Her emphasis on the professional nurse as the primary caregiver parallels primary care nursing

to the extent that continuity and coordination of patient care are provided. In addition, Halls concepts of nurses being accountable and responsible of their own practice are pertinent and applicable ideas.

Orem's model
SELF CARE MODEL Orem's model is centered on the individual and his/her need for self-care. The model is concerned with the provision and management of self-care. A requirement for nursing exists when a person is unable to maintain for him/herself self-care action which is therapeutic in sustaining life and health, recovering from disease and injury or coping with their effects. (Orem, 197 1: 1). This notion of self-care is unique to Orem's model. The essence of Orem's model is the nurse-patient relationship. This relationship by its very nature is unbalanced with the patient having a need and the nurse the ability to meet that need. (Orem, 1980:18). However, Orem's emphasis is that this relationship is complimentary: This means that nurses act to help patients assume responsibility for their health-related self-care by: making up for existent health-related deficiencies in patient's capabilities for self-care, and supplying the necessary conditions for the patients to withhold or to maintain or increase their capabilities for self-care in order to maintain, protect and promote their functioning as human beings.

We chose the first theory because as student nurses we in this rotation can fill up the gap of the models tenets. Also as in this rotation we can help the patient at our own way relieve their loneliness, anxiety and express their feelings and thoughts. And help them cope with their stay in the institution. And in the case of the second theory we chose this because in relation to our client, we can easily observe that client lack to do some self-care.

SUMMARY OF NURSING DIAGNOSES

Posttraumatic Stress Disorder related to witnessing a serious violence Low self-esteem related to doubt concerning self-worth and abilities Interrupted family process Related to relationship crisis with family members ability to relate to each other Self care deficit related to inability to maintain good hygiene

NURSING CARE PLAN

NURSING DIAGNOSIS Posttraumatic Stress Disorder related to witnessing a serious violence OBJECTIVE At the end of our three weeks of nursing care the client will be able to: y Identifies situations events/images that trigger recollections and accompanying responses of a past traumatic experience (arguments or fights) Uses learned adaptive cognitivebehavioral therapeutic strategies to manage symptoms of emotional and physical reactivity (attending process groups for group deep-breathing techniques, relaxation exercises. Relates understanding that anger, self-blame INTERVENTION y Maintain the clients safety and integrity during posttrauma episode, using appropriate therapeutic interventions according to facility policy. y Conduct a suicide interview by questioning the client about selfdestructive acts or gestures RATIONALE y First priority is to protect the client and others from harm and injury during posttraumatic episode, since client may experience escalating anxiety, depression, or suicidal thoughts. y A suicide interview provides for clients safety clients with posttraumatic syndrome may become depressed and may have suicidal tendencies. y Active listening builds trust, allows the client to vent, decreases feeling of isolation, and guides the student nurse towards significant problem areas. EVALUATION

Listen actively to the clients details and ruminations about the recollections surrounding the traumatic events

y y

and guilt are common in persons who have experienced or witnessed traumatic events in which others were injured, assaulted or threatened. Verbalizes ability to control or manage symptoms or emotional and physical reactivity that tend to occur during recollections of the traumatic events. Demonstrates ability to remain significant calmer when exposed to situations or events that symbolize or are similar to the original traumatic events. Verbalizes reduced stress. Demonstrates ability to deal with emotional reactions in an individually appropriate manner.

Avoid statement that dictates to the client what to feel, think, and do.

The clients behaviors and decisions are best influenced by the clients needs, desires, and lifestyle , not by the singular opinions of others. Deepbreathing/relaxation exercise provides slow, rhythmic controlled patterns that decrease physical and emotional tension, which reduces the effects of anxiety and the threat of painful recollections. Cognitive therapy helps the client substitute irrational thought, beliefs, or images for more realistic ones and thus promotes a greater understanding of the clients actual role in the traumatic event, which may decrease

Teach client adaptive cognitive-behavioral strategies to manage symptoms of emotional and physical reactivity (dread, helplessness, shortness of breath etc) that accompany intrusive recollections of the traumatic event. -slow, deepbreathing technique - relaxation exercise -cognitive therapy - desensitization

Express own feelings/reactions, relief from guilt related to the traumatic event. Demonstrate appropriate changes in lifestyle/ getting support from SO/ friends as needed. Participate in plans for care/ counseling

guilt and self-blame. Systematic desensitization helps the client gain mastery and control over the past traumatic event by progressive exposure to situations and experiences that resemble the original event, which eventually desensitizes the client and reduces painful effects.

