INTRODUCTION

When it comes to the treatment of patients with chronic schizophrenia, the glass is only half-full.

Jeffrey Lieberman

According to the American Psychiatric Association (1980) as cited in Townsend (2005), mental health is simultaneous success at working, loving and creating with the capacity for mature and flexible resolution of conflicts between instincts, conscience, important other people and reality. It is the successful adaptation to stressors from internal or external environment, evidenced by thoughts, feelings and behaviors that are age-appropriate and congruent with local and cultural norms (Townsend, 2005). Persons who are in a state of emotional wellbeing, or mental health, function comfortably within society and are satisfied with their achievements (Johnson, 1993). Mental illness, on the other hand, is characterized by maladaptive stressors from the internal or external environment, evidenced by thoughts , feelings and behaviors that are incongruent with the local and cultural norms, and interfere with the individuals social, occupational, and/or physical functioning (Townsend, 2005). In taking care of the client with mental illness, it is important that the role of the nurse is realized. The practice of psychiatric nursing is characterized by those aspects of clinical nursing care that involve interpersonal relationships with individuals and groups as well as a variety of other activities (Manfreda & Krampitz,1977). The nurse-client relationship is the foundation on which psychiatric nursing is established. It is a relationship in which both participants recognize each other as unique and important human beings (Townsend, 2005). Joint planning ot

cooperative and collaborative efforts with other professionals are also an essential part of providing nursing service.

Purpose of the Paper The purpose of this paper is display and analyze the pattern of behaviours both positive and problematic as exhibited by the client. It will attempt to showcase the possible causes and process of manifestation through the different theories in the psychiatric field. Objectives Objectives of this paper as seen in the requirements include: 1. Identify the behavioral problems presented by the client 2. Analyze the variables or factors that led to the behavioral problems 3. By use of existing theories of understanding mental illness causation, construct a written paradigm that led to the behavioral problems 4. Specify cues that point to the problems, supported by quotations from the process recordings, results of examinations, reports from the family or ward staff, or anything that is relevant to the problem 5. Analyze the Nursing Care Given 6. Share insights on the care of the client The client was assessed during the secondary level of experience and his environment and influences particularly the family and community were assessed during the tertiary level of experience. This behavioural analysis will the case of R. M., a 49 year old male diagnosed with undifferentiated schizophrenia. Going through the experience of caring for the client, it has been a fruitful journey from start to finish. Being exposed and caring for a person dealing with the problems presented by the cruel world has become a challenge that gives a sense of fulfilment once accomplished.

SIGNIFICANCE OF CASE

Schizophrenia is a positive growth experience used by the person to cope with an insane world. Schizophrenia cannot be understood without understanding despair. R.D. Laing Schizophrenia has great impact on the individual and society. About 23 per cent of all patients admitted for the first time to state hospital are categorized as having schizophrenic reactions. The lifetime prevalence of schizophrenia is 1% worldwide with no differences related to race, social status, culture or environment (Mariani, 2004 as cited by Varcarolis, 2004). The most typical age for onset of schizophrenia is during the late teens and early twenties (APA, 2000 as cited by Varcarolis, 2004). The greatest number of these patients became ill during the ages of 15 to 25 years. Few people develop the illness after the age of 50 years. It has been estimated that more than 50 per cent of all mentally ill persons are victims of schizophrenic reactions. In most instances, the onset of the disorder is gradual (Manfreda & Krampitz, 1977). In terms of social losses, schizophrenic reactions extract a stupendous toll from society, both financially and productively. Not only are many of these persons unable to provide for their own needs, but they are individuals who may not be able to marry, form family units, or assume a career in which they might contribute or create something of beneficial use to society (Manfreda & Krampitz, 1977). It is generally believed that the chances for recovery are increased when the disorder is identified and treated in its earliest stage. Of the number of patients who

do improve, about 80 percent are discharged during the first year of hospitalization. However, the prognosis is less favourable when the reaction occurs in later life (Manfreda & Krampitz, 1977). That is why it is important the immediate identification, prevention and promotion of mental health is established. It is believed that the prevention of schizophrenic reactions is dependent upon educating parents, parent substitutes, teachers and all persons who come into contact with a person. Changing attitudes will modify behavior and education decreases the possibility of having mental illness (Manfreda & Krampitz, 1977).

CLIENT PROFILE
The client is R. M. C. Muvillion, a 49 year old male who lives in Block 27, Lot 4, M-3 Phase II, Bgy. 35, Dagat-Dagatan, Maypajo, Kalookan City. He has been a mentally ill patient since he was 16 years old. He is currently single and lives with his twin sister, Ms. Muvillion, and her children. He is the 6 th child in a brood of 8. He is unemployed and is unable to go to high school. He is currently confined in National Center for Mental Health. Client was brought to the National Center for Mental Health by his sister on June 17, 2011 It is his second admission for the year. The reason for admission includes reports of inability to sleep, bumubulong-bulong, tumatawa mag-isa, di mapakali and kinakausap ang sarili as stated by the clients sister. (See Appendices for Nursing Health History and Mental Status Exam) The discussion of behavioural problems and strengths exhibited by the client during interaction in secondary level of experience and other behaviors related by family in the tertiary level of experience will be provided and explained in the theoretical framework part of this paper.

THEORETICAL FRAMEWORK
To discuss the behaviors of the client systematically and in detail, Maslows hierarchy of needs was utilized by the student nurse to demonstrate the possible causes and analysis of the clients behavioural strengths and problems. This

framework showcases the humanistic perspective which focuses on growth and selfactualization rather than on curing diseases or alleviating disorders (Carson & Butcher, 1992). The behavioural problems and strengths will be discussed per level of the hierarchy of needs although the discussion will not merely focus on the humanistic perspective but also on other related perspectives.

(See Next page for the Paradigm)

HOPELESSNES IMPAIRED COPING S MECHANISMS DERIVES GOOD GROOMING DISTURBED PLEASURE HABITS BODY IMAGE FROM LACK OF GOOD INSIGHT MEMORY AND COGNITION LOW SELF-ESTEEM AND ASSUMES HIGHLY CRITICAL OF REPONSIBILITY SELF FEELINGS OF DECREASED GOOD ABANDONME SOCIAL SOCIAL NT INTERACTION CUES FEARS AND FOLLOWS RULES ANXIETIES SUBSTANCE ABUSE GOOD IMPULSE CONTROL

Both Maslow (1956, 1968, 1971) and Rogers (1961) assumed that all persons have an intrinsic potential for self-actualization that can be stifled, however, by extrapsychic determinants. According to Maslow (1943), people's basic needs must be sufficiently gratified before they can pursue the fulfillment of what he calls the higher, transcendent meta needs related to self-actualization. Maslow asserted that people's complete psychological maturation occurs only when their potentialities are fully developed and actualized. Everyday conscious desires are to be regarded as symptoms, as surface indicators of more basic needs. If we were to take these superficial desires at their face value me would find ourselves in a state of complete confusion which could never be resolved, since we would be dealing seriously with symptoms rather than with what lay behind the symptoms. Thwarting of unimportant desires produces no psychopathological results; thwarting of a basically important need does produce such results. Any theory of psychopathogenesis must then be based on a sound theory of motivation. A conflict or a frustration is not necessarily pathogenic. It becomes so only when it threatens or thwarts the basic needs, or partial needs that are closely related to the basic needs (Maslow, 1943).

BIOLOGICAL AND PHYSIOLOGICAL NEEDS

Because this is the first level in the Maslows Hierarchy of Needs, it is important that it is sufficiently satisfied. The needs that are usually taken as the starting point for motivation theory are the so-called physiological drives (Maslow, 1943). Two recent lines of research make it necessary to revise our customary notions about these needs, first, the development of the concept of homeostasis, and second, the finding that appetites (preferential choices among foods) are a fairly efficient indication of actual needs or lacks in the body.

Homeostasis refers to the body's automatic efforts to maintain a constant, normal state of the blood stream. Cannon (2) has described this process for (1) the water content of the blood, (2) salt content, (3) sugar content, (4) protein content,

(5) fat content, (6) calcium content, (7) oxygen content, (8) constant hydrogen-ion level (acid-base balance) and (9) constant temperature of the blood. Obviously this list can be extended to include other minerals, the hormones, vitamins, etc. (Maslow, 1943). Behavioral Problem Substance Abuse Behaviors These behaviors are outlined under this need level because of the emergence of substance abuse behaviors as a result of the unfulfillment of physiological needs like food. During tertiary level of experience, clients immediate family was interviewed as to the clients condition prior to acquiring mental illness. The informant stated that the environment of the client and their day-to-day living was slightly dismal as money is not enough to buy food and procure daily needs. In addition, the client lived in Divisoria which is a very challenging, violent and hostile environment. Because of hostile environment, peer pressure and lack of food to sustain the body, the client was said to inhale rugby (drug inhalant) as an alternative. Poor economic status and peer pressure are one of the most common risk factors in exhibiting substance abuse behaviors (Townsend, 2005). According to the Banaag & Daiwey (n.d.), drug use in the Philippines is prevalent among street children wherein inhalants, such as rugby, are the substance of choice among these children as it is cheap and readily available. It is also said to promote a feeling of immediate fullness and ecstasy. Rugby is an example of an inhalant substance which are readily available, legal and inexpensive which makes it the drug of choice of poor people and among children and young adults (Townsend, 2005). The highest use of inhalant substances is seen in the 12 to 25 year old age group. In retrospect, even though problem behavior arouse because of lack of physiologic need, specifically food, it is not the only possible cause for the clients behavior. According to Perkinson (2011), the distribution of adolescents with substance abuse disorders cluster around dysfunctional families, particularly those of families with broken marriages (Perkinson, 2011). Teens at first, use drugs under

peer pressureas a means by which they gain the acceptance and feelings of belonging from the peer group. Because of probable lack of love and belongingness at home, the client attempted to acquire this from the outside of the home. R. M.s use of rugby during his teen years may be perceived as a precipitating factor for his development of schizophrenia at the age of 16 years old. However, this has been controlled already as the client was not reported to partake in drug use. Other substances like his alcohol and nicotine should be given emphasis as the client has difficulty in controlling impulse to smoke and drink alcohol in the community. Poor impulse control to Alcohol and Nicotine Alcohol is a natural substance which exerts a depressant effect in the CNS, resulting in behavioural and mood changes (Townsend, 2005). Alcohol and nicotine can be perceived as a physiological need by the client and fulfilment of this need is a must for R. M.. It was related by the clients sister that R. M. and members of the family explicitly agreed that alcohol drinking and smoking is not permitted in the household. However, R. M. buys from a location far from the house to fulfil his need for alcohol and cigarettes. This has also been a sore topic for the client as he was immediately defensive upon interview of his social history. NURSE: Ay, tanong ko lang po. Umiinom po ba kayo ng alak o naninigarilyo? CLIENT: (long pause) Dati lang yun. Dati lang yun. An acknowledgement from the client of the disadvantage of drinking alcohol and smoking cigarettes may be a first step for improvement of this behavior. At present, it can be hypothesized that poor impulse control causes the clients behavior. Disorder in self control involve disturbances in the ability to regulate an impulse an urge to act (Halgin & Whitbourne, 1993). Behavioral Strength Good impulse control to food At present, physiological needs of the client are being met. In the National Center for Mental Health, rules are established and they are followed well by the

client. He verbalized that he is well satisfied with the food given to them . As this physiologic need is satisfied, the impulse to eat or take large amounts of food is controlled. With this, the client can focus on other needs. At home, the clients sister has informed us that R. M. is provided with food as he needed. She added that she usually allots him a portion of their food everyday and even give him money to buy merienda. It may seem contradicting that the client can control impulse in eating food more than what he needs while he has a poor impulse in alcohol drinking and smoking. However, it can easily be explained by the definition of vices. While eating is a physiological need which was satisfied by the patient and his community, alcohol drinking and smoking are called vices. Vices are wants that are harmful to a person. They take the form of a physiological need to a person addicted to them. Because vices are not tolerated by the clients family and is not constantly or immediately gratified, there exists an unfulfillment of that need. SAFETY NEEDS When the physiological needs are largely taken care of, this second layer of needs comes into play. You will become increasingly interested in finding safe circumstances, stability, protection (Maslow, 1943). You might develop a need for structure, for order and some limits. Because the physiological needs were met, the next focus of R. M. would be safety and security needs. Unfulfillment of these needs are usually not perceived by adults and are commonly seen in children (Maslow, 1943). A lack of security in childhood, often provided by parents, may result to a compromise in the persons development into adulthood (Halgin & Whitbourne, 1993). The neurotic individual may be described in a slightly different way with some usefulness as a grown-up person who retains his childish attitudes toward the world. That is to say, a neurotic adult may be said to behave 'as if' he were actually afraid of a spanking, or of his mother's disapproval, or of being abandoned by his parents, or having his food taken away from him. It is as if his childish attitudes of fear and threat reaction to a dangerous world had gone underground, and untouched by the growing up and learning processes, were now ready to be called out by any stimulus that would make a child feel endangered and threatened (Maslow, 1943). Behavioral Problems

Fears and Anxieties The client has never exhibited paranoid or persecutory delusions or hallucinations. However, he has exhibited fears and anxieties about violent behavior in the community he has lived in. NURSE: (stares at people playing basketball) CLIENT: (abruptly turns to nurse) Mahilig magpatayan ang mga tao sa Divisoria, Yung mga Intsik, kinakain yung mga Hapon. Yung mga Ilokano, kinakain mga Bicolano. Patayan talaga din sa Divisoria. Violent environment increases the clients recurrence of problems and relapse of mental illness. It acts as a stressor to the clients condition. Anxiety produces various subjective and objective symptoms in an individual. Since the client was taking antipsychotics and antidepressants, it was important to differentiate whether the clients behavior may be attributed to the drugs or caused by other factors. Many usual symptoms of anxiety such as restlessness, tremors, rigidity, foot shuffling, and hand movements were actually drug effects. The student nurse maintains eye contact, facial tension, and thought content which are more accurate indicators of anxiety in the client. May define anxiety as apprehension caused by a threat to some value that an individual holds essential to his existence. Situations that precipitate anxiety usually involve choiceConsideration of others is important in making choices. Tension between personal freedom and commitment to the group or social context of ones life can cause anxiety (Rawlins et al., 1993, p. 187). This explains the clients preoccupation with going home. Behavioral Strengths Follows Rules An understanding of the safety and security by the person ensures that we have arrived at the right doorstep. A person with unfulfilled needs of safety has difficulty with talking with strangers and he is probably deviant because he protects himself from the stimuli before it happen upon him. In the clients case, the need for

safety has already been fulfilled that is why he is able to follow rules and commands by the student nurse. Often, other patients have difficulty in following rules because of inherent deviant behavior and apathy to order. BELONGINGNESS AND LOVE NEEDS If both the physiological and the safety needs are fairly well gratified, then there will emerge the love and affection and belongingness needs, and the whole cycle already described will repeat itself with this new center. Now the person will feel keenly, as never before, the absence of friends, or a sweetheart, or a wife, or children. He will hunger for affectionate relations with people in general, namely, for a place in his group, and he will strive with great intensity to achieve this goal. He will want to attain such a place more than anything else in the world and may even forget that once, when he was hungry, he sneered at love (Maslow, 1943). It has been stated that adverse life events have been found to increase in weeks prior to symptom occurrence. Family characteristics, marital discord and communication deviance are all linked to incidence and relapse of schizophrenia (Wicks Nelson & Israel, 2009). In our society the thwarting of these needs is the most commonly found core in cases of maladjustment and more severe psychopathology. Love and affection, as well as their possible expression in sexuality, are generally looked upon with ambivalence and are customarily hedged about with many restrictions and inhibitions. Practically all theorists of psychopathology have stressed thwarting of the love needs as basic in the picture of maladjustment. Many clinical studies have therefore been made of this need and we know more about it perhaps than any of the other needs except the physiological ones (Maslow, 1943). This is the level of hierarchy that the client is in right now. In his perception, it has been unfulfilled since he was abandoned by his father and their other siblings to venture in the U.S.A. when he was 4 years old.

Behavioral Problem

Feelings of Abandonment NURSE: Pakikwento nga po ninyo sa akin ang mga nangyari para po madala kayo dito. CLIENT: (silent with eyebrows in a knot) Gusto nila ko ikulong dito. When client is asked the reason why he is brought to the hospital, he said that he was brought here to be imprisoned or ikulong. He also adds that his family members tricked him into going into the hospital to leave him here. While this may be true and may only be a practical move of the family and not real abandonment, it presents as another case of abandonment from the family to the client. Client first talked about being abandoned when asked if his family visits him here.

NURSE: Nakadalaw naman po yung mga kamag-anak ninyo? CLIENT: Hindi. (pause) Okay lang yun. Walang kaso sa kin yun. This action shows the self-defensive action and barriers erected by the client as what he says is the opposite of what he wanted. Days after, without prodding, the client stated that he does not really want to go home and is content to stay in the hospital. He said that it is okay with him if he is left alone. However, this was contrary to what was reviewed in the chart as on the day prior to interaction with client, he stated to the doctor that he wanted to go home though the doctor said that they still cannot contact his family and he is not yet cleared to go home. Client also talked about his father who left him when he was 4 years old to live with his siblings in America. He said that the only persons left to him where his mother and sister. The client has been abandoned by a large part of his family and at present he thinks that his only source of support is his sister, who has abandoned him still in this institution. This has been supported by his sister who recounts about their relationship with their father and the discord present in the family. Kami lang talaga ang naiwan. Hindi man nga sila tumutulong sa pag-aalaga kay R. M. e . When asked if communication is still present within the family, the clients sister said that Matagal naman ng hindi masyadong maayos e. Nung namatay yung

nanay ko, siyempre hindi na ako yung lalapit kasi baka isipin nila ginagamit lang naming dahilan si R. M. para makahingi ng pera. According to Salter (1940) as cited in Bretherton (1992), familial security in the early stages is of a dependent type and forms a basis from which the individual can work out gradually, forming new skills and interests in other fields. When familial security is lacking, the individual is handicapped by the lack of a secure foundation from which to work. Because the clients family is not secure and a father figure is absent, the client is handicapped. He may have been dependent on his mother this whole time because of the lack of a father. When his mother passed away last year, it is probable that the client feels insecure and abandoned by the people he loves. Although R. M.s mother has not really been entirely pleasant, as revealed by the clients sister, R. M. was dependent on the mother. With this last link on love, he may have rejected the fulfilment of this level of need. The clients sister reported that sometimes their mother also belittles R. M. though she stands up for him for other people who are belittling him. They are constantly involved in fights also although their mother is less firm in disciplining R. M.. The clients mother can be called a schizophrenogenic mother (FrommReichmann, 1948 as cited in Halgin & Whitbourne, 1994). According to this view, schizophrenia can be induced in a child through a mothering style characterized by confusing kinds of communication, overintrusiveness, and devaluation of childs sense of self-worth. Moreover, the patient together with his family grew up in Tondo-KalookanDivisoria area, which may not to be conducive for living. The place is purported to be generally untidy and disorganized, cluttered and masikip. There were incidents of crimes in the area, such as hostage taking, robbery, gang wars and other forms of violence which the client has described. The clients sister is a sewer and his niece works in a factory. He has no occupation making their life impoverish with deprivation to some basic needs. Based on the Maslows hierarchy of needs, this could indicate unmet physiologic needs, as well as safety and security needs of the patient (Videbeck, 2007).

The client with schizophrenia is thought to be fixed in the rapprochement phase of development in Mahlers theory of object relations harbouring fears of abandonment and underlying rage. This phase is extremely critical in the ego development of the child as it is during this time when the child becomes increasingly aware of his separateness from the mothering figure. If the mothering figure is available to fulfil emotional needs as they are required, the child develop a sense of security in the knowledge that he or she is loved and will not be abandoned. However, if emotional needs are inconsistently met, feelings of rage and fear of abandonment develop and often persist into adulthood (Townsend, 2008). The theory of object loss also suggests that depressive illness occurs as a result of having been abandoned during the first 6 months of life. Because during this period, the parent represents the childs main source of security. This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of illness in response to loss. The client stated before that he has never seen his father. He also expressed that he does not care if he has not seen him. The client also develops a mistrust of others and impaired social interaction because of this feelings of abandonment. He may prohibit himself from forming relationships as they may abandon him later on in life (Townsend, 2008). During tertiary level of experience, it was related by the clients sister that they were provided with tickets and passports to go to America. However, R. M. was quite angry about it and didnt want to go so he tear his passport into two. Upon hearing this, their father changed his mind because of fear of R. M.s condition. Since then, communication over the years has been stilted. According to the double-bind hypothesis (Bateson et al., 1956 as cited in Halgin & Whitbourne, 1994), the schizophrenic individual develops faulty communication and thinking process through years of being exposed to conflicting messages from other family members. Researchers contended that the parents of people with schizophrenia often give vague, indefinite, and fragmented messages lacking in direction (Singer & Whynne, 1963 as cited in Halgin & Whitbourne, 1994).

Decreased Social Interaction Decreased social interaction is defined as the insufficient or excessive quantity or ineffective quality of social exchange (Doenges, 2004). Socialization is the ability to for cooperative and interdependent relationships with others. Problems with all other aspects can contribute to relational consequences of maladaptive neurobiological responses. Social problems are often the major source of concern of families because these are more prominent. Direct effects include inability to communicate coherently, loss of drive or interest, deterioration of social skills, poor personal hygiene and paranoia. Indirect effects on socialization involve low self esteem related to poor academic and social achievement, social inappropriateness, disinterest in recreational activities, and stigma related withdrawal by friends, families and peers. Stigma represents a major obstacle in developing relationships and adversely affecting the quality of life (Stuart & Laraia, 2001). In the client, it can easily be observed that he is reluctant to join in group activities. He prefers to play alone or with the student nurse. At first it was hypothesized that the client may have an inherent introvert personality. However, at further assessment in the tertiary level of experience, it was soon found out that the client had actually been an extrovert in the community. Makikita mo yan kung sino sino ang kausap. Sobrang lakas pa ng boses. Kaibigan nun halos lahat ng tao dito, stated by the clients sister. She then reported that through the years she has cared for the client, the client becomes withdrawn and develops impaired social interaction only when his mental illness relapses. In the community, stigma was also not present as the client has been part of the community for a long time already and has been accepted as part of a close knit group in the community. In the humanistic perspective, unfulfilled love and sense of belongingness decreases clients motivation to fulfill the next part of the hierarchy of needs which is esteem needs. With the unfulfillment, of love and sense of belongingness, the clients social interaction is impaired as he perceives that he is unable to receive love and belong to a group as expected of a normal human being. Social Interaction is explained better by the Interpersonal Perspective related also with the Humanistic Perspective.

