Nursing Process

I. Assessment (interview was done on July 28, 2010)

A. General Data
Patient’s Initial: L.E.
Address: CAPIZ Informant: Patient L.E.
Age: 44 y.o. Date of Admission: March 20, 2010
Sex: Male Order of Admission: Escorted by ACR Officer B.D.

Date of birth: August 10, 1965 No. of days in this Hos.: 132 days
Civil Status: Married
Occupation: Driver
B. Chief Complaints
“For Psychosis Observation” (recommended by Dr. Ramona)
C. History of present illness (interview was done on July 28, 2010)
On December 11, 2008, the client attended a Christmas Party. He was on his way home driving a van
while under the influence of alcohol when suddenly he swerved and collided with a tricycle. He remembered
waking up in the hospital and was later reported; that the person that was driving the tricycle had died. He felt
sad of what had happened. Several weeks before his trial, he claimed that his lawyer told him to hide, though
he felt that it was really his fault. He went into hiding he said and tried to live his life. According to him
months past, he started to hear voices. When he asked about his how he dealt with the voices, he said that he
just ignored and paid no attention to what he hears.
On July 28, 2009, the client was caught by police and he was immediately jailed. (Reports shows, that
even the jail attendants, noticed that he was mumbling to himself a lot while he was incarcerated.) The legal
complaint was filed later almost a year.
On February 15, 2010 was when his court appearance was scheduled. He was tried for Reckless
Imprudence resulting to Homicide and Damage Property. (During the trial, it was noted that the client was
answering softly and was in a stooped position with poor eye contact.) After in which, he was examined by
Dr. Ramona S. Magayanes. He was referred to be admitted to a mental institute for further observation for
psychosis. Dr. Ramona prescribed medication for the client but the client was unable to purchase it
(medication is unrecalled by client). The said doctor filed a certification of recommendation to be admitted to
NCMH in which the judge, Judge Alicia A. Cruz-Barios approved of.
On March 20, 2010, the client was admitted at NCMH pavilion 4 (Forensic Pavilion) whom was
escorted by officer B.D. of ARC Aklan. He was treated here and observed. He was diagnosed with paranoid
schizophrenia. He was given chlorpromazine 200mg as his medication which was discontinued in the month
of May 15, 2010.
On May 15, 2010, he was re-diagnosed to be “Severe depressive episodes without psychotic symptoms,
improved and competent. His sertraline was discontinued June 13,2010. Ever since then client has been off his
medication until to this date but his diagnosis is as is (SEVERE DEPRESSIVE EPISODES WITHOUT
PSYCHOTIC SYMPTOMS; IMPROVED AND COMPETENT)

D. Past History
1. Childhood Illness: Varicella (1973)
2. Adult Illness: Unrecalled
3. Immunization: Unrecalled by patient
4. Previous Hospitalization: Rafael S. Tumbokon Memorial Hospital (2002)
5. Operations: Eplor. Lap. (2002)
6. Injuries: Stabbed on his right side…. (1995)
7. Medications: -
 8. Allergies: None

E. System Reviews(interview was done on July 29/30, 2010)

1. Health Perception- Health Management Pattern

For the past 6 months, the client seldom experienced episodes of fever usually accompanied with cough
and colds. But earlier, in cases of such, he does not take any medications. Instead, he just increases his fluid
intake or he just lets it go away on its own. The client smokes about 5-10 sticks of cigarettes a day and drinks
occasionally usually a half bottle of Tanduay Rhum once every week or a bottle of San Miguel Beer before
sleeping. He was involved in a vehicular accident which caused him to be convicted of Reckless Imprudence
resulting to homicide back in his hometown in Aklan.

At present, the client rates his health with, 5/10. (0- lowest,10-highest) Upon Interview the client stated
that he has been getting sick a lot lately. He usually experience colds and coughs and he thinks it is because of
the overcrowding of patients at their pavilion, he doesn't take any multivitamins or any dietary supplements.