NURSING DIAGNOSIS Low self-esteem related to doubt concerning selfworth and abilities

OBJECTIVE At the end of our three weeks of nursing care the client will be able to: y Client demonstrates self-care (appearances/hygien e) appropriate for age and status. Initiates conversation with staff and others. Demonstrations absence of selfdeprecating statements. Verbalizes realistic positive statements about self and others. Acknowledges encouragement from others. Practices techniques for increasing esteem and assertiveness. - Asks for assistance when necessary. - Asserts self to have needs met.

INTERVENTION y Activate the client to wash, dress, comb hair, and use appropriate toiletries. Praise the client for all attempts at engaging staff appropriate. y

RATIONALE The act of attending to grooming and the results increase confidence and esteem. Positively rewarded behavior tends to be perpetuated, which helps the client to distinguish between self-defeating and self-enhancing socialization. Some families need reminders to support one another. Positive strokes from significant others greatly increase the clients selfworth/esteem. Keeping appointments increases the clients sense of importance/ worth/esteem. The more the client expresses positive aspects of self, the less likely the client

EVALUATION

y y

Engage the family in plans to give genuine praise to the client when warranted.

Keep all appointments with the client.

Teach the client to identify positive aspects of self by different methods

Speaks in clear audible tones Replaces negative selfdeprecating thoughts with realistic thinking.

(verbalize, write, draw)

is to focus on negative aspects.

NURSING DIAGNOSIS Interrupted family process Related to relationship crisis with family members ability to relate to each other

OBJECTIVE At the end of our three weeks of nursing care the client will be able to: y Family expresses feelings of hope and optimism regarding the family members mental illness. Family members communicate and relate to each other in a healthy, effective manner. Family will demonstrate the ability to work together and accept the changing roles of its individual members. Family guides the mentally ill person/ member toward independence within her capabilities. Family exhibits the capabilities necessary to care for the person with mental illness.

INTERVENTION y Establish the degree to which the family function and integrity are interrupted as a result of the family members mental illness. - Is the family functioning as a cohesive unit, or is it fragmented and disorganized. - Is the family capable of meeting the needs of the mentally ill person? y

RATIONALE Establishing family function is the first step in identifying areas in need of help. Families of persons with these disorders tend to have a high degree of functional impairment and may require interventions from a variety of sources including nursing, social work, and psychology, psychiatric. The nurse can coordinate to the appropriate health care team t help meet the needs of the family system and individual members Identification of family communication patterns and interpersonal relations can help the nurse to focus o

EVALUATION

Identify dysfunctional and harmful patterns of communication within the family.

Involve the family in therapeutic modalities relevant to its needs, In collaboration with the interdisciplinary mental health care team.

Acknowledge the familys sacrifice and team work in caring for the mentally ill member

Educate the family with information, knowledge, and available resources n the literature.

specific behaviors that would benefit from therapeutic intervention. Time tested therapeutic modalities are useful in promoting more functional and effective communication and behavioral patterns among family members. Recognizing the family selfless behavior, demonstrates respect and appreciation for the family as a caring and cohesive unit. Education and other supportive resource help family members to learn new strategies and begin to make the necessary changes to promote a stronger, more effective family system.

NURSING DIAGNOSIS Self care deficit related to inability to maintain good hygiene as evidenced by: - nails are dirty - presence of body odor

OBJECTIVES OF CARE Within our care, the client will consistently performs self care activities like bathes, dresses, grooms, brushes teeth, toilets, launders clothes and clean and trim nails.

INTERVENTIONS  Monitor continually the extent to which self care deficits interfere with the clients functions.

RATIONALE - Monitoring the clients functional abilities in an ongoing way helps to determine the clients strengths, and do areas need assistance. Personal hygiene assistance helps to preserve the clients dignity and self esteem. The client feels more comfortable and less confused if personal supplies are available. Routine and structure organize the clients chaotic world and promotes success. The act of grooming and its results can influence the clients attitude in a positive way.

EVALUATION At the end of our care, the client has able to improve self care as evidenced by: - clean nails - take a bath every day - less body odor - laundering clothes - Change clothes every day.

 Assist with personal hygiene, appropriate dress, grooming and laundering.