In this section, it is said that there are two ways of viewing our relationships with other people. First, the social-exchange view, is based on the premise that we form relationships with each other to satisfy our needs (Thibaut & Kelly, 1959 as cited in Carson & Butcher, 1992). Each person in a relationship wants something from the other and the exchange that results is essentially like trading or bargaining. In the clients case, this can be applied when the client talked about how he makes friends. NURSE: Sino-sino po yung mga kaibigan ninyo sa loob (referring to Ward 9). CLIENT: Hindi kaibigan. Kakilala lang. NURSE: Ah, paano po kayo nakikipagkilala sa kanila. CLIENT: Siyempre di ba makikipagkilala ka lang kapag may kailangan ka. A second way, according to Homans (1961) as cited in Carson & Butcher (1992), is in terms of social roles. We subscribe to certain behaviors and role expectations in terms of obligations, rights, duties and so on that the person is expected to meet. If one fails to live up to others role expectations, serious complications are likely to occur. In the clients case, the formation of intimate personal relationships has been nothing short of disastrous as his initial intimate relationship with the family, which is that of the child and his parent, failed to deliver in role expectations.

Behavioral Strengths Good Social Cues As stated earlier, the client has deficient social interaction and has a history of impaired social interaction. However, this has improved in that the client has developed good social cues. He is able to identify common reactions of society to certain actions. This can be observed in his interaction in socialization, meal eating and in talking with other people. There was an instance during a chess game when the client moved a piece by mistake. He immediately stopped and returned the piece to its original position. However, he said, Ay, touch move nga pala and proceeded with putting the chest piece to where he placed it last. It shows that the

client has a sense of right and wrong and has a consideration for the feelings of others. He is also able to admit his own mistake.

ESTEEM NEEDS Self-esteem is present when a person has a realistic awareness of his or her abilities and limitations (Videbeck, 2002). A person has self-esteem when he seeks self-respect and respect from others, works to achieve success and recognition in work, and desires prestige from accomplishments (Townsend, 2008). Chronic low self esteem, on the other hand, is a long-standing negative self evaluation or feelings about self or self-capabilities usually caused by fixation in an earlier level of development, continual negative evaluation of self or capabilities from childhood, personal vulnerability, life choices perpetuating failure, ineffective social or occupational functioning, feelings of abandonment by significant others, willingness to tolerate violence, chronic physical or psychiatric conditions and antisocial behaviors (Doenges, 2004). According to Maslow (1943), all people in our society have a need or desire for a stable, firmly based, (usually) high evaluation of ourselves, for self-respect, or self-esteem and for the esteem of others. By firmly based self-esteem, we mean that which is soundly based upon real capacity, achievement and respect from others.

Behavioral Problem Low Self-Esteem and Highly Critical of Self The client displays low self-esteem in the interaction with the student nurse. First instance that the student nurse identified low self-esteem in the client was

during art therapy. At the initiation of art therapy, client claimed that he didnt like drawing at all. NURSE: Gusto niyo pong magdrawing? CLIENT: Hindi naman ako magaling magdrawing e. Iba na lang. With further encouragement, client draw, at first, in imitation of the student nurses work. Eventually, he was able to conceptualize his own. However, when asked what he has drawn, he says that it is nothing, it doesnt mean anything and he is not really good in drawing or interested. Next identification of self-esteem was during mental state examination and survey. Client was asked what his goal in life was. He answered that he does not have a goal in life. Even when he was little, he claimed that he really had no dream. He further stated that he is not the type of person who is goal-oriented but allows things to happen as fate dictates. The client also seldom likes to involve in group activities. Most activities preferred are one-by-one with the student. During group basketball, he immediately sits at the sidelines after having shot a basket and claims to be tired. He also stated that he does not like playing basketball. However, when the student nurse invited the client for a one-on-one with the basketball, he displayed enthusiasm in playing. When asked what his hobbies are, the client always answers that he does not have any hobby or interest. He claims that he only knows things but is not really good at them. During basketball or chess, whenever he is able to shoot or win a game, he claims that they are always chamba or chance. He immediately erects a self-defense by belittling himself before anyone can comment on his action and belittle him. Client also display a fear of failures. In a basketball game, there was an instance when he was not able to shoot a single ball. He sat after a couple of rounds and stated that he was tired. Then, he immediately exclaimed that he did not dream of being a basketball star when he was young. NURSE: (Silent)

CLIENT: Hindi ko man pinangarap maging sikat. Yun bang magpabida. He also backs down whenever there is pressure for fear of not being able to follow through. His slouched posture and inclination to turn away when speaking with a person or look down may also show his low self-esteem. On a positive note, even if client has low self-esteem he is able to try activities and play with other people even for a short time. For example, in the basketball game and exercises, he actively participates in activities. In doing artworks or plays, he does start doing the things though he stops when he does not want to continue further. The client is also assertive when the need arises. He also speaks in a loud voice and counts the numbers aloud during counting. There are also times when he seems to show off his abilities to the student especially during reading and salawikain interpretation. As stated by Doenges (2004), one cause of low self-esteem is a continual negative evaluation of self or capabilities from childhood. The client has been a mentally ill patient since the 1990s. Because of this, he may be viewed by the family or the neighbourhood with stigma and many may have their own conceptions about his actions. This limits the clients potential and capabilities. When the client was interviewed about what he usually does at home, he answers that he seldom do anything at home. He usually just stay there and no activities are assigned to him. He stated that he is prohibited by his family in using sharp objects especially the knife because he might kill somebody. Although this seems a logical course of action by the family, it may add to the low self-esteem of the client and shows lack of trust by the caregivers. In addition, deficiency of tasks and absence of role in the home makes the client devoid of responsibility and decreases control of his surroundings as his family controls it. This increases personal vulnerability and makes the client avoid tasks which he perceives (as perceived by his surroundings) that he cannot accomplish. Parental rejection may also be a cause for someone to be uncertain of self and other human relationships; he may feel inadequate and feel unimportant

leading to low self esteem. Repeated defeats and failures can also destroy selfworth (Stuart & Laraia, 2001) Because of his condition, R. M. also remains single and is unable to form his own family. This decreases the support for the client and may accentuate the fact that he has failed with an important phase of a man in society. Low self-esteem, as stated by Doenges (2004) may also be caused by ineffective social or occupational functioning. With clients introvert personality or keeping to himself, he increases his feelings of inequality and depression. Lastly, Doenges (2004) attributes low self-esteem to feelings of abandonment by significant others which was also felt by the client. This enables the client to reduce his self-worth as he presumes himself to be unwanted by others especially his family. According to Maslow (1943), a hierarchy of needs motivates human actions. These needs begin with physiologic needs, then safety needs, then security and belonging needs. After those needs comes the need for self-esteem. The final need is self-actualization or the ability to realize ones full innate potential. The fulfilment of human needs requires dynamic movement throughout the various levels in the hierarchy. Each human need in the hierarchy must be met first for a person to be motivated on the second need in the hierarchy. In the clients case, he is at present, unfulfilled in the love and self-belonging needs that is why both self-esteem and self-actualization needs are not met. Satisfaction of the self-esteem need leads to feelings of self-confidence, worth, strength, capability and adequacy of being useful and necessary in the world. But thwarting of these needs produces feelings of inferiority, of weakness and of helplessness. These feelings in turn give rise to either basic discouragement or else compensatory or neurotic trends. An appreciation of the necessity of basic self-confidence and an understanding of how helpless people are without it, can be easily gained from a study of severe traumatic neurosis (Maslow, 1943). As client has absent sense of belonging, it affects his need to love and be loved. Love accompanies changes in relationships such as birth, marriage, divorce,

illness and death. The client, through the years because of his chronic illness, was less viewed as a member of the family and his role was lost. He has lost a sense of security of his self and of belonging to a larger group. As a result, there is also a loss of self-esteem. Any change in how a person is valued in relationships can threaten his need for self-esteem. A change in self-perception can challenge sense of selfworth, which the person may experience as a loss (Videbeck, 2002). A loss of role function and the self-perception and worth ties to that role may accompany the client and lead to low self-esteem. Because of this, there is both internal and external factors which block or inhibit the clients striving toward fulfilment and threatens personal goals and individual potential (Videbeck, 2002). As stated before, internal factors may include clients introvert personality and low self-esteem and external factors may include family, community or societys perception of him because of his mental condition which inhibit growth. At this stage, client may be using his superego or the perfection principle. The superego, which develops between ages 3 and 6 years, internalizes the values and morals set forth by primary caregivers (Townsend, 2008). Derived from a system of rewards and punishments, the childs esteem is enhanced whenever he is rewarded for good behavior and conscience is formed whenever he is punished for bad behavior. When the superego becomes rigid and punitive, problems with low self-confidence and low self-esteem arise (Townsend, 2008). Also, his ego used regression as a defense mechanism to make him an introvert in order to prevent challenge on his beliefs.

COGNITIVE NEEDS In 1970, Maslow added this level in the Hierarchy of Needs Pyramid. Cognitive Needs include the need and search for knowledge and meaning. Fulfillment of this knowledge need allows us to move to a higher level in the search for actualization. In the cognitive-behavioral perspective, focuses on thought and information processing process as they apply to distorted thinking and maladaptive

behavior. This will be discussed in conjunction with the humanistic perspective and Needs theory of Maslow. Acquiring knowledge and systematizing the universe have been considered as, in part, techniques for the achievement of basic safety in the world, or, for the intelligent man, expressions of self-actualization. Also freedom of inquiry and expression have been discussed as preconditions of satisfactions of the basic needs. True though these formulations may be, they do not constitute definitive answers to the question as to the motivation role of curiosity, learning, philosophizing, experimenting, etc. They are, at best, no more than partial answers.

Behavioral Problems Poor Insight Although poor insight may reflect a poor coping mechanism (which will be discussed later in this chapter), it can also be explained by an impairment in cognition. Cognitive processes the thoughts, images and techniques involved with information processing and their impact on behavior (Carson & Butcher, 1992). It cannot be denied that the client is involved with much thought processing. Insight is defined as being able to recognize and accept the fact that one is ill even though the dynamics of the illness are not understood (Manfreda & Krampitz, 1977). Because of altered thought processes and denial of illness, the client may have developed poor insight of his disease. A poor insight leads to poor prognosis (Townsend, 2005). Client is able to identify the institution as a mental hospital. However, he has never stated, even once, or acknowledged that he is a mentally ill patient. As stated earlier in the feelings of abandonment part, the client thinks that he was brought to the institution just to lock him up and wash their hands off of him. Behavioral Strengths Good Cognition and Memory

Surprisingly, the client has very good cognition and memory which is only blunted by his inability to process that he is a mentally ill patient. During Mental Status Examination, client has been able to answer everything correctly and do the actions required properly. His memory is quite clear. His stories about going to different places and achievements have all been confirmed by his sister. His recent memory and past memory is intact. That he was a dilis vendor when he was young was quite true although the clients sister said that he pocketed all the earnings and didn't return the capital. The client is also able to calculate correctly and read aloud. It should be remembered that the client is an elementary graduate.

AESTHETIC NEEDS An appreciation and need for beauty is the next level in the hierarchy. It is mainly a fulfilment of the search and appreciation for beauty, balance and form.

Behavioral Problems

Disturbed Body Image A disturbance in body image is defined as confusion or dissatisfaction in mental picture of ones physical self (Doenges, 2004). As part of the activities in NCMH, a mirror is given to the clients for them to see what they look like. Upon seeing self, the client immediately said, Ang pangit ko. He then immediately returned the mirror to the facilitator. At a repeat of the activity, the client refused to look at the mirror saying he knows what he will see. In a way, this disturbance in body image is a recurrence of the self-esteem issues of the client. However, there is also a factor in fulfilling the needs of the client for a search and appreciation of beauty. This beauty is defined by society and as such, he rejects himself because he thinks that he is unable to fulfil what he perceives as beautiful.

Behavioral Strength Derives Pleasure from Activities Deriving pleasure from activities is also a fulfilment of the needs for beauty. This is an opposite of anhedonia. Anhedonia is defined as the inability to experience pleasure (Townsend, 2005). This is a particularly distressing symptom that compels some clients to attempt suicide. Experiencing the opposite of anhedonia is good for the client because it prohibits him from becoming depressive. In addition, it facilitates his growth through the years. As explained by his sister, he is joining all the activities in the barangay even without prodding. He engages in cockfights, basketball games, kara krus and other activities. An experienced pleasure with activities helps facilitate activity therapy in the client. It decreases time spent on brooding about problems and thoughts. Good Grooming Habits The self is also part of the fulfilment of the aesthetic needs. Being pleasing to the self also helps increase self-esteem. Good grooming habits also helps in developing and maintaining relationships. The clients good grooming habits should be attributed to the familys care for him. Because of proper training and advice on the client, he has kept the habits of taking care of himself and grooming every day. It has become an everyday routine to the client. SELF-ACTUALIZATION Rogers (1961) stated that self-actualization is a process of differentiating potentialities inherent in the makeup of the individual. This process, which is forward-moving, constructive, and self-enhancing, becomes possible only when people receive positive regard from others and learn to think positively of themselves. Each individual, according to Rogers, has the capacity to be self-aware and to label what occurs accurately; when one's need for positive regard is met, then, one's tendency toward self-actualization becomes manifested. When an individual's self-concept is relatively congruent with his or her experience, the actualizing tendency can operate without impediment. The individual can develop, then, into a fully functioning person who is open to the richness of experience, who has few defenses, and who is self-aware.

Drawing from their definitions of self-actualization as well as from their therapeutic experiences and observations, Maslow (1943) and Rogers (1961) defined certain unique characteristics of self-actualizing people. Such a person, they maintained, has the following: an accurate perception of reality, a high level of creativity, few defenses, a high level of integration, personal autonomy, unconventional ethics, a need for human kinship, compassion, humility, deep and harmonious interpersonal relationships, a respect for others, a desire to establish new forms of communications and intimacy, and an ongoing concern with personal growth. In addition, Maslow (1943) highlighted these characteristics: spontaneity, receptivity, a problem-centered approach to life, detachment, a fresh appreciation of things, a democratic attitude, a unique value system, a capacity to cope with circumstances, and a likelihood of having peak experiences. Rogers (1961) added, moreover, these qualities: an openness to nature and other people, an unconditional self-regard, an inner freedom, authenticity, a yearning for a spiritual life, an indifference to material comforts, a feeling of closeness to nature, and a skepticism of science and technology. It is with a heavy heart that I realize that the client has not achieved any of the characteristics of the self-actualized person because of the unfulfillment of other levels of the Hierarchy of Needs.

Behavioral Problems Hopelessness According to Beck et al. (1979), negative expectations of the environment, of the self, and of the future serve as the basis for depression. These cognitive distortions arise out of a defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others. The outlook for the future is one of pessimism and hopelessness (Townsend, 2008, p. 342). Hopelessness is defined as subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf (Doenges, 2004).

Hopelessness is one of the end result of the client as a result of all the other behaviors particularly low self esteem. This increases risk for depression as the symptoms of depression are depressive mood, fatigue, hopelessness, low selfesteem, change in weight or appetite and insomnia. Once, the client was asked what his goals in life were. NURSE: Ano pong planong ninyong gawin pagkalabas po ninyo dito sa ospital? CLIENT: Wala. Wala naman akong pangarap e. Impaired Coping Mechanisms Defensive Coping is defined as Repeated projection of falsely positive selfevaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard(Doenges, 2004). Psychological disturbance often result from defects in the ego. To protect against anxiety, a person must use a variety of tactics that keep unacceptable instincts and feelings out of conscious awareness (Halgin & Whitbournw, 1994). Freud called this tactics defense mechanisms . The ego is always being attacked, and a way to protect the ego is through defense mechanisms. Defense discomfort, mechanisms to deal are with cognitive stress distortions that a person uses

unconsciously to maintain a sense of being in control of a situation, to lessen and (Videbeck, 2003). Because defense mechanisms arise from the unconscious, the person is unaware of using them. The overuse of defense mechanisms, however, stops people from learning appropriate methods to resolve anxiety-generating situations (Videbeck, 2003). According to Alfred Adler as cited in Kaplan & Sadock, (1981), psychosis is produced by the interplay of somatic factors and psychological factors. It is important to recognize and understand the patients personal logic, even if it is incoherent, that led to the patients delusions and fantasies. These patients often suffer from a sense of failure, real or imagined. They do not recognize this and also do not accept the societal definition of failure. This then make them turn to defense mechanisms to compensate for the sense of despair and hopelessness brought by failure to achieve significance in the world. (Kaplan & Sadock, 1981). Manifestations

of psychosis includes the experience of having disorganized thoughts, speech, and behavior (Keltner, 2007). Freud also postulated that schizophrenia was a regression in response to frustration and conflict with others. In addition, the psychoanalytic theory also states that distortions in the reciprocal relationship between the infant and the mother results to closeness and dependence of the child to his parents. In Freuds view, psychological disorder results from serious imbalance between the ids needs and the superegos restrictions. As the clients relapse may have been due to lack of control over substances, the ids needs may have impeded the superegos restrictions. As cited by Kaplan (1994), Federn stated that an adolescent who had a conflicted mother-infant relationship, experiences difficulty differentiating self from others, and separating himself to his parents. Thus, it impedes his capacity to identify his own tasks, to cope with external stimuli or stressor, and develop internal locus of control or motivation. As the ego is disintegrated, the client is taken away from the bounds of reality and the control for inner drives is distorted. DENIAL Denial refers to avoiding the awareness of some painful aspect of reality by negating sensory data (Sadock & Sadock, 2007). It functions to protect the ego from things that the individual cannot cope with and allows the person to isolate him or herself from the full impact of a traumatic situation. It is a mechanism used to evade or escape the unpleasant or disagreeable realities of living by ignoring or refusing to acknowledge their existence. Schizophrenic patients may deny and withdraw from the emotionally painful aspects of the real world with its anxietyproducing situations (Manfreda & Krampitz, 1977). As with the clients poor insight, an extreme case of denial is at hand. IDENTIFICATION Identification is an attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires (Townsend, 2005). Identification is the primary defense mechanism used in delusions of grandeur.

Delusions of grandeur are false personal beliefs wherein an individual has an exaggerated feeling of importance, power, knowledge or identity (Townsend, 2005). Although there is no delusions presented during interaction, the clients sister reported delusions of grandeur prior to hospitalization. Sinasabi niya siya raw yung stuntman ni Robin Padilla nung nanood kami sa TV. When asked about former occupation, the client answered that he was a dilis vendor before and has been a construction worker. While the former was confirmed by her sister, the latter was denied. This may show the clients want to acquire a sense out of life and gain an occupation. Adler (1937) as cited in Halgin & Whitbourne (1994), said that the neurotic adult is someone who feels very inferior or unworthy, a feeling that originated in childhood. In order to feel more self-confident, the individual begins a pattern of putting on a false front of superiority. This is the point at which the individual becomes the victim of desire to overcome weakness. An idealized self is created to cover up the real self that feels inadequate and unlovable. The person becomes trapped by this scheme when confronted with the fact that the idealized selfs unrealistic goals, by definition, can never fully be met. REACTION FORMATION The use of reaction formation is to transform an unacceptable impulse into its opposite (Sadock & Sadock, 2007). Reaction formation is defined as preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors (Townsend, 2005). The client uses reaction formation when talking about his feelings of abandonment. When the topics revolve around his not being visited, his father, his siblings and his relationship with other people, he always vehemently say That its okay with him. There was a time that he blurted out that it is okay if he stays in NCMH forever although it was seen on the chart that he confessed to wanting to go home to the doctor in charge. PROJECTION

What occurs in this defense mechanism is that the client perceives and reacts to unacceptable inner impulses and their derivatives as though they were outside the self (Sadock & Sadock, 2007). Projection is defined as attributing feelings or impulses unacceptable to ones self to another person (Townsend, 2005). Although there is no personal experience of observation of hallucination in the client, it is seen in the chart and reported by the clients sister that the client is seen talking to self, laughing out loud and hearing voices. Although the exact form of auditory hallucination cannot be determined, the client is using projection to exhibit these hallucinations. SUPPRESSION The client also uses suppression which is defined as the voluntary blocking of unpleasant feelings and experiences from ones awareness (Townsend, 2005). Whenever unpleasant topics are discussed, the client remains silent and does not want to discuss said issues. His facial expression changes and his body posture shows avoidance. When asked if the client wants to change the topic, he nods and allows the change of topic. He then returns to his normal behavior, smiling and talking about himself.

TRANSCENDENCE Because the client has not reached self-actualization, transcendence is also not achieved. Transcendence is considered the ability to help other people achieve self-actualization.

NURSING CARE PLAN

They've always tried to help me, but having schizophrenia, it was hard to receive the help.

Robert Lawson

SECONDARY LEVEL
During the stay at the ward, the nurse identified priority problems to be intervened. The following are the nursing diagnosis identified in the client in NCMH during secondary level of experience only two of which were constructed in the Nursing Care Plan: 1. Impaired Social Interaction related to Lack of Interest, effects of

schizophrenia 2. Decreased Ability to Express Feelings related to possible feelings of inadequacy 3. Chronic Low Self-Esteem related to feelings of abandonment from significant others and personal vulnerability 4. Impaired Dentition related to poor dental hygiene

IMPAIRED SOCIAL INTERACTION RELATED TO LACK OF INTEREST

The client exhibits insufficient quantity and quality of social exchange with other people. Unconfronted problems may lead to not absent display of a deep level of understanding or awareness, causing thought content disturbance. This can be manifested by displaying passivity. The camouflage offered by the passive behavior can only increase tension which can lead to impaired interpersonal growth and affect interaction (Stuart & Sundeen, 1995). Subjective cues assessed in the client support this problem. This include clients verbalization of, wala naman akong problema and frequent replies of wala when asked if there is anything he wants to talk about or if there is anything he is thinking about. He also stated that hindi naman ako makikipagkilala kung walang kailangan, di naman kailangan yun. Objective cues, on the other hand,

include mental status findings wherein client avoids gaze though he maintains eye contact during interaction, fidgets with hands or clothes, picks at skin, has a loud speech volume with normal quality of speech, is often prodded to respond to questions, is in a calm mood, does not deny illness but is reluctant to talk about it. During socialization, client does not speak with others and only speaks with nurse and he does not initiate conversation and only talks when spoken to. The goal of nursing care is for client to be able to effectively interact with others after a month of nursing intervention. Objectives include identification of feelings that lead to poor social interactions, expression of desire in achieving good social behavior, development of effective social support system and increasing interaction with others. Nursing interventions include: Take note of social behaviors with caregiver and other individuals at Establish therapeutic relationship and provide active friendliness to Discuss with client possible behaviors that produce discomfort to client Explore ways of handling the identified situations as active Have the client list at least one positive thing about self once a day to Reinforce socialization skills through participation of client in activities Role model proper social skills especially when interacting with client

the ward and recognize speech patterns and nonverbal communication used; allow verbalization; to make him aware of what changes could be generated; involvement is the effective way to produce change needed; enhance self esteem; to strengthen social skills of client and promote feelings of self worth; to give an example.

