Henrico Paulo Ordiales August 10, 2010

BSN129 Sir Julius Cheong

I. Background Information

Dela Cruz, Xyrus Bryan y Bodoso Male 20 years old Nov. 5, 1987
#34 Panamitan, Kawit Cavite
Filipino Roman Catholic Elementary Graduate
Father: Rodelio Dela Cruz
Mother: Lilia Bodoso
Admitted: Oct. 7, 2008
Presenting Complaint: Nagwawala, nananakit, tumatawa mag-isa
Diagnosis: Undifferentiated Schizophrenia

II. Objectives

1. To let the mentally ill patient express their thoughts and feelings
independently
2. To establish a therapeutic, simple and credible communication
3. To improve the interaction of the patient to the nurse and others

III. Brief Description of the following:

A. Environment
- The nurse patient interaction took place at the ground of pavilion 1
at around 4:30pm. There are different kinds of trees around the ground. There
were patients who were making noise inside the ward but it didn’t interrupt our
interaction. 1st the sky is dark, after 30 minutes the sky turn into sky blue.

B. Nurse
- The student nurse was prepared for the interaction. The distance of
the student nurse from the patient during the conversation was 2 feet. The
emotional status of the student nurse is okay.

C. Patient
- The patient looks straight and sometimes looking to his left and
right. The patient sits in a straight body. In terms of physical appearance, the
patient’s nails are short with clean hands but odorous smell.
IV. Record of Interaction

Nurse Patient Interaction Defense Mechanism Rationale

SN> Ang pangalan ko ay None
Paulo 19 years old. Ikaw
anung pangalan mo at
edad?
P> Ako si Xyrus Bryan
Dela Cruz 21 years old
nakatira sa Bicol

SN> Anu-ano mga Suppression, Resistance The patient may not like
ginawa mo kaninang the environment in the
umaga? institution so he
P> Di ko alam consciously excludes his
awareness to the things he
usually do in the
institution.

SN> Tumutulong ka ba sa Suppression, Resistance The patient may not like

mga Gawain dito? the environment in the
P> Di ko alam institution so he
consciously excludes his
awareness to the things he
usually do in the
institution.

SN> Ano masasabi mo Reaction formation The patient may not like
sakin? the presence of a
P> Mabait companion so when
SN> ano pa? further asked about the
P> Di ko alam things he like about his
companion, he didn’t add
any more things to say.
SN> Alam mo ba kung None
ano tawag sakin?
P> Studyante
SN> Anung klaseng
studyante?
P> Feu
SN> Tama taga Feu ako
pero student nurse pa lang
ako
SN> Ikaw, ano masasabi Introjection The patient may
mo sa sarili mo? unconsciously integrate
P> Mabait, masipag the characteristics of his
companion as his own.

SN> Ah, eh anu-ano mga Resistance The patient shows

pagkain niyo dito? antagonism towards
P> Baboy remembering the things
SN> Anu pa? that may trigger his
P> Tinolang Manok anxiety
SN> anu-ano ang
makakain mo sa Tinolang
Manok?
P> Gulay
SN> Tama! Sige anung
gulay meron sa Tinola?
P> Di ko alam

SN> Anon man mga Resistance The patient shows

paborito mong pagkain? antagonism towards
P> Di ko alam remembering the things
SN> Eh mga chichirya? that may trigger his
P> Pringles tsaka anxiety
chocolate

SN> Wala ka bang Resistance The patient shows

maikwekwento sakin? antagonism towards
P> Di ko alam remembering the things
P> Nanay ko that may trigger his
nagtratrabaho sa palengke anxiety
SN> Anu tinitinda ng
nanay mo?
P> Isda
SN> Eh ang tatay mo anu
trabaho?
P> Karpintero
SN> Alam mo ba kung
anu ginagawa ng
karpintero?
P> Gumagawa ng bahay
SN> May alam ka bang The patient shows The patient shows
hayop? antagonism towards antagonism towards
P> Di ko alam remembering the things remembering the things
P> Pusa, kalabaw that may trigger his that may trigger his
SN> Ano pa? anxiety anxiety
P> Di ko alam

SN> Kamusta naman ang

pakiramdam mo?
P> Mabuti
SN> Nagsisipilyo ka ba at
ilang beses kayo naliligo?
P> 6 na araw. Malinis Compensation Overachievement in one
ako. area to offset perceived
deficienceies in another
area.

Psychiatric: mental
health nursing (4th
edition) by: shiela l.
videbeck. p.47-48

IV. Evaluation
The first objective was not met because of the patient’s inability to express
easily his thoughts and feelings but the last two objectives were successful because
of the simple conversation that the student nurse and the patient had, I can say that
the patient somehow improve his interaction to others and to the nurse. There are
still changes need to be made especially on how to be successful in therapeutic
communication and also to improve the time management.