 Provide clean clothing/grooming/toile ting supplies as needed.

 Establish routine goals for self care.

 Activate the client to initiate the activity of grooming even when unwilling.  Ensure that the client is clean and well groomed

A neat appearance prevents the embarrassment and emotional trauma that result from being an object of ridicule. Positive reinforcement increases the feelings of self worth and promotes continuity of functional behaviors.

 Praise the client for attempts at self care and each successfully completed task.

ANNOTATED READING
Dealing with the Depths of Depression By Ben Martin, Psy.D.

I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would be not one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better it appears to me. Abraham Lincoln Imagine attending a party with these prominent guests: Abraham Lincoln, Theodore Roosevelt, Robert Schumann, Ludwig von Beethoven, Edgar Allen Poe, Mark Twain, Vincent van Gogh, and Georgia OKeefe. Maybe Schumann and Beethoven are at the dinner table intently discussing the crescendos in their most recent scores, while Twain sits on a couch telling Poe about the plot of his latest novel. OKeefe and Van Gogh may be talking about their art, while Roosevelt and Lincoln discuss political endeavors. But in fact, these historical figures also had a much more personal common experience: Each of them battled the debilitating illness of depression. It is common for people to speak of how depressed they are. However, the occasional sadness everyone feels due to lifes disappointments is very different from the serious illness caused by a brain disorder. Depression profoundly impairs the ability to function in everyday situations by affecting moods, thoughts, behaviors, and physical well-being. Twenty-seven-year-old Anne (not her real name) has suffered from depression for more than 10 years. For me its feelings of worthlessness, she explains. Feeling like I havent accomplished the things that I want to or feel I should have and yet I dont have the energy to do them. Its feeling disconnected from people in my life, even friends and family who care about me. Its not wanting to get out of bed some mornings and losing hope that life will ever get better. Depression strikes about 17 million American adults each yearmore than cancer, AIDS, or coronary heart diseaseaccording to the National Institute of Mental Health (NIMH). An estimated 15 percent of chronic depression cases end in suicide. Women are twice as likely as men to be affected. Many people simply dont know what depression is. A lot of people still believe that depression is a character flaw or caused by bad parenting, says Mary Rappaport, a spokeswoman for the National Alliance for the Mentally Ill. She explains that depression cannot be overcome by willpower, but requires medical attention.

Fortunately, depression is treatable. In the past 18 years, the Food and Drug Administration has approved several new antidepressants, including Wellbutrin (bupropion), Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). According to the American Psychiatric Association (APA), 80 to 90 percent of all cases can be treated effectively. However, two-thirds of the people suffering from depression dont get the help they need, according to NIMH. Many fail to identify their symptoms or attribute them to lack of sleep or a poor diet, the APA says, while others are just too fatigued or ashamed to seek help. Left untreated, depression can result in years of needless pain for both the depressed person and his or her family. And depression costs the United States an estimated $43 billion a year, due in large part to absenteeism from work, lost productivity, and medical costs, according to the National Depressive and Manic Depressive Association. The three main categories of depression are major depression, dysthymia, and bipolar depression (sometimes referred to as manic depression). Major depression affects 15 percent of Americans at one point during their lives, according to the U.S. Department of Health and Human Services. Its effects can be so intense that things like eating, sleeping, or just getting out of bed become almost impossible. Major depression tends to be a chronic, recurring illness, Laughren explains. Although an individual episode may be treatable, the majority of people who meet criteria for major depression end up having additional episodes in their lifetime. Unlike major depression, dysthymia doesnt strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesnt interfere with everyday tasks, victims rarely feel like they are functioning at their full capacity. According to the National Alliance for the Mentally Ill, almost 10 million Americans may experience dysthymia each year. Finally, bipolar disorder cycles between episodes of major depression and highs known as mania. Bipolar disorder is much less common than the other types, afflicting about 1 percent of the U.S. population. Symptoms of mania include irritability, an abnormally elevated mood with a decreased need for sleep, an exaggerated belief in ones own ability, excessive talking, and impulsive and often dangerous behavior. Study after study suggests biochemical and genetic links to depression. A considerable amount of evidence supports the view that depressed people have imbalances in the brains neurotransmitters, the chemicals that allow communication between nerve cells. Serotonin and norepinephrine are two neurotransmitters whose low levels are thought to play an especially important role. The fact that women have naturally lower serotonin levels than men may contribute to womens greater tendency to depression. Family histories show a recurrence of depression from generation to generation. Studies of identical twins confirm that depression and genes are related, finding that if one twin of an identical pair suffers from depression, the other has a 70 percent chance of developing the disease. For fraternal twins or siblings, the rate is just 25 percent. Environmental factors, however, also play an important role in depression. When combined with a biochemical or genetic predisposition, life stressors (such as relationship problems, financial difficulties, death of a loved one, or medical illness) may cause the disease to manifest itself. John (not his real name), 25, was diagnosed with depression for the first time last year when he and his girlfriend ended their three-year relationship. I