Evaluation of nursing care is seen on the performance measures of the client after a month. Expected outcomes that the client will be able to do include identifying uncomfortable situations and ways to confront them, manifesting proper social interaction, decreasing withdrawn behavior, be observed interacting with

other people with good quantity and quality of speech. After interventions, the client was improving in his social interaction. He has been able to open up to the student nurse and converse with other people. Whenever an acquaintance is introduced to him, he smiles and offers his hand. He is able to talk with improved quantity and quality of speech and withdrawn behavior is diminished.

DECREASED ABILITY TO EXPRESS FEELINGS RELATED TO POSSIBLE FEELINGS OF INADEQUACY

Individuals with decreased ability to express feelings often stay away from other people. Although this was not observed in the community by the clients sister, it is evident in the clinical setting that the client wants to be alone and is preoccupied with his own inner world. By avoiding others because of this disability, client denies himself the opportunity to share experiences with them and to develop satisfying relationships with them. Since the kind of experiences the patient needs in order to improve can come only from continuing relations with others, it is important for the nurse to help bring about such relations (Schwartz & Shockley, 1956). Subjective cues include the clients verbalization of wala naman akong problema and frequent replies of wala when asked if there is anything he wants to talk about or if there is anything he is thinking about. Objective cues, on the other hand, include findings similar to the findings in impaired social interaction. Goal of care is for client to be able to express self properly while talking or gesturing and resolve problems that led to hospitalization. Objectives of care include participating in the trust relationship, fulfilling role and responsibilities within the context of the relationship, Identifying problems and behaviors that led to hospitalization, discussing feelings, concerns and ideas.

Nursing interventions include:

Introduce self to client for it will help client know what to expect from you.

 Obtain clients perception of his or her problems and hat client expects to gain from relationship or hospitalization as clients actions are based on his perceptions. Assess clients behavior, attitudes, problems and needs as baseline data essential. Establish a regular schedule for meeting with the client as regular schedules provided consistency, which enhances trust. Do whatever you say you will do and do not make promises you cannot keep as client must know what to expect and will trust you when you follow through. Encourage the client to ventilate feelings as client needs to identify and express feelings Evaluation of care include successfully terminating nurse-client interaction, manifesting role and responsibility in ward and interaction, verbalizing reasons for behavior prior to hospitalization and identifying feelings concerns and ideas. There was a successful nurse-client interaction in every interaction. Although feelings and concerns were not really consulted to the student nurse at the end of intervention, client was able to open up in some parts and identify his feelings.

TERTIARY LEVEL
During the tertiary level of experience, the student nurse has also intervened and developed a family nursing care plan with the clients family in the community. Strengths of the family and community will be discussed first followed by the nursing care plan, Strengths of the Family Because the family has been the caregiver of the client since he was 16 years old and developed mental illness, some knowledge and common interventions are already known by the family. Emphasis, update and repetition is the main vein of the interventions.

Familys strengths include (1) united decision-making process, (2) providing care unconditionally, (3) understanding of limitations and possibilities of R. M.s illness, (4) patience and perseverance in caring for the mental patient and (5) adequate coping behaviors with regards to having a mentally ill member of the family. Strengths of the Community The environment may seem to pose a threat to the clients illness because of the noise and stress that it may give the client. However, it may be possible that this sort of environment is quite conducive for the client because of its familiarity and the many activity areas it present. Activity areas include the cockpit arena, basketball court, streets for kara krus and others. They are literally a few feet away from their house so activity is not sparse. That other members of the community do not stigmatize the family because of the clients mental illness is also one of the main advantage of the community. The people in the neighborhood know that R. M. is mentally ill but they converse with him and engage him in play. Because of that, R. M. is not confined to their house all day and is able to participate in activities outside. The only downside of this community is their inadequate knowledge about the effects of alcohol, Cobra, and cigarette to the client which may alter his intake of medications.

PRESENCE OF HEALTH DEFICITS: SCHIZOPHRENIA, UNDIFFERENTIATED TYPE

As concluded by Espana (1996), the caregivers are more used to fulfilment of physiologic needs because there are the basic things done for any human being with or without illness. Among the physical tasks, the top 4 tasks are usually learned at home. It can also be seen that main problems of caregivers is present also in the client. These include inability to understand patients behavior (12%), dont know how to manage violent behavior (6%) and financial loss (4%) (Espana, 1996). Among patient problems that can be instructed to the family upon release of client, Espana (1996) lists noncompliance with medications (14%), recurrence of symptoms (6%) and side effects of medications (6%) as the most common

problems. These were taken in to consideration in the health teaching part of the community visit. Related to factors include: A. Inability to make decisions with respect to taking appropriate health actions due to inadequate knowledge as to alternative courses of action open to them B. Inability to provide adequate nursing care to sick member due to: 1. Inadequate knowledge about disease condition (nature, severity,

prognosis, and management) 2. 3. Inadequate knowledge of nature and extent of nursing care needed Prolonged disease or disability or progression which exhaust

supportive capacity of family members C. Inability to provide a community environment conducive to personal development due to: 1. Lack of knowledge of community people

Goal of nursing care is for the family to implement effective coping strategies to prevent hospital readmission of R. M. and control the symptoms of the schizophrenia as well. Objectives include: After the nursing interventions, the family would be able to: Explain why and how Schizophrenia develops Report the risk factors for Schizophrenia Enumerate the signs of schizophrenia Express the importance of complying with prescribed drug regimen Report the side effects of the drugs Identify effective coping strategies Accept the condition as a disease needing medical intervention Acknowledge social stigma

Demonstrate relaxation techniques Participate in family therapy as needed Express desire to seek medical help before the disease develops into Visit the psychiatrist for regular follow up Correct misconceptions about mental illness Be equipped with ways on how to handle the client at home Know relapse prevention List foods that are beneficial and not beneficial for the client Employ identified coping strategies in daily life Explain ways of enhancing coping skills and self esteem of client: o o o Problem solving Express self Acceptance

the acute stage

Emphasize the importance of family evaluation Describe the importance of fulfilling personal needs of the family o o Creative family leisure time Me time

members:

Resolve identified family issues both personal and as a family

Compromise with one clear decision to manage the condition of the ill family member Nursing Interventions include: Conduct initial survey and critical incident stress debriefing (CISD) for assessment Discuss the pathophysiology of Schizophrenia using different theoretical frameworks a. Genetic b. Anatomical/Physiological c. Psychodynamic Explain the risk factors for the disease

Explain the signs and symptoms of Schizophrenia a. Autism: an attempt to deal with the pain of failing to relate to other people; own world b. Associative looseness: Connection is apparent to the speaker/client but not to the speaker/nurse/family member c. Ambivalence: conflicting emotions of love and hate; leads to apathy d. Affective Indifference or Inappropriate affect: feelings that do not fit a situation

Stress the importance of seeking medical help before the disease state worsens Encourage sharing their newly acquired knowledge about the disease with others Discuss prescribed drug regimen including name, indication, dosage, time, duration, and side effects a. Chlorpromazine: Upang mawala ang mga delusion at halusinasyon, pagsasalit mag-isa at hirap sa pagtulog b. CNS: Inaantok, pero hindi makatulog, masakit ang ulo, panghihina, panginginig ng kamaya, hindi mapakali, EPS. CV: Mababang BP, mabagal ang tibok ng puso, atake. EENT: Pagbara ng ilong, malabong mata, lumiliit ang pupil, nahihirapang makakait sa maliwanag. GI: Parang gustong magsuka, tuyo ang bibig, hirap sa pagtae, paglalaway. Hematologic: Anemia. Respiratory: Pagliit ng lagusan ng hangin. Other: Lagnat, heat stroke, pagpapawis. c. Drowsiness (avoid driving or operating dangerous machinery; avoid alcohol, increases drowsiness), sensitivity to sun (avoid prolonged sun exposure, wear protective garments or use a sunscreen), pink or reddish-brown urine (expected) and dizziness (change position slowly; use caution climbing stairs; usually transient)are common. d. Report immediately any of the following: sore throat, fever, unusual bleeding or bruising, rash, weakness, tremors, impaired vision, dark urine, pale stools, yellowing of the skin and eyes.

Emphasize compliance to medications Educate about misconceptions and myths about schizophrenia Discuss ways on how to handle behavior especially violent behavior

Educate on the proper nutrition needed by the mental patient Enumerate symptoms of relapse and how to prevent relapse Emphasize the prohibition of vices especially alchohol, Cobra and cigarette Alleviate fears and anxieties of caregiver Facilitate identification of coping strategies Explain ways of enhancing coping skills and self esteem of client: o Problem solving skills: involves identifying the problem, exploring all possible solutions, choosing and implementing one of the alternatives, and evaluating the results o o o Step by step approach - helps achieve clear solutions Encourage client to express self help client express feelings in a safe way; Acceptance express acceptance of person but not behavior.

Emphasize the importance of evaluating: o o o o Evaluate parenting skills, communication skills, discipline and behavioral methods Treatment is effective if client is able to follow house rules and expectations at home If effective, modest progress will occur over time. If not, alterations in methods should be considered

Describe the importance of fulfilling personal needs of the family members: o o Me time Creative family time - doing things together such as in work, relaxation, exercise, using of computer resources for fulfillment of own leisure as well as family enjoyment (interactive CDs on relaxation techniques or exercises)

Perform deep breathing exercise with the family Provide handouts of the lecture Reinforce regular checkups with physician Assist with questions Secure contract for implementing identified coping strategies

Conduct family therapy a. Identify immediate difficulties with the client b. Decide activities that will be assigned to client c. Optimistic d. Discuss experiences with psychotic episode e. Control emotional intensity

Coordinate with the barangay and health center regarding the clients condition, and what should be done should the family seek help from them (i.e. manic episodes, violent episodes).

Encourage the family to seek help from them in times of trouble.

Evaluation of care was done and the family has been able to accomplish performance measures indicated.

RECOMMENDATIONS
Recommendations for care are extracted from Espanas (1996) graduate thesis entitled Filipino Familys Caregiving Capacity for Selected Schizophrenics in a government tertiary hospital.

For families of schizophrenics , the following are the needed strategies in the care of the mentally ill:

Learn about the disorder. Family member must learn all he can about schizophrenia as understanding helps one cope.

Encourage patient to comply with treatment. The most important factor in keeping schizophrenics out of the hospital is have them take their medications regularly. The best compliance with treatment is obtained when the family works with the patient to help him or her remembers the medicine

Handle the symptoms. One must try his best to understand what his love one is going through and how the illness causes upsetting or difficult behavior. One must not criticize the patient or act alarmed

Learn

to

recognize

the

warning

signs

of

relapse.

Stay

calm,

acknowledge how the person is feeling, suggest the importance of getting medical help and do what you can to help him or her feel safe Handle the crisis. In some cases, behavior caused by schizophrenia can be bizarre and threatening. If confronted with such behavior, one must maintain calmness and non-judgemental. Also, be direct in whatever you say and be clear about limits of acceptable behavior and get medical assistance Commit the ill person to the hospital. A schizophrenic who has deteriorating physical and psychological condition requires immediate confinement. Manage patient from day to day. Caregivers should be consistent in their dealing with the schizophrenic so as not to add confusion and further stress. Be positive and supportive of your mentally ill relative. Give your schizophrenic relative a lot of encouragement to regain his former skills and interest Look after yourself and other family members. Be good to yourself. Let go of guilt and shame. Take comfort and gain strength from the positive things your family has experienced together. Involve other family members in the care.

As a recapitulation for families of schizophrenics, a good family environment is a major factor in the treatment of schizophrenic. What is needed in order to cope with the illness is time, a good understanding of the illness and support from others who are experiencing the same crises.

For psychiatric nurses The components of nursing functions that need to be enhanced include the following: To encourage positive and caring attitude among families and other caregivers in the care of the mentally ill. An attitude of acceptance can initiate greater understanding and tolerance of the ill persons future problems. To educate the nurses themselves and the family regarding the latters role in recovery of the schizophrenic To become actively involved in family education programs on schizophrenia in which other members of the health team can participate. The education program for families must include the importance of consistency and psychotherapy. It must also include methodologies that are family-oriented and symptom-based. Nurses can assume leadership in this program. Nurses have close and ongoing contact with families hence are more familiar with family responses and coping behaviors Maintain an open communication with all persons involve in the care of the schizophrenic. occupation This includes communication psychiatrists and between families, workers. To nurses, improve therapists, social

communication at the unit level, prospective team care planning is essential. Nurses must routinely assess family coping. This should indicate an assessment of the readiness of the family to discuss their issues and concerns related to the care of a schizophrenic relative.

This information should be addressed at regular ward meetings so that the health team can focus their attention on the issues. This kind of planning will reassure the family that they are not alone in their problems and that the health team is ready to help them. Nurses, for their part, must not only be patient focused but knows how to do family care planning. The health teaching function of nurses should be enhances ro address concerns like low values on seeking help from the health team and reporting of side effects of medication. Regular family meetings and even home visit is necessary to ensure continuity of care. Keep abreast about the latest developments about schizophrenia through attendance in continuing education programs

INSIGHTS

A desire to be in charge of our lives, a need for control, is born in each of us. It is essential to our mental health, and our success, that we take control. - Robert Foster Bennett

Certainly, the psychiatric health nursing experience has been one of the most fulfilling and interesting clinical experience I have ever encountered. Everything in the care was new yet it calls out to something that is basic in every man having a heart, a mind, an instinct and compassion. At first, it has been really difficult to care for the mental patient because it is very demanding. Every word and action one does should be carefully thought of to avoid any problems because the deterioration of mental health is very complex and dynamic. A few words and actions can create a havoc in a persons mind and life. I appreciate also that I was able to look into other cases of my classmates. We were able to compare and contrast the different phases of the human mind and how individual it is. I was able to see persons in a different light and I have gained a new perspective. I, for one, have become very conscious of everything I say. This is because I have realized in this rotation, that we all shape each others lives. We are like sculptors that in every chiselled block, we are formed to what we are now. Inside the sculpture is the real us, vulnerable yet true to nature. I also realized how man can be strong to face problems that others cannot. Having said all that, I can say that this is an experience that will guide me in all of my life.

REFERENCES
Alesi, E. G., et al. (1981). Mental health nursing: A bio-pscycho-cultural approach. Mosby: St. Louis Banaag, C. & Daiwey E. (n.d.). Drug abuse among Filipinos: The situation. Drug Abuse Prevention Among Children Philippine Initiatives. Retrieved on September 29, 2011 from http://www.mentorfoundation.org/pdfs/prevention_perspectives/1.pdf Bretherton, I. (1992). The origins of attachement theory: John Bowlby and Mary Ainsworth. Developmental Psychology (28): 759-775 Carson, R. & Butcher, J. (1992) Abnormal psychology and modern life. Minnesota: HarperCollins Publishers Inc.

Doenges, M., Moorhouse, M. F. & Geissler-Murr, A. (2004) Nurses pocket

guide: Diagnoses, interventions, rationales 9th edition. Philadelphia: F. A. Davis Co. Espana, L. (1994). Filipino familys caregiving capacity for selected schizophrenics in a government tertiary hospital.[Graduate thesis] University of the Philippines College of Nursing Manila Halgin, R. & Whitbourne, S. (1994). Abnormal psychology: the human experience of psychological disorders. USA: Wm. C. Brown Communications, Inc. Kaplan, H. I., et al.(1994) Kaplan and Sadocks synopsis of psychiatry. Lippincott Williams and Wilkins: Philadelphia. Karch, A. M (2010). 2010 Lippincotts nursing drug guide. Lippincott Williams and Wilkins: Philippines.

 Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007). Psychiatric Nursing. Manila: Elsevier Inc.

Maglaya, A (2009). Nursing practice in the community. Manila: Argonauta

Corporation.

Manfreda, M. & Krampitz, S. (1977). Psychiatric nursing 10th ed. Philadelphia:

F. A. Davis Co.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review

(50), 370-396 Perkinson, R. (2011, February 22). Substance Abuse in Teens. Retrieved August 30, 2011, from Alcoholism and Drug Abuse Information Page: http://www.robertperkinson.com/ Rogers, Carl. (1961). On Becoming a Person: A Therapist's View of Psychotherapy. London: Constable Sadock, B. & Sadock, V. (2007) Synopsis of Psychiatry. Philadelphia: Lippincott Williams & Wilkins. Schwartz, M. & Shockley, E. L. (1956) The nurse and the mental patient. New York: Russell Sage Foundation Stuart, G. W. & Laraia, M. T. (2001) Principles and Practice of Psychiatric Nursing. Missouri: Mosby - Year Book Inc. Stuart, G. W. & Sundeen, S. J. (1995) Principles and Practice of Psychiatric Nursing. Missouri: Mosby Year Book, Inc. Townsend, M. (2008). Essentials of psychiatric mental health nursing 4th Ed. Philadelphia: FA Davis Company Varcarolis, E., Carson, V. & Shoemaker, N. (2006), Foundations of psychiatric mental health nursing. China: Elsevier, Inc.

 Videbeck, S.L. (2002) Psychiatric mental health nursing. Philadelphia: Lippincott Williams & Wilkins. Wicks-Nelson, R. & Israel, A.C. (2009) Abnormal Child and Adolescent Psychology. New Jersey: Pearson Prentice Hall.

APPENDICES
NURSING HEALTH HISTORY
PATIENT PROFILE NAME: R. M. C. Muvillon AGE: 48 SEX: Male CIVIL STATUS: Single BIRTHDATE: September 9, 1962 ADDRESS: Block 27, Lot 4, M-3 Phase II, Bgy. 35, Dagat-Dagatan, Maypajo, Kalookan City DATE OF ADMISSION: June 17, 2011 RELIGION: Roman Catholic EDUCATIONAL ATTAINMENT: Grade 5 RACE: Filipino OCCUPATION: None LIVES WITH: Twin sister and her children in their mothers house DIAGNOSIS: Undifferentiated Schizophrenia IDENTIFICATION: Mole on face Scars on chest and back area Surgical scar on abdomen HISTORY OF PRESENT ILLNESS: Client has been mentally ill since 1990s with admission at the center on December 2010. He came to NCMH on June 17, 2011 with sister. He was ambulatory with a fresh injury. He has multiple abrasions on the right knee. He was responsive

but responses are irrelevant. He was incoherent and uncooperative and was not oriented to place, person and time. During his first days inside NCMH, client was disturbed and exhibited restlessness. He was seen masturbating at his bed and was put on restraints. He was passive to queries and most thoughts are illogical. 2 weeks after admission, client speaks spontaneously though slightly stunted. Most thoughts are illogical and tangential. Agawan kasi ng asawa sa amin kaysa magkagulo, kaya asawa ko. He has poor impulse control, insight and judgement. His sister who supplied information in the chart, worte in the family section her name, Roselyn and Jovens as the clients only family who could support him. Ms. Muvillion, 48, is a sewer; Roselyn, 18, is a factory worker and Joven, 16, is a student. Rosana also verbalized observations in the client, Di natutulog, di mapakali, nagsasalita mag-isa, kung ano-ano sinasabi, nanlilisik yung mata. GORDONS FUNCTIONAL HEALTH PATTERNS: Health Perception and Health Management Pattern Client has never verbalized that he is ill. He does not speak about his admission though when asked why he was admitted, he stated Para ikulong. He always takes a bath and washes his hands. He urinates on trees when he feels the impulse to urinate to he says this to the student nurse beforehand. He dislikes brushing his teeth but claims to do so. He participates in the activities inside the ward. He always takes his medicine which he stated was given to him in the morning and in the afternoon. He states that his wounds came from the mosquitos. He has a 10 cm abdominal, operative scar, midline and anterior in aspect which he said came from a fight he had before. Nutritional and Metabolic Pattern Client eats whatever is prepared in the hospital. During breakfast, bread and salabat is often served. During lunch and dinner, rice and viand like fish and meat is served. Client has good impulse control in eating and stops eating whenever he feels full. He eats fast, however, and drinks lots of water. He has normal weight for his age. He has difficulty eating sometimes because of poor dentition (yellowish and some black teeth, sometimes halitosis, with caries) and loss of teeth.

Elimination Pattern Client claims that he defecates once a day in the toilet though he urinates many times. There are times during session that the client urinates though behind trees whenever he feels the impulse. Activity and Exercise Pattern Client participates in the ward exercise every morning. However, he rarely engages in activities and prefers to stay in a corner. Sleep- Rest Pattern Client claims to always sleep and reports no difficulty in sleeping. He says that he has no difficulty falling asleep and does not easily wake up. Dreams are not reported. Sleeping and resting are the major activities of the client. Cognitive- Perceptual Pattern Client is able to add, multiply and subtract. He rejects any hallucinations. He has good attention and is conscious to time, person and place. He has intact remote, recent and past immediate memory. He is able to interpret Aanhin mo pa ang damo kung patay na ang kabayo with Wala ng silbi yung damo kasi wala ng paggagamitan. Role- Relationship Pattern Client claims that he only stays at home and does not work prior to hospitalization. He did experience working as a construction worker and seller of dilis. Self-Perception Pattern When asked how he perceives himself, client answers Okay naman. Coping- Stress Pattern Client has never verbalized that he has problems or anxieties. However, due to constant questioning of client, it seems that he is anxious about going out of the institution. Values- Belief Pattern Client states that he believes in God but he is not an ardent believer.