2. Nutritional Metabolic Pattern

The usual time they eat their breakfast is around 5:00-5:30am. The usual food they serve in the morning
is 1cup of Coffee and 4pcs of Pandesal. For lunch, they usually eat fried fish such as tilapia, galunggong,
bangus with rice. He seldom eats vegetables and fruits because it is seldom served. For Dinner usually they
serve Slices of pork, chicken or “giniling” with rice. He has a good appetite; he also mentioned that the serving
rationed is not enough to satisfy his hunger. His usual fluid intake is 6 cups of water (est. 240cc a cup), and he
seldom drinks soda and fruit juices.

3. Elimination Pattern

6 Months prior to admission, the client voids without any discomfort, no use of any diuretics and
urinates about 6-7 times a day or depending on the client's fluid intake in about less than a glass full per void
(240cc) with a characteristic of clear to yellow-orange in color. He eliminates twice or thrice a week with a
characteristic of hard, formed, and brownish in color with a little difficulty. He doesn't take any laxatives.

At present there is no problem in client's voiding and experience no difficulty; same with defecating.

4. Activity- Exercise Pattern

The patient doesn't perform any exercise except for their daily routine exercise in jail which is about 30
minutes of walking around the vicinity.

At present, he still doesn't perform any exercise; He usually just lay around or sleep because he feels
easily tired and usually don't have the energy to perform such activities but sometimes when there are student
nurses he is able to perform some exercises as part of their socialization activity.
Client says that they take baths once a day in the morning around 4 a.m.

5. Sleep- Rest Pattern

For the past 6 months the client has been having hard time to sleep. He usually tries to sleep early but
ends up lying around in his bed thinking about the things that happened to him and if he does fall asleep early
he wakes up early in the night because of nightmares and he usually experience early awakenings. He feels that
his sleep is not enough for him and has insufficient energy for the day.

Upon Interview the client stated that he tries to sleep around 7:00pm and finds himself awake till 12:00
midnight, "Maaga akong humihiga pero hindi naman ako makatulog, ang dame ko kasing naiisip lalo na yung
pamilya ko" as verbalized by the client; then he wakes up at 5:00 in the morning to take their medicine and eat
his breakfast and do his morning care. By 7:00am he then tries to sleep again and wakes up during lunch time.
The client states that they sleep on the floor of the cell.

6. Cognitive- Perceptual Pattern

The client is very much involved with the upbringing of his children. He and his wife consult each other
in making important decisions such as financial matters and things that concern the family. He used to have
reading glasses which he does not recall the grad. He does not have hearing difficulties or changes in his
memory for the past 6 months and he feels that his senses and reflexes are keen and responsive. He confesses
that ever since his vehicular accident with the tricycle; he started to hear voices.

At present the patient stated that his right eye is getting blurry which started about a year ago, but other
than that there no changes in his memory and his reflexes are keen and responsive. He admits that he has had no
episode of voices he would hear 3 months ago.

. 7. Self- Perception Pattern

Prior to confinement, the client sees himself as a happy and outgoing person. He gets along well with
people like his co-drivers, neighbors, friends and family. The most thing that stressed him most of the time is
when he and his wife has misunderstanding and leads to an argument and he likes his personal belongings not to
be touched by anyone even his wife, but other than that he feels good about himself and is happy with his life

Upon the interview, everything changed. According to him, he feels that there is no chance for him to
get out of NCMH, and he feels very depressed about his situation especially he feels that no one is taking care
of his case and his wife isn't able to visit him because of some reasons like the distance and monetary problems.
"Hindi pa nga ako dinadalaw ng misis ko, miss na miss ko na sila ng mga anak ko at sobrang nawawalan na
akong ng pag asa dahil wala man lang tumutulong sa akin para maayos ko ang kaso ko" as verbalized by the
client.

8. Role-Relationship Pattern

The client lives with his wife together with their 4 children in aklan. They have a nuclear type of family
and are very happy with the relationship he has with them. He loves his family very much and they support each
other especially in difficult situations and he is the breadwinner of their family.

