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MANILA DOCTORS COLLEGE Pres.

Diosdado Macapagal Boulevard Metropolitan Park, Pasay City

In partial fulfilment Of the Requirements of the College of Nursing in Related Learning Experience

Psychoactive substance abuse


Submitted by: Group CA8 Amarille, Andrea Kristina Caberte, Iris Co, Jovial Anne Dimaya, Avone Mae Gadingan, Barbara Litam, Laura Jeunesse Pereyra, Honeylet Punay, Franchell Marianne Salgado, Dennisse Jane Sangalang, Jose Noel Santos, Cienna Mae Vidallo, Wilson Ace

MANILA DOCTORS COLLEGE Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay city I. ASSESSMENT A. General Data Residents Initials: R.C III Address: Caloocan City Age: 35 yrs old # of days in the Hospital: 2mons and 3wks Place of Birth: Taguig City Date of Admission: Sept. 21, 2010 Order of Admission: Ambulatory Informant: R.C. III (Client), M.C (Sister) Date of History Taking: 12/08/2010 B. Chief Complaint Dad gumamit na naman ako. Agapan niyo ako pero ayoko sa rehab. Gusto ko sa place na may peace of mind. as verbalized by the client. C. History of Present Illness 21 years prior to confinement (1989), His uncle was a police official and caught a bag of drugs. Out of curiosity, he got some and he played with it by throwing it on the open drainage with some tadpoles on it then one of his friends saw him and asked him what he is holding then his friend tasted it and recognized that it was shabu. After that incident, his friends brother bought it from him. He enjoyed earning a lot of money that he got used to it and eventually he also started taking shabu and marijuana at the age of 15. At that age, he was put to rehabilitation center at Bicutan for 6 months. When he was there, he had friends who are drug lords. They wanted to be friends with R.C because they know that R.C. could help them get out of rehab center because his father was a general. He took medications to withdraw the drugs in his body but he forgot those drugs. 20 years prior to confinement, he continued using it again with his friends. When he uses drugs, hes awake for 2-3 days. He is with his friends and they will play cards, drink alcoholic beverages and have sex with different women. He continued doing this and use shabu and marijuana intermittently until 19 years old. 16 years prior to confinement, his parents decided to put him again to a rehabilitation center because they notice that R.C. is taking higher dose of shabu than before. He stayed at Plane View for 6 months. When he was at the rehab he refrained from using drugs. He took medications to detoxify the drugs in his body but he forgot again those drugs. Unfortunately, when R.C. went out of rehab, he goes back to his vices which are taking shabu and marijuana. From 20 years old to 33 years old, he used marijuana and shabu intermittently. 2 years prior to confinement, he stopped using shabu and marijuana because he had a girlfriend and he became a father but unfortunately, they had a big problem and separated. He got depressed and started using shabu again. On the day of confinement, he asked his father to bring him in a place where there is a peace of mind. His father chose San Jose Home Care. Sex: Male Civil Status: Single Occupation: None Date of Birth: Sept. 22, 1974

D. Past History 1. Childhood Illness/es: Chicken pox (9 years old) 2. Adult Illnesses: Acute Appendicitis (2010) 3. Immunization: BCG, DPT, OPV, Hepa B, Influenza (annually) 4. Previous Hospitalization: September 2010 (UST hosital) 5. Operation/s: Appendectomy September 2010 (UST hospital) 6. Injuries: Ice pick stab left deltoid (unrecalled) 7. Medications taken prior to confinement: none 8. Allergies: Medicol E. Systems Review- Gordons Eleven Functional Health Pattern (December 8, 2010) A. Health Perception- Health management Prior to confinement, according to the client he rarely gets sick. Sometimes in a year he doesnt get sick and whenever he gets sick his remedy was enough rest and sleep. He drinks 1-2 bottles of San Miguel Light every other week and he consumes two packs of cigarettes a day. He uses prohibited drugs like shabu and marijuana every day. He doesnt perform testicular examination. The client experienced ice pick stab in his left shoulder. During confinement, according to the client, he never had colds or cough. He consumes 5-6 sticks of cigarette a day. He neither drink nor did take prohibited drugs. He drinks the prescribed medication to prevent any complications and for his full recovery. As much as possible he avoids all of the things that could be stressful or could make him depressed so that his condition wouldnt worsen. B. Nutritional-Metabolic Pattern

