1

I. MENTAL STATUS EXAMINATION

A. GENERAL APPEARANCE
Patient X is a 21 years old that appeared older than his stated age. He was fairly
thin. He’s tall with the height of 5’6” and weighs 51 kilograms. She was
diagnosed of Bipolar, Affective Disorder, and Current Episode Manic with
Psychotic Symptoms.
On the first day, while she greeted me appropriately with a handshake, her
palm was notably cold. She nervously and sheepishly apologized for this. Patient
doesn’t wear any make ups on her face. No jaundice and no cyanosis. Good
skin turgor and warmth to touch. Her ears are well curved pinna and no
deformities or discharges. Her nose is symmetrical with no nasal discharges and
nasal septum is in midline and no nasal fissures. She doesn’t have neck vein
engorgement, no masses and no lesions noted. She has clear breath sounds as I
auscultated her back, with symmetrical chest wall expansion, no lesions or
deformities or scars, no retractions, and no lagging. Abdomen is soft, flat, non-
distended, and no tenderness. Patient’s extremity with no gross deformities, no
edema, pinkish nail bed, full and equal pulses, and with good capillary refill. She
has big scars on her left portion of her forehead because she was physically
abused by her live in partner before. She also has pockmarks all over her arms
through her hands and legs. She also has bruises in her hands due to her abusive
live in partner before. She has an intact, pale and dry skin all over of her face
and body. She always took a bath every morning. No jewelries like watch,
earrings or body piercing, and rings on her fingers. No body tattoos. Her nails
were clean and trimmed as often. She was dressed in colorful wrinkled, dirty with
food stains on it with matching brown bonnet, which made her appeared
overdressed for the intake interview, cooperative, oriented to time and place;
disoriented in person stated “Hindi ko kilala ang nanay ko at di ko alam kung
buhay o patay na siya”, have flat affect, flamboyant manner and interactive
throughout the entire interview. Her manner of speech was noted to be quite
and at times loud. Throughout the course of the interview, she tapped her
fingers on her bed, looked around the room frequently, and smiled nervously
every few seconds. Well kempt and eye contact was noted to be intense and,
at times, unwavering as she looked at me with wide eyes.
On the second day, she was pale and she had slightly fever; temp: 37.6
“nilalagnat at nilalamig ako ngayon” stated by the patient. She took a bath
early in the morning but wears the same clothes as yesterday. Her affect was
labile, but appropriate to the content of her speech; she became tearful when
she stated “Namimiss ko na yung bunso kong kapatid, mahal na mahal ko yun
kahit na minsan sinasaktan niya ako pero mahal ko yun.” Well kempt and eye
contact was noted and at times unwavering as she looked at met with wide
eyes and darting looks. She was cooperative and interactive even though she’s
not feeling well. She participated well in our activity. She danced like she had
never dance before. I also let her sing but she sang only few and became teary
eyed again because she missed her youngest brother. As she walked going to
comfort room, her walked was not normal, she walked little by little as if she’s
walking in the stairs. As she keeps on walking, she keeps on saying words that I
can barely hear even her mother. As she went back, she looked agitated and
sits on her bed and keeps on playing her fingers again. Well kempt and eye
 2

contact was noted to be intense and, at times, unwavering as she looked at me

with wide eyes.
On the last day of our duty, she was dressed in colorful and appropriately
according to weather, age, and gender and flamboyant manner; wearing a
clean jacket, clean brown bonnet, and clean pajamas with clean socks. Still
doesn’t wear any make up on her face. She has pale and dry skin all over her
face and body. She took a bath at around 12:30 in the afternoon before I
interviewed her. Still doesn’t have any jewelry on her body like, watch, earrings
or body piercing, and rings on her fingers. Well kempt and eye contact was
noted to be intense and, at times, unwavering as she looked at me with wide
eyes. She looked agitated and frequently looking down on her bed and playing
her fingers throughout the interview.