MENTAL STATUS EXAMINATION

Content of Thought If the client narrates delusions, it cannot be confirmed at present. However, he does not report that he knows they are rich he has no delusion of being talked about. He also does not have a false idea about the functioning of his body and he does not have a false idea of his self. He, however, perceives that his sister placed him inside the institution to imprison him. In the chart, the interviewer also noted that the client perceives the examiner with suspicions of detaining him longer in the institution. Client is also preoccupired with going out of the hospital and is impatient to go home which is contrary to prior statements that he is content to stay in NCMH. However, he does not pose threat of escape and impatient to be released from detention. As stated in the chart, client has a delusion that family tricked him into a consultation (this, however, has not been confirmed yet by the student nurse). He does not exhibit paranoia or magical thinking. Form of Thought

Client needed prodding to talk though he has since changed to being able to talk spontaneously and asks questions spontaneously. He display and abundance of ideas without circumstantiality though sometimes there is slight tangentiality. There is no thought blocking. He does not display associative looseness, neologisms, clang associations, word salad and perseveration. He is able to display abstract thinking. However, client tends to repeat stated words for emphasis. For example, when asked where he lives, he answers Tondo, Balot, Kalookan, Maypajo and with a nod from nurse, repeats it again, Dun ako nakatira sa Tondo, Balot, Kalookan, Maypajo. Perception Client has always denied hallucinations (hearing voices or seeing things), Affect Clients language is spontaneous and there is no language impediment. His speech is loud at times and is slow. He now spouts productive things though there are slight mumblings at times. He has appropriate affect at times though there are many times that the client has a restricted affect.

Sense of Self Client does not display echolalio, echopraxia and depersonalization. However, he sometimes display imitation as seen in art therapy wherein he copied others works though he has never imbibed a behavior formed from another person. Volition Whenever client is winning, he always says Chamba lang yun repeatedly. Then, he does not participate anymore. This can be interpreted as the client has already fulfilled his need of winning or in the case of the basketball game, of shooting in the basket. It can also show ambivalence in feelings or inadequate interest or motivation based on the need-fear dilemma the simultaneous need and fear of intimacy with regards to playing with others.

Impaired Interpersonal Functioning and relationship to the external world Client needs to be constantly reminded for the need of personal hygiene. He also likes to stay by himself though he is able to interact with other. Psychomotor behavior The client does not display anergia though he rarely interacts with others. He does not display waxy flexibility, posturing or pacing and rocking though he usually fidgets in his sit and moves his hands. Associated Features The client is able to experience pleasure and he always smiles or laugh when he does. He does not display anhedonia or regression. Judgement and Insight Client has good judgement though he has impaired insight and may have a denial of disorder. According to the chart, he denies it then admits it but refuses to seek help. Attitude and General Behavior The client appears well, strong and healthy. He does appear older that his chronological age though he is mature in appearance. He dresses the hospital uniform for patients but is not meticulous. He usually scratches everywhere on his body. His usual general mood is calm but not apathetic. He does not report any leisure but sleeping. He claims that he does not converse with other people because he is not fond of spinning stories. He also does not read though he is able to. He follows commands usually when he is asked by the employees to pour water in the toilet or comfort room which he does regularly. He claims that he is usually seclusive though he is not afraid of making acquaintances. Though he remembers them by name, he does not really call them friends but are acquaintances (kakilala). Client is able to speak spontaneously when ask but does not really talk at length. Attitude and General Behavior During Interview

Client is attentive and cooperative during interview. He answers questions though he becomes silent when he does not want to answer the question. Whenever he speaks at lenth, his voice is quite loud though when he answers wala naman, it is soft. His posture is normally relaxed though he usually crosses his legs when sitting. Whenever, we are in a face-to-face position, client alternates between a body posture implying moving away from the nurse and facing her squarely. He maintains eye contact, however, whenever answering a question or is asked a question. Client expresses emotions through facial expressions as well. He smiles and laughs at appropriate times. However, when topic at hand is unwanted, expression turns indifferent and eye contact is removed. When turned away, he usually is looking up something at a distance though immediately goes back to interaction. Client walks erect though slouching is also evident. He usually picks at himself or clothing and hand movements are present. He is usually twitching at his seat. He has motor coordination and is able to follow the exercise implemented. His general activity is average. Streams of Mental Activity Client answers questions relevantly though with diminished productivity and there are times that patient refuses to answer questions. He usually answers questions with average reaction time though there are times that he answers rapidly. With unwanted questions, he starts with a hesitation and is low in responding. Emotional Reactions Whenever the client is asked how he feels, he always say that he is okay and that he does not have any problems. Mental Trend: Content of Thought The client is reluctant to talk and give an account of the beginning and subsequent causes of mental disorder. The examiner then proceeded with appropriate questions to identify if client has a persecutory trend, hypochondriacal ideas, nibilistic ideas, grandiose ideas, hallucinatory experiences or delusions.

When asked if he has the feeling of being watched or suspicion of being talked about, the client stated in the negative. He also claims that he does not feel as if someone is reading his mind. He states that relations with family is okay though this was not divulged comprehensively. He also does not have semantic delusions about health or strength. He states that overall he is healthy and he does not feel anything untoward. He expresses that he does not have any dreams or plans for the future. He does not say that everything is lost or destroyed though he does not seem to have a purpose for living. Inside, it seems like he has cut off himself from the rest of humankind as he does not like to establish a relationship with others or maintain relationship with his sibling. He stated that he is okay with staying inside the mental institution and not visited by his relatives, The client does not have any grandiose ideas about strength, power, wealth or high birth because he stated that he was poor before and his work was in construction. He, however, mentioned that his parents and siblings are all in America and has left him and his twin sister with their mother since he was 4 years old. In the account of the client, it seems that he does not have any hallucinatory experiences (at present) as he states that he does not hear things or have peculiar thoughts (he stated that he does not really think much). He does not see any extraordinary images or smell anything different. When asked if the client is always thinking, he answered in the negative. He stated that he rarely thinks about things and is content to sleep all day or sit for hours. He does not convey what he thinks about because he maintains that he does not think at all. He said that he is the type to forget problems readily or not confront them. He said that he does not have difficulty in decision-making and does not fear anything though he said that he fears those which he encounters at the first time like a dog which he does not know and may bite him. When asked how he socializes with other people, he states that he does not do that. He thinks that he is not sensitive and has never felt that people are talking about him. He has not heard anything about him on the radio or TV and no extraordinary experience has happened in his life. He does not think that people can read his thoughts. He states that he has a huge appetite though he does not feel any changes in his body. He does not feel sick.

The client was silent when asked if he blames himself for a bad happening. He answered, however, the next question which asks if he has a problem with money which he answered that all people do though he does not incur debts. He does not think that there is anything special that happens to him. He does not hear any voices and says that he hears this only from real people. He does not think that he dreams while awake. He does not feel or taste anything different. Sensorium, Mental Grasp and Capacity A. Orientation Client is oriented to place, time and person. He remembers me and his other wardmates. He knows that he is in a mental institution and remembers the date and time today. B. Data of personal identification; memory He remembers his family members and his occupation as a construction worker. He also recounted that he was a seller of dilis in Maypajo when he was young. C. Memory of the recent past Client remembers that he was brought in NCMH by his twin sister for checkup and she has never returned since to visit him. When asked about his complete address, he says Tondo, Balot, Caloocan, Maypajo and not the street and number. Before, he said that he lived there with his niece and twin sister but he rectified this recently and said that it was his mothers house and he and his sister lived there together with her husband and 4 children though the client only goes there to sleep. He said that she brought him here in NCMH on June. D. Retention and immediate Recall Client immediately recalls auditory material. He also remembers any visual material tested. He also has a long auditory memory span. E. Counting and Calculation He is able to count 1-20 as fast as possible and is able to carry out multiplications. He subtract from 100 and keep subtracting 4. F. Reading Client refused to read as he said that he has difficulty in seeing material as it contains small words and his eyesight is not as good as before.

G. Writing Clients writing is in cursive form and he writes freely though slow. H. School and General Knowledge Client is not inclined to impart general knowledge though he remembers Dr. Jose Rizal as the national hero and Rizal Park as the place where his remains are. I. Intelligence Rating Client has considerable intelligence and is fast on the uptake though this cannot still be ascertained for sure. J. Command Client is able to follow commands when he closed his eyes, folded the paper in half and placed it on his lap. He also helps in arranging the materials after socialization though he does this only when asked to. He has never really volunteered to be helpful up to this day. Decision-Making Client does not feel anything different with his illness or what he feels. He does not think anything out of the ordinary is happening. When asked the reason he was brought to NCMH, he does not speak of anything and is silent though when he is asked another question he answers readily. He is reluctant to tell the nurse the reasons. Client states that he does not have any plans and is content to stay here in NCMH. He, however, has appropriate decision-making skills as when he was asked what he will do when there is a fire, he stays that of course he will immediately run away.

NURSE-PATIENT INTERACTION
1ST Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will: Be oriented to the setting of National Center for Mental Health Establish rapport with patient Set a contract with the patient (purpose, activities and meeting) Identify activities of interest of the client and needs to be addressed Perform initial assessment (observations only) If possible, identify if with insight and his relationship with others Patient-Centered: At the end of duty, the client will: Be at ease with the student nurse Establish rapport with student nurse Be at ease to open up misgivings, apprehensions, problems and anxieties Verbalize intention to honor contract set Verbalize willingness to do activities and assessment of needs NARRATION Interaction PATIENT VERBAL NONVERBAL VERBAL NONVERBAL (Sinundo ng student nurse mula sa ward ang kliyente at sabay sila naglakad palabas ng ward. Magkatabi silang naglalakad habang nakatingin sa baba ang kliyente.) Magandang umaga po Nakatingin sa Tumatango at sir. Ako po pala sila kliyente. tumingin sa student NURSE

M. H.. Student nurse po ako mula sa UP. Kayo po ba si Roberto? Bale, okay lang po bas a inyo na magusap tayo saglit ngayon? Maglalakad lang po tayo saglit tapos kung gusto na ninyong umupo, sabihin lang ninyo sa akin. Ah, paikot lang po dito sa garden. Bale, ako po pala ang magiging isa sa student nurse ninyo dati sa loob po ng isang buwan. Ang gagawin lang po natin ay mag-uusap tungkol sa mga iniisip ninyo, kung may problema kayo. Atsaka may mga activities din po tayong gagawin. Ano po palang gusto ninyong itawag ko sa inyo? Okay, Roberto, ano nga po pala ulit pangalan ko? Di ba nagpakilala po ako kanina? Di na po ba ninyo matandaan? M. po ang pangalan ko. Baka po napapagod

Naglalakad habang nakatingin pa rin sa kliyente. (Same as above)

Oo.

nurse. Tapos binalik ang tingin sa paligid. Timingin ulit sa student nurse. Tumigil sa paglalakad at tumingin sa paligid.

Saan ba tayo pupunta?

(Same as above) (Same as above)

Grunts

Tumango. Mabagal na naglalakad.

(Same as above)

Roberto.

(Same as above)

Tumitingin sa student nurse tapos ibabalik ang tingin sa paligid. Ngumiti (apologetically).

Ngumiti din at tinuro ang nameplate. Pagkatpos, hinawakan ang balikat ng

Sige.

Nauna sa student nurse at umupo sa mga upuan ng magkatabi at medyo

na kayo. Upo po muna tayo dito Bale, Roberto, sabi ko nga kanina. Ako yung magiging student nurse mo ng isang buwan pero hindi yun araw-araw. May mga araw lang akong darating. Okay lang ba sa iyo yun? Mga 30 minutes hanggang 1 oras lang din yung gagawin natin. Sa September 17 yung huling araw namin. Madalas exercise, atsaka mga drawing yung mga activities namin. Tapos, kakain din pagpatapos na. Anuano po ba yung madalas na ginagawa ninyo dito? Alam po ba ninyo kung nasaan kayo ngayon? Anong klaseng ospital po? Sabi po ninyo, natutulog at kumakain po kayo dito. E anong oras naman po kayo nagigising at naliligo? Ano po yung madalas na pagkakasunudsunod nung mga ginagawa ninyo?

pasyente. Tapos, tinuro ang mga upuan. Kumuha ng papel at pinakita ang mga petsa ng pagdating.

Oo, okay lang.

harapan. (Horseshoe position) Nakatingin sa student nurse at nagkabesa. Kinakamot ang paa.

Nakatingin sa pasyente at hawak ang papel.

Tahimik, medyo matagal ng kaunti. Pagkatapos, Natutulog, kumakain, paminsan may exercise din.

Nakatingin sa student nurse, linipat ang kabesa ng paa. Nagkakamot sa damit.

Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above) (Same as above)

Sa ospital.

Nakatingin sa paligid.

Tahimik (matagal). Tahimik (medyo matagal). Pagkatapos, Maaga kaming naliligo dito. Pagkatapos maligo, ayun kakain atsaka iinom ng gamot. Tapos wala ng gagawin, matutulog

Nakatingin sa baba o sa paa. Nakatingin sa estudyante. Nakangiti at ginagamit ang kamay sa pagsasalita.

Ano pong madalas ninyong kinakain? Ano-ano po yung mga iniinom ninyong gamot? Nakapagsipilyo na po ba kayo? Yung mga kasama ninyo, hindi po ba kayo nagkekwentuhan sa loob? Sino po madalas ninyong kinakausap kapag may problema kayo? Hindi po ba kayo pwede lumabas dito sa garden? E, nung nasa bahay po kayo, anong madalas po ninyong ginagawa? Ah, nagtitinda po pala kayo ng dilis. Bago po kayo pumasok dito, nagtitinda po kayo ng dilis? Ah, ilang taon na po ba kayo ngayon? Ah, 62 na po kayo?

(Same as above)

(Same as above)

na lang ako. Ayun, tinapay atsaka gulay. Paminsan isda atsaka karne. Di ko alam e.

Nakatingin sa estudyante. Nakatingin sa estudyante. Nakatingin sa paligid pero tumitingin pa rin sa estudyante. Nagkabesa at nakatingin sa student nurse. Tumingin sa ward.

(Same as above)

Oo.

(Same as above)

Oo, paminsan.

(Same as above)

Meron naman. Pero madalas natutulog lang ako. Hindi.

Tumingin sa paligid pagkatpos sa pasyente. Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. Tumatango habang nagsasalita ang pasyente.

Tumingin sa garden.

Wala rin. Nagtitinda ako ng dilis sa palengke. Nung bata ako mga disi-siyete ako nun.

Nakatingin sa estudyante at ngumingiti. Nagkakamot ng ulo at nag-iisip.

Ay, bakit po ang sabi ninyo kanina 62 po kayo?

Mukhang curious ang itsura Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. Medyo gulat ang tono.

62. 48 years old.

Mabilis ang pagsagot. Nakatingin sa estudyante.

1962 ako pinanganak.

Tumatawa at ngumingitng tumitingin sa estudyante.

Ah, kailan po ang birthday ninyo? Ah, kasama po yun dun sa mga date na nandito kami. Natatandaan niyo pa po ba yung mga araw na yun? Ah, August 24, 2011 po. Miyerkules po ngayon, mga 9:45 na pa sa relo ko. Gaano na po ba kayo katagal dito?

Tumatango habang Sa September 9, 1962. nakatingin sa pasyente at nagsasalita ito. Kinuha ulit ang papel Anong araw na ba mula sa bulsa at ngayon? pinakita sa kliyente.

Nakatingin sa estudyante, Tinignan din ang papel.

Tumingin sa relo at tumingin sa pasyente.

Ah, August 24 na pala.

Tumatango.

Ah, kailan po ba kayo pumasok dito. Alam niyo po ba yung dahilan kung bakit kayo pumasok dito?

Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above) (Same as above)

2 buwan na.

Nagkabesa at tumitingin sa estudyante. Nakatingin sa paligid. Tahimil (matagal). Inalis ang kabesa niya. Nakatingin sa baba at ang katawan ay medyo nakalayo sa nurse. Tumitingin sa paligid.

Nung June. -

Tahimik.

Sabi po ninyo September 9 kayo, pinanganak. Saan po kayo ipinanganak? Sa Divisoria po kayo nakatira ngayon?

Nakatingin lamang sa pasyente na parang naghihintay na magsalita ito. Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above)

Tahimik.

Tahimik matagal. Sa Tondo pero lumipat kami ng Divisoria. Hindi sa Paco. Sa Tondo kami dati tapos lumipat ng Divisoria. Sa Tondo na ako pinanganak pero tagaMindoro ang nanay

Humarap sa estudyante.

Ah, sa Paco po pala. E, di malapit lang. Anong probinsya po

Tumatango habang nagsasalita ang pasyente.

Tumitingin sa paligid at kapag sumasagot ay tumitingin sa estudyante. Habang nagsasalita, ginagamit ang kamay para mag-eksplika.

ba kayo galling. E, sino po pala ang kasama ninyo sa bahay? May asawa po ba kayo, anak? E, yung mga magulang ninyo. Nasaan po? Ah, kailan pa po? Eh, yung tatay po ninyo? Tahimik. Ano pong naramdaman ninyo tungkol dito? Tahimik.

Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above) (Same as above)

ko. Yung kapatid kong babae atsaka yung anak niya. Tahimik matagal. Wala. Ah, patay na nanay ko. Medyo matagal na. Wala akong tatay. Lumaki akong walang tatay. Wala naman.

Nakatingin sa estudyante at nakangiti. Nakatingin sa baba. Matter of fact ang pagkasabi. Nagpalit ng kabesa ulit. Nakatingin sa baba pero tumitingin din sa estudyante. Nakatingin sa harap. Umiiling ng pakontikonti at sumusulyap sa estudyante. Nakatingin sa estudyante (expectantly). Ngumingiti at nakatingin sa baba.

(Same as above) (Same as above)

Nakatingin sa kliyente. Nakatingin sa pasyente, at medyo umabante pa paharap sa pasyente. Tumatango.

Sabi po ninyo, kasama po ninyo yung kapatid atsaka anak niya. Ano pong pinagkakaabalahan niyo doon? Wala po kayong hilig gawin sa bahay kahit po manood ng TV o kaya magbasa ng dyaryo? Ano pong pangalan ng kapatid ninyo atsaka yung anak niya. O yung mga magulang po ninyo?

Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above)

Wala naman.

Wala.

Nakangiti pa rin at tumitingin sa estudyante.

(Same as above)

________ at ________.

Matter-of-fact ang pagkasabi.

(Same as above)

__________ at

(Same as above)

_________. Kumusta naman po yung relasyon ninyo sa kapatid ninyo? Dinalaw na po ba nila kayo dito sa nakalipas na 2 buwan? Silence. Alam niyo po ba kung bakit? Ano pong nararamdaman ninyo tungkol dito? Eh, sa lugar po ninyo, may mga kaibigan po ba kayo? Ah, marunong po pala kayong magbasketball. Ah, hindi po sa liga. Ano pa pong madalas ninyong ginagawa kasama nila? Ano po bang trabaho ninyo bago kayo pumasok dito? Ah, sa bahay lang po kayo. E yung pong kapatid ninyo? Silence. (Same as above) Okay naman. Tumatango.

(Same as above)

Hindi.

Nakatingin lang sa pasyente. (Same as above) Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente. (Same as above)

Di ko nga rin alam. Wala naman.

Nakatingin sa baba pero tumitingin din sa estudyante. Nakatingin sa nagrorole play. Nakatingin sa estudyante. Nakatingin sa paligid.

Oo, mga kamag-anak atsaka mga kakilakilala lang. Sa basketball.

Nakatingin sa estudyante

Ngumingiti at nakatingin sa pasyente. Tumatango. Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente Medyo curious ang itsura. Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente Nakatingin sa pasyente. (Wala ng

Eh, hindi naman yung Tumitingin sa paligid may laban. Shoot lang at kapag sumasagot ay tapos may pera ganun. tumitingin sa Hindi. Sa kanto-kanto lang kami. Wala naman. Yun lang. estudyante. (same as above) (Same as above)

Wala naman. Sa bahay lang. Nagtatrabaho sa labas.

(Same as above)

Nakatingin sa baba.

Nakatingin sa baba.

Kayo po Sir, ano po yung mga plano o gusto ninyong gawin sa buhay? Wala po ba kayong kinahihiligang gawin?

maisip na itanong) Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente (Same as above)

Wala naman.

Nakatingin sa paligid.

Yun nga, paminsan magbasketball dun sa amin, -

Ah, mabuti po pala mahilig kayong magbasketball kasi kasama po yun sa activities namin. Pagkatapos din po nito, kain po tayo dun sa mesa. Eh Sir, sabi po ninyo magdadalawang buwan na po kayo dito. Paano po kayo napunta dito? Napansin ko pong ayaw po ninyong pagusapan. Sa susunod na lang po, kapag okay nap o sa inyo. Dun na lang natin pag-usapan, okay lang po ba? Ayun po pala Sir. Yung mga paguusapan natin, sa atin lang pong dalawa yun. Kung may dapat pong malaman ang doctor atsaka lang po natin sasabihin sa kanya, okay po ba yun? Inaantok na po ba kayo?

Ngumingiti.

Parang energetic magsalita at nakatingin sa estudyante. Tumatango.

Nakatingin sa pasyente, at medyo nakausog paharap sa pasyente

Nakatingin sa baba at di tumitingin sa estudyante.

Nakatingin sa pasyente, at medyo umabante paharap sa pasyente.

Tumango.

Nakatingin sa pasyente

Oo.

Humihikab. Nakatingin sa paligid.

Nagtatanong ang itsura.

Oo, inaantok na ko. Pwede na ba akong

Tumatango,

bumalik dun? Inaantok na ko e. Ah okay po. Ayaw po Nakatingin sa Tumayo. muna ba ninyong pasyente. kumain? Sige po tara. Basta po Tumayo dun at sabay Tumatango ang Sir, tandaan lang po na naglakad ng kliyente habang ninyo yung mabagal kasama ang naglalakad. pinagusapan natin pasente. Pagkakakita sa ward ngayon. Babalik po helper, hinubad ang ako sa susunod na tsinelas. Kinuha, at lingo, mga ibinigay sa ward Miyerkules po iyon at helper. Tapos may gagawin po pumasok sa ward. tayong activities. (Hawak ng student nurse sa balikat ang kliyente. Pumasok sa ward at sinabi sa Nurse, Maam, balik na raw po si Sir ditto, inaantok na raw po siya. At sinabi sa kliyente, Sir,, balik po ako next week ah. Tumango ang kliyente ng hindi nakatingin sa estudyante at bumalik sa loob ng kuwarto na dirediretso ang tingin.)