According to the client, he was breastfed until 1 year old and then was bottle fed until the age of 5. He had no eating problems such as difficulty in swallowing and dental problems although he has dentures at his 5 front upper teeth since he was 17 years old due to fraternity. He has poor appetite whenever he is taking drugs. Most of the time, he eats meat and vegetables like cabbage and beans only. He eats 1-2 times a day and his meal would consist of a cup or two cups of rice depending on the served viand. He drinks about 4-6 glasses of water a day and he always drinks soft drinks about 1-2 liters a day. During confinement, according to the client, he experienced weight gain. Di ko alam exactly ilan yung na gain kong weight pero dati sobrang payat ko as in bungo. As stated by the client. He would only drink about 6-7 glasses of water a day and a 1 liters of softdrinks. He eats on time and he has a good appetite. He takes vitamins and supplements like Centrum 1 tab daily. C. Elimination Pattern When he was young the client was potty trained. He was never scolded whenever he fails to do that. Prior to confinement, he had no problems in urinating and defecating. He does not use laxatives and does not feel any discomfort. He urinates 4-5 times a day with a characteristic of dark yellow in color and output is almost the same as his intake. He defecates regularly every morning with a characteristic of a brownish and semiformed stool. The client had no odor problems and doesnt experience excessive perspiration. During confinement, the client defecates 1-2 times a day with a characteristic of a brownish and semi formed stool. According to the client he urinates 6-7 times a day with a characteristic of light yellow. The client does not perspire a lot.

D. Activity Exercise Pattern Prior to confinement, the client had a regular form of exercise like walking, jogging, military exercises and tai-bo for about an hour. During his spare time, he usually spends time with friends and hangout. The patient is independent from doing activities such as eating, bathing, toileting, and grooming. During confinement, the client spends most of his time in the ward roaming around or just resting, read magazines and watch television. He stated that he his form of exercise is walking and push ups. The client stated that their usual activities every time there are student nurses are remotivational activities, music and arts therapy, bibliotherapy, sandwich making, newspaper reading and games. E. Sleep-Rest Pattern

Prior to confinement, the client had difficulty in falling asleep because of the effect of the drugs (shabu or marjuana) he was taking. He sleeps 4 am in the morning and wakes up at 1pm. He is also experiencing difficulty of going back to sleep after waking up. There were no nightmares experienced by the client. During confinement, the client slightly feels restless. He sleeps at around 1-2 in the morning because he cant stop thinking about his problems. He wakes up 5 in the morning. Body clock ko na yun eh as verbalized by the client. He doesnt sleep at noon because there are student nurses in the afternoon that ask them to join their activities. He doesnt experience any nightmares. F. Cognitive- Perceptual Pattern

According to the client, he started walking on his first age. His mother taught him new words when he was 1 year old. His first word was mama. He learned the alphabet and counting numbers in his school. Prior to confinement, the clients vision is 20/20. He doesnt use eyeglasses. He also has no difficulty hearing and does not use hearing aids. The client found it easy learning new things by watching and listening. The client speaks English and Filipino. During confinement, the clients vision and hearing are still the same. He learned new things by watching and listening. The client speaks English and Filipino when talking with other residents. G. Self Perception- Self Concept Pattern

Prior to confinement, the client felt bad about himself and he is insecure to many things like his educational attainment. The client was so free in doing things that he wanted. He stated that Feeling ko rejected ako kaya ina-isolate ko yung sarili ko. Feeling ko pinag-uusapan nila ako. During confinement, most of the time, the client feels good about himself. The client is relaxed, especially when there are student nurses. Masaya may student nurse, may ginagawa. as stated by the client. The client wants to have a business when he goes out of the institution and take a vocational course for his own good. He plans to change his way of living for his daughter. He formulated 3Ds: Dependent on God, Determination, and Discipline.

H.

Roles-Relationships Pattern

According to client, his Grandmother and yaya were the ones who took care of him because his parents were usually in the field. He wasnt raised strictly. Most of the time his tantrums were tolerated. He was raised spoiled. Prior to confinement, he goes first to his friends and use prohibited drugs whenever he has problems. During confinement, the client lives with the other clients in the ward. His family visits him every Sunday. He has a good relationship with other residents. Whenever he has problems, he will talk to other residents whom he called his close friends and relate his problems to them. I. Sexuality- Reproductive Pattern

According to the client, he was circumcised as soon as he was born. The client had four serious girlfriends. His first sexual intercourse was when he was 16 years old. Prior to confinement, he has an active sexual life and he had multiple sexual partners. During confinement, the client established a good relationship with other residents. The client behaves well even in front of the opposite sex and in front of the student nurses. Sexual relationship is no longer his priority as of the moment. J. Coping-Stress Tolerance Patterns

According to the client, the cause of his depression was when he got separated with his girlfriend and his baby. After that incident, he went back to his vice which is drug abuse. He decides for his own. During confinement, according to the client he only thinks of his daughter and misses her a lot because she stays with her mother. That is the only problem that he always thinks. The client finds it somehow enjoying whenever there are activities prepared for them. Napakaswerte ko sa pamilya ko kasi napaka-supportive nila sa kabila ng mga nagawa ko as verbalized by the client. Kaya madali ako nakakarecover. K. Values Belief Pattern