At present, J.E's wife is currently the breadwinner of their family because of his situation. He hasn't been
able to see his wife since he was brought to NCMH and he is devastated that his wife has to work for their four
children and he feels that he can't perform his responsibility as the head of their family which upsets him a lot.

9. Sexuality- Reproductive Pattern

The client states that he is satisfied with his sexual relationship with his wife. "Kaya nga naka apat kami
e" as verbalized by J.E. He's very thankful for his wife for satisfying his needs not only emotionally but sexually
as well. “Kapag ayaw niya, nialalambing ko lang siya at saka konting suyo” he added. They do not use any kind
of artificial contraceptives.

At present the client is not sexually active.

10. Coping- Stress Pattern

Prior to confinement, the biggest stressor for L.E. is his case. He has been constantly bothered by it
which gave him severe depression and anxiety. 3months before his admission in NCMH he mentioned that he
has been hearing voices in which he doesn't want to tell what kind of voices he was hearing and what it was
telling to him. He became apprehensive upon the question and doesn't want to answer anything about the voices
he heard. He also likes his personal things not to be touched.

Upon Interview, client is still depressed that he won't see his family anymore and he feels hopeless that
he can ever get out NCMH. He said he usually talks with his fellow inmates and ask for their advice. Often
times he just tries to sleep it of when he feel depress. When asked about if he had any suicidal tendencies, he
said that he has thoughts or idea of committing suicide. He says when he gets those kinds of thoughts or idea he
would just avert his thinking to something else.

11. Values- Beliefs Pattern

The client is a Roman Catholic but does not go to church regularly. He goes to church about 3 times a
month. But given the chance, he goes to mass with his family. He says he has a good relationship with the Lord
and if he has problems he prays and asks for his guidance and help. He prays the rosary before sleeping and he
believes he has a strong faith to our Lord.

At present, he prays a lot because he believes that God is the only one who can help him in his endeavor.
He doesn’t want anything else for himself any more. He just wants the security and good future for his children
and the happiness of his wife. Client feels hopeless as well because he believes his case will never be prioritize
and he would live his remainder of his life in prison.

F. Family Assessment

Name Age Relation Sex Occupation Educational

attainment
S.E 29 Wife Female House Maid 3rd year high
school.
J.E 12 Son Male None Grade 6 student
K.J.E 11 Daughter Female None Grade 6 student
S.M.E 6 Daughter Female None Kinder
L.J.E 2 Daughter Female None None

G. Heredo
Maternal- Hypertension, Mental Retardation
Paternal- Hypertension
H. Developmental History

Theorist Age Task Patient Description

Sigmund Freud 45 Genital Previous to his
confinement in NCMH
as stated in his
Gordon’s he states that
him and his wife’s
sexual relationship is
quite satisfactory. He
also states that his wife
supports him not only
sexually but
emotionally as well. As
of now client is not
sexually active and
hasn’t masturbated.
Erik Erikson 45 Stagnation At present, the patient is
not socializing because
he is preoccupied by his
case. “Hindi na ako
binibisita ng asawa ko.
Nawawalan na ako ng
pagasa”, as stated by the
client.
Jean Piaget 45 Formal Operation The patient responds
slow every time he’s
been asked a question.
No eye contact and his
head is stoop down
every time he answers a
question. “hindi ko
madalas Makita
pamilya ko. Namimiss
ko na mga anak ko.
Nawawalan na ako ng
pagasa”, as stated by the
client.
Lawrence Kohlberg 45 Post-conventional One reason that may
have been the cause of
depression of the patient
is due to the case that he
has right now because
 the guilt that he feels
still remains within his
thoughts, also he’s
thinking about the status
of his case if he still has
a chance of living his
life outside the
Institution of NCMH.
Secondly he always
thinking of the
condition and situation
of his family, like on
how’s the education of
his children, how’s
there way living and
what kind life will they
have in the near future
now that he is
imprisoned inside
NCMH. Lastly he also
stated that whenever he
feels something bad
like a headache he just
forces himself to sleep
just to abide the pain
because when he tries to
ask for any medication
from the institution he
just get scolded.
James Fowler 45 Paradoxical- The patient insisted of
consolidative following his lawyer’s
advice to hide but deep
inside he knew that he
is wrong or guilty. He
admits to himself that
he is guilty for what he
has done.

