Past

Psychiatric History

May 14, 1995 - Miss Anabelle Mabilangan was referred by DSWD because she was seen roaming around
Quirino Avenue, she was not in herself and just murmuring things while walking. They decided to take
her on National Center for Mental Health to have her assessed because of the conclusion that she was
mentally ill. The information about her was gathered through the people who was around her before
she was reported to the social workers. She was then diagnosed with undifferentiated schizophrenia on
the same year.

Medical History

Miss Anabelle was diagnosed with type 2 Diabetes year _____.

ORIENTATION PHASE (July 12, 2023, 2:30PM – 3:00PM)
Nurse Patient Communication Rationale
Verbal Non-verbal Verbal Non-verbal Technique
“Hello po, good - Smiles and “Magandang hapon” - Smiles Giving recognition It shows that the
afternoon po Ma’am waves hand - Maintains nurse recognizes the
Anabelle” - Maintains moderate client as a person, an
moderate eye contact individual that gives
eye contact - Good and the client fulfillment
- Open open posture of her worthiness
posture - In face-to- without judgement.
- In face-to- face position
face position with the
with the nurse
client

“Ako po si Jichelle at - Makes eye No response - Nods her Giving information Informing client
siya naman po si contact head about the facts gave
Obrey Carl, mga - In face-to- - Smiles her knowledge about
nursing student na face position - Maintains the topic and what to
nagmula sa Saint to the client moderate expect on the
Mary's University, - Good and eye contact interaction. It also
Bayombong Nueva open posture - Good and bult trust with the
Vizcaya” - Leans open posture client.
forward - In face-to-
- Movement of face position
hands with the
nurse

“Makakasama niyo - Makes eye No response - Nods her Establishing specifics Setting up clear
po kami mula ngayon contact head of the relationship, boundaries of
July 12 at 13 ng 1PM - In face-to- - Smiles time date, place and relationship, time,
– 5PM hanggang July face position - Maintains duration of meetings date, place and
14, 8AM - 12PM ng to the client moderate duration of meetings
umaga para sa aming - Good and eye contact clearly orients the
grand socialization” open posture - Good and patient when, where,
- Leans open posture and how will begin,
forward - In face-to- go on and end the
face position interaction.
with the
nurse
- Makes eye
contact - Nods her
“Ma’am Anabelle, - In face-to- “Sige po ma’am, okay head Establishing Establishing
bale po lahat ng face position lang po.” - Smiles confidentiality confidentiality means
mapag uusapan natin to the client - Maintains respecting patient’s
dito at mga - Good and moderate right to keep her
information na open posture eye contact information
makukuha namin - Leans - Good and especially her mental
mula sa inyo ay hindi forward open posture and physical health
namin ipagsasabi sa - In face-to- related care.
iba ng wala kayong face position
permiso. Okay lang with the
po ba yon sa inyo? nurse
- Makes eye
contact - Nods her
“Makikinig po kami - In face-to- No response head Establishing trust and Building a trusting
sa mga sasabihin niyo face position - Smiles rapport relationship with the
at may mga activities to the client - Maintains patient facilitates a
din po kaming - Good and moderate more reliable data
nakahanda sa open posture eye contact collection because of
susunod na araw na - Leans - Good and easier disclosure of
makaoagbibigay din forward open posture information by the
ng kasiyahan sa - In face-to- patient
inyo.” face position
with the
 nurse

- Makes eye - Smiles

contact - Maintains
“Kamusta naman po - In face-to- “Ayos lang naman moderate Broad openings It allows the patient
kayo dito ma’am? face position ako dito” eye contact to take the initiative
to the client - Good and to introduce topic. It
- Good and open posture also simplifies that
open posture - In face-to- the patient has the
- Leans face position lead in the
forward with the interaction.
nurse

- Makes eye - Smiles

contact - Maintains
“Maari po ba naming - In face-to- “Hindi ko rin alam e, moderate General leads This gives the patient
malaman ang rason face position basta nandito lang eye contact an interaction to
ng pamamalagi niyo to the client ako” - Good and begin with, by
rito” - Good and open posture initiating a topic can
open posture - In face-to- have an idea to re-
- Leans face position focus the interaction
forward with the to something
nurse interesting.