B. BEHAVIOR
Patient D was seated quietly as I interviewed her. Patient D was Hyperactive
and has mannerisms like when I asked her “Ate kamusta ka ngayon?” “Okay
lang naman po” stated by Patient D while she was busy playing with her hands.
Psychomotor activity noted like she looked agitated with hand wringing. She
was talking very that I and her mother can’t barely hear and understands what
she was saying and often with racing thoughts, feeling extremely restless and at
times impulsive, and she became easily distracted with her surroundings.
Patient D was cooperative, attentive, and sometimes aggressive throughout the
interview. Sometimes she became sad or angry. She seated quietly as I
interviewed her. Patient also has mannerisms like she keeps on playing her
fingers. Patient A noted to have tensions particularly when she is angry stated
“Ayaw ko ng sumagot sa mga tanong mo” while crying and has nothing to do
to relax her.

C. SPEECH
Patient D’s speech noted to have pressured speech because she often rapid
but constantly talking and cannot be interrupted.
Patient D was emotional and stated “Gusto ko ng mamatay. Kinukuha na ako ni
Willie” while crying and has soft low tone of voice.
Patient D speech was of normal in rate; sometimes loud in volume sometimes
soft, rhythm; sometimes monotone, dysarthria, and slurred, and spontaneity.
Speech content was fluent.
Patient D was exhibited loosening of associations and flight of ideas; she
unpredictably shifted the topic of conversation from “Kumain na ako kanina ng
kanin at gulay” shifted to “Kaaway ko silang lahat pero mahal ko pa din sila.”

D. MOOD and AFFECT

Patient D stated her mood to be “medyo depressed lang” I asked her “Ano
pong dahilan at depressed po kayo?” “meron kasing mga bumubulong sakin at
sinasabi na naghahanda na sila sa langit kasi mamamatay na ako ngayon”
stated by Patient D. Her affect was restricted to the depressed range and was
noted to be quite blunted, with very little change even while discussing
potentially happy content but when she is unable to cope with the voices; she
stays in bed, experiences abdominal pain, and feels hopeless.
 3

Patient D described her current mood as anxious on the second day as stated
“Gusto ko ng umuwi kasi baka walang nag aalaga sa anak ko at miss ko na siya
pati yung bunso kong kapatid.” Her affect was full range affect and labile
because she was giggling when there is nothing funny happening and while she
was stating that, she was crying and later on she will smile and will cry again.
Patient D described her current mood happy on the third day as stated
“Makakalabas na daw ako next week Tuesday, yeyyyy.” She hears the voices
reminding her of prior mistakes and prays that her symptoms will resolve. Her
affect was not labile and was appropriate to given context and congruent with
his stated mood.

E. THOUGHT PROCESS
Thought Content
“Ate ano pong ginagawa niyo kapag malungkot po kayo?” “Kinakausap ko
lang po yung anak ko kasi siya nagbibigay sakin ng kasiyahan kahit na andami
kong problema po” stated by Patient D.
“May winoworry po ba kayo ngayon ate? At ano po yun?” “Yun po yung mga
bumubulong sakin na buo buong ispirito” Auditory Hallucination noted and she
became easily distracted with her surroundings. She spoken randomly words
also but I can’t barely understand and it’s not clear of what she’s saying.
“Ate sa tingin mo po ba may mga tao dito na sasaktan ka?” “Wala naman po”
stated by Patient D.
Patient D exhibited loosening of associations and flight of ideas; she
unpredictably shifted the topic of conversation from “Kumain na ako kanina ng
kanin at gulay” shifted to “Kaaway ko silang lahat pero mahal ko pa din sila.”
Perseveration noted stated “May buo buo akong mga salita gaya ng den den,
joane, lizelle, at ruffa mae.”
Patient D has delusion of Grandeur. She wants to be the richest woman and
produce a helicopter. She claims to have a good handwriting that she was
awarded the best handwriting. Patient D also wants to propose her high school
teacher for marriage. Patient D claimed her uncle had a bad intention towards
her and being told that she was crazy.
Patient D’s speech flowed easily and she expressed herself clearly. She
sometimes pausedmid-sentence, appearing to be distracted by unseen stimuli,
and at times had to be refocused on the conversation.
Patient D does not have any phobia.