couldnt do anything because I was totally absorbed with the whole break-up issue, he says. It was impossible for me to sleep, and I would wake up at 3 or 4 in the morning and literally shake. And when it was time to wake up, I just couldnt get out of bed. In addition, substance abuse and side effects from prescription medication may also lead to a depressive episode. And research shows that people battling serious medical conditions are especially prone to depression. According to the U.S. Department of Health and Human Services, those who have had a heart attack, for example, have a 40 percent chance of being depressed. Seasonal affective disorder, often called SAD, is a striking example of an environmental factor playing a major role in depression. SAD usually starts in late fall, with the decrease in daylight hours and ends in spring when the days get longer. The symptoms of SAD, which include energy loss, increased anxiety, oversleeping, and overeating, may result from a change in the balance of brain chemicals associated with decreased sunlight. The exact reason for the association between light and mood is unknown, but research suggests a connection with the sleep cycle. Several studies have suggested that light therapy, which involves daily exposure to bright fluorescent light, may be an effective treatment for SAD. Medical professionals generally base a diagnosis of depressive disorder on the presence of certain symptoms listed in the American Psychiatric Associations Diagnostic and Statistical Manual. The DSM (presently in the fourth edition) lists the following symptoms for depression: depressed mood loss of interest or pleasure in almost all activities changes in appetite or weight disturbed sleep slowed or restless movements fatigue, loss of energy feelings of worthlessness or excessive guilt trouble in thinking, concentrating, or making decisions recurrent thoughts of death or suicide. The diagnosis depends on the number, severity and duration of these symptoms. Even with this list of symptoms, diagnosing depression is not simple. According to the National Alliance for the Mentally Ill, it takes an average of eight years from the onset of depression to get a proper diagnosis. In making a diagnosis, a health professional should also consider the patients medical history, the findings of a complete physical exam, and laboratory tests to rule out the possibility of depressive symptoms resulting from another medical problem. The symptoms of the depressive part of bipolar disorder are the same as those expressed in major (unipolar) depression. Because of the similarities in symptoms and the fact that manic episodes usually dont appear until the mid-20s, some people with bipolar disorder may mistakenly be diagnosed with unipolar depression. This may lead to improper treatment because antidepressants carry the risk of triggering a manic episode.

Summary of the article:

This article talks about ow to deal with depression it is said that depression is a form of occasional sadness everyone feels due to lifes disappointments is very different from the serious illness caused by a brain disorder, on the otherhand depression profoundly impairs the ability to function in everyday situations by affecting moods, thoughts, behaviors, and physical well-being. Several individual shared their thought s under depression and this is how it goes, For me its feelings of worthlessness, she explains. Feeling like I havent accomplished the things that I want to or feel I should have and yet I dont have the energy to do them. Its feeling disconnected from people in my life, even friends and family who care about me. Its not wanting to get out of bed some mornings and losing hope that life will ever get better. Women are twice as likely as men to be affected. Many people simply dont know what depression is. A lot of people still believe that depression is a character flaw or caused by bad parenting, says Mary Rappaport, a spokeswoman for the National Alliance for the Mentally Ill. She explains that depression cannot be overcome by willpower, but requires medical attention. Fortunately, depression is treatable. In the past 18 years, the Food and Drug Administration has approved several new antidepressants, According to the American Psychiatric Association (APA), 80 to 90 percent of all cases can be treated effectively. However, two-thirds of the people suffering from depression dont get the help they need, according to NIMH. Many fail to identify their symptoms or attribute them to lack of sleep or a poor diet, the APA says, while others are just too fatigued or ashamed to seek help. Left untreated, depression can result in years of needless pain for both the depressed person and his or her family. It is said that there are three main types of depression these are major depression, dysthymia, and bipolar depression. Major depression "tends to be a chronic, recurring illness," Laughren explains. Although an individual episode may be treatable, "the majority of people who meet criteria for major depression end up having additional episodes in their lifetime."Unlike major depression, dysthymia doesn't strike in episodes, but is instead characterized by milder, persistent symptoms that may last for years. Although it usually doesn't interfere with everyday tasks, victims rarely feel like they are functioning at their full capacity. According to the National Alliance for the Mentally Ill, almost 10 million Americans may experience dysthymia each year.Finally, bipolar disorder cycles between episodes of major depression and highs known as mania. Bipolar disorder is much less common than the other types, afflicting about 1 percent of the U.S. population. Symptoms of mania include irritability, an abnormally elevated mood with a decreased need for sleep, an exaggerated belief in one's own ability, excessive talking, and impulsive and often dangerous behavior.