EVALUATION OF OBJECTIVES The objectives have been met accordingly though interaction was cut short, contract has been set. Thorough assessment is not achieved as it was not part of the goal. However, client may not be at ease with the student nurse and was not able to discuss his anxiety and fears or the reason for admission. Nevertheless, there was rapport between the client and the student nurse as the interaction progressed. Contract has also been set and agreed upon by both parties. The client verbalized willingness to do activities. ANALYSIS Observations Client is not very talkative but is quite energetic when he wants to speak. He does not answer immediately but gives answers nevertheless. Most answers are monosyllables but he was able to volunteer information on his own. The client still has an intact memory and is oriented to place. However, he is reluctant or he does not want to talk about the reason for admission. In

addition, his movements are worth to note. It seems that he cannot sit still though he does not stand up. He crosses his legs every time and his posture is slouched. Whenever he does not want to talk about something, his body movement says it (changing direction of sitting position or looking at the ground). He is not aggressive and is silent when he does not want to speak of something. He talks about his family freely though there may be some issue not tackled well. It seems his only family is his sister and his niece and he has no family. This has to be confirmed as the client looked reluctant in talking about marriage and children. REFLECTIONS I was a bit disappointed today because our interaction was cut short as he was feeling sleepy. It should have been evident to me from the start because he was not really focused though I think he wanted to go out of the ward for a while. I was not really scared at our first interaction though during interaction, I was a bit nervous because I was doing all the talking and I was running out of questions. I realize that there are times that I cannot ask directly because I felt that it was too invasive but I realize now that I should have like the topic about his father. However, I think, I did the right thing when I didn't pursue the reason for admission because it was clear that he didn't want to talk about it. I asked about it twice and he never answered me back or was silent all the time. Overall, I think it was still productive because I was able to set the contract and was able to know my patient well. Im hoping for a more productive interaction next time.

2nd Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will: Perform assessment (MSE and physical assessment) Maintain good and trusting relationship with client Adapt a two-way relationship with patient and open communication Perform activities (exercise, name-tag making/art therapy and socialization) Determine history of present illness and relationship to society

ASSESSMENT Patient Profile NAME: R. M. C. M AGE: 48 CIVIL STATUS: Single ADDRESS: Paco, Manila LIVES WITH: Sister and niece Health History Client arrived in National Center for Mental Health on June for a check-up. He was left in the ward by her sister who brought him. Client stated that he drinks two tablets of medicine one in the morning and one in the afternoon. He admitted to smoking cigarettes, drinking alcohol and gambling in the past though he claims to have stopped said activities now. He relaxes by sleeping. He claims that he does not feel any medical problems and was not diagnosed with any health problems. NARRATION Interaction Client was fetched from the ward. Upon interaction, student nurse offered the slippers and set a contract with the patient that they should be returned after the interaction. I asked the client if he remembers me and he answered in the affirmative. When I asked him what my name was, he smiled apologetically and scratched his head. And then I told him that Im M., a student nurse from UP and he nodded. I asked him to repeat it and he repeated my name. AAnd then I said, At kayo po si R. M.. Oo, he answered and then he stated his full name. Then I told him if he would like to take a walk around the garden and he nodded. Then, as we were walking, I also asked him if he has already taken a bath and brushed his teeth and he said Yes. As we were walking in the pathway, I asked him, Kumusta naman po kayo?. He answered, Okay naman. As we were walking slowly I also lead him the way by touching his shoulder. And then I told him the outline of activities today and he agreed to do them willingly. After walking around the path, we pulled two chairs and sat at face to face. However, the client was facing to the left so I asked him to move and face me. At first, clients body posture is turning away but he eventually sat face to face also. Eye contact is maintained.

I asked him, where he is now and he answered mental. I asked him how he likes it here and he answered that it was okay. I asked how he is getting on, and he said that it was okay. I asked him if he had anyone to talk to inside the ward and he said that, Hindi naman ako mahilig sa kwentuhan. I asked him what he likes doing then, and he answered, Wala naman. I asked him if he knows anyone inside and he said Oo yung mga pasyente, kilala namin sa apelyido. I asked him who his friends were inside and he answered, Kakilala lang. I asked him, Paano po pala kayo napunta dito. He answered, Dinala ako ng kapatid ko para sa check-up tapos iniwan niya ko dito. I asked again, Ano pong mga dahilan at nagpacheck-up po kayo?. Like the first time this question was asked, client was silent and his body language is moving away from the student nurse. He is also looking at the ground. I said, Ayaw ninyo po bang pag-usapan?. The client did not reply. Then I said, Kung ayaw niyo pong pag-usapan, nirerespeto ko po iyon pero andito lang po ko ako kapag may gusto kayong sabihin. I then asked him, if he has any concerns or problems. Then he told me that he had none. May iniisip po ba kayo o nararamdaman? And he answered in the negative. And then he said, Problema naman ng mga tao ay pera. Un naman talaga ang problema ng mga tao. Kapag wala kang pera, paano ka gagasta. And then I asked him if he had any past problems with money, and then he said, Lahat naman ng tao. And then I asked him, who he goes to if he has difficulties like this, and he replied, Hindi naman ako nangungutang. And I assured him that I didnt think of that and I added, Pero ngayon po sinasabi po ninyo na wala po kayong pinoproblema? And the client nodded. There were also instances wherein the client was yawning so I asked him if he was usually sleepy at these times and he answered yes. I told him that activity and exercise will be good for him so he must participate in the exercise later. And then, I asked him if it was okay if I will ask him questions and he answer them. And he agreed. From the MSE, I asked him the mathematical questions and memory. He was able to answer correctly. After that, it was time for the exercise activity. During the exercise activity, the client was able to follow the steps correctly. When the leaders said that they could join in the counting, the client exclaims loudly. There was no facial expression during exercise though client told me that he was relaxed. I asked him if he was still feeling sleepy and he answered in the negative. Next activity was the art therapy. During art activity, the client was cooperative. He was first to finish though he didn't really draw anything in it and just traced the lines of his names

with a green pen. When I asked why he chose the green color, he said that because the pen was the one nearest to him. While arranging the materials, I asked the client to help me in returning the pens and he complied readily. After the name-tag making, the socialization and eating part was next. Because the client was not in the first socialization and he may be starving, he ate very fast and finished his serving. When I asked him if he wants another drink, he said Yes. After that, we had to return the clients to the ward. I asked him if enjoyed the activities and he nodded. I told him that we will meet tomorrow and there are activities that we will be doing. And then, I summarized the activities we did today. EVALUATION OF OBJECTIVES The objectives have been met successfully. I was able to assess some aspects of the mental status of the patient though history is little. Rapport and trust is present and there is open communication. However, anxieties, fears and problems were not identified as the client answered that he has no problems. ANALYSIS Problems Identified Some issues identified that client is uncomfortable with the reason for coming in NCMH and issues with his family and sister for leaving him here. Though the client did not show any outward reactions, he was vehement in stating that its okay for him to be left here. I think that it is quite different from what he actually felt as from the tone of his voice, his wall of defenses has been erected by his statement. I think he has wallowed into himself so as not to experience the feeling of maintaining relationships that will ultimately lead to his abandonment. REFLECTIONS I was satisfied with our NPI today. I was happy because he remembered me as it has been many days since we last talked and he seemed okay with what transpired. I was feeling anxious at first because I know that the client seldom volunteers conversation and is not very talkative. It

was good that he participated well in all the activities. I had a difficulty about following through the conversation but it was better than the week before. I know its not good to sympathize with the patient but I feel sorry for him being left here by his family. Its ultimately, the highest form of betrayal not to be recognized as a member of your family. And it seems, its only his sister who he talks about all the time as his family so I think that he really felt left by everyone. When I try to put myself in his shoes, I feel confused of the various emotions that I would experience. I would feel defensive thinking that I can take care of myself and on the other hand How can they do this to me, theyre my family. It certainly creates ambivalent feelings. Ive never felt afraid of my client before because he is not the aggressive type and merely stays silent when he finds the topic unfavorable to him. But today, I felt the tiny sliver of apprehension because of the sudden introduction of wanting to stay here and being comfortable here and also the vehemence in his denial of being unvisited. However, I think that is also quite normal. Overall, I am happy that the client is starting to open up and give his own say in matters.

3rd Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will: Perform assessment (MSE and physical assessment) Maintain good and trusting relationship with client Adapt a two-way relationship with patient and open communication Perform activities (exercise, art therapy and socialization) Determine history of present illness and relationship to society Be able to establish rapport and trust of client Help client communicate feelings Use therapeutic communication techniques Gain more insight regarding the feelings of client Explore his family dynamics Encourage client in verbalization

 Explore feelings regarding condition Patient-Centered: At the end of duty, the client will:

Express feelings of trust and willingness to interact Increase interaction with others Be able to share his feelings about self and experiences Be able to disclose feelings about his family

ASSESSMENT Patient Profile NAME: R. M. C. Muvillon AGE: 48 BIRTHDATE: September 9, 1962 CIVIL STATUS: Single ADDRESS: Maypajo, Tondo DATE OF INTERVIEW: September 1, 2011 SEX: Male RACE: Filipino OCCUPATION: Construction Worker LIVES WITH: Twin sister, husband and their children in their mothers house Health History Client arrived in National Center for Mental Health on June for a check-up. He was left in the ward by her sister who brought him. Client stated that he drinks two tablets of medicine one in the morning and one in the afternoon. He admitted to smoking cigarettes, drinking alcohol and gambling in the past though he claims to have stopped said activities now. He relaxes by sleeping. He claims that he does not feel any medical problems and was not diagnosed with any health problems.

PROCESS RECORDING Observation of Setting: The student had introduced herself and stated the purpose of interview to the client. This communication exchange took place at about 9 oclock in the morning. The client, was from Ward 9 Pavilion 1 of NCMH. The interaction took place in the garden with a lot of open space. The client and the nurse were sitting on two chairs facing each other. The open space keeps the client feel secure and relaxed.

The second setting is inside the activity area after the rain. Client and nurse where first sitting on benches in a horseshoe position for the art therapy. They later moved to two benches where the nurse is facing the client and the client is turned sideways. The latter position is prone to breaking eye contact. Chairs facing face to face are more conducive to the communication.
NURSE PATIENT ANALYSIS VERBAL NONVERB VERBAL NONVERBA AL L (Sa ward, sinundo ng student nurse mula sa ward ang kliyente. Hinihintay ng nurse sa nurses station ang kliyente.) Magandang Gumagami Oo. Sinuot ang Giving recognition is a umaga po R. t eye tsinelas at therapeutic M.. Ito po ulit contact nakangiti. communication yung tsinelas and Naglakad technique that shows na malumana palabas ng awareness of clients ipapahiram y na ward. individuality. According ko sa inyo. boses, at to the interpersonal Kukunin ko diretsong theory by Sullivan, the na lang po pustura. health teams role is as ito ulit a participant observer, mamaya meaning that the pagkatapos therapist both ng mga participates in and gagawin observes the progress natin. Okay of the relationship lang po ba (Videbeck ,2002). iyon? Identification of client is also important. The question was asked as a form of assessment of memory as well as reminding the client of the nurse-client relationship. Bale, kumusta naman po kayo? Naglalakad ng mabagal habang nakatingin sa pasyente. Gumagami Okay naman. Nakatingin sa estudyante. Greeting, reorientation of client and calling client by name helps increase self awareness and sense of self. Active friendliness is also helpful to encourage

Nakatulog po ba kayo ng maayos?

t ng malumana y na boses. (Pareho sa itaas)

client to interact and verbalize.

Oo.

Tumitingin sa estudyante kapag sasagot at tumitingin sa paligid. (Pareho sa itaas) (Pareho sa itaas) (Pareho sa itaas) Tumatango habang sumasagot at nakatingin sa estudyante. Naglakad papunta sa itinuro ng estudyante.

Nakakain na po ba kayo? Ano pong kinain ninyo? Nakaligo na rin po ba kayo? O sipilyo po.

(Pareho sa itaas) (Pareho sa itaas) (Pareho sa itaas) (Pareho sa itaas)

Oo. Tinapay. Atsaka salabat. Kanina.

Mamaya pa. Hapon ang pagsisipilyo namin e.

The question is asked to ascertain sleep patterns. Inability to sleep also increases anxiety and may also imply increased thinking (Stuart & Sundeen, 1995). Hygienic and comfort measures are important facets of health that must be introduced to the mentally-ill patient (Townsend, 2008). Eating problems may also be ascertained by asking through interview.

A ganun po ba. O sige po, banda po tayo dito.

Tinuro ang kamay sa mga upuan. Naglalakad pa rin. Hinawakan sa balikat ang pasyente.

Bale, ang gagawin po natin ulit ngayon, usap po muna

Malumana y na boses at nakatingin sa

Tumatango at nakatingin sa baba.

Touching the patient involves risk especially if the client is not comfortable with body contact and is paranoid (Videbeck, 2002). However, it may also show support and signals relationship with client. Assessment if client is comfortable with simple touches is still needed. Not looking directly at the nurse may be a sign of discomfort. According to Townsend (2008), the individual

tayo habang hinihintay natin yung iba sa exercise tulad po ng napagkasund uan natin para pagusapan natin yung mga iniisip inyo o kung may problema po kayo ganun. Tapos, pagkatapos ng exercise, kain na po tayo. Tapos magdodrowin g tayo mamaya atsaka maguusap ulit. Okay lang ba sa inyo iyon? Sige, dito po tayo. Saan ninyo gusto?

pasyente.

whose posture is slumped, with head and eyes pointed downward, conveys a message of low selfesteem.

Kumuha ng dalawang upuan at inilagay sa tabi.

Umupo nakatagilid sa estudyante.

Sige, okay lang po kaya

Tingin sa kliyente.

Humarap sa nurse.

Making the patient decided allows him to show decision-making skills. Decision-making skills help the client enjoy the achievement of a successful decision or learn that he or she can survive a mistake and identify alternatives (Videbeck, 2002). Sitting at an oblique angle shows that the client may be uncomfortable. A face to face position allows the nurse to

na humarap na lang po kayo dito para makapagusap tayo ng mas maayos?.

Tumitingin sa nurse.

assess the client correctly and is able to converse with client with eye contact. Eye contact shows interest in what the client has to say and establishes communication (Videbeck, 2002). The placing of hands in between thighs may signal discomfort or drawing of barriers.

May gusto po ba kayong pag-usapan ngayon?

Nakatingin sa kliyente.

Wala naman.

Nakatingin sa nurse.

Giving broad openings is a therapeutic communication technique used to clarify that the client is the one to take the lead and introduce the topic. It indicates the acceptance by the nurse and value of the clients initiative. The response of the client showed continuous withdrawal, but this can reinforce feelings of loneliness, that nobody cares and can increase suspiciousness and disinterest (Schwartz & Shockley, 1956). Observation of client carefully and consistently may help the nurse understand client and decrease difficulty. There were observable nonverbal cues was manifested by the client. According to Birckhead

Kung meron po kayong gustong sabihin na problema o pagusapan,maari niyo pong sabihin sa akin.

Nakatingin sa kliyente.

Wala.

Ang dalawang kamay ay magkahawa k at nakalagay sa pagitan ng binti.

(1989), nonverbal communication can be manifested by the client through body movements and facial expressions, substituting nonverbals for verbal communication. May hawak po akong papel na susulatan ko at panggagaling an din nung mga itatanong ko sa inyo. Kung gusto po ninyong makita, e hindi ko naman po itinatago.Tun gkol lang din naman po ito sa mga sinasabi ninyo para hindi ko makalimutan . Okay po ba? Sabi po ninyo, nakatulog kayo ng maayos. E habang tulog po kayo, hindi naman po kayo mabilis Inurong ang upuan patalikod. Pinakita ang papel sa kliyente. Tumatango habang tinitignan ang papel. According to Schwartz and Shockley (1956), awareness of client withdrawal is the first step in dealing with a withdrawn client. Through this view, the client becomes more real and alive, and the nurse has to be sensitive to the client, especially her behavior, nonverbal cues, appearance, and changes during interaction. Giving information and instructions to the client clarifies expectations for the day. Client is more at ease and shows increased participation. Re-opening from a clients given response shows active listening. It also helps reinforce clients belief that the nurse acknowledges what he says, keeps it as true and values it as important to remember.

Nakitingin sa kliyente at gumagami t ng malumana y na boses. Hawak ang ballpen at

Hindi naman.

Nakatingin sa estudyante at nakaharap. Nakalagay pa rin ang dalawang kamay sa pagitan ng

magising?

papel ngunit hindi nagsusulat . Medyo nakausog paharap sa kliyente.

hita. Body language of client shows a closed reception (Videbeck, 2002). Body language of the nurse, on the other hand shows attentive presence. Attentive presence is being with the client and focusing intently on communicating with and understanding him or her (Skott, 2001 in Videbeck, 2002). The nurse can maintain attentive presence by using open body language such as standing or sitting with arms down, facing the client, and maintaining moderate eye contact especially as the client speaks. Done to assess sleeping patterns.

Nakakailang oras po kaya kayo nakakatulog? Bago po iyon, ano po yung mga ginagawa ninyo sa loob? Hindi po ba kayo nakikipagusap sa mga kasama ninyo? Ano pong dahilan?

(Pareho sa itaas)

Tama lang.

(Pareho sa itaas)

(Pareho sa itaas)

Natutulog lang ako.

(Pareho sa itaas)

Assesses activities and interests.

(Pareho sa itaas)

Hindi.

Nagkabesa at nakalagay ang isang kamay tuhod. Nakatingin sa

(Pareho sa itaas)

Hindi naman ako mahilig

Assesses social interaction. Body language of client may show a closed reception (Videbeck, 2002). Clients personality may show no desire in

makipagkwent uhan e. Tulog lang ako.

estudyante.

Ano po ba ang mga kinahihiligan ninyong gawin? Naglilininis po ba kayo ganun o tumutulong sa loob? Ano pong mga iniisip ninyo? May problema po ba kayo?

(Pareho sa itaas)

Wala naman. Natutulog lang ako. O kaya nagbubuhos dun sa CR.

Nakatingin sa estudyante at tumitingin sa paligid. Ginagalaw ang kamay.

establishing social relationships. People who have difficulty in establishing relationships may be depressed or withdrawn. Client has deficient activity or interest in doing activities.

(Pareho sa itaas)

Wala naman.

(Pareho sa itaas)

Wala.

Nung bago po kayo pumasok dito, ano po ang mga naging problema ninyo sa buhay?

(Pareho sa itaas)

Wala naman akong kaaway e.

Nagpalit ng kabesa at hinahagod ang binti. Ang mukha ay nagpapahiw atig talaga ng wala. Umiiling. Umurong patalikod ng konti ang ayawan.

Latency of response is seen when the client take up to 30 seconds to respond to a question. He may answer some questions with I dont know because he is simply too fatigued and verwhelmed to think of an answer or respond in any detail. Client also exhibit signs of agitation or anxiety, wringing their hands and having difficulty sitting still. The client is then said to have psychomotor agitation (increased body movements and thoughts) such as pacing, accelerated thinking, and argumentativeness (Videbeck, 2002). Client refuses the word friends and insists

Ah, wala po kayong

(Pareho sa itaas)

Kakilala lang.

Nakalagay ang

kaaway? O mga kaibigan po, meron po ba?

Kapag po sa mga kakilala, paano po kayo makitungo? Paano po yung relasyon ninyo sa kanila? Maayos ba? Tumutulong po kayo sa kanila ganun? Kung hindi po sa ibang tao, e dun po sa malapit sa inyo? Yung pong kapatid ninyo ganun? So, parang nakasanayan na po ninyong hindi makialam sa lahat ng tao, ganun po ba? Paano po kayo nakikipagkilal a sa iba?

(Pareho sa itaas)

Anong makitungo?

dalawang magkapaton g na kamay sa isang tuhod habang nakakabesa. Nakakunot ang noo.

merely on the word acquaintances, He may have a slight aversion to close or intimate relationships.

(Pareho sa itaas) (Pareho sa itaas)

Hindi naman ako nakikialam sa ibang tao.

Maliit ang mata at umiiling.

These shows clients lack of concern on other peoples situation or circumstances. However, it may also pertain to clients personality of not interfering in other peoples business.

(Pareho sa itaas)

Hindi.

Medyo umabante paharap ang katawan.

(Pareho sa itaas)

Oo.

Nakatingin sa estudyante at tumatango.

Medyo umusog pa paharap. Diretso ang likod. Nakatingin sa kliyente at nakausog

Hindi ako nakikipagkilala e.

Sa pagkakatand a ko po, ang sabi ninyo sa

E di ba, kapag tinawag nung iba mong kakilala yung

Umiiling. Inalis ang kabesa at magkadikit ang paa na nakaupo. Ginagamit ang kamay sa pageksplika

This conversation merely emphasizes clients lack of desire to attempt or initate interaction or conversation especially if he has nothing to gain from it.

akin dati, magkakakilal a po kayo dito sa apelyido. Paano po ninyo nalaman yung pangalan nila?

Ah, so ganun po ninyo nalalaman yung pangalan ng iba. E sa labas po, paano po kapag wala po kayong kakilala? Ako po kasi, kapag kunwari po, bago ako sa isang lugar, siyempre gusto ko pong makipagkilal a sa iba kahit na hindi ko kakilala ganun. Sa pagkakaintin di ko po sa sinabi ninyo, para po sa inyo, hindi kailangang kumausap ng

ng konti paharap sa kanya. Gumagami t ng malumana y na boses habang nasa kandungan ang papel at hawak ang ballpen. (Pareho sa itaas)

isa sa pangalan niya. Nalalaman ko na rin yung pangalan niya. Hindi na kailangan magpakilala.

at nanlalaki ang kamay. Yumugyogyo g ang katawan paharap at patalikod habang nagsasalita.

Kapag hindi mo kakilala, bakit mo naman kakausapin di ba.

Nakataas ang panga. Nakatingin sa estudyante.

Medyo umurong ng kaunti.

Siyempre, kung may kailangan ka, magpapakilala ka. Pero kung wala, hindi naman kailangan yun.

Nakikinig at nakatingin sa estudyante.

Self-disclosure shows genuiness on the part of the nurse. It allows personal experiences to relate to to clients experience or show clarity and modeling (Townsend, 2008).

Dahandahang nagsasalit a habang nakatingin pa rin sa kliyente.

Oo, ganun naman yun e.

Tumatango.

Restating or repeating the main idea of what the client has said is a therapeutic communication technique that lets the client know whether or not an expressed

ibang tao kapag wala kang kailangan.

Sinubukan niyo na po bang kumausap ng ibang tao kahit wala kayong kailangan?

So, sumasagot lang po kayo kapag kayo ang kinakausap?