Thought Processes
Patient D exhibited loosening of associations; she points do not hang together
logically. Ideas shift in an apparently unrelated way and flight of ideas; she goes
from one thought to another in logical sequence but is headed far from the
original topic. She unpredictably shifted the topic of conversation from “Kumain
na ako kanina ng kanin at gulay” shifted to “Kaaway ko silang lahat pero mahal
ko pa din sila.”
Patient D was spontaneous it means I do not have to keep asking questions.
Patient D readily volunteers information.
Patient D was Goal Directed, she answers the main questions about why she
came and what she needs, and does not stray to other related topics by asking
 4

“Ate ano pong dahilan at andito po kayo?” “May mga nakakausap po kasi
akong hindi niyo po nakikita at may mga bumubulong po sakin. Dahil na rin po
sa trauma na naranasan ko sa dati kong kinakasama dahil po binubugbog po
niya ako dati po kaya po dinala po nila ako dito sa BGH para po mapagamot
po ako” stated by Patient D.
Patient D noted Blocking because she stops, pauses, and starts somewhere else
when asking a question “Sino sino po kayo sa bahay niyo ate?” “Mama ko, ako,
at yung mga kapatid ko at…” patient stops and there was an interruption to the
normal flow of speech. Patient D may appear to forget where she was in the
conversation when she resumes talking.
Patient D noted to have Perseveration. She goes over and over the same point
or idea stated “May buo buo akong mga salita gaya ng den den, joane, lizelle,
at ruffa mae.”

Orientation
She was oriented to time by asking her “Anong oras na po ngayon ate?” “1:25
ng hapon po” stated by Patient D while looking to my watch. Patient D was
oriented to place by asking her “Alam mo po ba ate kung nasan ka ngayon?”
“Opo, dito po sa BGH nag papagamot po sa sakit ko” stated by Patient D. She
was also oriented to place by asking her “Anong bwan at taon po ngayon
ate?” “October po at 2019 po” stated by Patient D; Disoriented in person stated
“Hindi ko kilala ang nanay ko at di ko alam kung buhay o patay na siya”.
On the second day Patient D was lethargic and has trouble remaining alert and
appears to want to drift off to sleep, but can be aroused. Patient D has trouble
concentrating on the interview and seems unable to maintain a coherent train
of thought. Obtundation noted Patient D was difficult to arouse and needs
constant stimulation to stay awake. Patient D may seem confused and unable
to participate in the interview by asking her “Ate, anong makwekwento mo
ngayon?” Patient D was staring at the interviewer with darting looks.

Memory
Both long – term and short – term memories are assessed.
I assessed her long – term memory by asking “Ate, alam niyo pa po ba yung
pangalan ng school niyo noon elementary pa po kayo?” “Opo, sa Cabuyao,
Elementary School po sa Bolinao po” stated by Patient D.
I assessed also her short – term memory by asking “Ate, ano pong kinain niyo
kaninang umaga?” “Kanin po na may noodles po” stated by Patient D. “Ate,
anong ginawa niyo kahapon?” “Wala po, nakahiga lang po ako kahapon”
stated by Patient D.

General Intellectual Level

Patient D has basic knowledge and was aware of social events by asking “Ate,
sino yung Presidente ng Pilipinas?” “Si President Rodrigo Duterte po” stated by
Patient D. “Anong Capital ng Pilipinas ate?” “Manila po”

Concentration
Patient D achieved a 12/15 on the mini-mental status exam, which she missed
one point for recall of one of the five objects which is glass; pen, ruler, paper,
 5

toothbrush, glass and one point for repetition of numbers which is 15; 5, 20, 15,
10, 0 and one point for spelling of words which is high school; apple, dog, cat,
bird, high school. Patient D was attentive and concentrated throughout the
interview.

