MALADAPTIVE PATTERN NGCM 105 RLE MENTAL STATUS EXAMINATION BMC Psychiatric ward February 10 & 17, 2013

C.I.: Ms. Mary Andre Lim

A. General Description 1. Appearance a. Apparent age- 39 b. Manner of dress- well-dressed, properly groomed c. Cleanliness- neat d. Posture- slightly leaning forward e. Unusual gait- none f. Facial expression- varies with emotions g. Eye contact- can maintain eye contact h. Pupil dilatation or constriction- normal i. General state of health and nutrition- the patient is well-fed and doesnt have any physical illness 2. Speech a. Rate- normal b. Volume- moderate c. Amount- normal d. Characteristics- normal, answers appropriately 3. Motor activity a. Level of activity- moderate b. Type of activity- picture analysis, walking c. Unusual gestures or mannerisms- none 4. Interaction during the interview- She answers appropriately and able to expand her ideas. She is more cooperative now and shares her insights about the topic being discussed. B. Emotional State 1. Mood- normal 2. Affect a. Range- normal b. Duration- normal c. Intensity- normal d. Appropriateness- normal C. Experiences 1. Perceptions a. Hallucinations- none b. Illusions- none D. Thinking 1. Thought content (YES/NO) a. Delusion- yes, she thought we are the owner of the hospital b. Depersonalization- none c. Hypochondriasis- none d. Ideas of reference- none e. Magical thinking- none f. Nihilistic ideas- none g. Obsession- none h. Phobia- none

2. Thought process a. Circumstantiality- yes b. Loose association- yes c. Perseveration- no d. Thought blocking- no e. Flight of ideas- yes f. Neologisms- no g. Congentiality/Tangentiality- no h. Word salad- no i. Others- none 3. Thought content preoccupation a. Obsession/Compulsion- no b. Thought content delusion 1. Delusion of grandeur- none 2. Delusion of persecution- none 3. Delusion of religiosity- none 4. Suicidal Intention Rating Scale- 0 5. Remarks and Findings- normal 4. Sensorium and Cognition a. Level of consciousness- alert, alive, awake b. Memory 1. Immediate- intact 2. Recent- intact 3. Remote- impaired c. Confabulation- no d. Level of Concentration and Calculation- Good e. Information and Intelligence- Good f. Judgment- Good g. Insights- Good 5. Ego Defense Mechanism- suppression 6. Level of self-esteem a. Subjective assessment 1. Things the client like about him/her- she did not verbalize 2. Things the client would like to change about him/her- she wanted to go home and be out of the institution. b. Objective assessment 1. Eye contact- can maintain eye contact 2. Participation in group activity- cooperative and active 7. Current Medications- risperidone, clonazepam 8. Evaluation of the clinical instructor

MALADAPTIVE PATTERN NGCM 105 RLE PROCESS RECORDING BMC Psychiatric ward February 10 & 17, 2013 C.I.: Ms. Mary Andre Lim A. General Information 1. Clients Initials- A.J. 2. Age- 39 3. Civil Status- Single 4. Educational Background- Elementary level 5. Hobbies and interests- cooking, gardening, watching movies B. General Objectives At the end of the rotation, the client will be able to verbalize feelings and thoughts. C. Specific Objectives At the end of the rotation, the client will be able to: a.) Express self. b.) Participate in the activities. c.) Share ideas. d.) Communicate insights. D. Description of the environment- the environment is calm, quiet and conducive to therapeutic communication. E. Appearance of the client- well-groomed F. Dates of Interaction- February 10 & 17, 2013 Nurse Verbalization Clients Verbalization and nonverbal communication Oo. Nakatulog ako ng maayos. Inferences/Analysis/Communicati on Techniques Nurses thoughts and feelings

Nakatulog ka ba ng maayos kagabi?

Closed-ended question

I think the client is telling the truth. And Im happy that she slept well. She maintains eye contact and answers appropriately

Anong oras ka nagising? Kumain ka na ba?

Kaninang umaga. Oo, kumain kaming almusal, longganisa at gelatin ang dessert. Okay naman. Wala naman akong nararamdamang masama. Nagluluto ako sa karinderia tapos naglilinis ng bahay. Mahilig din akong manood ng pelikula ni Sharon Cuneta.

Closed-ended question

Kamusta naman pakiramdam mo ngayon?

Open-ended question

She learned to express herself and vocalize more of her feelings.

Maaari ka bang magkwento tungkol sa mga ginagawa mo bago ka pumasok sa hospital na ito?

General leads

I am glad that she is now sharing her ideas and she is starting to tell stories of her life.

Last Sunday, February 17, we had our last duty for the 6 th rotation at the BMC psychiatric ward. At first, my patient is hesitant and doesnt want to open up but on the long run, I observed an improvement on her status. She is slowly talking and sharing her insights to us. She is preoccupied with going home. As I checked her chart, she has been staying in the institution for almost twenty years and she doesnt have any recorded visitors since then. Theres a reported incident that she was bitten by the other patient in her ears. As I conducted the physical assessment, I noticed her ears obviously bitten and her pinna has been cut, both ears are like that.

My stay in the psychiatric ward made me thankful of my life now. I thank God that He didnt put me in the situation of my patient. I also learned to appreciate and love my family more. Im glad that we dont have to undergo the sufferings that my patient experienced.

Positive symptoms (+) flight of ideas (+) word salad (-) delusion (-) hallucinations (-) disturbed thinking (-) ambivalence Negative symptoms (-) apathy (-) blunted affect (-) catatonia

Received patient awake, well-groomed and w/o any contraptions F D - Verbalization of feelings - Patient answers with a yes/no - Patient doesnt expand her feelings A - Assessed patients self-esteem - Encouraged patient to express self by using exploring as a therapeutic communication - Allowed patient to verbalize what shes thinking - Focused on patients nonverbal cues R Patient is now verbalizing her thoughts and expands on her ideas