Nakatingin sa kliyente at nakausog ng konti paharap sa kanya. Gumagami t ng malumana y na boses habang nasa kandungan ang papel at hawak ang ballpen. (Pareho sa itaas)

Siyempre, kapag kinakausap ka, sasagot ka di ba. Pero kung hindi, hindi na kailangan yun.

Palingalinga ang katawan.

statement has been understood and gives him or her a chance to continue or clarify if necessary (Townsend, 2008). According to the clients response, he does not intiate interaction with others unless needed. It shows inability to develop an interpersonal relationship with others.

Opo.

Nakatingin sa estudyante.

Habang nandito po

(Pareho sa itaas)

Wala. Ok lang sa akin kahit

Nakatingin sa

According to Peplau (Townsend, 2008), failure to develop skills on competition, compromise, cooperation, consensual validation and love of self and others results in an individuals difficulty with participation in confronting the recurring problems of life. It is the nurses responsibility to help clients improve their problem-solving skills so that they may achieve their own resolution. The major taks of Eriksons generativity

kayo, ano pong plano ninyo?

andito ako kahit di ako dinadalaw. Ok lang kahit di ako nakakalabas. Ok lang naman sa akin e. Kahit naman dati di naman ako nagpaplano.

estudyante. Habang ginagamit ang kamay sa pagemphas ize.

Hinahayaan niyo na lang pong dumating kung ano ang darating?

(Pareho sa itaas)

Oo. Ok lang sa akin kahit andito ako.

Nakatingin sa estudyante.

O sige po, ngayon po naman, may mga tanong po ako na kukunin ko dito sa nakasulat sa papel ko. Kung ano po yung kaya ninyong sagutin, yun po yung ibigay ninyo. Hindi naman po ito exam o kung ano pa man.

Kinuha ang papel sa kandungan . Tinignan ito habang hawak ang ballpen. Tumingin sa pasyente.

O sige.

Tinignan ang papel. Tumatango.

vs. stagnation phase is to achieve life goals established for oneself while also considering the welfare of future generations (Townsend, 2008). As with the client, nonachievement of this goal results in lack of concern for the welfare of others and total preoccupation with self. He becomes withdrawn, isolated with no capacity for giving the self to others. Answering for the client is nontherapeutic as it limits the clients ability to answer for himself. It is also judgemental and may lead to wrong assessment. Nurse gives instructions from the client and asks for willingness to participate and understanding.

Okay lang po ba? Alam niyo po ba kung nasaan tayo ngayon? Opo, nasa National Center for Mental Heatlh po tayo. Mental hospital. Anong ward po kayo? Opo, tama po iyon. Anong taon na po tayo ngayon? Ah, opo yun po yung petsa natin ngayon. E yung taon po? Ano po ang panahon natin ngayon? Ano po yung panahon natin? Di ba meron po yung umaaraw atsaka umuulan. Yung panahon po natin ngayon, ano po kaya iyon? Tama po iyon. E kapag

(Pareho sa itaas)

Sa mental hospital. Pavilion 1. Ward 9. Mental Hospital. Pavilion 1.

Mabilis ang pagsagot.

Nakatangi n sa pasyente.

(Pareho sa itaas)

Tumingin sa papel tapos sa pasyente. Nakatingin sa pasyente.

September 1.

(Pareho sa itaas)

2011. September 1, 2011.

Nanlalaki ang mata. Nakakabesa.

Nurse has started the mental status examination. In this phase of the interaction, nurse is assessing client of orientation to place. Clarification of details is necessary to explain which is vague or incomprehensible. It helps search for mutual understanding and clarifying what has been said. It facilitates and increases understanding for both client and nurse (Townsend, 2008).

Tumingin sa papel tapos sa pasyente Gumamit ng kamay sa pageksplik a.

Ano yun?

Nakakunot ang noo.

Tag-ulan. Kasi August atsaka September maulan.

Nakadikit pa rin ang dalawang paa. At nakaupo.

Nakatingin sa

Marso atsaka Abril.

Nakatingin sa

maaraw po, ano pong mga buwan iyon. Opo. E, ano naman po ang araw natin ngayon? Tama. E yung kalye kung saan po kaya nakatira. Ano pong pangalan? Opo, diba sabi po ninyo, tagaPaco po kayo? Saan pong kalye kayo sa Paco? Yung kasama po sa address ninyo? Ano po yon? Pwede po kayang isulat ninyo?

pasyente.

estudyante.

Tumingin sa papel tapos tumingin sa pasyente. (Pareho sa itaas)

Huwebes. Huwebes ngayon.

Tumingin sa ward.

Ha? Kalye?

Nakatingin sa estudyante.

Malumana y at mabagal na nagsasalit a.

Tondo, Balot, Kalookan, Maypajo

Nagbibilang sa kamay. Pasuraysura y ang katawan ng kaunti.

Naguguluh an ang boses. Kinuha ang malinis na papel at ballpen at ibinigay sa pasyente. Nakadung aw sa sinusulat ng pasyente at nakaabant e ng kaunti papunta sa

Pajo. J. Maypajo. Kasi kapag isang direction yung lalakarin ko sa Tondo. Kapag yung isa naman, labas ng Kalookan yun. Kapag yun isa, dun sa may Blumentritt. Tondo, Balot, Kalookan, Maypajo.

Nagsulat habang nagsasalita.

Slow giving of instruction facilitates understanding of patient. Here, nurse has difficulty understanding what client has said because of the initial misunderstanding that Paco is the clients place of residence which is actually Maypajo. However, when asked for a complete address, the client insists that the given address is the complete address and stated that he can give directions going there though he cannot state the street.

Ahhh. So dito po kayo nakatira kasama ng kapatid ninyo?

So ano po yung kumpletong address ninyo?

kanya. Kinuha ang papel at ballpen mula sa pasyente. At tumingin sa kanya. Medyo umurong at bumalik sa dating pwesto. Nakatingin sa pasyente.

Oo.

Nakatingin sa estudyante.

Eto nga, Tondo, Balot, Kalookan Maypajo.

Tumingin sa papel

Ayun, maguumpisa na raw po yung exercise natin. Tara na po. Ituloy na lang po natin pagkatapos nating magexercise ha. Bale, sa huli po nating pinagusapan yun pong lugar ninyo. Meron po akong

Lumingon dahil may tumawag na kaklase. Tumayo at magkatabi ng naglakad sa pasyente. Hawak ang balikat, iginiya sa pwesto ng exercise. Hawak ang papel at krayola at inilagay sa harap ng pasyente. Nakatingin

Lumingon din.

Focusing is taking notice of a single idea or a single word which works especially when communication is unclear or thought is moving rapidly (Townsend, 2008). Distraction in the environment limits interaction.

Tumayo at sumunod sa nurse.

E di ako marunong magdrawing e.

Nasa itsura na ayaw gawin ang activitiy.

Art therapy offer an analogic portrait of an individuals life. These portraits become artistic metaphors, examples of the here and now. It gives the

blangkong papel dito atsaka krayola. Idrowing po ninyo yung pamilya ninyo atsaka yung bahay ninyo.

sa pasyente at malumana y ang pagsasalit a.

Ah, hindi naman po ito pagandahan. At wala rin naman pong tamang sagot. -

Nakangiti at nakatingin pa rin sa pasyente.

Kinuha ang black na crayola at gumuhit ng bahay.

E yung pamilya niyo po.

Nakaabant e ng kaunti papunta sa pasyente at tinitignan ang drawing. Nakita na bahay lang ang dinrowing. Nakatingin sa pasyente.

Ayan.

Gumuhit ng bahay at pinakita sa nurse.

ability to vent emotions through the process of art which allows for both distance and perspective (Moschini, L., 2006). Art therapy allows the therapist and the client to embrace defensive measures by making them part of the treatment plan. It seems that the client only performed the task though he is not inclined to do it. He seems to have difficulty in selfexpression. Smiling lessens the feeling of being threatened.

Hindi ako marunong magdrawing e.

Medyo paurong ang katawan mula sa mesa.

Doona (1979) states that it cannot always be assumed that resistance to engage in interaction is always motivated by fear of closeness. He may not understand completely the nature of interaction and the assistance the nurse can offer. Or in this instance, the client may simply not enjoy

the activity. Ah, kahit po ano. Kahit ganito lang.. Nagdrawin g ng stick figure sa isa pang papel . Tumitingin sa dinodrawing ng nurse. Kinuha ang crayon na ginamit ng nurse. Tapos ng magdrawing. Umiiling. Client may not want to convey expression or feelings. Drawings made may be associated with twin sister who lives in their house now in Maypajo.

Sino po ito?

Ano pong relasyon nila sa inyo?

Wala po silang relasyon sa inyo? Okay. Dito naman po sa isang papel. Isulat po natin yung taon, atsaka yung mga importanteng nangyari sa atin sa taon ngayon. Ngayong taon po?

Tinuro ang babae sa drawing. Nakatingin sa pasyente, malumana y ang boses. (Pareho sa itaas)

Wala. Tao. Siya yung dun sa bahay. Wala.

Wala.

Nakatingin sa nurse.

Kumuha ng papel at inilagay sa harap ng pasyente.

Wala namang importanteng nangyari sa akin e.

Medyo paurong ang body language.

Client is not participative and may not want to do the activity or is not interested.

Gusto niyo po bang mag-usap na lang tayo dun sa isang tabi?

Nagtataka ng ekspresyo n ng mukha. Tumayo at naghanap ng mauupuan .

Wala naman e.

Tumatawa ng kaunti.

Sige.

Tumayo din at sumunod sa nurse.

It is important to develop decisionmaking skills in the client and respect decisions if activites are unwanted. The client may only want

Balik po tayo dun sa paguusap natin kanina. Di ba sabi ninyo, taga-Maypajo po kayo. Anong siyudad po iyon? Ah ganun po ba? Ngayon po, nasa Mandaluyong po tayo. Doon naroroon ang NCMH. Yung pong tinitirhan po ninyo dati. Maynila nga po iyon. O sige. Ito pong mga sasabihin ko. Tandaan niyo po. Pagkatapos po, itatanong ko po ulit sa inyo mamaya. Tandaan niyo po itong mga sasabihin ko ha. Mangga, Mesa, Pera. Yun po. Tapos sagutin niyo naman po

Linabas ang papel at tinignan. Pagkatapo s, tumitingin din sa pasyente. Nakatingin sa pasyente. Tapos tumingin ulit sa papel.

Di ko alam e. Ako kasi laking Maynila lang. Ito lang yung alam ko.

Tumitingin sa paligid.

someone to talk to and not pursuing the activity is his choice. Assesses for orientation.

Tumatango.

Nakaabant e paharap sa pasyente.

Sige. Mangga, Mesa, Pera.

Tumatango. Nakatingin sa estudyante.

Assesses recall.

Tumitingin sa papel tapos sa pasyente.

97. 97 -3, 94. 94-3, 91. 91-3, 88.

Sumasagot at nakatingin sa estudyante.

Assesses attention.

ito, 100-3. Tapos tuloytuloy po yung pagminus niyo ng 3. Ok po. Tama po yun. Ngayon naman, Ulitin naman po ninyo yung 3 salitang pinatanda ko sa inyo kanina. Ok po. Tama po yun no. Ngayon po, sabihin niyo po kung ano itong hawak ko. Ano pong gamit ng ballpen?

Nakatingin sa pasyente.

Mangga, Mesa, Pera.

(Pareho sa itaas)

Assesses recall.

Ngumingiti . Pagkatapo s. Tinaas ang ballpen. Nakataas pa rin ang ballpen habang nakatingin sa pasyente. Pinakita ang wristwatch . Tumingin sa pasyente tapos sa papel.

Ballpen.

(Pareho sa itaas)

Assesses oral naming in language and identification of use.

Pansulat.

(Pareho sa itaas)

E ito po..

Relo. Para malaman ang oras. Walang pero pero pa.

(Pareho sa itaas)

Tama po iyon. Eto naman po. May sasabihin ako, uulitin ninyo yung eksakto. Walang utal o butal. Walang pero pero pa

(Pareho sa itaas)

Asseses for ability to repeat words and auditory memory span.

Ayun po. Ang galing walang butal. Meron po akong papel ditto na may nakasulat na salita. Gawin niyo po yung nakasulat.

Nakangiti. Kumuha ng papel na may nakasulat na Ipikit mo ang iyong mga mata.

Kinuha ang papel at pumikit paharap sa estudyante.

Okay po. Ngayon, itupi po ninyo sa dalawa. Tapos ilagay ninyo sa kandungan ninyo. Opo. Magsulat po kayo ng kahit anong pangungusap . Kahit ano pong gusto ninyong isulat. Opo. Kahit ano pong gusto ninyong isulat.

Nakatingin sa papel.

Ganito?

Tinupi at tumingin sa estudyante.

Praising may promote the clients selfesteem. However, Videbeck (2002) recommends that giving factual feedback, rather than general praise, reinforces attempts to interact with others and gives specific, positive information about improved behaviors. Asseses for ability to follow commands. Asseses for ability to follow commands.

Iginigiya ang uli (for emphasis)

Pwede kong isulat yung Ang bata ay mabait?

Nagtatanong ang mukha at nakaharap sa estudyante.

Asseses ability to write and construct cohesive sentences.

Tumatang o.

Ano pong dahilan bakit po iyon ang naisip ninyong isulat?

Nakatingin sa pasyente at nagsasalit a sa

Yun lang ang naisip ko e.

Nagsusulat. Pagkatapos ibinalik agad sa estudyante. Ang bata ay mabait. Nakatingin sa estudyante. Nagkakamot sa paa.

Nung bata po ba kayo, mabait din po ba kayo?

malumana y na boses. (Pareho sa itaas)

Okay lang.

Sa Maypajo din po ba kayo lumaki nung bata po kayo? Kasama po ninyo yung kakambal ninyo? Ano po kasi ulit pangalan niya? O yung anak niya po? Sila lang po bang dalawa ang kasama ninyo? May iba pa po bang anak si Ms. Muvillion? Ah, edi sila pong lahat.

(Pareho sa itaas)

Oo.

Nakakabesa at nakahawak ang dalawang magkasaklop na kamay sa tuhod. (Pareho sa itaas)

(Pareho sa itaas)

Oo.

(Pareho sa itaas)

Changing of topic is not therapeutic and loses focus of conversation. The nurse takes initative for the interaction away from client. This happened because there si difficulty in aksing questions as they had been maintained from the nurses side only (Videbeck, 2002).

(Pareho sa itaas) (Pareho sa itaas) (Pareho sa itaas)

Ms. Muvillion.

(Pareho sa itaas) (Pareho sa itaas) (Pareho sa itaas)

Roselyn. Hindi. Marami sila e.

Nurse assesses for family background, information and interaction.

(Pareho sa itaas)

Oo. Ilan ang sasabihin ko?

Nagpalit ng kabesa.

(Pareho sa itaas)

Joan, Butoy, palayaw lang niya yun. Roselyn at si Joven.

Si Ms. Muvillion

(Pareho sa itaas)

Hindi.

Nagtuturo gamit ang kamay habang binibigkas isa-isa ang pangalan at tumitingin sa itaas habang nagiisip. Umiiling.

Client shows recall and memory of family members.

Seeking clarification

lang po ba ang kapatid ninyo? May iba pa po kayong kapatid? Ano pong pangalan simula sa panganay. E kayo, pangilan po kayo?

clears misconceptions.

Nagtataka ng tono ng pananalita. At sinusulat ang pangalan. Nagtatano ng ang itsura. Nakatingin sa pasyente at gumagami t ng malumana y na boses. Medyo umabante ng upo.

Remedios, Rebecca, Renato, Reynaldo, Rodrigo, Junior.

Binibilang sa kamay. At tumitingin sa gilid habang nag-iisip.

Panglima. Atsaka si Ms. Muvillion. Hiwahiwalay kami. Bata pa. Nasa Amerika sila.

Oo nga po. Siya po yung kasama niyo sa bahay. E, nasaan po yung iba ninyong kapatid?

Tumitingin sa sinusulat ng estudyante. Yumugyog patalikod ang katawan kasama ang nakakabesan g paa.

Nung bata pa po kayo naghiwahiwal ay? Ano pong dahilan? Ilang taon po kayo nung mangyari yun?

E, hiwalay mga magulang ko e.

Nakatingin sa nurse.

Probing or persistent questioning of the client is not therapeutic. It tends to make the client feel used or invaded. Clients have the right not to talk about issues or concerns if theychose. Pushing and probing by the nurse will not encourage the client to talk (Videbeck, 2002). Client may feel invaded by nurses questions.

May komunikasyo n pa po ba kayo sa kanila? Ano pong naramdaman ninyo nung

Nakatingin sa pasyente at gumagami t ng malumana y na boses. (Pareho sa itaas)

Apat na taon pa lang.

Nagisip muna at tumingin sa ibaba. Tapos sumagot.

Wala. Hindi kami naguusap.

Nakatingin sa ibaba.

(Pareho sa itaas)

Kahit umalis yung tatay ko, wala naman

Nakatingin sa baba. At medyo

naghiwahiwalay po kayo?

Wala po kayong galit na naramdaman o pagkalungkot ? Nasaan po ang tatay niyo ngayon? Sabi niyo po, yung nanay ninyo yung nagpalaki sa inyo. Kumusta po ang relasyon ninyo sa kanya? Sabi niyo nga po. Kailan po siya namatay? Bago po siya namatay, paano po ang relasyon ninyo? Maganda naman po ba? E yung tatay niyo po, kumusta po?

(Pareho sa itaas)

akong naramdaman. Hindi ko naman siya hinahanap. Wala naman sa akin. Sanay naman ako. Wala.

paurong ang body language. Pagkatpos magsalita, tumingin sa estudyante. Nakatingin sa estudyante. Interpreting is used which is not a therapeutic technique. The clients thoughts and feelings are his own not to be interpreted by nurse (Videbeck, 2002). Asking relevant questions facilitates conversation. Client may be unclear with question or is avoiding answering through vehement declarations.

(Pareho sa itaas) (Pareho sa itaas)

Sa amerika.

(Pareho sa itaas) Dismissive .

Patay na yun e.

(Pareho sa itaas)

Nung isang taon.

(Pareho sa itaas)

Wala. Wala na siya. Patay na yun e.

Mabilis ang pagsagot at nakatingin sa estudyante. (Pareho sa itaas)

(Pareho sa itaas)

Nasa amerika yun. Kami lang ni Ms. Muvillion naiwan dito.

Nakatingin sa estudyante.

Si Ms. Muvillion din po ang nagdala sa inyo dito diba? Ano pong dahilan sa pagdala niya po sa inyo dito?

(Pareho sa itaas)

Oo.

(Pareho sa itaas)

Medyo umabante paharap.

Tahimik Nakatingin sa baba.

O sige po. Lakad po tayo. Ikot lang po tayo ng isang beses dito tapos balik na po tayo sa ward. Naiintindihan ko po kung

May pumasok mula sa labas. Tumayo rin. Nakatingin sa pasyente. Hawak ang balikat. Nakatingin sa

Dun tayo sa labas.

Tayo agad.

Mabilis na naglalakad. Tumitingin sa baba. Tumatango.

According to Eriskon, trust is the intial developmental raks described (Townsend, 2008). If it has not been achieved, the components of relationship development becomes more difficult. The client may have trust issues in confronting source of mental condition. Or, he may still be unwilling to face it or tell it to others. It is imperative, therefore, for the nurse to convey an aura of trustworthiness which requires that she possess a sense of self-confidence. Trust must be earned. Clients action show lack of desire to talk about topic and he changes the direction of focus.

Tinaas ang kilay ng

Offering self is a therapeutic technique

ayaw ninyong pagusapan iyong dahilan kung bakit po kayo napunta dito. Nandito lang po ako.

pasyente

sabay. Naglalakad.

Bale yung Nakatingin Oo. Sige. Hinubad ang pinagusapan sa tsinelas at natin ngayon pasyente. ibinigay sa yung pong estudyante. pamilya Naghintay sa ninyo, yung gate at mga kapatid pumasok na. ninyo na sabi niyo po ay nasa Amerika. Atsaka kanina pong umaga yung tungkol sa pakikipagusap po sa ibang tao. Bukas po ulit, balik po ako. Usap po tayo ulit. (Hawak ng student nurse sa balikat ang kliyente habang naglalakad pabalik sa ward. Pumasok sa ward ang pasyente.)

that focuses on showing that one is available, showing willingness to listen and understand the client. Offering self means offering interest, presence and desire to understand (Videbeck, 2003). Having a supportive look can ease client distress and discomfort (Birckhead, 1989). The nurse summarizes what has occurred during the interaction. It facilitates flow and identifies objectives and purpose (Townsend, 2008). .

EVALUATION OF OBJECTIVES The objectives have been met accordingly as client was examined and exercises were done. However, art therapy was not successful in expressing the clients feelings. Thorough assessment is not achieved as it was not part of the goal. However, client may not be at ease with

the student nurse and was not able to discuss his anxiety and fears or the reason for admission. Nevertheless, there was rapport between the client and the student nurse as the interaction progressed. Contract has also been set and agreed upon by both parties. The client verbalized willingness to do activities. ANALYSIS The student nurse used summarizing, disclosure, giving information, restating, reflecting, fousing, asking relevant questions, probing, active listening and changing the subjects as techniques. According to Townsend (2008), while other techniques are effective in getting the answers like probing, they are considered untherapeutic. Appropriate disclosure of the nurse was provided. Problems Identified Some issues the client is uncomfortable with include the reason he was brought to this hospital, the reason why his sister didnt visit him and what he feels about certain things. The clients memory is okay. However, this is the first time that I observed that his responses are a bit inconsistent especially regarding his familys whereabouts. Before, he said that his father is already dead. But now, he says that he isnt but is in America. However, he is consistent in saying that he does not feel abandoned and he is okay with his father leaving them. I also observed that he is the type of person who does not want to talk with other people He is oriented to place, person and time because he remembers the date that the employees told them and he checks the wall clock in the ward. He follows commands well. He does not ramble on. He, however, is not very talkative and rarely establishes relationship with other people inside the ward. He knows them and speaks to them at times but he does not really befriend them. He also confessed that he is the type of person who keeps things to himself. Clients personality and behavior looks normal but he is not able to establish a close relationship well with other people. He is not aggressive, however, and does not shy away from contact. However, though he is not withdrawn from other people, he rarely initiates contact with them unless necessary or forced. He talks about things that he can respond to and expresses his opinion.