Ability to Abstract and Generalize

I asked her to tell how two objects are different or alike. I named two items and I
asked her how these differ and how they are similar by giving examples like
APPLE and ORANGES, TREES and FLOWERS, HOUSES and CARS, DOGS and CATS.
Patient D can easily differentiate it by stating “Apple at Orange ay parehas po
na prutas pero ang apple po ay kulay red at ang orange po and kulay
orange.” “Yung Trees at flowers naman po ay parehas po silang plants pero
yung puno po ay naaakyat at yung flower naman po hindi.” “Yung House at
Cars naman po ay parehas po silang mga bagay po pero yung bahay po
tinitirahan po ng tao at may mga kwarto po di po gaya ng sasakyan ginagamit
lang po sa pag byahe.” “Yung Cats and dog’s naman po parehas po silang
mga hayop po pero yung cats po nag mmeow at yung aso naman po ay
tumatahol.”

Suicidal Ideation
“Gusto ko ng mamatay. May bumubulong sakin na naghahanda daw si James
sa langit at nag – aalay sila ng alak para sa pag akyat ko sa langit ngayon po.”
Patient D has auditory hallucinations.

F. INSIGHT
Overall, this client appeared forthright and reliable. She was open about her
condition and expressed interest in obtaining help.
Patient D was aware and understands her illness and need for treatment by
asking “Ate ano pong dahilan at andito po kayo?” “May mga nakakausap po
kasi akong hindi niyo po nakikita at may mga bumubulong po sakin. Dahil na rin
po sa trauma na naranasan ko sa dati kong kinakasama dahil po binubugbog
po niya ako dati po kaya po dinala po nila ako dito sa BGH para po
mapagamot po ako” stated by Patient D.

G. JUDGEMENT
Patient D’s judgment was poor, as she wants to kill herself and was acting on a
delusional pretext.
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I. NURSE – PATIENT INTERACTION

DAY 1

NURSE CLIENT THERAPEUTIC ANALYSIS

COMMUNICATI
ON

Greeting the client by name,

“Good - Smile indicating awareness of change,
Afternoon - Stares or nothing effort the client has
Giving made all show that the nurse
po Ate” - Distant Information
- Slouch recognizes the client as a
person, as an individual.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
 7

“Andito Greeting the client by name,

po ako - Stares indicating awareness of change,
ngayon, - With or nothing effort the client has
bukas at Giving made all show that the nurse
darting Information
hanggan looks recognizes the client as a
g Sabado - Distant person, as an individual.
para po - Slouch (Reference: Videbeck.
makipagk Psychiatric Mental Health
wentuhan Nursing. P 112)
sa inyo.”

“Wala po.” Broad openings make explicit

“May Broad openings that the client has the lead in
gusto po the interaction.
- Poor Eye
ba Contact (Reference: Videbeck.
kayong - Sigh Psychiatric Mental Health
pag- - Soft tone Nursing. P 112)
usapan?” of voice
- Distant
- Slouch

When client deal with topics

superficially, exploring can help
them examine the issue more
“Ilang “22 po” Exploring fully. Any problem or concern
taon na can be better understood if
po kayo?” explored in depth. If the client
- Poor eye
contact expresses an unwillingness to
- Distant explore a subject, however, the
- Slouch nurse must respect his or her
wishes.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“November The nurse encourages the client

“Kailan po po.” to concentrate his or her
kayo energies on a single point, which
Focusing may prevent a multitude of
ipinangan - Soft tone
ak?” factors or problems from
of voice overwhelming the client. It is
- Slouch also a useful technique when a
- Poor Eye client jumps from one topic to
Contact another.
- Distant
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
 8

“Opo.” Indicates nurse is listening and

“Novemb - Low Voice Restating validates, reinforces, or highlights
er po, - Distant something patient has said.
tama po - Poor Eye (Reference: Videbeck.
ba?” Contact Psychiatric Mental Health
Nursing. P 112)

General leads indicate that the

“Tapos nurse is listening and following
po?” what the client is saying without
- Stares with General leads taking away the initiative for the
eye interaction. They also
- Trying contact encourage the client to
to get - Slouch continue if he or she is hesitant or
closer uncomfortable about the topic.
to her (Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