I. Physical assessment

A. Physical Examination
Date of Examination: July 30, 2010, 3 p.m.

Height: 5’4 Actual Weight: 120lbs

Actual Height: 162.56 cm Ideal Body Weight: 130.24 lbs

Vital Signs:

Temperature: 36.9°c
PR: 80 bpm
RR: 18 cpm
BP: 100/70 mmhg

Regional Examination

GENERAL APPEARANCE:

Patient walks in a slouch position. Often patient is in a stoop position and with poor eye contact.
Patient is well groomed. Patient also looks weak (anergia). Refer to Mental status Examination
1. Skin
I:
 varies from light to deep brown
 generally uniform except in areas exposed to the sun
 tattoo in his left chest, right deltoid muscle and left scapular area
 Presence of scars in the abdominal area, keloid because of surgery
about 23 cm and stab wound in left iliac region horizontal line about 5 cm

P:
 No edema , dry skin
 Uniform; within normal range
 (+) diffuse asymmetrical crust on both lower extremities

2. Nails
I:
 Convex curvature, angle of nail plate about 160°
 Smooth texture
 Highly vascular and pink in color
 Intact epidermis

P:
 After 3 seconds positive blanch test of capillary refill

3. Head and Face

I:

• Rounded normocephalic and symmetrical in shape

• Asymmetric facial features
• Symmetric facial movements
P.
• Absence of mass and nodules
• Uniform consistent skull

4. Eyes
I:

• Eyebrows evenly distributed; skin intact

• Eyebrows symmetrical aligned
• negative discharge and discoloration
• whitish color on right lens of the eye
• dark circles around the eyes (eye bags)
• Intact extraocular muscle
• 20/40 visual acuity
• Squinting of eyes
• Leans head forward towards the reading material

P:
• Negative edema on lacrimal gland
• Intact trigeminal nerve
5. Ears
I:
• Color same as facial skin
• Symmetric
P:
• Mobile
• Firm
• Not tender
• Pinna coils

6. Nose
I:

• Symmetric
• No discharge
• Uniform in color
P:
• Not tender
• Facial sinuses not tender

7. Mouth and Pharynx

I:

• Ability to purse lip

• Symmetry of contour
P:
• Elastic lips
• Positive gag reflex

8. Neck
I:
Muscle equal in size
• Head centered
• Coordinated , smooth movements with no discomfort
P:
• Lymph nodes not palpable
• Small, smooth and painless thyroid gland

9. Spine
I:

• Spine vertically aligned

P:
• no tenderness

10. Thorax/Lungs
I:

• Symmetrical
• Tan in color

P:
• Full expansion
• None mass
• Equal bilaterally tactile fremitus
Per:
• Normal breath sounds
A:
• negative adventitious breath sound

11. Cardiovascular/Heart
I:

• (-) heaves, lifts and thrills

A:
• S1 heard at aortic,pulmonic tricuspid, and apical
• S2 heard louder at base of heart
PA:
• Symmetric pulse volumes
• Full pulsations, thrusting quality

12. Breast
I:

 Symmetrical areola nipples

 Red to pinkish in color

P:
 (-) nodules

13. Abdomen
I:
• (+) keloid in the abdominal area,because of surgery
about 23 cm vertically
• (+) scar ,stab wound, in left iliac region horizontal line about 5 cm

• Uniform in color
• Rounded
• Symmetric contour
• + pain on hypogastric area 6/10

A:
•(+) bowel sounds 5 bowel sound/minute
• Absence of bruit sounds
Pa:
• Non-palpable liver
• No tenderness

Per:
• Tympany sound over the stomach
• Dullness over the liver
14. Extremities
I:

•(+) crust on both crural and sural area

• (+) pulsation on right antecubital area
P:
• Firm muscles
15. Genitals
I: N/A

16. Rectum and Anus

I: N/A

17. Neurologic Exam

-Oriented to person, place, and time.

