University of the Cordilleras Governor Pack Road, Baguio City, Philippines 2600 (+6374) 442-2564, 442-8219, 442-8256 E-mail:

webmaster@bcf.edu.ph website: www.bcf.edu.ph

COLLEGE OF NURSING SY 2013-2014 1st Semester BSN3-2 Group 3

Name: Orly Age: 24 years old I. PRESENTATION A. General Appearance

Diagnosis: Paranoid Schizophrenia Date of Interview: December 10, 2013(Tuesday)

The patients appearance is appropriate with age and height. During the interview, he wore a green polo shirt, denim shorts, and a pair of slippers and is seated on bed. The patient appears to be untidy. He has dirty clothing, unkempt hair, long fingernails and toenails with traces of dirt evidently seen on both. At the time of the interview, the patient was alert and responsive. B. General Mobility a. Posture and Gait The patient slouches when seated but holds himself erect when standing and walking. His mannerisms include manually hyper extending his fingers and scratching his head. b. Activity The patients movement are organized and purposeful during the interview. He moves in a normal pace and does not show any signs of over and under activity. c. Facial Expression The patients facial expressions are very much appropriate to his verbal responses during the interview. He was composed and receptive to whatever the student nurse asks him. C. Behavior The patient was friendly and warm to me during the interview. He was sitting on bed calmly. He interacts well with the student nurse and as what I had observed; he has a good relationship with his co-patients at that time. D. Attitude towards the Examiner The patient accepted the student nurse warmly. He entertained my questions and answered almost all of them. However, his eye contact was poor. He often looks down. II. STREAM OF TALK A. Characteristic of Talk During my conversation with the patient, I noticed that he is spontaneous most of the time. However, there are times in which blocking is evident in between his speech. His articulation words were clear but the content is slightly vague. B. Organization of Talk The patient was eager to talk with the student nurse. He tries to answer every question that I ask him however, in his answers, I apparently observe succession of circumstantiality and tangentiality. He provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times, he doesnt arrive at the answer at all.

LEVEL 3. NCM 103 Care of Clients with Problems in Oxygenation, Fluid & Electrolyte Balance, Metabolism and Endocrine

| 1st SEM SY
2013-2014

University of the Cordilleras Governor Pack Road, Baguio City, Philippines 2600 (+6374) 442-2564, 442-8219, 442-8256 E-mail: webmaster@bcf.edu.ph website: www.bcf.edu.ph

COLLEGE OF NURSING SY 2013-2014 1st Semester BSN3-2 Group 3

III.

EMOTIONAL STATES AND REACTION A. Mood At the course of the interview, the patients mood was euthymic. His feelings were appropriate to the situations as he relays his answers to the student nurse. His mood was just appropriate and basing from his gestures and other nonverbal cues, his mood is fitting to the situation. B. Affect The patients affect is appropriate as well. There is a marked harmony between thought content, emotional response, and expressiveness. When asked, Kumusta ti aldaw yu manung?, he replied, Mayat met. with a smile.

IV.

THOUGHT CONTROL A. Perceptions Throughout the interview, the student nurse didnt observe any manifestations of illusions and hallucinations. He told me that he never experience when asked if he experiences any of the two. He was very calm and composed.

V.

NEUROVEGETATIVE STATE A. Sleep The patient usually sleeps at 12 in the midnight and usually wakes up at 5am getting at least 5 hours of sleep. Hanak makaturog di rabii pasado alas dose the client reported. He says that he finds it hard to sleep at night and instead, he just spends his time reading a pocket book until he falls asleep. Five in the morning for the patient is too early for him to wake up that is why he attempts to go back to sleep, but then, he is unable to do such. This is a manifestation of late or terminal insomnia. B. Appetite The patient has increased appetite. He eats a lot and hes not choosy in his food. Haan ak napili ti makan., reported by the patient. C. Diurnal Variation The patients mood is usually fine during the interview relaxed and interested to the questions given.

VI.

GENERAL SENSORIUM AND INTELLECTUAL STATUS A. Orientation The patient is well oriented of the time, place and person. When asked during the interview if what date and time was it, he answered correctly. However, as the conversation progressed, we noticed that he is confused and not well oriented with the time. The patient is also oriented with the situation since he knows that he is in the BGHMC Psychiatric Ward for his treatment. B. Memory The patient doesnt have difficulty recalling remote memories. When asked what was his age, he replied; 24 years old akun.. The patient also has a good memory when it comes to remembering recent and immediate memories.

LEVEL 3. NCM 103 Care of Clients with Problems in Oxygenation, Fluid & Electrolyte Balance, Metabolism and Endocrine

| 1st SEM SY
2013-2014

C. Calculation

University of the Cordilleras Governor Pack Road, Baguio City, Philippines 2600 (+6374) 442-2564, 442-8219, 442-8256 E-mail: webmaster@bcf.edu.ph website: www.bcf.edu.ph

COLLEGE OF NURSING SY 2013-2014 1st Semester BSN3-2 Group 3

The patient was given simple mathematical tasks like 1+1, 2-1, 18-7, 6x7 and he likes it. He was able to answer all of them but there were long pauses before he can finally give the answer. D. General Information The patient knows basic general information like the current president of the Philippines and even of the United States. He know the capital of some Philippine provinces and he was able to name the national hero of the country. E. Abstract Thinking, Judgement and Reasoning The patient was given a maxim translated in Ilocano to evaluate his reasoning and abstract thinking. He was asked to explain the quote Try and try until you succeed. He was able to explain it but not profoundly. He said, Aramidem amin nga kayam nga maaramid. And when asked to elaborate, he refused to. He was also given a situation wherein someone left her wallet, and he was asked what he should do. He replied, Haan na met siyak am-ammu, isu han kun isubli. VII. INSIGHTS The patient understands that he needs to go to the hospital for his treatment. Since he was 24, he knew that there is a problem in him and he even asked his aunty to bring him to the doctor.

LEVEL 3. NCM 103 Care of Clients with Problems in Oxygenation, Fluid & Electrolyte Balance, Metabolism and Endocrine

| 1st SEM SY
2013-2014