REFLECTIONS I was satisfied with our NPI today. I was happy because he remembered me and he seemed okay with what transpired. I was feeling anxious at first because I know that the client seldom volunteers conversation and is not very talkative. It was good that he participated well in all the activities. Though the client is still not very expressive, I felt that we had a rapport and trust was established already. If he has concerns, I he think, in time, he will be ready to express them willingly. At this point, I understand that he is still not ready. During interaction, I still feel awkward with silences but whenever I observe the patient, I can see that silence comforts him so the awkwardness in me is lessened. What really frustrates me is finding a topic that he can talk about or at least express his feelings on. I think, I should perform an activity individually so I can draw him out. Sometimes, I feel that I am an ineffective communicator whenever I ran out of things to say. It feels so awkward to suddenly change topics or bring it out from nowhere. I guess, this is what I have to work on. I am not really good with conversing with non-gregarious people because Im not really talkative as well though I express my thoughts or feelings now and then. Im more comfortable with talkative people because Im accustomed to them and I can usually take the gist of what theyre talking about and respond in short responses. With my patient, I think that him being silent about some concerns and is not very makuwento is a mixture of factors its a part of his condition, its part of his personality, a part of it is that Im a stranger and that we don't have the same interest. However, he actually answers well with questions that interest him or that requires a plausible answer. I think, my mistake in our communication, is I ask him on questions on HOW he converses with other and Im not focusing more on what he FEELS in starting a conversation with another. However, now that I realize that, I will be more careful next time. At present, I am positive that we will have fruitful encounters in the future.

4th Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will:

 Maintain good and trusting relationship with client Be able to establish rapport and trust of client Help client communicate feelings Use therapeutic communication techniques Gain more insight regarding the feelings of client Explore his family dynamics Encourage client in verbalization Explore relationship with others Explore feelings regarding condition Perform activities (therapy and socialization) Patient-Centered: At the end of duty, the client will: ASSESSMENT Patient Profile NAME: R. M. C. Muvillon AGE: 48 BIRTHDATE: September 9, 1962 CIVIL STATUS: Single ADDRESS: Maypajo, Tondo DATE OF INTERVIEW: September 1, 2011 SEX: Male RACE: Filipino OCCUPATION: Construction Worker LIVES WITH: Twin sister, husband and their children in their mothers house Express feelings of trust and willingness to interact Increase interaction with others Be able to share his feelings about self and experiences Be able to disclose feelings about his family

PROCESS RECORDING Observation of Setting: The student had introduced herself and stated the purpose of interview to the client. This communication exchange took place at about 9 oclock in the morning. The client, was from Ward 9 Pavilion 1 of NCMH. The interaction took place in the garden with a lot of open space. The client and the nurse were sitting on a bench sitting side by side to each other. However, he was turned sideways to look

at the nurse and the nurse is also in the same position. It allows for better communication and the open space keeps the client feel secure and relaxed. During activity with chess, the nurse and client are facing each other. Both are relaxed. The client has both his feet on the bench on an Indian sitting position while nurse is sitting sideways.
INFERENCES, ANALYSIS THOUGHTS AND FEELINGS (Sa ward, sinundo ng student nurse mula sa ward ang kliyente. Hinihintay ng nurse sa nurses station ang kliyente.) Magandang Oo. I was feeling okay and not The nurse greets the umaga, R. M.. [nods] apprehensive about the client and calls her Eto yung incoming interaction. I through her first name, tsinelas mo. was hoping to dispel the signaling that she is Kukunin ko na awkward initiation of unique and that she is lang conversation. being recognized pagkabalik (Videbeck, 2003). Giving natin dito. recognition is a [looks at client therapeutic and smiles] communication technique that shows awareness of clients individuality. Greeting, reorientation of client and calling client by name helps increase self awareness and sense of self. Naalala mo pa ba ako? M.. [smiles] Curious if client still remembers her. Im happy that he still remembers me. Part of reality orientation wherein a person can distinguish the real world from a dream, fact from fantasy and act accordingly (Videbeck, 2002). It also checks the clients memory. NURSE PATIENT

Opo. [laughs] Kumusta ka naman dito?

Okay naman.

Client seems to reply in monosyllabic words.

Exploring The nurse asks the client how she feels, as this could start the conversation as topic on feelings could be raised and explored (Videbeck, 2002). The nurse follows up by exploring. Exploring is a therapeutic technique that delves further into a subject, idea, experience or relationship (Videbeck, 2003).

Kakagising mo lang ba?

Nakatulog ka ba ng maayos? Kasi napansin ko na mapula yung mata mo. Hindi ka naman nahihirapan makatulog? Lakad muna tayo. Ikot tayo, para maexercise ka. [holds client in arm] Nakapagsipilyo ka naman ba? Ah, mamaya pa ba? Nakakain ka naman kanina? Ah, may kape ba? [looks at client and maintains

Hindi, nakahiga lang ako. [walks, looks directly] Oo. Matagal din yung tulog ko.

Clients eyes are red which m,ay be caused by lack of sleep or oversleeping. Seems like he was telling the truth.

The question is asked to ascertain sleep patterns. Inability to sleep also increases anxiety and may also imply increased thinking (Stuart & Sundeen, 1995).

Hindi.

Sige. [paces with student nurse and moves in the direction] [Silent] [Nods]

Nurse wanted to know if clients sleeping habits changed. Nurse feels conflicted if its okay to touch him. Seems the client is a bit accustomed to it by now.

A light touch on the elbow, shoulder or hand or just being there indicates caring (Videbeck, 2002).

Maybe he didnt hear me. Nurse remembered prior conversation that they brush in the afternoon. Nurse starts with small talk. I was surprised there was coffee because I knew there wasnt/

Tinapay, salabat atsaka kape. Hindi, parang kape kung ibigay nila yung salabat. Mainit.

Hygienic and comfort measures are important facets of health that must be introduced to the mentally-ill patient (Townsed, 2008). Eating problems may also be ascertained by asking through interview.

eye contact.] Ahhh. Nakaligo ka na rin ba?

[Looks at student] Oo. Kanina. Maaga.

Ano palang gusto mong pag-usapan natin ngayon?

Wala naman. [eye contact with student]

I think that I should always start with inquiring if he was already groomed so we will do it if he hasnt. Slightly feeling apprehensive because she expects the clients answers would one-word again.

Broad openings Allowing the client to take the initiative in introducing a topic make explicit that the client has the lead in the interaction (Videbeck, 2002). Offering of self. Making onself available or offering presence, intereset and desire to understand must be unconditional as it increases clients feelings of self-worth (Videbeck, 2002). A leading question which may be beneficial if client is responsive. However, he is not. Or may be that is really his answer.

Kung may gusto kang ikwento sa akin, makikinig ako.

[Silent] Wala, wala naman akong ikukwento.

Nurse was thinking on how to make the client open up.

May mga problema ka ba o iniisip?

Wala. [shakes head]

Gusto mo bang magkwentuhan na lang tayo ngayon?

Oo. [nods]

I am thinking of a way for the client to open up about his anxieities. Equally frustrated that he wont. If he says, he doesnt have any problems, should I believe him? is what Im thinking. Drops attempt to allow client to confide and will instead focus on exploring clients preoccupations.

Offering the client the decision about the activity allows him to show independence and decide by himself. Sitting squarely facing the client gives the message that the nurse is there to listen and is interested in what the client has to say

Sige, dun tayo sa may upuan. [goes to bench] Ayun, sige. Medyo harap

[umupo din sa bench] [shifts direction

I was feeling relaxed at this point because client is responsive at participative today. Though I was apprehensive at first

ka sa akin para mas makapagusap tayo ng maayos. Anong pinagkakaabal ahan mo ngayon? Alam niyo po ba kung nasaan tayo? Tama po yun. Ok naman po ba yung pamamalagi ninyo dito? Ano na pong petsa ngayon? Ah, kung Sept. 1 po nung Thursday na huli tayong nagkita, bale Sept 2 nung Friday.

to nurse.]

Wala naman. Natutulog lang. [crosses legs]

because it seemed I disturbed his sleeping time and he still does not confide on problems if he has any. Slightly disappointed that the client is not talkative but that has been established before so I expected it.

(Townsend, 2008).

Broad openings allows the client to take over the conversation (Townsend, 2008). Reality orientation allows the nurse to assess perception of reality of the client and corrects misperception or reinforces correct perception of the environment.

Pavillion 1. Mental hospital. Oo. Okay naman. [maintains eye contact with nurse] Hindi ko alam e. I was thinking that the client is really oriented to place, person and time. He never seem to be out of touch like his other colleagues inside. He also has a sharp memory though at times he opts to forget things or is silent and not want to talk about them.

September 3 nung Saturday. September 4 kahapon. September 5 na ngayon. [looks at distance while thinking]

Tama po yun. Saan nga po ulit kayo nakatira?

Tondo. Balut. Kalookan. Maypajo. [maintains eye contact with nurse] Dun nga.

Alam niyo po ba yung street kung saan kayo nakatira? Ah, paano po pumunta doon?

Sa palengke yun e. Tapos may

I have difficulty identifying if what the client says is true because I have no knowledge of the streets in Manila. However, it seems he knows what he is talking about. He just cannot direct me how to

Placing location in perspective helps nurse

Ituro niyo nga po sa akin yung papuntang Maypajo. Ano pong sasabihin sa drayber para makapunta ng Maypajo? Sabi niyo nga po, pero kung sakali pong dadako ako dun, paano po ako pupunta? Ginawa niyo po yun?

tricycle.

[Long silence, client has confused look on face] Taga-Balut ako e. Kaya naman kung lalakarin. Mula nga sa Makati hanggang sa Makati kaya kong lakarin. Oo. Mahilig akong naglalakadlakad. [shifts feet] Wala naman. Nagpo-pool kami dati. [makes gesture with hands for pool] Hindi naman. Marunong lang.

go there. It increases my frustration and it increases his so I was thinking that I should stop in this line of questioning soon.

gain information if client really knows and helps identify pattern of thinking. Client may gain insight about this.

At this point, I was thinking if the client was really a vagrant or had been a vagrant at a time. This is due to the fact that he goes whenever he wants to. He does not really go back home unless to sleep. He goes many places with only walking. Merely curious.

Giving leads allows the patient to take direction of conversation (Townsend, 2008).

Anong pa po yung hilig ninyong ginagawa?

Loss of focus deviates from the goal of the interaction (Townsend, 2008). It may be untherapeutic.

Ah, magaling po kayong magpool? [leans forward, with open posture and eye contact with client] Sino po kasama niyong nagpopool? Sa Tondo po?

Yung mga kakilala ko lang sa amin. Sa Maypajo.

Shows interest. I was trying not to be judgemental but it really seems that the client was not doing any work before or it may be contractual because he said that he was a construction worker. Client seems comfortable now in talking about relationships than before because he is able to talk about them freely.

Open posture suggests that the nurse is open to what the client has to say.

Nurse attempts to identify social relationships and ability to maintain them. So far, the client has indicated that he has

Oo nga po sa Maypajo. Alam niyo pa po ba yung mga pangalan nung mga kasama ninyo? Ahhh. Ano po ba yung apelyido nila? Sa ward po, may mga kaibigan na po ba kayo o kinakausap sa ward? Anong pinaguusapan ninyo?

Apelyido lang. [scratches thighs and back]

friends before and many acquaintances he does not really consider as friends.

Sa apelyido lang kami magkakakilala. Oo. Nag-uusap naman kami.

Wala. Di naman ako mahilig makipagkwentuh an e. [scoffs slightly]

E ano pa po yung hilig ninyong ginagawa? Magchess po? Marunong po kayo? Ahh. Alam niyo pong laruin pero hindi ninyo kinahiligan.

Marunong naman. Pero hindi ko hilig. [looks directly at nurse] Oo.

I believe the client when he says this but there are many times I think that he could have been a good storyteller because of his manner. I know many people who talk like he does about something and they are storytellers in recounting there experiences. I want to explore other activities that we can do together.

Client has always maintained that it is part of his personality that he does not really like conversing with other people.

Assesses for interest, hobbies and activities that the client wants.

Shows understanding.

Restating Repeating what the client has said lets the client know whether ab expressed statement has been understood (Townsend, 2008).

Eh, dama po marunong

Ganun din. Parang chess

I want to explore other activities that we can do

Assesses for interest, hobbies and activities that

kayo?

pero hindi ako mahilig. Marunong ako magpusoy. [looks at floor] Oo, pero dati yun [does not look at nurse].

together.

the client wants.

So, ang hilig niyo po ay magpool. Ano pa pong mga hilig niyo? Ah, pusoy po? Yung sa baraha?

Every time vices or bad behavior comes up, client looks a little ashamed. He always insists dati pa yun.

According to Townsend (2008), the individual whose posture is slumped, with head and eyes pointed downward, conveys a message of low self-esteem.Not looking directly at the nurse may also be a sign of discomfort. It was the first time that the client asked a question on the nurse.

Magchess po pala tayo mamaya pagkatapos ng exercise. Okay lang po ba yun? Ayun po. Kumusta naman po kayo dito? Mayroon po ba kayong kakaibang nararamdaman ? Yung pong mga galos at sugat ninyo, saan niyo po galing?

May dala ka? Sige. [looks at nurse]

I was happy that he seems perked about the activity.

Okay naman.

Wala.

I was trying to identify where his wounds came from and is he has contact dermatitis. The client is always rubbing his arms or thighs and I am sometimes distracted. I think it may be a side effect of his medication.

Broad Openings Allows client to take over the conversation (Townsend, 2008).

Ah, wala. Ganyan talaga yan. Malamok dito e. [examines wounds] Oo. Paminsan. Pero di ko na pinapansin. Oo. Thinks of a topic to introduce so conversation wont be cut. Thinks of a way to continue conversation.

Concerns and hygienic concerns of the client is part of the nursing responsibility.

Ah, kinakagat po kayo ng lamok. Eh, ngayon po ba, gusto niyo ng umuwi? Ah, nagbago po ba yung isip

Changing of topic may also effect a change in focus. Reflecting or directing client actions, thoughts

Oo. Gusto ko ng

Surprised because client had a change of feelings.

ninyo sa paguwi? Kasi dati po sabi ninyo okay lang sa inyo dito.

umuwi. [shifts feet, looks at nurse]

Maybe recent conversations about his family enabled him to miss them. I was also thinking that maybe his prior answers showed his using reaction formation, acting opposite to what he feels. He may be using the defense mechanism to protect her ego from the anxiety that can be brought by the expression of his real feelings. (Stuart & Sundeen, 1995). I was feeling curious why he went to Baseco and what he was doing there.

and feelings back to client encourages him to recognize and accept his own feelings (Videbeck, 2002).

Nung nasa labas po kayo, anong mga lugar po yung gusto ninyong pinupuntahan? Yung Baseco po dito sa Maynila? Paano po kayo napunta dun? Tapos po..

Sa Baseco. Naliligo ako dun. [reminiscing face] Nagjeep ako.

Keeping things in perspective eliminates loopholes in story and allows validation of truthfulness. It also allows the nurse to assess pattern and consistency of thinking o client.

Ayun punta akong Baseco, maglalakad.

General leads Giving encouragement to continue may indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. It entered my mind that the client may have delusions or he may have a misconception of the place. This one was difficult for me to explore because I really dont know much about the places he talks about so I Reality orientation When the client has a misperception of the environment, the nurse defines reality (Townsend, 2008).

Ahh.. Paano po kayo nakakaligo dun? Sa pagkakaalam ko po kasi, parang barangay yung

Dagat kasi yung Baseco e.

Hindi. Sa kabila nun yung South Harbor tapos dito sa harap ung Baseco. Naliligo

Baseco. Sino pong kasama ninyo?

ako dun. Ako lang. Marami din pumupunta dun na ibang tao. Eh, libre e. Hindi ako naliligo dun na parang yung may tabo atsaka sabon ah. Hilig ko yung lumangoy. Dun ako parati. [Laughs]

Bakit po Baseco ang napili ninyo puntahan?

dont know if hes telling the truth or not. I was not really feeling icky that he swims in a place that is dirty but I was observing that he was looking at me like Im about to judge him about that. I didnt show any feelings of judgement at all so I hope he removed that thought.

Exploring places of interest and social activities provides a broader picture of the client.

Ah, kailan pa po kayo nahilig lumangoy? Ano-ano pa po yung kinahiligan ninyo nung bata kayo? Ahhh. Opo, nilaro ko din yun dati. E yun pong holen? Ano pong pangalan ng mga kaibigan ninyo?

Nung bata ako.

Text. [with the motion of text in his hands] Oo. Naglalaro kami ng jolen nun nung mga kaibigan ko. Si Dodong atsaka si Intek. Sila yung kasakasama ko nun. [scrunches up face trying to remember names]

I wanted to find out if he really didnt have any interests as he claimed. He said he does not like singing, playing basketball, reading, watching TV, talking with other people which are the most common forms of hobby I know.

Introducing another subject causes nurse to take over the direction of the discussion. It may be untherapeutic (Townsend, 2008).

This time, I wanted to identify factors in his childhood that affected him. I wanted to know if he was a loner or if he had difficulty making friends before. And in his reply, it seems not. Now, Im more curious what caused him to drop back from reality. I think its time to go on with his relationship to his family and if indeed he was left by them at the age of 4.

Exploring helps examine issue more fully. Any problem or concern can be better understood if explored in depth (Videbeck, 2002).

Yun pong mga kapatid niyo po, kasama din po ba ninyong naglalaro noon?

Hindi. Umalis na sila nun e. Kami na lang ni Ms. Muvillion yung naiwan.

Sa mga kapatid niyo po, sino po yung pinakamalapit kayo?

[silent for a long time] Parang paborito ganun? E kapatid ko sila e. Pantaypantay lang. Si Ms. Muvillion yung kasama ko ngayon. [silent] Okay naman.

Honestly, its difficult to believe that he knows all of his siblings names and age if he was away from them since age 4 and no communication was done ever since. Thats what I was thinking.

Nurse aims to identify patterns of relationship in the family.

Ah. Di po ba kakambal niyo si Ms. Muvillion. Kumusta naman po yung relasyon ninyo? [leans forwards] Di po ba, si Ms. Muvillion yung nagdala sa inyo dito? Ano pong dahilan bakit dinala niya kayo rito? Nakikita ko pong hindi kayo kumportableng pagusapan yun. Kung may problema po kayo, maari niyo pong sabihin sa akin.

Feels slightly apprehensive if client will react the same way he does every time this comes up.

[Tahimik nakatingin sa baba, hindi nagsasalita]

Exploring allows client to delve further into a subject, experience or relationship. However, if he chooses not to disclose further information, the nurse should refrain from probing in an area that obviously creates discomfort (Townsend, 2008). Looking at the ground shows signs of discomfort on the topic being introduced or discussed.

Wala naman.

Stays calm. Is slightly feeling disappointed inside that the client still does not want to share but I have decided that I wont probe it today again if he does not want to talk about it.

Making observations and Offering of self are the two therapeutic techniques involved here. Verbalizing what is observed or perceived encourages client to recognize specific behaviors (Townsend, 2008). Making oneself available increases clients feelings of selfworth (Townsend, 2008). Looks at ground shows discomfort about topic being discussed.

Hindi po ba gumugulo sa inyo yung dahilan sa pagpunta niyo

Wala yun andito na ko. [looks at ground]

Client understood former question because he answered now. Makes it clear that his silence before states that he does

dito? Mukha po palang hindi na tayo mageexercise kasi parang yung exercise natin ay yung pagikot at paglalakad na. Gusto niyo po bang magchess na lang tayo?

Ah.

not want to talk about it. Thinks of another activity that the client may enjoy. Client is visibly relieved that the line of questioning about his personal life has ended,

Oo. Sige. [looks visibly relieved] [stands and moves in crisscrossing directions but steadies once arm is felt] I was happy that we will be doing an activity again.

When unwanted topics are introduced, nurse must be careful in treading through the conversation and know when to back off (Videbeck, 2002). [Personally, I think signs of discomfort are normal in sensitive topics so I dont evade the line of questioning. I stop when he becomes unresponsive already.]

Sige kunin po muna natin. [Stands and takes clients forearm]

Naglaro ang student nurse at kliyente ng chess. Tahimik ang pareho habang nagisisip na may panaka-nakang pagsasalita. Nanalo ang kliyente. Ano pong gusto ninyong kulay? Eto na lang. [Lifts black horse] Ay, oo nga no. [moves to bring back queen to original place but stopped] Ah, pero madaya na yun kasi natira ko na. [Allows queen to be eaten]. Ikaw na susunod. O, nanalo po kayo. Ang galing niyo pala dito e. Hindi. Nachamba lang. Feeling happy that the client has identified what his mistake was and identified socially acceptable behavior that nandadaya is wrong. A person who

Ah, kakainin ko na po yung queen ninyo. [as client gets rookie with his queen]

Ah. Hindi po [Smiles] yun tsamba marunong po talaga kayo. Ah, tara na raw Ah sige, tara. po. Kakain na. Ah, maghugas muna pala kayo ng kamay. Eats with others. In the conversation, clients were asked if they like apples. Client answered, Hindi. Matigas yun e. Pan de coco mas maganda. Sige, lakad po ulit tayo. Sige [goes to bench where we played chess]. Kalian yung socialization? Though we often talk about when we are going to start and end our interaction, client may have forgotten and ask about it. I was quite surprised that he was the first one to talk to me. During socialization, he never talks to anybody or initiates conversation so I was really surprised. I explained the schedule for him to understand fully. This time, the role was reversed and the client comes first in the conversation. It was a little unnerving to let go of the reins in directing the conversation but Im happy to observe this change in my client.

Ah, sa 19 po. September 19. Lunes po yon. Bakit niyo po natanong? [surprised tone] Ah di ba po. Yun po yung pinapaliwanag ko po sa inyo. Mga 2 linggo pa po kami. Sa Miyerkules po hanggang sa Biyernes sa susunod na linggo [explains schedule] Gusto niyo pa

Hanggang kailan ba kayo dito? [looks at ground that he is treading on] Ahh..Wala naman.

Babalik na ba?

Because other clients are

Nurse aims to identify patterns of relationship in

po bang magkwentuhan o gusto niyo na po bumalik sa ward? Nasa desisyon niyo po iyon kung gusto ninyong bumalik o dito po muna tayo. Sige po. Sa susunod po ulit. Ay, yun po palang tsinelas. [smiles]

[looks at the direction of other patients who are walking towards ward] Ah, sige. [walks to ward]

going back to the ward, I was trying to give an option to the client.

the family.

Nurse aims to identify patterns of relationship in the family.