When client deal with topics

“Cabuyao po superficially, exploring can help
sa Bolinao them examine the issue more
“San po Exploring fully. Any problem or concern
kayo Pangasinan
po.” can be better understood if
nakatira explored in depth. If the client
ate?” expresses an unwillingness to
- Soft tone explore a subject, however, the
of voice nurse must respect his or her
- Distant wishes.
- Slouch (Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Ahh sa “Oho.” Indicates nurse is listening and

Bolinao Restating validates, reinforces, or highlights
po.” something patient has said.
- Darting
looks (Reference: Videbeck.
- Noddin - Slouch Psychiatric Mental Health
g - Loud tone Nursing. P 112)
of voice
 9

The nurse encourages the client

“Sino po “Mama ko at Focusing to concentrate his or her
ang yung mga energies on a single point, which
kasama kapatid ko may prevent a multitude of
niyo pati yung factors or problems from
doon?” anak ko.” overwhelming the client. It is
also a useful technique when a
client jumps from one topic to
- Good eye another.
contact (Reference: Videbeck.
- Slouch Psychiatric Mental Health
Nursing. P 112)

“Ang alam ko When client deal with topics

“Ilan po 10 pero yung superficially, exploring can help
ba kayo iba bumibisita them examine the issue more
lang.” Exploring fully. Any problem or concern
sa bahay
niyo can be better understood if
doon?” explored in depth. If the client
- Soft tone expresses an unwillingness to
of voice explore a subject, however, the
- Good eye nurse must respect his or her
contact wishes.
- SLouch
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Mga kapatid Thought blocking: stopping

“Sinu-sino ko, yung Exploring abruptly in the middle of a
po?” matanda…” sentence or train of thought;
- Stop to sometimes unable to continue
answer the idea
- Eye-Rolling (Reference: Videbeck.
- Slouch Psychiatric Mental Health
Nursing. P 162)

“Nabang General leads indicate that the

git niyo po Stares for a nurse is listening and following
mga while. “anak what the client is saying without
kapatid General Lead taking away the initiative for the
ko”
niyo at interaction. They also
yung encourage the client to
matanda - Soft tone continue if he or she is hesitant or
at sino po of voice uncomfortable about the topic.
yung isa?” - Slouch (Reference: Videbeck.
- Distant Psychiatric Mental Health
Nursing. P 112)
 10

For verbal communication to be

“Anak “Opo.” Consensual meaningful, it is essential that the
niyo po?” Validation words being used have the
same meaning for both (all)
- Teary Eyes participants.
- Slouch (Reference: Videbeck.
- Poor eye Psychiatric Mental Health
contact Nursing. P 112)

“Sino po Help to clarify patient’s feelings;

ulit, - Stares Clarification ideas; and perceptions; provides
kapatid - Darting explicit correlation to patient’s
mo po, looks actions
yung - Slouch (Reference: Videbeck.
matanda, - Distant Psychiatric Mental Health
ikaw at? Nursing. P 112)

Silence often encourages the

“Sige po. - Stares client to verbalize, provided that
Hindi ko - Eye-Rolling it is interested and expectant.
Silence Silence gives the client time to
na po - Darting
ipipilit Looks organize thoughts, direct the
kung sino - Distant topic of interaction, or focus on
yun.” - Slouch issues that are most important.

Silence Much nonverbal behavior takes

place during silence, and the
nurse needs to be aware of the
client and his or her own
nonverbal behavior.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Wala
“May naman, kasi The nurse asks the client to
mga wala naman consider people and events in
dito yung Encouraging
ginagawa comparison light of his or her own values.
po ba anak ko po.” Doing so encourages the client
kayo sa to make his or her own appraisal
Bolinao na - Teary Eye rather than to accept the
ginagawa - Soft tone opinion of others.
niyo rin of voice
dito.” - Distant
- Slouch
 11

“Napapa
nsin ko
lang po
palagi po Looks at her Making Client cannot verbalize or make
ninyong fingers while Observation them understood.
nilalaro scratching
yung daliri (Reference: Videbeck.
niyo.” Psychiatric Mental Health
Nursing. P 112)
Observed
the
patient
scratching
her fingers