-Takes time to answer questions.

Motor function:
• can stand alone
• Negative Romberg test
Can perform finger to nose test
Reflexes:
• ++ patellar on left ; + right patellar
• + Achilles
• + triceps
- Babinski
MENTAL STATUS EXAMINATION:

*Appearance

The patient posture is slouch with head facing down and he has poor eye contact upon interview. He has
slow body movement and responsiveness of speech during our interview.

*Mood and Affect

The patient felt anxious during interview. The patient felt sad during interview. He seem a shame to
himself whenever he talks to other people. When asking some questions to him he interacts minimally with a
few words and gesture.

*Thought Process and Content

The patient thinks slowly, and he doesn’t easily respond when asking questions. The patient tend to be
negative and pessimistic. During the interview the client jumps from one topic to another as evidenced by using
the defense mechanism of Anne Freud which is “ Suppression ” and he takes to analyze before answering
question. Moreover; he often have thoughts of commiting suicide as evidence by hopelessness because his
family do not visit him and his case has no progress.

*Sensorium and Intellectual Processes

The patient is oriented to time and place as evidence by responding our questions correctly though he
takes time in organizing his thoughts.

*Judgment and Insight

The patient is still depressed that he won’t see his family anymore and he feels helpless that he can get
out NCMH. During the interview he feel guilty about the incidents happened before and this would leads to
suicidal thoughts for him. The patient seek advice to his fellow inmates to compensate his depressions and also
he tries to sleep when he feel depress.

*Roles and Relationship

Because of what happened to his life, the patient can’t perform his responsibility as the head of their
family which upsets him a lot. He feels isolated and felt alone inside NCMH.

*Physiologic and Self-Care Consideration

During interview the patient stated that he has been getting sick a lot as evidenced by experiences of
colds and cough related to overcrowd at their pavilion. The patient has a balance diet specifically pandesal and
coffee in the morning, for lunch fish with rice and for dinner pork chicken or giniling. He has good appetite.
The patient drinks about 6 cups of water and he seldom drinks soda and fruit juices. Whenever the he needs to
void he had no discomfort and defecates twice or thrice a week with little discomfort.

II. Personal/ Social History

Habits: - Rank in the Family: 2nd eldest
Vices: Alcohol, Smoking Travel: N/A
Lifestyle: Sedentary Educ. Attainment: Elementary Grade 1
Social affiliation: HGL (Happy Go Lucky)
Client’s usual day like: Client wakes up around 4a.m.and bathe together with all his inmates outside the
building and breakfast is served around 5:30 a.m. The Client would just lay down and sleep until lunch time
around 12 p.m. After lunch, client would walk around the cell or lay down on the floor and sleep. Around 6
p.m. dinner is served. Patient would try to sleep around 7 p.m. but ends up still awake until 12 midnight which
he often just lays down until he falls asleep.
III. Environmental History
Currently the patient resides at NCMH in Pavillion 4 where it is known as the forensic ward (criminal
ward). The area is gated and surrounded by high walls with barbwires attach around the top of the walls. Client
lives in one cell (est. 60 sq. meters) with about 50 or more inmates who are suffering from psychosis
(schizophrenia, bipolar, mental retardation, etc). The area is very crowded and with a very distinct musty smell.
The flooring where they sleep (no beds) is cemented. In the cell is where they urinated and defecate. A bucket
of food is delivered to them through the use of a “plangana”. The container has no lid of any sort. Food is given
to them through plastic trays prepared by other inmates who are capable and competent. Water used for bathing
and drinking is taken from “Nawasa”. Ventilation is adequate. Huge windows with gates can be found
throughout the building.