According to the client, he started praying when he was 4 years old and it was taught by his mother and teacher. Prior to confinement, his family goes to church but he doesnt go with them. Dati talaga wala akong sinasanto santo nun kundi drugs. as verbalized by the client. During confinement, he realizes that religion and God is really important for him especially when he is experiencing difficult problems. He never forgets to pray at night. He asks God for forgiveness, strength and guidance not only for himself but also for his family. He stated that he will never lose hope and faith to God and when he goes out he will depend on God. F. Family Assessment NAME R.C.II N.C. O.C M.C. RELATION Father Mother Brother Sister AGE 69 74 33 29 SEX M F M F OCCUPATION Retired Doctor None None EDUCATIONAL ATTAINMENT College graduate College graduate Special education College graduate

G. Heredo Familial Illness Maternal: Diabetes mellitus Paternal: CVA H. Developmental History Theory (Theorist) Psychosexual (Sigmund Freud) Age 0-18 months Developmental Task Oral Stage Patients Description - The client was breastfed until the age of 1. He was bottle fed afterwards. Whenever he cries, he was given milk by his grandmother & yaya. He had problems weaning because he preferred milk more than food. - The client was potty trained by his grandmother. He was never scolded whenever he fails to do that. He has his own yaya to fix his things. - The client loved his mother more than his father. He sometimes plays with his genitals in his room with lights off. - The client has many friends of his same sex but he doesnt have problem dealing with the opposite sex. He plays basketball and goes out with his friends. - The client had his first girlfriend when he was 13 years old. He had his first sexual intercourse when he was 16 years old. He had multiple sexual partners especially when taking drugs.

18 months3 yrs. Old 3-5 yrs. Old

Anal Stage

Phallic Stage

6-11 yrs. Old

Latency Stage

12 yrs. Old and above

Genital Stage .

Theory (Theorist) Psychosocial (Erik Erikson)

Age Birth1 yr. Old

Developmental Task Trust vs. Mistrust

Patients Description - He was well taken care of by his grandmother. He was cuddled whenever possible. His grandmother would sing a lullaby for him to go to sleep. - He was raised spoiled. Most of the time his tantrums were tolerated. He is able to get all the things he wants. His grandmother is supportive to him. Sometimes he was scolded by his dad and makes him face the wall for an hour. His grandmother is okay with what he is doing while his parents are not. - The client had freedom in doing the things he wants. He doesnt do house hold chores because he has his own nanny. He received a medal back then and his parents gave him a bicycle as a reward. - The client did not excel in school as compared to his brother and sister. One time, he put thumb tacks on the teachers chair. He didnt go to his classes. Instead, he just played with his friends. He was often called in the principals office. - Out of curiosity, he tried drugs and it became his habit. He enjoyed selling it too. He feels like James Bond whenever hes on drugs. He also joined fraternity and been into fights and injuries. He goes first to his friends and use prohibited drugs whenever he has problems. - The client had four serious relationships. Others are just flings, sex trips, and casual sex. He had a child with his last girlfriend but their relationship didnt go well that much.

2-3 yrs. old

Autonomy vs. Shame and Doubt

4-5 yrs. old

Initiative vs. Guilt

6-11 yrs.ol d

Industry vs. Inferiority .

12-18 yrs. old

Identity vs. Role Confusion

19-40 yrs. old

Intimacy vs. Isolation

Theory (Theorist) Cognitive (Jean Piaget)

Age Birth2 years 2-7 yrs. old

Developmental Task Sensorimotor Stage

Preoperational Stage

7-11 yrs. old 12 and above

Concrete Stage Formal Operations Stage

Patients Description - He was taught by his mother new words for his vocabulary to increase. He was 8 months old when He said his first word: mama. - He stopped being fed with milk by the age of 5. His mother continued teaching the client different things, but sometimes the client had a hard time understanding the things that were taught to him. He learned the alphabet and counting numbers in his school. - He did poor in school because he always cut classes. He always wanted to play with his friends. - The client was the one responsible in his decisions for himself. He was able to determine what is right from wrong. Even he knew that drugs are not good, he felt that he escapes his depressions. Patients Description - Sometimes the client disobeyed his parents. He was punished whenever he does something wrong. Whenever he is wrong, his father commands him to face the wall or sometimes gives him a mild punch on his stomach. His grandmother will spank him. - The only thing that would greatly affect his actions is when other people think of him as bad person.

Theory (Theorist) Moral (Kohlberg)

Age Birth to 12 yrs. old

Developmental Task Preconventional Level (Selfinterest)

1335 yrs. old

Conventional Level (Social Approval)

Theory (Theorist) Spiritual ( James Fowler)

Age 3-7 yrs. old

Developmental Task Stage I Intuitive-Projective faith

7-12 yrs.ol d 13-20 yrs.ol d 21- 45 yrs.ol d

Stage 2 Mythic-Literal faith Stage 3 SyntheticConventional faith

Patients Description -They go to church every Sunday. He started praying when he was 4. His prayers were taught by his mother and teacher. Generally, his faith is dependent to his parents. He imitated the practice without understanding the meaning of it. - He gradually understood what he was praying for. - As he grew old, he doesnt come with his parents anymore to hear mass. Instead, he goes out with his friends. -This is the time when he was away from his family, he always prays at night. He always gives thanks and asks for forgiveness. Included in his prayers are his family and friends.