- Makes eye - Maintains

contact moderate This means going
“Ilang taon na po - In face-to- “Dito? Bago lang ako eye contact Exploring further into a subject
kayo dito sa facility face position dito, palipat lipat ako - Good and or an idea. This also
ma’am?” to the client e. Dati doon sa open posture explores the patient’s
- Good and kabila” - In face-to- orientation and
open posture face position examine her issue
- Leans with the more fully.
forward nurse
 - Makes eye - Maintains
contact moderate
- In face-to- eye contact
face position “Dati sa pav. 6 ako, - Good and Focusing This means
“Saang doon po to the client tapos pav. 9 tapos open posture concentrating on a
ma’am?” - Good and dito pav. 10” - In face-to- single important
open posture face position point
- Leans with the
forward nurse

- Makes eye - Maintains

contact moderate
- In face-to- eye contact
“Ilang taon po kayo face position “Sa pav. 6, isa. Sa pav - Good and Focusing
sa bawat pavilion to the client 9, dalawa. Dito, bago open posture
ma’am?” - Good and lang ako dito. Nilipat - In face-to-
open posture lipat ako e, hindi ko face position
- Leans alam kung bakit” with the
forward nurse

- Makes eye - Maintains

contact moderate General leads
“May asawa na po ba - In face-to- “Mayron” eye contact
kayo ma’am?” face position - Good and
to the client open posture
“Nasan po siya - Good and “Hindi ko alam e” - In face-to-
ma’am?” open posture face position
- Leans with the
“May mga anak na forward “Meron, tatlo” nurse
din po ba kayo?”

- Smiles
- Makes eye - Maintains
contact moderate Exploring
- In face-to- eye contact
“Binibisita po ba kayo face position “Hindi na matagal - Good and
ng pamilya niyo dito? to the client na” open posture
- Good and - In face-to-
open posture face position
- Leans with the
forward nurse

- Makes eye - Smiles

contact - Maintains
- In face-to- moderate Exploring,
“Sa tingin niyo po, face position “Wala, hindi ko alam eye contact Formulating plan of Making definite plans
anong daghilan ng to the client e. Walang pera, may - Good and action increases the
hindi nila pagbisita?” - Good and covid” open posture likelihood that the
open posture - In face-to- client will cope and
- Leans face position share more
forward with the effectively in a
nurse situation.

WORKING PHASE
Nurse Patient Communication Rationale
Verbal Non-verbal Verbal Non-verbal Technique
“Hello ma’am - Waves hand “Ma’am Jichelle at Sir - Smiles Asking questions Reorienting the client
Anabelle, - Smiles Obrey” - Waves hand id efficient if she still
natatandaan niyo pa - Maintain - Maintain remembers the
po ba pangalan moderate moderate place, time, date and
namin?” eye contact eye contact people she
- Good and - Good and interacted to.
open posture open posture
- In face-to- - In face-to-
face position face position
to the with the
Client nurse

“Ano po mga - Maintain “Naglilinis, naglalaba, - Maintain Exploring To dig more details
pinagkakaabalahan moderate nagluluto.” moderate and topics to initiate
niyo ma’am bago po eye contact eye contact more serious
kayo napunta dito sa - Good and - Good and conversations.
facility? open posture open posture
- In face-to- - In face-to-
face position face position
to the with the
Client nurse

