CAPITOL MEDICAL CENTER COLLEGES, INC.

#4 Sto. Domingo Avenue, Quezon City

COLLEGE OF NURSING

PROCESS RECORDING #1
(Orientation Phase)

Name___Robert M.
Dayao____________________Age___25___________________
Address_____________________________________________________________
_
Dateof Birth__9/22/83____________Date of
Admission_______________________
Educational Attainment_College
Graduate__________________________________
Diagnosis_Undifferentiated
Schizophrenia__________________________________
Setting____At the
Garden_______________________________________________
Date/Time of
Interaction_____9/16/10____________________________________

DESCRIPTION OF THE PATIENT

He is well groomed, coherent but uses minimal eye contact. He
shows excitement and has a lot of prepared topics to talk about. He
knows where he is and recognizes the people around him but he is
always insisting that he is from other dimension and is immortal: in
short there is a thought process deficit on him.

DESCRIPTION OF ENVIRONMENT
Quiet and peacful environment. Held at the Garden

OBJECTIVES
To establish rapport, to gain the trust of the client and to have an
initial assessment to his physical, emotional and metal status.
 NURSE THERAPEUTI PATIENT ANALYSIS
C TECHNIQUE

Good morning I am Robert M.

sir, i am AJ, your Dayao, 25 years
student nurse for old from Pasay
the next two city
weeks. Is it ok sir
if you introduce
yourself too?

OK sir thanks, I prefer

what language english. . . so
do you prefer for what do you
our want to talk
conversation? about? showbiz
english or or politics?
tagalog? -Flight of ideas
-Grandiose
Delusion
Showbiz nalang Aaahh.. you
ser, so can you know what, i like
share to me any filipino movies a
of you insights lot, i even have
about it? my own movie,
“ang darling
kong aswang”
-Restating w/ Kristine
hermosa and im
her leading man

You are the Yes i have many

leading man? moveis made
-Presenting like “panday, ok
the reality ka fairy ko, etc.”

I see, but what i Yes, but im the

remember is Vic one who made
sotto is the it, i have many
leading man other self i have
there, not you. a twin w/c is on
other
 dimension, he is
immortal, just
like me, we are -Grandiose
not subjected to delusion
death. are you
No im not, im just immortal too?
a human being,
mortal, just like IM IMMORTAL! i
you and me have
superpowers
like laser eyes
just like cyclops
and i am sent to
invade the
earth. in fact i
have invaded 38
planets.

I can see that

you have a broad
imagination, but
as what i have
said earlier, that Why are you not
cant be possible. believing in me?
because we are i have an arch
just human enemy from
being. planet x named
Joey de Leon, he
is so bad. he has
his sidekick
named Vicente
Sotto, and i
have my
subordinates
too, my
bestfriend cupid
and Kc Montero.
EVALUATION

He is very particular with showbiz and politics thats why he asked

me earlier about that 2 topics. He has used many defense
mechanisms and has an obvious flight of ideas, loosening of
association and other thought process deficit.
 CAPITOL MEDICAL CENTER COLLEGES, INC.
#4 Sto. Domingo Avenue, Quezon City

COLLEGE OF NURSING

PROCESS RECORDING #2
(WORKING PHASE)

Name___Robert M.
Dayao____________________Age___25___________________
Address_____________________________________________________________
_
Dateof Birth__9/22/83____________Date of
Admission_______________________
Educational Attainment_College
Graduate__________________________________
Diagnosis_Undifferentiated
Schizophrenia__________________________________
Setting____At the
Garden_______________________________________________
Date/Time of
Interaction_________________________________________________

DESCRIPTION OF THE PATIENT

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________

DESCRIPTION OF ENVIRONMENT
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________
OBJECTIVES
To further assess his mental status and to strenghten the
rapport that has been made.

CAPITOL MEDICAL CENTER COLLEGES, INC.

#4 Sto. Domingo Avenue, Quezon City

COLLEGE OF NURSING

PROCESS RECORDING #3
(TERMINATION PHASE)

Name___Robert M.
Dayao____________________Age___25___________________
Address_____________________________________________________________
_
Dateof Birth__9/22/83____________Date of
Admission_______________________
Educational Attainment_College
Graduate__________________________________
Diagnosis_Undifferentiated
Schizophrenia__________________________________
Setting____At the
Garden_______________________________________________
Date/Time of
Interaction_________________________________________________

DESCRIPTION OF THE PATIENT

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________

DESCRIPTION OF ENVIRONMENT
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
___________________________

OBJECTIVES
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________

CAPITOL MEDICAL CENTER COLLEGES, INC.

#4 Sto. Domingo Avenue, Quezon City

COLLEGE OF NURSING

MENTAL STATUS ASSESSMENT

A.General Appearance and Behavior

The patient is a muscular young man appearing his stated age,

wearing the blue shirt, short and slippers as their uniform. He has a good
skin tone. He is shaved, and has an overall neat appearance and adequate
hygiene. He sits with his legs crossed and his arms and wrists was restless
and do not stay on one side. He talk to the interviewer with a calm and
peaceful way. No agitaion was noted. He maintains minimal eye contact.

B. Affect

He shows Labile type of affect.

C. Mood

Subjectively he reports feeling nothing and claims that he is the one

who chose to admitted there. Objectively, he appears wierd and sceptic
about his sorroundings. His emotional expression is liable, of full range
and appropriate to content. He shows a wierd emothion when he is
talking about his family particularly his father.

D. Thought process

He speaks spontaneously and very rapidly. Becoming pressured at

times, but he is interruptible. Volume is occasionally loud. Rhythm and
expressive intonation are normal. Speech is understandable, but some
words are poorly articulated because of the high rate of speech
production. His thoughts are not logical including many irrelevant details.
flight of ideas, Loosening of associations, Tangentiality, Ideas of reference
was noted.

E. Thought content

Often time you will see him talking alone like he’s talking to
someone he cant see. he also reported that sometimes he sees some
politicians and tv personalities that even talks to him. He is experiencing
this hallucinations only thrice a day. he is also showing a critical type of
grandiose delusions.

F. Cognitive evaluation

he is alert and awake throughout interview. intact to person, place

and date. also able repeat 5 digts forward and backward. able to
remember short term and long term. he also recognizes the previous
presidents but only for ramos to aquino, noynoy. and he is weak in
calculations and abstractions.

G. Insight

Poor insight, he is not aware of his responsibilities, the main reason

why he’s there and he doesnt recognize his present problem.

H. Judgement

Fair. He cooperates with staff even though he doesn’t know why he

needs hospitalization.
NURSE THERAPEUTIC PATIENT ANALYSIS
TECHNIQUE