Stage 4 IndividuativeReflective faith

I. Physical Examination (December 8, 2010) Vital Signs BP = 130/90 RR = 17 cpm PR = 80 bpm T = 36.8 C

Anthropometric Measurements: Actual Weight: 66 kg Actual Height: 57 (1701.8 cm) BMI: 22. 83 Ideal body Weight: 63.58 kg

Regional Examination: A. Skin Inspection: -Skin colour is light brown -No presence of rashes or any lesions -Absence of edema -Presence of tattoos on the left arm -Presence of scars in the forehead and in deltoid area (1 cm) Palpation: -No presence of rashes or any lesions -Absence of edema -Skin is smooth and warm to touch - Skin turgor the skin springs back to previous state with score of +2 -Absence of palpable mass and nodules B. Nails Inspection:

-Clean with minimum length of nails -Nail bed colour is pink Palpation: -Smooth in texture. -Capillary refill about 2-3 seconds C. Hair Inspection: -Skinhead -Presence of body hair and evenly distributed D. Head and Face Inspection: -Normocephalic and symmetric -With symmetrical facial movements -No swelling Palpation: -Smooth skull contour -Absence of nodules and masses -No tenderness noted E. Eyes Inspection: -Symmetrical and parallel eyes. -No presence of lesions in the eyelids. -Brows are thick separated from each other -Eyelashes are curved outward and evenly distributed -Dark eye bags present -Upper and lower conjunctiva pink in colour -Sclera appears white -Cornea is transparent and appears shiny and smooth -Pupils black in colour, round, reactive to light and accommodation Palpation: -Absence of edema, masses and nodules -No tenderness noted -Visual fields: client can see objects in periphery -Extra ocular movement test: able to follow six directions of gaze -Eyes are parallel aligned -Visual acuity test: able to read newsprint

F. Ears Inspection: -Colour same as surrounding skin -Symmetrical -No abnormal discharges. -Hearing Acuity test: able to hear normal voice tone -Weber's test: air conduction is greater than bone conduction Palpation: -No tenderness noted G. Nose Inspection: -Located at the midline. -Same colour as surrounding skin -No swelling or inflammation. -No presence of exudates and mucus secretions.

Palpation: -No tenderness noted H. Mouth and Pharynx Inspection: -mucous membranes are moist -Lips light pink in colour -Absence of swelling, lesions and ulcerations -Tongue able to move freely -Incomplete set of teeth (5 false teeth in the front upper chamber) I. Neck Inspection: -Located at the midline. -Able to flex and hyper extend neck without discomfort Palpation: -No tenderness noted -No palpable lymph nodes J. Spine Inspection: -Straight -No signs of bulging or deviations. Palpation: -No presence of lumps or masses. K. Thorax and Lungs Inspection: -Does not use accessory muscle to breathe. -Normal rate and rhythm of respiration Palpation: -Symmetrical chest excursions. -No presence of abnormal masses and deformities. -Absence of tenderness over the chest wall Percussion: -Symmetrical resonant sounds heard Auscultation: -No presence of abnormal breath sounds

L. Cardiovascular/Heart Inspection: -No visible pulsation. -No exaggerated lifts and thrills in the area. -No distended and bulging veins Palpation: -No presence of lumps and masses. Auscultation: -Cardiac rate of 80 bpm with regular rhythm -Absence of heart murmurs and bruits M. Breasts Inspection: -Colour same as surrounding skin -Round shape, symmetrical and intact skin -No discharge noted -Absence of masses

Palpation: -Absence of tenderness N. Abdomen Inspection: -Uniform colour of the abdomen -Round in shape -No prominent pulsation -No presence of any distention or any bulging. -Umbilicus is located at the midline with no presence of discharges Auscultation: -Audible 5-35 bowel sounds per minute per quadrant Percussion: -Tympany over the abdomen Palpation: -Absence of tenderness O. Extremities Inspection: -Symmetrical body parts Palpation: -Firm and smooth. -No swelling or any nodules. -No muscle tenderness P. Genitals - Not Assessed Q. Rectum and Anus - Not Assessed Mental Status Examinations: General Appearance - The client is well-groomed. He is wearing clothes that are appropriate for the climate, place, and time. He is cooperative and attentive during the whole physical examination. He is in appropriate mood with eye to eye contact and good posture during the interview. II. Mood and affect -He is usually relaxed. He was able to maintain focused throughout the interview. His answers were relevant to the questions. He shows emotions (smile, laughs and serious) while talking. He has consistent mood towards her affect. III. Level of consciousness: -The client is alert, conscious and coherent IV. Speech -Patient is able to produce words clearly. The client's voice tone was loud enough to be heard. V. Thought process and perception -The client was able to sustain the whole interview. -The client does not have auditory, visual and tactile hallucinations throughout the interview. -Clients perception about the questions is congruent with his answers. -Client is able to participate in mentally requiring games/ activities.