Ay oo nga. [removes slippers]

Client seems to have forgotten to return the slippers so I had to remind him of it. I was hesitant at first because it seems selfish to reclaim it but we had to honor the contract we set. I was surprised and very grateful because Ive long been wanting to hear words of acknowledgement from the patient like Thank you or something like that. I know that I shouldnt expect it but I think its sign of good understanding of social relationship if he did so I was happy in this change in him.

Contracts, written or verbal, shows agreements between two parties that must be honoured. This reflects consistency and may promote trust in the nurse as she is consistent with her words. The client may have been experiencing a process of growth as he is showing signs of understanding and having social cues.

[leans down to take tsinelas]

[waits for student to get up] Sige. [raises hand at looks at student, then goes inside, smiling]

EVALUATION OF OBJECTIVES Majority of the objectives were met. Student nurse was able to maintain good and trusting relationship with client. Rapport and trust was established as client talks about experiences and childhood exploits. His relationship with others is also assessed. Of all the patient-centered objectives, the one where the client will explicitly state his feelings for his family was not achieved. The reason for this is that the client rarely talks about his relationship with his family.

ANALYSIS Client is more visibly relaxed today. Interaction was unforced and very spontaneous. Because of this, client volunteers more information and may be talkative at length. My observations about the problems of the client remain the same as the previous interaction he has difficulty intiating relationship, he likes to keep to himself and he lacks great deal of activity.

REFLECTIONS I know that a therapeutic interaction should have a purpose. However, it becomes difficult when you always lose track of what to say next and if you encounter such a huge wall to break in your client. Sometimes, I held interactions with my client and not talking about anything in particular or me thinking about leading the conversation in a way that I could assess him or procure new knowledge about him. We just go with the flow and its strangely not awkard when it becomes that way. I think this is therapeutic in a way because he seems to not talk with anybody of his own will so our conversations forces him to speak and also it makes him alive when he talks about what hes done and things about him (except with issues about admission and his family). While this should make me feel frustrated, I felt strangely light today. Maybe because I was not constantly worrying about what proper things to stay and acted as I would with my client as I would a person his age. Our tone was light and unawkward today so I think we both had a good time. I feel happy that we have made a connection and he was able to recount past experiences with me. Though I really wanted to know from his own lips what transpired prior to admission or to hear him admit that he has mental illness, I dropped it because it always makes the client uncomfortable. I tried to ask it subtly within our conversations, he just never drops a hint. When I look at my client now, I see not a mentally ill patient but a normal guy who is afraid to talk with others and is unwilling to form relationships. And I think that one of the reasons he doesnt also talk much with others or even say sorry or thank you is that he had often relied on himself in the past. I was never afraid of him but I was feeling for a person like him and how to be on his shoes. I cant label it sympathy or emphaty because Ive never acted on it though I felt is at some time or the other. It also crossed my mind, that despite his many stories about his sister, he really was a vagrant because rarely comes home. During our play at the chess, the client was really concentrating. At first, I thought he was mimicking my moves and didn't really know how to play chess because he cant seem to place the pieces on their proper places. But once everything was settled, he steadfastly won the game. I never intended for him to win but I was secretly happy that he was able to do so on his own which helps him recognize his

skills. I was also surprised when he asked a question from me voluntarily. It was a shock because he never did that before. Usually, I have to ask hin questions and he answers them. But never did he ask me one before, especially about our stay in NCMH. My last encounter with him was the real clinching point of this episode. Before, he never looks at me when he goes inside. But now, he raised his hand to say goodbye and didnt leave me staring at him from the back. I felt really warmed over and was very ecstatic because it signaled change in the client and it also clinches our relationship.

PROGRESS NOTES IN THE COMMUNITY

1ST Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will: Be able to observe community and household environment of the patient Establish a contract agreed by both the student nurse and the family concerned State purpose of interaction Establish rapport with family and other significant people in the clients life Assess the family regarding its health habits, knowledge and practice in caring for the patient Identify main concerns, feelings and emotions of the client in caring for the patient Plan with the client on courses of action upon discharge of client and in the next few visits of the student nurse Identify goals of the family upon discharge of the client

Identify present stresses, if any, of the caregivers of the client Intervene as necessary

Patient-Centered: At the end of duty, the client will: Establish rappor t with the student nurse Agree and reach a contract of the visits with the student nurse Explain family structures and practices present Relate caring practices towards the client with mental illness of the family Express concerns and feelings of the family towards the client with mental illness and in caring for hum Identify goals of the family upon discharge of client Be at ease with the student nurse and relay anxieties and fears Plan with the student nurse on the courses of action

NARRATION OF INTERACTION Setting At first, we had difficulty finding the clients house because the addresses in that barangay were said to be changed and the address we had was the old address. Eventually, we were able to locate the clients family with the help of the barangay officers. It is clear that there is a difficulty in managing the barangay because of its quite large population. As stated by the officers, their barangay structure has a block officer to facilitate programs in each block. Programs on mental illness are not given much priority though health is a top priority. The clients home has two floors made of concrete and wood. The space of the house could be described as constricting and narrow. The first floor is used as the as the sala, dining room and kitchen. The bedrooms are situated upstairs. The clients sister mentioned that the client has his own space to sleep on the second floor. They also have a pet dog. They live near

the river which is splayed with garbage and the houses are congested. They are also a few steps away from a basketball court, a sari-sari store and the cockpit.\ Only the clients sister, Ms. Muvillion is present in the first interaction. She said that she is the only one left because her children works and stays live-in with their employers while another studies and has a part-time job. Interaction At first, we introduced ourselves and our purpose. We asked if she was Ms. Muvillion and if she is the sister of R. M.. With that question, it was clear to her what our purpose was so she led us inside her house. She immediately asked how R. M. is and what his condition is. We replied that he seems to be doing okay in NCMH. I told him how R. M. is improving and how he has good impulse control and is able to converse with others. I also told her about him enjoying the activities we prepared and how he willingly participated. She told us that R. M. was also like that in the community. She related how he likes to narrate stories to others and talk with people. She recounted how he often goes with their neighbors to the cockpit fights and how he participates in the basketball games. We asked her how she is doing now and how she is and her family and she answered that they are doing okay. They are comforted that R. M. is doing okay in NCMH and that she is of a mind to visit him as soon as she is able for she relayed that she had been busy this few months thats why she was not able to visit him. She said that, at the present, she has no worries or problems. We requested that she relay how she felt when R. M. was in the house and what his actions were. She told us that convincing R. M. to be readmitted to NCMH was difficult because he usually does not want to go so it is always a trial and error method. She confirmed that she tells R. M. that they will only be going for a check-up but will have him readmitted. She says that there are times when they really only go to NCMH for check-up but this admittance in June 17 was not part of it. She relayed that R. M. was diagnosed as mentally ill since he was 16 years old. She does not know when R. M. was first admitted to NCMH but she knows that her mother has already had R. M. admitted there. Ms. Muvillion said that because their family was split when they were still little, she did not live with R. M. at first. Her mother and a younger brother were R. M.s companions in

Divisoria. Ms. Muvillion was with a live-in partner at that time. When they split, she moved in with her children in Divisoria with her mother. When their house in Divisoria was sold, Ms. Muvillion, her children, her mother, R. M. and their brother moved into their place here in Maypajo. Ms. Muvillion and her mother were the caretakers of R. M. with her mother as primary caregiver. When their mother died last year and their younger brother working abroad, Ms. Muvillion has become R. M.s primary caregiver. Ms. Muvillion has lived with R. M. for 20 years now. She said that she has lost count of the number of times she had R. M. admitted in NCMH. The last one last January and the one prior that on December. She said that this year, his recoveries are more short and lapses are fast. This admittance was brought about by R. M.s inability to sleep, talking and laughing by himself, presenting with bloodshot eyes and incessant walking around the house. She claims that through the years, she has mastered when R. M. will relapse and when he is in a bad mood. She usually takes him to NCMH to be admitted whenever he mumbles by his own, looks in space, has bloodshot eyes, is unable to sleep and refuses to take his medicine. She says that she thinks he had a relapse this time because of his refusal to take medicines and his vices which are smoking and drinking alcohol. She said that she was unable to prevent R. M. from drinking even if she prohibited him from doing so and her statements to the sari-sari stores and neighbors to not give him any alcohol. She said that R. M. is very wise in procuring money usually in cockfights and gamblings. She said that sometimes, their neighbors ask him to buy them something and they will then give him the change. He is also given a shot at times by the lasenggeros. She said that by giving him money the people also allow him to indulge in his vices. Even though the sarisari stores around them do not allow him to buy anymore, he ventures far so that he is unrecognizable and is able to buy a cigarette and a Cobra energy drink or alcohol. We asked her if she has set any rules in the house with R. M. and she replied that she had. She always instructs him that it is not allowed in this house for him to smoke or drink. He must also take a bath regularly and eat. It is also imperative, she said, that he drink his medicines. Ms. Muvillion showed us his Chlorpromazine tablets which are still many in number. Sometimes, she tells him that if he will not drink medicines she has no choice but to bring him back to NCMH because he will again display symptoms if he will not drink his medicine. She says this is effective at times but is not always effective. There are also times when the family locks him out

of the house and tells him that they will not allow him to enter if he does not drink his medicine. This, she says, is usually effective because he agrees to drink his medicine. About his activities, she says that he rarely stays at home and does not involve himself with household duties. Kapag inuutusan ko, parati niyang sinasabi na di niya kayang gawin. Outside, he plays with other kara krus and cockfights. We asked if there were any problems she encountered with R. M.. She said that there are not really many because R. M. has not yet been violent towards her. However, she is at a loss on what to do whenever he does not want to drink his medicine. In addition, she says that R. M. is usually gone for days traveling to places on foot though he always returns to that house because he remembers it. She claims that he has gone as far as Nueva Ecija by himself. He also usually consumes their meal and is constantly hungry. Sometimes, she gives him money to buy his food but he usually buys Cobra or cigarettes with it. She also says that sometimes he won't let them sleep with his loud mumblings and constant wanderings around the house. This last episode, she resigned from her work as a maid because her children reports to her that they are in fear because of their uncle and that he usually lords over them because she is not there. We asked her what she feels about R. M. and his illness and she confessed that there are a lot of times that they fear him and what will happen to them. Some of her children even told her that they should just relocate to another place and leave R. M. in NCMH but she claims that even though she entertained that thought, she quickly put it away because she says that he also pity and worry about him as his only relative that can support him. He, she claims, is the reason they have not yet moved from the area. We told her that it is normal for a human being to feel what she feels and complimented her about her dedication in caring for R. M.. We then proceeded to ask her what her plan is in taking care of R. M. once he was discharged. She told us that she will take him in as before. It has been many years since he was first admitted and the family is accustomed to this cycle of admittance. She just added that she would take extra precaution this time to keep R. M. off his vices and will encourage him to do more activities. EVALUATION OF OBJECTIVES The objectives of the interaction were met. A contract was set and rapport with family was established. It is unfortunate that only the primary caregiver is present and it seems she will

only be the one intervened upon. However, she is the leader of the family and promises to discuss and relay to other members of the family learnings and skills acquired. ANALYSIS It is clear upon inspection and observation that the community plays a big role in R. M.s life and in his sickness. Since he has lived here for more than 20 years and his disease started early in his life, he is well known in the community as is his illness. At present, there is a negative and positive effect of the community in the client. The positive effect is that it negates my prior hypothesis that the client may have been an introvert. As stated by the clients sister, he is anything but a silent person. Tahimik lang siya kapag umeepekto na naman yung sakit niya. Otherwise, she says that he is quite talkative and is able to relate stories and converse with their neighbors. In addition, there are many activities present in the community. These include the cockfights, kara krus, basketball games and many neighbors who talk to him. I remembered that he was good in chess games and it is possible that he learned that from the community as he was just an elementary graduate. Ms. Muvillion also said that the community supports her in taking care of R. M. which is quite beneficial for the family. She said that there is no stigma now though there were times when they make fun of R. M.s actions (but not to his face) and she is firm in reprimanding them. The negative effect of the community also constitutes one of the main problems concerning the client. His vices like drinking alcohol and Cobra and smoking are funded not by his sister who prohibits them but by the neighborhood whenever they give him small changes or balato in cockfights. It is frustrating for the clients sister and there are times that she feels she cannot do anything about it so she just let him be. In my analysis of the family relationship, there is fear of R. M. present in R. M.s nieces and nephews and sometimes in his sister. However, this is outweighed by their concern for him. Ms. Muvillion became his caregiver willingly and though he has become a burden of the family, it is not viewed as such. Oo, wala nga siyang ginagawa dito, pero di ko naman siya pwede pabayaan. Problems of the family in taking care of R. M. include giving medication, facilitating activities, handling changes in mood and limiting vices. There is also limited knowledge of the clients mental illness.

REFLECTIONS It was a tiring day because we got lost and ventured to another block. Fortunately, the barangay officials were really helpful and accommodating. Honestly, I had bad perceptions about R. M.s family because they do not really visit him during the month I had my duty there. Even though he never said anything bad about Ms. Muvillion and her family, I had this perception because I find it coldhearted not to go to your twins birthday even just to see how he is doing. So I was really surprised to find Ms. Muvillion friendly and accommodating. She was happy to hear from us and to know about R. M.s condition. I eventually concluded that maybe she really did not have the time or cannot live their house because she is the only one living there. Whatever her reasons are, I realized that it is wrong to judge a person especially before you have even met her. Anyway, Im really impressed with how Ms. Muvillion handles R. M. though I think she is firmer than she lets on. She is able to identify symptoms of relapses, handle anxious behavior, provide him with medications. She told me that she can even sacrifice their food just to buy R. M. his medicines. I was pretty surprised when she showed me R. M.s medications in a box. Even though it is not very obvious at the onset, Ms. Muvillion really cares for her brother and her sacrifices are evidence of that. More than an introvert, I think R. M. likes being alone and independent. Ms. Muvillion describes her brother as very resourceful (for he is able to get money even though he does not really work and she does not give him any) and quite talkative. Now, that was slightly surprising though I got snippets of how he can be during my interaction with him. He can talk in length about some things but is very mum in others. It seems he enjoys a lot of activities in the community and I think that is good for him. That he is a mentally ill person does not seem to faze most members of the community and they still interact with him. I think that is quite unexpected though I shouldn't really be surprised as he has lived with them for most of his life.

2nd Day
OBJECTIVES Nurse-Centered: At the end of duty, the student nurse will:

 Maintain rapport and good and trusting relationship with clients family Determine history of present illness and relationship to society Identify the patient in the community setting
Gather relevant information regarding the client and the family, including the

family dynamics, interactions, coping mechanisms, resources, perception of the clients condition, anxieties and concerns and goals of care Alleviate anxieties and fears in caring for the client Acknowledge plan and goals for care and assist in achieving them Implement agreed upon plan of teaching and activities Provide health teaching about myths on mental illness, handling behavior and follow-ups NARRATION We started in an afternoon today because we had a meeting with Kyras (my partner) client in the morning. The client was in the process of sewing retasos into basahans which is her main livelihood. She was formerly a live-in household helper and was forced to resign because of R. M.. Client is honest in saying that sometimes there are resentments felt about their situation but it soon dispelled from her mind. She says she is accustomed to taking care of R. M. having taken over the role of primary caregiver when their mother died. We started the interaction with a summary of what we have talked about in the previous day. We also informed her of the day when we will arrive next. Then, we discussed the purpose of our interaction today which is to find an answer for her concerns and problems and health teaching of the important components in taking care of a mentally ill patient. We asked her how she is doing today and she said that she is fine. She is sewing rags to add to their income. Ms. Muvillion is currently alone in the house. However, she has 4 children all working while one is also a student. Joanna, the eldest, is abroad working as a domestic helper. Roselyn, her next daughter, is also working as a live-in household helper. The next one is a student who works live in. And the youngest studies and works part time in a mechanical auto repair shop. When asked what she thinks led to R. M.s mental illness she replied that R. M. was mentally ill since he was 16 years old and he was with a bad crowd in Divisoria. She recounted that he was sniffing rugby then and was smoking and drinking at the same time. She does not

really know how he came about because he was not with her when he started having mental illness but thats what others told her. It may also add, she said, that their mother is a little bit controlling. And she was with R. M. since he was born. When asked how R. M. is in the community, the client replied that R. M. was really friendly in the community. He has many friends and is very resourceful in gaining money even though she does not urge him to. However, at home, R. M. does not really work. Paminsan iniisip ko ginagawa lang niyang dahilan yung sakit niya para magtrabaho. We then asked how R. M. phrases his refusal. Ayun, sasabihin niya, di niya alam gawin. We explained to the client how this behavior may be part of his illness and his saying that he does not know how to do it may be part of his defense mechanism meaning he may feel that he cannot do something properly so he rejects doing it in the first place. However, we urged her to phrase her requests in a good manner and tell R. M. that it is part of her rules that he has a part in the household chores. By giving him a responsibility, he also gains an activity and purpose. We tell her how he works in NCMH when requested to perform a task so we told her to be patient and not nag R. M. at times when he says he cannot really do it. We then proceeded to ask her if she is the only primary caregiver of the patient and how is the family and financial support. She told me that it is true that they have siblings abroad and that their father is abroad. She has never seen him but there is communication especially when their mother was alive though it was infrequent. She said that they rarely give financial support and does not really ask about R. M.s condition. She said that she does not really want to ask now especially that their mother is dead because they might think she is using R. M.s condition as an excuse. The client then proceeded to cry as she relates how they never really gave support. Ako nagpapakain, ako nagpipilit magpaligo, ako ang nag-aalaga kay R. M., yun na nga lang ang maitutulong nila, pera, pero hindi pa nila binibigay. Paminsan nga sinasabi ko, kayo kaya dito. Their younger brother who lived with R. M. when they were young sometimes calls but seldom gives also. She said, when they were still in Divisoria, they already had passports, R. M. and her, to go to USA. They were being petitioned by their father. However, R. M. became very angry and tear his passport apart. After that, she said, their father became frightened and their migration did not push through.

Because the client is crying though she is really braving it through, we gave her a tissue and she laughed saying she gor really emotional. We then praised her for her efforts in taking care of R. M. and asked that she continue being a good sister and caregiver to him. After all the discussions, we proceeded in the health teaching part of our interaction. We asked her what she understands about mental illness. She said that she does not really know much about the illness though she understands the symptoms and how to handle them. She knows that mental illness can be triggered by something and may be hereditary. She also proceeded to say that the medicines really help in curing the sickness. We asked her what are her ways in handling the mentally ill patient. She tells us that she stays consistent and firm at all times. She gives the client money at times which is good because it shows trust of the client however this leads to his buying Cobra energy drink and alcohol. Whenever she feels frightened and senses that R. M. is not in a good mood, she locks him out of the house and does not let him come in. They also hide the knives so that he wont have any inclination to be violent. When asked if there were instances wherein the client was violent, she answered that she has never experienced it although he sometimes hit on his mother. She is however providing R. M. with food especially after his hospitalization because he always eats a huge amount. She always request him to take a bath every day. Sometimes, she converses with him though she tells me that R. M. often gets out of the house before any sincere conversation strikes up. We then asked the client to choose on the health teaching topics we have prepared today. We asked her what she really wanted to know about and she chose handling behavior and the family with the mentally ill patient. We then proceeded to tell her of the techniques in handling a mentally ill patient and what to expect and do in these cases. She was very interested I handling delusions and hallucinations and she recounted a time when R. M. said that he was the stunt double of Robin Padilla in one of his movies. She tells us that the people in their neighborhood humors him whenever he speaks about these. We then told her how to deal with hallucinations and delusions.

EVALUATION OF OBJECTIVES

The objectives have been met successfully. I was able to assess some aspects of the family and concerns raised. Rapport and trust is present and there is open communication. Appropriate interventions were applied and health teaching was given. Overall, the interaction was quite fruitful for both parties. ANALYSIS The clients family is very responsive today and she is considerably more at ease. With the family secrets out in the open, I can assuredly say that trust has been given and service should be offered in return. I guess what happened was also not easy for Ms. Muvillion. When I think about it, I think this situation really accentuates the statistics that women are relatively more stable emotionally than men. Considering that R. M. and Ms. Muvillion are twins suffering the same fate, it is not difficult to suppose that there is a very high risk for Ms. Muvillion to have developed mental illness also. Fortunately, it does not seem so. In fact, Ms. Muvillion seems capable of handling problems because she has a good perspective in life. Maybe, it also helps that she has a goal in life and that is to see her kids in good standing. Reading between the lines, I can suppose that their mother did not make their life easy. She seems to be a controlling figure in the familys life. However, her unwavering loyalty and care shows in that she didnt leave R. M. to face his illness alone and cared for him. The main glitch in this fami REFLECTIONS
Its so sad to think that a family can be broken just like that. It is very difficult for me to feel these emotions because fortunately, we are a whole family and most of my extended family are not broken as well. I cannot for the life of me imagine how a father can leave his children just like that. From R. M. and Ms. Muvillions stories, it was as if they were really abandoned and forgotten. I felt so sad seeing Ms. Muvillion tear up in talking about her siblings remembering the matter-of-fact way R. M. related this to me. They were opposite reactions but it nevertheless shows us how this event affected their lives greatly. However grudgingly Ms. Muvillion accepted responsibility for R. M., however she may complain about taking care for him, I think it really speaks a lot about their relationship for her to take care of him. It is no wonder R. M. usually considers Ms. Muvillion as his only sibling. Though he has mentioned the others, he does not talk about them as often as he does about her.

In contrast to our former meeting, I was more at ease and confident today. I think I know what to expect and the client looked really interested in what we have to offer. It was interesting talking with her and I was pleasantly surprised that she is engaged in our discussions. She asks questions and offers solutions on her own. I think, it comes with having the real experience of living every day with a mentally ill patient. One time, I lost my track of thoughts and I blurted out and asked if caring for the client at home every day isn't very taxing? Because honestly, just an hour of interacting with the client was really tiring for me because I was always careful in everything I do. Oh, it was easy when he is in a good mood, but it sure is difficult when he isn't. I keep comparing our caregiving with that of the real primary caregivers and I dare say that they really take the gold. Its not that Im not doing my care out of compassion and empathy, I am. But in hindsight, what they provide is unconditional love. It is the love that even if youre really burdened, you just can't let go of the person. It is when you sacrifice something of yours just to provide something of his. And to think that he cannot really give anything in return. I am really amazed and humbled by these persons. At the end of the day, I am still just a student who took care of the client for a couple of days. I will eventually leave him. In contrast, they will forever be at his side (whether they liked it or not). Maybe, out of a sense of duty but more probably because they do care.