- Nods and “Hindi ko rin alam e, - Maintain Silence Provides peace for
No response listen pagod na pagod kasi moderate her to think and
- Maintain ako. Sinumpong ako eye contact express what she
moderate dahil sa pagod - Good and needs to share.
eye contact siguro.” open posture
- good and - In face-to-
open posture face position
- in face-to- with the
face nurse
 - Maintain - Eyebrows are
“Napagod po kayo sa moderate “Wala hindi ko rin creased Encouraging Helps the client
paglilinis kaya kayo eye contact alam e, basta - Maintain expression appraise her own
sinumpong. Ano - Good and sinumpong nalang moderate feelings.
pong ginawa niyo open posture ako.” eye contact
nung sinumpong po - In face-to- - Good and
kayo?” face position open posture
to the - In face-to-
Client face position
with the
nurse

- Maintain - Maintain
“Hindi naman po ba moderate “Nalulungkot moderate Making observations Verbalizing what the
kayo nalulungkot dito eye contact siyempre pero okay eye contact nurse perceives that
ma’am?” - Good and lang” - Good and sometimes patient
open posture open posture cannot verbalize.
- In face-to- - In face-to-
face position face position
to the with the
Client nurse

- Maintain - Smiling
“May gusto po ba moderate “Wala, ako nalang. - Clapped Asking questions
kayong i-kwento eye contact May tanong ako hands
samin ma’am?” - Good and sayo. Ilan kayong - Maintain
open posture Magkakapatid?” moderate
- In face-to- eye contact
face position - Good and
to the open posture
Client - In face-to-
 face position
to the nurse

- Hands
counting
- Good and - Smiles
“Nako, kayo dapat open posture “Kami kasi pito kami. - Maintain Changing the subject Diverting questions is
ang tatanungin ko - Maintains Pangalawa ako sa moderate intended to change
niyan ma’am.” moderate pangatlo.” eye contact the topic at state
eye contact - Good and which is the personal
- In face-to- open posture information of the
face position - In face-to- nurse
with the face with the
client nurse

- Shake head
- Maintain
- Good and moderate
“Binibisita naman po open posture “Wala na, hindi na” eye contact Exploring
kayo ng mga kapatid - Maintains - Good and
niyo? moderate open posture
eye contact - In face-to-
- In face-to- face with the
face position nurse
with the
client
- Maintain
moderate
- Good and eye contact
“Natatandaan niyo open posture “Matagal na, nung - Good and Placing time or event Assessing time frame
po ba ang huling - Maintains nakaraang taon pa." open posture sequence and sequence of an
bisita nila?” moderate - In face-to- event overtime
 eye contact face with the
- In face-to- nurse
face position
with the
client
- Maintain
moderate
eye contact
“Ah ganon po ba?” - Good and “Oo, ewan ko din.” - Good and
open posture open posture Voicing doubt
- Maintains - In face-to- Expressing
moderate face with the uncertainty about
eye contact nurse the reality of the
- In face-to- patient’s perceptions
face position which permits the
with the patient to become
client aware of her
answers. The nurse
will encourage the
- Maintain patient to re-
moderate evaluate what she
- Good and eye contact said.
“Ano po ang open posture “Okay lang, wala - Good and
madmanmdaman - Maintains akong magagawa e” open posture Encouraging
niyo na hindi nila moderate - In face-to- evaluation It helps the client
kayo binibisita?” eye contact face with the appraise her own
- In face-to- nurse
face position
with the
client - Smiles
- Maintain
- Good and moderate
“Ano pong gusto open posture “Uwi ako saamin, eye contact
niyong gawin pag - Maintains maglilinis, punta ako - Good and Formulating a plan of
nakalabas po kayo moderate sa bukid, magtanim” open posture care
dito sa facility?” eye contact - In face-to-
- In face-to- face with the
face position nurse
with the
client

TERMINATION PHASE (July 14, 2023, 9:00 – 11:00PM)