VI. Cognitive Functions -Client is oriented with time and date -He was able to cope up with the interviewer -client was attentive and cooperative during the interview VII. Memory -Client was able to recall remote memories -Client was able to answer accurately some of the questions thrown to him. After a brief discussion, the client can summarize what the topic was about. - The client can repeat series of numbers approximately 5 numbers - The client can recall his past experiences and he can remember recent events of the day VIII. Language / Vocabulary: - The client can speak English, Japanese, Arabic, and Filipino - The clients language is congruent with what he wants to express. - The client can define a word and use it in a sentence appropriately -The client can tell similarities between an orange and an apple -The client has a good judgment IX. Sensory Perception and Coordination: a. Visual Perception: client is able to point out the object asked by the nurse b. Stereognosis: client is able to recognize the object while he was feeling it and with eyes are closed c. Graphesthesia: client outlined the shape drawn on his palm with his eyes closed d. Kinesthesia: Client is able to perceive direction of movement e. Texture discrimination: client is able to perceive roughness and smoothness of the object f. Auditory agnosia: client is able to identify sounds produced by the nurse g. cortical motor integration: client is able to perform semi-skilled task such as folding a piece of paper

B. Cranial Nerves I- Was able to identify odors while his eyes were II- Pupils reactive to light and accommodation. Pupils constrict when light passes through III, IV, VI - Able to follow the six cardinal directions of Gaze V- Corneal reflex is present and able to report pain (sensory) and able to clench teeth (motor) VII- Able to move facial muscles a. able to raise his eyebrows b. able to frown c. able close eyes tightly d. able to show his teeth e. able to smile f. able to puff out his cheeks VIII- Doesnt have difficulty in hearing words; IX, Xa. Able to say ah. b. No asymmetry on the soft palate and the posterior pharynx

c. Gag reflex is present `XI- Can resist force applied by the examiner (Shoulders) XII- Able to bring out tongue and is not deviated. X. Motor functions: - Equal muscle strength -Able to resist force applied by examiner -Able flex and extend the joints without restriction -Able to grip the examiners thumb XI. Reflexes: -In General the client has good reflexes -Biceps reflex: +2 -Triceps reflex: +2 -Brachioradialis reflex: +2 -Patellar reflex: +2 -Achilles reflex: +2 XII. Sensory motors: -Client able to report pain -Client can differentiate hot from cold -Client can respond during light touch -Client can feel vibration in the Interphalangeal Joint of the big toe -Client can move his fingers up and down -Client can identify the number drawn on his palm -Client able to discriminate one from two points in a minimal distance XIII. Cerebellar Function a. Gait -Client has a good posture and balance -swinging of the arm and movement of the legs are opposite to each other. b. Rombergs test - The client maintains an upright posture first with eyes open and with eyes closed c. Pronators Drift - Client can maintain his position well for 30 seconds with eyes closed and open d. Coordination Arms: -Client can pat his legs rapidly -Client can turn his hand over and back rapidly -Can touch each finger with his thumb rapidly -No awkwardness of the movement -Client can touch the nurses index finger to his nose alternately for about four times in different direction Legs: -Client is able to place his heel to the opposite knee down and then run down to his shin to foot. II. Personal/Social History Habits: In the ward, the client usually paces back and forth, eating, reading magazines, watching TV, smoking, etc. He also participates in the activities with the student nurses. Vices: Smoking, drinking alcoholic beverages, gambling Lifestyle: His lifestyle is somehow active due to the different activities that need to be

accomplished especially with the student nurses. Social Affiliation: None Clients usual day like: The client usually wakes up at 5 am doing their normal routine like morning care, eating breakfast, taking their medications. If there were student nurses, they would provide the residents different activities. He eats dinner at 6 pm and usually sleeps at 2 am. Rank/Order in the family: eldest son/father Travel: None Educational Attainment: College Undergraduate Occupation: Businessman III. Environmental History Before confinement the patient lives at a duplex storey house. Their house is well constructed. Services such as electricity, water supply, and regular garbage collection are present. Their house is accessible to health care facilities such as Health Centre, Hospital, and Pharmacy. Commercial Establishments is also accessible. Means of transportation such as jeepney, bus, taxi, pedicab, and tricycle are present. The client is currently staying at San Jose Home Care. The home care as observed was composed of 4 wards with bathrooms inside. In between the 2 ward is an activity area where all the residents would participate in the activities provided. The home care is surrounded by trees and plants. IV. O.B. GYNE History (Not applicable) V. Pediatric History (Not Applicable)