Broad openings make explicit

“May “Wala naman Broad Opening that the client has the lead in
ikukuwent po.” the interaction. For the client
o po ba who is hesitant about talking,
kayo sa broad openings may stimulate
akin?” - Distant him or her to take the initiative.
- Slouch (Reference: Videbeck.
- Soft tone Psychiatric Mental Health
of voice Nursing. P 112)

When client deal with topics

“Wala po superficially, exploring can help
akong them examine the issue more
“Ano Exploring fully. Any problem or concern
pong ginawa
kanina po.” can be better understood if
ginawa explored in depth. If the client
niyo expresses an unwillingness to
kanina?” - Soft tone explore a subject, however, the
of voice nurse must respect his or her
- Distant wishes.
- Slouch (Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
 12

“Makipag When client deal with topics

“Ano usap po.” Exploring superficially, exploring can help
pong them examine the issue more
nagustuh fully. Any problem or concern
- Good eye can be better understood if
an niyong contact
ginawa explored in depth. If the client
- Slouch expresses an unwillingness to
natin - Distant
ngayong explore a subject, however, the
araw nurse must respect his or her
ate?” wishes.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
“Hanggan
g dito
nalang po
ang ating It’s frequently useful for nurses to
usapan. “Sige po Termination / summarize what patients have
Bukas po maraming Summarizing said after the fact. This
sana mag salamat din demonstrates to patients that
usap po po” the nurse was listening and
tayo. allows the nurse to document
Sumali po conversations.
kayo sa
mga (Reference:
activities https://www.scribd.com)
natin
bukas po.
Maraming
salamat
po”

DAY 2

NURSE CLIENT THERAPEUTIC ANALYSIS

COMMUNICATI
ON

“Good
“Good Afternoon din Introduction / Recognition acknowledges a
Afternoon po.” Giving patient’s behavior and highlights
Ate.” Recognition it without giving an overt
- Sits compliment.

Smiled properly
and - Hand (Reference:
establishe shake https://www.scribd.com)
d eye - Smiles
contact - Good eye
 13

contact

“Anong “Nilalagnat at Expression of feelings and

nararamd nilalamig ako Encouraging encourages the client to make
aman mo ngayon.” expression his or her own appraisal rather
ngayon than to accept the opinion of
ate?” others.
- Soft tone
of voice (Reference: Videbeck.
- Good eye Psychiatric Mental Health
contact Nursing. P 112)

General leads indicate that the

“Uminom “Di po.” General Lead nurse is listening and following
po ba what the client is saying without
kayo ng taking away the initiative for the
gamot?” - Soft tone interaction. They also
of voice encourage the client to
- Good eye continue if he or she is hesitant or
contact uncomfortable about the topic.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Opo.” Indicates nurse is listening and

“Hindi Restating validates, reinforces, or highlights
po?” something patient has said.
- Darting
looks (Reference: Videbeck.
- Minimal Psychiatric Mental Health
tone of Nursing. P 112)
voice

“Ano po “Wala, pero Encouraging To understand the client, the

palang ako po yung description of nurse must see things from his or
trabaho naglalaba ng perception her perspective. Encouraging
niyo sa mga damit the client to describe ideas fully
Bolinao?” namin at ako may relieve the tension the client
yung nag- is feeling and he or she might be
aalaga nung less likely to take action on ideas
 14

anak ko. that are harmful or frightening.

Tapos (Reference: Videbeck.
tumutulong sa Psychiatric Mental Health
pag aararo.” Nursing. P 112)

- Teary eyes
- Soft tone
of voice
- Good eye
contact

“Nabang “Palay po.” Encouraging Encouraging the client to

git niyo po description of describe ideas fully may relieve
yung pag perception the tension the client is feeling
aararo. - Soft tone and he or she might be less likely
Ano po of voice to take action on ideas that are
ang - Looking at harmful or frightening.
inaararo the floor
(Reference: Videbeck.
niyo po?” Psychiatric Mental Health
Nursing. P 112)

