PATIENTS INFORMATION AND CLINICAL DIAGNOSIS NAME AGE : : Patient A

40 years old February 5, 2010 : Undifferentiated Schizophrenia

DATE ADMITTED: DIAGNOSIS

OTHER NON-PSYCHOLOGICAL BACKGROUND

HISTORY OF ILLNESS: Essential Hypertension Vulvovaginitis

MEDICATIONS CURRENTLY TAKING: Risperidone 2 mg HS Multivitamins 1 tab OD Gliclazide 30 mg OD

SPECIAL CARE RENDERED BP Monitoring every shift Low Salt, Low Fat Diet Monthly Weight Monitoring

PRE-ORIENTATION PHASE OBJECTIVES AND GOALS: OBJECTIVES AND GOALS:

To develop self-awareness intrapersonally and among the health team members for more efficient mental health service. To have a definite background regarding the patients pertinent information, presenting signs and symptoms and clinical diagnosis by chart reading and history taking. To establish the proper therapeutic techniques, for excellent utilization, in compliment with the patients clinical diagnosis and thought patterns.

SETTING SELF-AWARENESS: Before indulging into the proper interaction, our first obligation as a nurse is to look back on ourselves and have the ability to experience genuine feelings. Regarding this, we have conducted a self-awareness activity with the group and in conclusion, everything went well and everyone is prepared enough to engage in the process.

CHART READING: All pertinent data, medical and psychological background, presenting symptoms and other vital information have been acquired and taken note of. Special care rendered was also been taken in consideration of. Proper communication techniques and behavior therapy have been established and planned for execution.

ORIENTATION PHASE OBJECTIVES AND GOALS OBJECTIVES AND GOALS:

To establish rapport with the client. To execute initial plan of action. To introduce self, inform contract and to utilize all the techniques and principles necessary for the benefit of the patient.

SETTING

Received a 40 year-old female wearing hospital uniform, fairly groomed, bathe, but with unfixed hair maybe due to thickness and length. Smiles at the moment she sat in front of me. Showed interest during the first engagement. Mumbles some times. Relevant to queries but with tendency to become irrelevant. Patient shows cooperation, willingness to listen and ventilate but have limited insight. She believes that she is getting smaller day after day and believes that she was admitted because of this delusion. Therapeutic communication tecniques were used to facilitate conversation.