VII. Laboratory Tests URINALYSIS (October 6, 2010) Components Normal Values Results Interpretation Normal. Yellow is due to urochrome that is present in the urine of the patient. The color varies with the amount of urine produced and also with the concentration of the solutes in the urine. The larger the volume of urine excreted, the lighter the color. The greater the concentration of solutes, the darker the color. Abnormal, Freshly voided urine is clear and usually contains no

Color

Pale to dark yellow

Yellow

Transparency

Clear

Slightly turbid

Specific gravity

1.010-1.030

1.030

Albumin

Negative

Negative

Sugar

Negative

Negative

Pus Cells

<5 / HPF

1-2 HPF

Red Cells

0 2 / hpf

0-2 HPF

Epithelial cells

Few

Few

Mucous Threads

Few

Few

sediment. Turbidity varies as a result of the number of organisms that are present. Turbidity increases as the number of organisms increases. There is a slight turbidity indicating presence of few organisms. Normal, It depends largely on hydration status. When fluid intake decreases, specific gravity normally increases. With high fluid intake, specific gravity decreases. Normal. Inside healthy kidneys, tiny filtering units called nephrons filter out wastes but keep in large molecules, like red blood cells and albumin (protein). Some kidney diseases damage these filters so albumin and other proteins can leak into the urine. Proteinalbuminin the urine can be a sign of kidney disease. Albumin levels can increase with heavy exercise, poor blood sugar control, urinary tract infections, and other illnesses. Normal. Normally, the amount of glucose in the urine is negligible, although individuals who have ingested large amounts of sugar may show small amounts of glucose in the urine Normal. WBC in urine is most commonly neutrophils. WBC up to 5/HPF are commonly accepted as normal. Greater numbers (pyuria) generally indicate the presence of an inflammatory process somewhere along the course of the urinary tract (or urogenital tract in voided specimens). Normal, Red blood cells up to 5/HPF are commonly accepted as normal. Increased red cells in urine is termed hematuria, which can be due to hemorrhage, inflammation, necrosis, trauma, or neoplasia somewhere along the urinary tract (or urogenital tract in voided specimens Normal, Epithelial cells in urine are generally of little specific diagnostic utility. Cells lining the urinary tract at any level may slough into the urine. In the case of voided samples, even cells from the genital tract can appear in the sample. Normal, this is a common finding in urine since the entire urine system is

Urates Calcium Oxalates

Few Few

Few Few

Bacteria

None

None

filled with mucus. This is a normal finding in urine and is only significant in cases of renal stones This is a normal finding in urine and is only significant in cases of renal stones. Calcium oxalate is a salt of oxalic acid, which in excess in the urine may lead to formation of oxalate calculi. The findings of some bacteria in urine is not unusual. Significant bacteria with white cells in large numbers indicate an infection, or renal or prostae disorders.

HEMATOLOGY (October 6, 2010)

Components

Normal Values

Results

Interpretation Normal, Hgb has the unique property of combining reversibly with oxygen and is the medium by which oxygen is transported within the body. It is ironcontaining protein of RBCs. It takes up oxygen as blood passes through the lungs and releases it as blood passes through the tissues. With iron deficiency, bone marrow iron stores are rapidly decreases and the erythrocytes produced by the marrow are small and low in hemoglobin Normal, RBC is a cellular component of blood involved in the transport of oxygen and carbon dioxide. The patients RBC is below the normal range which indicates a shortage called anemia. It can result from a decreased rate of production of RBC. Normal WBC or leukocyte protects the body from invasion by bacteria and other foreign entities Normal. A neutrophil is a fully mature WBC capable of phagocytosis and essential in preventing and limiting bacterial infection High lymphocyte count or lymphocytosis is an abnormal increase in the number of lymphocytes. Common causes include viral and bacterial infections. Lymphocytosis typically causes no symptoms and is often discovered incidentally.

Hemoglobin

Female 120-160 g/L Male 140180 g/L

163

Red Blood Cell Count

4-6 x 10 12/L

5.7

White Blood Cell Count Differential Count Neutrophil

5-10 x 10 9/L

9.1

0.45-0.65

0.58

Lymphocyte

0.20-0.35

0.42

BLOOD CHEMISTRY (October 6, 2010)

Test Fasting Blood Sugar Serology VDRL (RPR)

Normal Values 4.2-6.4 mmol/L Non Reactive

Result 4.38 mmol/L Non Reactive

Interpretation Normal, It helps in measuring blood sugar levels and diagnosing diabetes. Normal, It measures substances, called antibodies, that can be produced in response to Treponema pallidum, the bacteria that causes syphilis.

X-RAY REPORT (October 6, 2010) Findings: Lung fields are clear. Heart is not enlarged. Diaphragm is intact. Impression: Essentially normal chest.