.
Pathophysiology:

Psych-Pathophysiology

Modifiable: Non-Modifiable
Diet Gender
Lifestyle Age
Vices Genetics
Sleep Hereditary
Environment Race/Culture
Developmental
Interpersonal Relationship

Psychodynamics/Cognitive Aspects Biological Aspect

Experience Perception of Stimuli

High Significant World

Loss
Self Brain Chemically imbalanced

Developed of Future
Dependency Signals through Neurons

Difficulties in Axon Terminal Releases

Relating events in Neurotransmitters:
Life (Serotonin, dopamine,
Norepinephrine, epinephrine)

Distorted Self Image

Travels across synapse

Internalize Anger Decrease amount of

Worthless neurotransmitters attached
Helpless to receptor sites
Hopeless
Guilt
Isolation
Shame, etc… Affects Reuptakes
Mood

NEGATIVE FEELINGS

DEPRESSION Suicidal DEATH

Client Base Psycho Pathophysiology

Modifiable Non-modifiable

Environment
Lifestyle Cultural
Male

Experience Stimuli

High Significant
Loss
Brain Chemically imbalanced

Developed of
Dependency Signals through Neurons

Difficulties in Axon Terminal Releases

Relating events in Neurotransmitters:
Life (Serotonin, dopamine,
Norepinephrine, epinephrine)

Distorted Self Image

Travels across synapse

Internalize Anger Decrease amount of

Worthless neurotransmitters attached
Helpless to receptor sites
Hopeless
Guilt
Isolation
Shame, etc… Affects Reuptakes
Mood

DEPRESSION
Laboratory:

NONE

Drugs:

DRUG INDICATIO ACTION SIDE NURSING PATIENT

NS EFFECTS/ADVER CONSIDERATIO TREACHIN
SE REACTIONS NS GS
Date Relief of: Chlorpromazi  Drowsiness  Be aware that  Encourage
Ordered:  Intractable ne is a  Jaundice drug may cause d caregiver
March hiccup neuroleptic  Hematological pink to red- to keep
20,2010 Management that acts by disorders: brown appointme
of: blocking the Agranulocytosis discoloration of nts for
 Psychoses postsynaptic  Cardiovascular: urine. follow-up
Generic To control: dopamine Postural  Monitor evaluation
Name:  Nausea receptor in the hypotension photosensitivity of dosage
Chlorpromazi and mesolimbic  CNS Effects: associated with regimen.
ne HCl vomiting dopaminergic Extrapyramidal chlorpromazine  Advise
system and effects, Cerebral therapy is a patient to
Brand Name: inhibits the edema, Allergic phototoxin avoid
Thorazine release of reactions of a reaction. If undertakin
hypothalamic mild urticarial severity of g activities
Classification and type or reaction occurs, requiring
: hypophyseal photosensitivity report to precision
Antipsychotic hormones. It  Autonomic physician. and mental
s has Reactions:  Watch for oral alertness
antiemetic, Occasional dry candidiasis that until drug
Dosage/Route serotonin- mouth occurs response is
: blocking, and frequently in known.
 Ocular changes
25 mg 3 weak patients  Caution
times/day PO antihistaminic receiving patient not
properties and phenothiazines. to stop
slight  Report taking this
ganglion- extrapyramidal drug
blocking symptoms that abruptly.
activity. occur most Explain
often in patients that abrupt
on high dosage. withdrawal
 When therapy of drug or
stops, dosage deliberate
must be tapered dose
off gradually skipping
over a period of can cause
several weeks onset of
extrapyra
midal
symptoms
and severe
GI
disturbanc
es.
 DRUG INDICATION ACTION SIDE NURSING PATIENT
S EFFECTS/ADVER CONSIDERATIO TREACHIN
SE REACTIONS NS GS
Date Treatment of: Sertraline  Autonomic  Be aware that  Advise
Ordered:  Depression inhibits Nervous System: effective patient to
May 15, 2010  Obsessive reuptake of Dry mouth and antidepressant use
compulsive the increased can promote caution
disorder neurotransmitt sweating. mania in when
Generic  Panic er serotonin  Central and predisposed performing
Name: disorder by CNS Peripheral people. hazardous
Sertraline with or neurons, Nervous System:  Monitor liver tasks that
HCl without thereby Dizziness and function test require
agoraphobi increasing the tremor. results and alertness
Brand Name: a amount of  Gastrointestinal: BUN and serum and not to
Zoloft  Posttrauma serotonin Diarrhea/loose creatinine levels drink
tic stress available in stools, dyspepsia in patients with alcohol or
Classification disorder nerve and nausea. hepatic and to take
:  Social synapses. An  Psychiatric: renal other
Antidepressa anxiety elevated Anorexia, dysfunction. drugs
nts disorder serotonin insomnia and  Monitor patient while
 Premenstru level may somnolence. closely for taking this
Dosage/Rout al result in  Reproductive: evidence of GI drug.
e: dysmorphic elevated mood Sexual bleeding.  Warm
50 mg once disorder and reduced dysfunction  When therapy caregiver
daily PO depression. (principally stops, to watch
This action ejaculatory delay withdrawal patient
may also in males). should be closely for
relieve gradual. suicidal
symptoms of  Watch closely tendencies,
other for suicidal especially
psychiatric tendencies. when
conditions therapy
attributed to starts or
serotonin dosage
deficiency. changes.
 Caution
patient not
to stop
taking
drug
abruptly.
Explain
that
gradual
tapering
helps to
avoid
withdrawal
symptoms.