“Para po may The nurse encourages the client

“Ano po makain po Focusing to concentrate his or her
ang kami.” energies on a single point, which
naitutulon may prevent a multitude of
g sa inyo factors or problems from
- Soft tone overwhelming the client. It is
ng pag- of voice
aararo?” also a useful technique when a
- Keeps client jumps from one topic to
looking at another.
the floor
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Ano “Masaya po.” The nurse asks the client to

pong Encouraging consider people and events in
nararamd expression light of his or her own values.
aman - Minimal Doing so encourages the client
niyo nung tone of to make his or her own appraisal
nabanggit voice rather than to accept the
niyo ang - Good eye opinion of others.
pag- contact
(Reference: Videbeck.
aararo?” Psychiatric Mental Health
Nursing. P 112)

“Ay oo “Opo sasali Encouraging Encouraging the client to

nga pala, po ako description of describe ideas fully may relieve
sasayaw mamaya.” perceptions the tension the client is feeling
tayo and he or she might be less likely
 15

mamaya. to take action on ideas that are

Maari mo - Good Eye harmful or frightening.
bang contact (Reference: Videbeck.
ibahagi - Smiles Psychiatric Mental Health
ang iyong Nursing. P 112)
talent sa
pagsasay
aw ate?”

“Ahh. - Silence Accepting An accepting response indicates

Okay po - Looking at the nurse has heard and
ate.” the floor followed the train of thought. It
does not indicate agreement
but is nonjudgmental.
Nodding
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

DAY 3

“Magandang Greeting the client by

“Good Hapon.” Giving Information name, indicating
Afternoon awareness of change, or
Po” nothing effort the client
- Smiles has made all show that
- Hand shakes the nurse recognizes the
- Good eye client as a person, as an
contact individual.
- Sits properly
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Kamusta “Okay naman Encouraging Expression of feelings and

ka po ako.” expression encourages the client to
ngayon make his or her own
ate?” appraisal rather than to
- Smiles accept the opinion of
- Good eye others.
contact
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
 16

“May “Wala po.” Broad openings make

ikukuwent Broad Opening explicit that the client has
o po ba the lead in the interaction.
kayo sa - Good eye For the client who is
akin?” contact hesitant about talking,
- Sits properly broad openings may
- stimulate him or her to
take the initiative.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

When client deal with

“Ano topics superficially,
pong exploring can help them
“Exercise.” Exploring examine the issue more
ginawa
niyo fully. Any problem or
kanina?” - Smiles concern can be better
- Good eye understood if explored in
contact depth. If the client
- Sits properly expresses an unwillingness
to explore a subject,
however, the nurse must
respect his or her wishes.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

“Ano “Okay naman Encouraging The nurse asks the client to

pong po, masaya.” Expression consider people and
naramda events in light of his or her
man niyo own values. Doing so
nung nag- - Smiles encourages the client to
exercise - Good eye make his or her own
tayo?” contact appraisal rather than to
- Sits properly accept the opinion of
others.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
 17

“Pagkata “Wala na po.” Putting e vents in proper

pos po ng Placing event in time sequence helps both the
exercise, or sequence nurse and client to see
ano po - Good eye them in perspective
yung next contact
- Sits properly (Reference: Videbeck.
na Psychiatric Mental Health
ginawa - Minimal
tone of Nursing. P 112)
natin?”
voice

“Ganun - Stares Clarification Help to clarify patient’s

po ba - Smiles feelings; ideas; and
ate?” - Sits properly perceptions
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)

When client deal with

“Ano pa “Nag-usap topics superficially,
pong lang po. Tapos exploring can help them
Exploring examine the issue more
nagustuh kinain yung
an niyong binigay niyo fully. Any problem or
ginawa sakin.” concern can be better
natin understood if explored in
ngayong depth. If the client
araw?” - Smiles expresses an unwillingness
- Soft tone of to explore a subject,
voice however, the nurse must
- Sits properly respect his or her wishes.
- Good eye (Reference: Videbeck.
contact Psychiatric Mental Health
Nursing. P 112)
“Oo naman po. Expression of feelings
“Kumain? Masarap po.” encourages the client to
Masarap make his or her own
Encouraging appraisal rather than to
po ba - Smiles expression
ate?” accept the opinion of
- Sits properly others.
- Soft tone of
voice (Reference: Videbeck.
- Good eye Psychiatric Mental Health
contact Nursing. P 112)
 18