On-going Appraisal

Wednesday (November 24, 2010) 6: 00 6: 10 Introduction of Student Nurse to Patient -The patient was able to introduce himself to the student nurse appropriately. 6: 10 6: 40 Nurse Patient Interaction -This process is used to emphasize explicit, nonjudgmental interactions that permit individuals to feel a sense of security as they share their emotions. -The patient was able to interact with the student nurse. Tuesday (November 30, 2010) 3: 00 3: 20 Introduction of Student Nurse to Patient -The patient was able to introduce himself to the student nurse appropriately. 3: 20 3: 30 Exercise - Brain chemicals are being released during exercise. Serotonin, dopamine, norepinephrine, and endorphins, are known to have strong effects on mood, helping reduce feelings of anxiety, stress and depression, while also helping to strengthen your immune system. -The patient was able to perform the exercise appropriately. 3: 30 3: 40 Small Group Meeting -To know if the patient can recall remote memory and to know how they spent their free time.. -The patient was able to recall remote memory. 3: 40 4: 00 Health Teaching about Nutrition - They would be able to apply basic health practices in their everyday lives, maintain a balanced diet containing much needed nutrients by our body. -The patient was able to understand the discussion and was able to share own ideas. 4: 00 4: 20 Biblio therapy (Bugtong) -To assess if the patient can analyze and use his reasoning skills. -The patient was able to interpret given riddles. 4: 20 4: 30 Action Song (Community) -The patient was able to imitate the action song. 4: 30 4: 50 Music and Art Therapy - Music with a strong beat or a fast song can stimulate brainwaves to resonate in sync with the beat, with beats bringing sharper concentration and more alert thinking. - Music with a slower tempo promotes a calm, meditative state. - It can also be used to bring a more positive state of mind and provides emotion release. Music and Art Therapy (Fast Song) -The patient drew a picture of himself with his daughter and wife dancing. He said that the reason why he drew that picture is because he misses his daughter. Music and Art Therapy (Slow Song) - The patient drew a picture of himself and his daughter during a birthday party with a bunny rabbit as his daughters gift. He said that the reason why he drew this picture is because he wasnt able to attend his daughters first birthday so he wasnt able to give the bunny rabbit. 4: 50 5: 00 Recreational Therapy (Game - The boat is sinking) - It can also help reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. -Activities like this also help the patient to relax and feel refreshed. - The patient was willingly participated in the game. 5: 00 5: 30 Snack (Peanut Butter and sandwich with Iced Tea)

5: 30 6: 00 Nurse Patient Interaction -This process is used to emphasize explicit, nonjudgmental interactions that permit individuals to feel a sense of security as they share their emotions. -The patient was able to interact with the student nurse. Wednesday (December 1, 2010) 3: 30 3: 50 Small Group Meeting -To know if the patient can recall remote memory and to know how they spent their free time. -The patient was able to recall remote memory. 3: 50 4: 00 Exercise - Brain chemicals are being released during exercise. Serotonin, dopamine, norepinephrine, and endorphins, are known to have strong effects on mood, helping reduce feelings of anxiety, stress and depression, while also helping to strengthen your immune system. -The patient was able to perform the exercise appropriately. 4: 00 4: 20 Newspaper Discussion -It would help the client be up to date with the latest news about our country and they could give their own opinions about each article which will help them in organizing their thoughts. -The patient shared his opinions about the article (Lotto). 4: 20 4: 30 Recreational Therapy (Game - Paper Dance) - It can also help reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. -Activities like this also help the patient to relax and feel refreshed. - The patient willingly participated in the game. 4: 30 5: 30 Recreational Activity (Binggo) - It can also help reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. -Activities like this also help the patient to relax and feel refreshed. - The patient willingly participated in the game. 5: 30 6: 00 Occupational Therapy (Food making of pancake with butter) -This therapy focuses on helping patient achieve independence. It can also help improve their cognitive, physical, and motor skills and enhance their selfesteem and sense of accomplishment. - It helps patients use their creativeness and produce something tangible out of patients own thinking and imagination. - The patient was able to complete the food making activity. 6: 00 6: 30 Nurse Patient Interaction -This process is used to emphasize explicit, nonjudgmental interactions that permit individuals to feel a sense of security as they share their emotions. -The patient was able to interact with the student nurse. Monday (December 6, 2010) 3: 30 3: 45 Exercise - Brain chemicals are being released during exercise. Serotonin, dopamine, norepinephrine, and endorphins, are known to have strong effects on mood, helping reduce feelings of anxiety, stress and depression, while also helping to strengthen your immune system. -The patient was able to perform the exercise appropriately. 3: 45 4: 00 Small Group Meeting -To know if the patient can recall remote memory and to know how they