Reaction:

In dealing with depressed clients as health care providers we must not only focus on giving right medication to clients who are depressed we need to explore or target right away the main cause of the problem. What we mean to accentuate here is that we are apt to treat the underlying cause of the problem, this then reveal that our treatment must focus on providing emotional support to clients who suffer from depression, and somehow we must be particular of the triggering factors that might give an additional depressive episode to these kinds of clients, indeed therapeutic management has been proven to give the ample cure or recovery to these clients.

CONCLUSION
After how many times we had our duty at Talay rehabilitation center, we can really say it was indeed a challenging experience. We consider it as the challenging part of all our duties because we were able to render good and correct therapies to our patients. We were able to encourage ourselves to develop therapeutic alliance and relationship with our clients. Through this we were able to know importance of meaning and value of human life in which we were able to appreciate the knowledge and skills that God had given to mankind. We were able to see how the health care professionals developed their skills in caring for patients and excecuting decisions for psychiatric patients. We are able to enhance our knowledge and skill as well as our attitudes in implementing different therapies especially our communication skills has also been polished. Therapeutic communication is very crucial in dealing with psychiatric patients and we are thankful that they cooperated well during our interviews although they seem to be moody patients, indeed they still show how previllage they are to be with us even if it was just for a short while. The Psychiatric rotation as a whole is full of fear and anxiety since this is different rotation we ever had but truly one of the exciting experience we had. Whether we are doing therapies or interacting with our patient, everything simply is amazing and quite a memorable experience. From the humorous stories and chats with classmates to the intellectual discussions on various manifestations of every patient during our ride in going to Talay wherein we were able to apply the theories we learned in the classroom lectures and discussions. Every day of duty is always a fun and looked forward to a new, exciting but knowledgeable experience because in this rotation we do not do perform routine procedures we are usually doing in clinical area at NOPH but instead we are exposed to different unexpected behaviors of patient. We must implement therapies that would increase their self worth. Because of these, we were able to realize one persons worth and importance as well as we are able to value their worth, dignity and integrity as a human being like us. Everything starts and always has an ending. It feels sad for us to leave the Psychiatric rotation because we have become used to it and the patients, the staff, aids which they have become a part of our lives. But what really count most are the experiences and the knowledge we learned in the short time of our duty at the Talay Rehabilitation Center, which will be forever live within our hearts.

BIBLIOGRAPHY

INTERNET:
y y y y www. slideshare.net/specialclass/predisposing-and precipitating/factors. retreive may 18, 2011 www. eric.ed.gov/ERICWebPortal/search/detailmini.jsp retreive may 18, 2011 Depression [http://www.nlm.nih.gov/medlineplus/ency/article/003213.htm] retrieve may 18,2011

ARTICLE:
y Ben Martin, Psy.D. Dealing with the Depths of Depression. PsychCentral. March to May 2011

BOOKS:
y y y y y y Norman L. keltner et.al. (2007) Psychiatric Nursing 5th edition. Singapore. Wanda K. Mohr. (2006) Psychiatric Mental Health Nursing. 6th edition Lippincott Williams and wilkins Philippines. Mary Ann Boyd psychiatric nursing 8th edition. mosby Inc. Gail W. Stuart and Michelle T. Larqia. Principles and practice of psychiatric nursing 8th edition. Mosby Inc. Alexandria, VA (2003). National Mental Health Association (NMHA), N Beauregard Street. Shryock H., M.D. Modern Medical Guide revised edition. Philippine Publishing House.