Nurse Patient Communication Rationale
Verbal Non-verbal Verbal Non-verbal Technique
“Magandang umaga - Smiles “Magandang umaga - Smiles Giving recognition
po Ma’am Anabelle.” - Wave hands din po” - Wave hands
- Good and - Good and
open posture open posture
- Maintains - Maintains
moderate moderate
eye contact eye contact
- In face-to- - In face-to-
face position face position
with the with the
client nurse
“Pasensiya na po sa - Smiles “Ayos lang, Mabuti at - Smiles Giving recognition
hindi naming - Wave hands nandito kayo - Wave hands
pagtuloy sa ating - Good and ngayon” - Good and
pagkikita kahapon open posture open posture
dahil sa malakas na - Maintains - Maintains
ulan. Kamusta naman moderate moderate
ho kayo?” eye contact eye contact
- In face-to- - In face-to-
face position face position
with the with the
client nurse
“Tulad po ng nasabi - Smiles “oo, natatandaan ko” - Smiles Giving information
naming nung - Good and - Good and
myerkules, may open posture open posture
inihanda po kaming - Maintains - Maintains
munting programa moderate moderate
dahil ito na po ang eye contact eye contact
aming huling araw, - In face-to- - In face-to-
July 14.” face position face position
with the with the
client nurse
Program proper
“May iba pa po ba - Smiles “Wala na po ma’am.” - Smiles and Encouraging Asking the patient
kayong gustong - Good and shakes her description of views to describe
sabihin?” open posture head perception feelings in the
- Maintains - Good and situation. To
moderate open posture understand the
eye contact - Maintains client, the nurse
- In face-to- moderate must see things from
face position eye contact her perspective.
with the - In face-to-
client face position
with the
nurse
“Dito na po - Smiles “Maraming salamat - Smiles Giving recognition
nagtatapos ang ating - Waves hand din po” - Good and
munting programa, - Good and open posture
nawa’y napasaya po open posture - Maintains
namin kayo. - Maintains moderate
Maraming salamat moderate eye contact
po” eye contact - In face-to-
- In face-to- face position
face position with the
with the nurse
client
Assessment Diagnosis Planning Intervention Evaluation
Subjective: Disturbed thought Short term goal: Independent Short term goal:
process as evidenced 1. Promoting Client Safety. Partially met
“Pito kaming by: - The client will Clients with schizophrenia - The client was able
magkakapatid, ano, express thoughts and are prone to injury due to express thoughts
pangalawa ako sa tatlo” a) disoriented to time of feelings in a auditory and visual and feelings in a
admission coherent, logical, hallucinations caused by coherent, logical,
“Hindi ko alam bakit ako b) lack of motivation goal-directed abnormalities in the brain’s goal-directed
nandito e, pagod ako c) disorganized thinking manner. processing of sensory manner.
kaya ako sinumpong e. - The client will information. - The client was able
sobrang pagod ako” - as demonstrate reality- 2. Establishing Therapeutic to demonstrate
verbalized by the patient based thought Relationships and Promoting. reality-based
processes in verbal Therapeutic Communication thought processes
communication. Establishing a therapeutic in verbal
Objective - The client will spend relationship and promoting communication.
Confused time with one or two communication with patients - The client was able
Memory loss other people on with schizophrenia involves to spend time with
Difficulty concentrating structured activity- creating a safe and non- two other people
neutral topics. judgmental environment where on structured
- The client will spend the individual feels comfortable activity-neutral
two to three five- expressing themselves. topics.
minute sessions with 3. Improving Thought - The client was able
the nurse sharing Organization and Reality to spend two ten
observations in the Orientation (10)-minute
environment within Helping patients with thought sessions with (us)
three days. organization involves assisting student nurse
them in organizing their sharing
thoughts, encouraging logical observations in the
thinking, and addressing any environment within
disorganized thought processes. two days.
4. Promoting Effective Coping
Strategies
Coping strategies for patients
with schizophrenia involve
developing adaptive ways to
manage symptoms and daily
challenges.
5. Initiating Patient Education
and Health Teachings.
By empowering patients with
knowledge and practical
strategies, they can actively
participate in their own care,
make informed decisions, and
improve their ability to manage
their condition effectively.
6. Administer Medications and
Provide Pharmacologic Support
Schizophrenia medications
include
typical antipsychotics and
atypical antipsychotics.