spent their free time.. -The patient was able to recall remote memory. 4: 00 4: 20 Health Teaching about Proper Hygiene - They would be able to apply basic health practices in their everyday lives, maintaining good personal hygiene to keep the body clean. -The patient was able to understand the discussion and was able to share own ideas. 4: 20 4: 30 Action Song (Christmas Song) -The patient was able to imitate the action song. 4: 30 5: 10 Recreational Therapy (Games - Pinoy Henyo) - It can also help reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. -Activities like this also help the patient to relax and feel refreshed. - The patient was willingly participated in the game. 5: 10 5: 30 Merienda (Noodles and bread with Iced Tea) 5: 30 6: 00 Nurse Patient Interaction -This process is used to emphasize explicit, nonjudgmental interactions that permit individuals to feel a sense of security as they share their emotions. -The patient was able to interact with the student nurse. 6: 00 7: 00 Interviewed the patient Tuesday (December 7, 2010) 5: 00 5: 10 Remotivational Activity (Alamat ng Rosas) - It is designed to help clients by promoting self esteem, awareness, and socialization. - It also focuses discussion on concrete things and ideas. - It accepts clients behavior, ideas and/or feelings as expressions of personal opinion. 5: 10 5: 30 Occupational Therapy (Wallet Making) -This therapy focuses on helping patients achieve independence. It can also helps improve their cognitive, physical, and motor skills and enhance their self- esteem and sense of accomplishment. - It helps patients use their creativeness and produce something tangible out of patients own thinking and imagination. -The patient was able to grasp instructions and was able to complete the activity with the assistance of the student nurse. 5: 30 6: 10 Occupational Therapy (Frame Making) -This therapy focuses on helping patients achieve independence. It can also helps improve their cognitive, physical, and motor skills and enhance their self- esteem and sense of accomplishment. - It helps patients use their creativeness and produce something tangible out of patients own thinking and imagination. -The patient was able to complete designing his personalize picture frame. 6: 10 6: 30 Snacks (Noodles and Bread with Orange Juice) Wednesday (December 8, 2010) 6:00 7:00 Interviewed the patient

Monday (December 13, 2010)

3: 30 3: 40 Small Group Meeting -To know if the patient can recall remote memory and to know how they spent their free time. -The patient was able to recall remote memory. 3: 40 4: 30 Taught the patient dance steps in preparation for their intermission number for the Christmas party. 4:30 5: 10 Recreational Activity (Binggo) - It can also help reduce depression, stress and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. -Activities like this also help the patient to relax and feel refreshed. - The patient was willingly participated in the game. 5: 10 5: 30 Merienda (Bread with peanut butter and Iced tea) 6: 00 7: 00 Interviewed the patient 7: 00 8: 00 Performed physical examination of the Neurological and Musculoskeletal System Tuesday (December 14, 2010) 9: 00 12:00 Christmas Party (Socialization) Discharge Plan M-medications -Solian 100 mg OD @ 8pm -Akineton 2mg for EPS -Nozinan 110mg HS @ 7pm E-exercise -Any form of exercise that the client wishes to perform as long as it is not contraindicated to his condition and his body can tolerate it. T-treatment -Provide social interaction programs to client. -Music therapy as this will improve interpersonal and communication skills -Psychotherapeutic Therapy H-health teachings -Instruct client to avoid food and drinks containing caffeine -Advise to continue taking prescribed medications -Encourage client to balance activity and rest -Tell relatives the side effects of the drugs and how to manage it accordingly -Provide a safe and quiet environment to the client -Consult physician if signs and symptoms persists O-OPD -Instruct client to refer to physician and psychiatrist for OPD follow-ups, especially routine check-ups. D-diet -Avoid caffeinated food and drinks -Drink at least 8 glasses of water a day -Eat foods rich in fiber -Eat foods rich in proteins and other nutrients

S-signs and symptoms Educate the family and significant others about the common signs and symptoms of depression which are as follows: -Feelings of helplessness and hopelessness. A bleak outlooknothing will ever get better and theres nothing you can do to improve your situation. -Loss of interest in daily activities. No interest in former hobbies, pastimes, social activities, or sex. Youve lost your ability to feel joy and pleasure. -Appetite or weight changes. Significant weight loss or weight gaina change of more than 5% of body weight in a month. -Sleep changes. Either insomnia, especially waking in the early hours of the morning, or oversleeping. -Irritability or restlessness. Feeling agitated, restless, or on edge. Your tolerance level is low; everything and everyone gets on your nerves. -Loss of energy. Feeling fatigued, sluggish, and physically drained. Your whole body may feel heavy, and even small tasks are exhausting or take longer to complete. -Self-loathing. Strong feelings of worthlessness or guilt. You harshly criticize yourself for perceived faults and mistakes. -Concentration problems. Trouble focusing, making decisions, or remembering things. -Unexplained aches and pains. An increase in physical complaints such as headaches, back pain, aching muscles, and stomach pain. Common sign and symptoms of depression must be dealt with accordingly, if symptoms continue consult a psychiatrist and physician.s