“Yung binigay The nurse encourages the

niyo po sakin client to concentrate his
na fudge bar or her energies on a single
“Ano po tapos yung Focusing point, which may prevent
bang tatlong orange a multitude of factors or
kinain na binigay ng problems from
niyo?” kasama niyo overwhelming the client.
po.” It is also a useful technique
when a client jumps from
one topic to another.
- Smiles
- Sits properly (Reference: Videbeck.
- Good eye Psychiatric Mental Health
contact Nursing. P 112)
When client deal with
“Maasim yung topics superficially,
orange pero exploring can help them
“Ano Exploring examine the issue more
pong masarap po.”
fully. Any problem or
lasa?” concern can be better
- Laughs understood if explored in
- Good eye depth. If the client
contact expresses an unwillingness
- Sits properly to explore a subject,
however, the nurse must
respect his or her wishes.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
An accepting response
“Ahhhh” - Smiles Accepting indicates the nurse has
- Good eye heard and followed the
contact train of thought. It does
Nodding - Sits properly not indicate agreement
but is nonjudgmental.
(Reference: Videbeck.
Psychiatric Mental Health
Nursing. P 112)
“May iba “Wala na po.” Asking for patient to
pa po ba Encouraging describe feelings,
kayong Description of perceptions, and views of
gusting - Moderate their situations. To
eye contact Perception
sabihin?” understand the client, the
- Good and nurse must see things from
open her perspective.
- Moder posture
ate - In face to
eye face (Reference: Videbeck.
contac position to Psychiatric Mental Health
t the nurse Nursing. P 112)
- Good - Smiles
 19

and
open
posture
- In face
to face
positio
n to
the
client
“Kung “Merry Giving recognition It shows that the nurse
ganun po, Christmas din. recognizes the client as a
maraming Salamat sayo person, an individual that
salamat Jenny at sa gives the client fulfillment
po ate sa mga kaklase of her worthiness.
tiwala mo. Mag ingat
pong rin kayo. Bye.”
ibinigay (Reference: Videbeck.
ninyo sa Psychiatric Mental Health
akin, sa - Moderate Nursing. P 112)
cooperati eye contact
on at sa - Good and
maganda open
po posture
ninyong - In face to
pagtangg face
ap. Merry position to
Christmas. the nurse
Good bye - Smiles
po. Ingat Waves
po kayo
parati.”

- Moder
ate
eye
contac
t
- Good
and
open
posture
- In face
to face
positio
n to
the
client
- Smile
Waves

I. Evaluation:
 20

In this process recording that I conveyed to Patient D, I have used many

therapeutic techniques to the patient mostly focusing, exploring, restating, and
validating. This techniques aid Patient D to respond normally to the questions
that I have asked to her. Not only I have established rapport to Patient D, I also
get the chance to know the feelings of Patient D as well as his mental status
during the interview.

However there is still lack of sharing of information from Patient D since she
responds shortly to the questions. Patient D still have the hesitation to share to
me her feelings that will decrease her anxiety.

II. Goals and Objectives:

In line with the evaluation above, the goal for the communication growth of this
nurse – patient interaction is that after 1 hour of nursing intervention, Patient D
will be able to increase the level of trust and self-confidence in conveying the
information.

Objectives:

After 1 hour of nurse – patient interaction, Patient D will be able to:

 Report her reasons of depression and anxiety

 Describe her plan of action in decreasing her level of anxiety
 Report her feeling of self-worth and satisfaction in life
After 1 hour of nurse – patient interaction, I, the student nurse will be able to:

 Jot down the additional recording of Patient D’s feelings

 Demonstrate additional therapeutic communication techniques

Sources:
Patient’s Chart
(Reference: Videbeck. Psychiatric Mental Health Nursing. P 112)
https://med.unr.edu/psychiatry/education/resources/mental-status-
examination
Kaplan and Saddock’s Synopsis of Psychiatry 10th Edition Chapter 7 – Clinical
Examination of the Psychiatric Patient