Republic of the Philippines Davao Oriental State College of Science and Technology Institute of nursing & Health Care

PSYCHIATRIC NURSING RLE: NEW DAT RECOVERY CENTER

NAME OF PATIENT: BIBOY AGE: 19 Y/OLD SEX: MALE CIVIL STATUS: SINGLE

DATE AND TIME: JANUARY, 14, 15, 16, 2013 NAME OF STUDENT NURSE: ABDUL CADER O. TIOTODA

I.PRESENTATION A. GENERAL APRPEARANCE: 01/14/13- resident is wearing short pans and white t-shirt, cap and blue slipper. 01/15/13- he is wearing color green basketball short and white t-shirt. 01/16/13- residents is wearing beach short and white t-shirt with black cap. B. GENERAL MORBILITY: 1. Posture and Gait: ( ) Normal ( ) Appropriate ( ) Inappropriate

Justification: He can stand and walk alone with proper facing. 2. Activity: ( ) Normoactive ( ) Agitated ( ) Hyperactive/restless ( ) Psychomotor retardation

Justification: he did not manifest any psychomotor retardation and he can perform his ADL.

3. Facial Expression: ( ) appropriate ( ) Inappropriate

Justification: mood is obvious, can manifest appropriate affect and emotion. Quantity: ( ( ( ( ) Smiling ) Happy ) tearful ) Ecstatic ( ( ( ( ) Worried ) Tensed ) distant ) frightened ( ( ( ) angry ) sad ) suspicious

Justification: he can smile and smiling it depends on the situation of the stimulus. C. BEHAVIOR: He is cooperative in activities, during NPI, and therapy. Maintaining eye to eye contact when he speaks. D. NURSE-PATIENT INTERACTION: ( ( ) Cooperative ) Initially Only ( ) uncooperative

Justification: He can cooperate to the NPI and therapy. E. QUALITY ( ( Justification: ) Warm ) Talkative ( ( ) distant ) hostile ( ( ) Suspicious ) others: ________________

II. STREAM OF TALK: A. CHARACTER OF TALK ( ) Spontaneous ( ) Deliberate

Justification: He can share the information what he want to share with us.

B. ORGANIZATION OF TALK: ( ( ( ( ) Relevant ) Incoherent ) Circumstantial ) flight of ideas ( ( ( ( ) Irrelevant ) Looseness of Association ) Tangential ) others: __________________

Justification: the client can always talk relevantly to what topic he wants to discuss. C. ACCESSIBILITY ( ( ) Good ) mute ( ( ) fair ) Poor ( ( ) self-absorbed ) Inaccessible

Justification: he is open to share some information but not full detailed. III. EMOTIONAL STATE AND REACTION A. MOOD ( ( Justification: ) Euthymic ( ) Depression ( ) Euphoria

) others: __________________

B. AFFECT ( ) Appropriate ( ) Inappropriate

Justification: what he feels inside it is appropriate to the stimulus. C. DEPERSONALIZATION AND DEREALIZATION ( Justification: ) Present ( ) Absent

D. SUICIDAL POTENTIAL ( ) Present ( ) Absent

Justification: he is not showing suicidal potential thing. E. HOMICIDAL POTENTIAL ( ) Present ( ) absent

Justification: he is not showing homicidal. IV. THOUGHT PROCESS A. PERCEPTION: Type: ( ) Present ( ) absent

Justification: he is no problem regarding to his perception. B.DELUSION: Type: ( Justification: C. IDEAS OF REFERENCE ( ) Present ( ) Absent ) Present ( ) Absent

Justification: he is not manifesting ideas of reference D. PREOCCUPATION AND RUMINATION. ( ) Present ( ) Absent

Justification: he is longing with family E. DEJAVU AND JAMAIS VU ( ) Present ( ) Absent

Justification: he is not showing any of these two.

V. NUEROVEGETATIVE DYSFUNCTION A. SLEEP ( ( ) Normal ) Late Insomnia ( ( ) Hypersomnia ) Mixed Insomnia ( ) Early insomnia

Justification: B. appetite ( ) Normal ( ) Increased ( ) Decreased

Justification: he can eat proper calories appropriate to his BMI (body mass index) C. WEIGHT ( ) Increased ( ) Decreased

Justification: the weight increased D. DIURINAL VARIATION Justification: ADL (activity of daily living) must be performing after the duty. E. ATTENTION SPAN ( ) Good ( ) fair ( ) Poor

Justification: he is attentive until the end of our activity. VI.GENERAL SENSORIUM AND INTELLECTUAL STATUS A. ORIENTATION Time: Justification: Place: Justification: ( ) Unimpaired ( ) Impaired ( ) Unimpaired ( ) Impaired

Person:

) Unimpaired

) Impaired

Justification: he is orientated the people around him. Situation: ( ) Unimpaired ( ) Impaired

Justification: he knows what kind of activity we had. B. MEMORY Remote: ( ) Unimpaired ( ) Impaired

Justification: he is still remembering his child experience. Recent: ( ) Unimpaired ( ) Impaired

Justification: he is still remembering the present memories. Immediate: ( ) Unimpaired ( ) Impaired

Justification: he can talk spontaneously. C. CALCULATION ( ) Good ( ) Fair ( ) Poor

Justification: he is good in calculation. D. GENERAL INFORMATION: ( ) Unimpaired ( ) Impaired

Justification: his self, place, time, everything was oriented to him. E. ABSTRACT THINGKING ABILITY ( ) Unimpaired ( ) Impaired

Justification: we assess him through idiomatic expression, and then he explains it correctly. VII. JUDGEMENT AND REASONG ( ) Unimpaired ( ) Impaired

Justification: he can talk whatever was on his mind.

VIII. INSIGHT ( ) Unimpaired ( ) Impaired

Justification: he talks about himself insight regarding to his life. IX. SUMMARY OF MENTAL STATUS EXAMINATION A. DISTIURBANCES IN ( ( ( ( ( ( ( Justification: B.DIAGNOSTIC CATEGORY ( ( ) Functional ) Non-Psychotic ( ) Organic ( ( ) Psychotic ) Presentation ) Stream of talk ) Emotional State and reaction ) Thought Content ) Neurovegetative Dysfunction ) General Sensorium and intellectual Status ) Positive signs of Organicity

) both functional organic

Justification: he is normal in the medical point of view. C. DSM IV DIAGNOSIS Axis IAxis IIAxis IIIAxis IVAxis V-