IX. List of Priority Problems

1. Risk for Self-directed Violence related to depression

2. Ineffective Coping related to client’s situation.
3. Hopelessness related to Abandonment
4. Disturbed sleeping pattern related to ruminative presleep thoughts.
5. Disturbed Sensory Perception: Visual related to
Altered vision as manifested by poor visual acuity: 20/70
6. Risk for Infection related to Improper Preparation and Transport of food
Ongoing Appraisal

Patient E.J was admitted at National Center for Mental Health on March 20, 2010 with the
recommendation of Dr. Ramona for "Psychosis observation"

He was then re-diagnosed on May 15, 2010 with "Severe Depression". His medication Sertraline was
discontinued on June 13, 2010.

July 28, 2010 - Introduction of Student Nurses to the patient was conducted and talked with the
patient to know more about their feeling or what we call

Nurse-Patient Interaction. Music and Art activity was also conducted to give an interpretation on what
kind of personality the patient has and what his

currently feel through music therapy.

July 29. 2010 - Occupational therapy,Biblio,Community Dance

Exercise and Entertainment.

July 30, 2010 - Grand Socialization Activity including Games, presentation of student nurses through
sing and dance and lastly termination of professional

relationship with client.

DISCHARGE PLAN:

M: Antidepressant medication if needed refer to physician

E: Perform range of motion exercises, daily for 30 minutes such as jogging, stretching, walking and jumping
jack to promote good blood circulation and increases endorphines, thus helps to decreasing depression.
Performing exercises also decreases stress

T: Occupational therapy as provided in jail

Therapeutic Communication by means of letting the client express his feelings

H: Teach him to identify mental relapse, provide knowledge in possible s/sx of depression
Be with the group than being alone
Have time to socialize with other inmates
Avoid sad thoughts by socializing more
Involve self in recreational activities that can cheer himpup
Instruct proper hygiene

O: - seek psychiatric help if needed

D: Eat fruits rich in vitamin C to increase immunity and promote wound healing
Eat green leafy vegetables, foods rich in fiber to lessen chance of constipation
Avoid bulk forming foods such as Plantain, bananas , soda…etc

S: WOF- worthlessness, suicidal ideation, blunt affect, stoop posture, altered appetite, tiredness, altered sleep
patterns, difficulty in concentration, hopelessness, guilt, soft voice and poor eye contact.