INFORMANTS: MSE

Orientation Phase A.General Apperance This is my 1st assessment to rosalie Working Phase A.General Apperance This is our 2nd assessment to jek-jek

> She is 24 years old and looks accordingly to her age > She still established and maintained good eye contact during our conversations > She has a mesomorphic body >She was wearing a white t-shirt, a pants and a pair > She has a fair complexion of slippers > Her lips were pinkish in color and her set of teeth >We noticed that she does her ADL properly was yellow with some tar. > Fouled odor not noted > She has a long hair >Have enough rest > She was wearing a Brown t-shirt, a blue pants and a pair of black slippers > She said that she took a bath and no unpleasant smell was noted > Her fingers and toenails were trimmed > She seems to have a good and neat appearance because of the way she carries herself > She maintains eye contact as we talk and no difficulty in speaking noted B. General Mobility B. General Mobility 1.Posture and Gait Partner jek-jek projects a semi-slouching posture. As she walks, she walks with a slow movement notice. She was able to move and does things by herself. She walks in a slow pace and careful movements. 2. Activity ( ) normoactive ( ) underactive 1.Posture and Gait Partner jek-jek projects a semi-slouching posture. As she walks, she walks with a slow movement notice. She was able to move and does things by herself. 2. Activity ( ) normoactive ( ) underactive

( ( ( ( (

) hyperactive ) agitated ) psychomotor retardation ) compulsive/ ritualistic ) stereotyping retardation

( ( ( ( (

) hyperactive ) agitated ) psychomotor retardation ) compulsive/ ritualistic ) stereotyping retardation

Our client on the first week especially on the first day was underactive. She was participative in the activities and games. She does not need assistance in performing. However still some of clients movement were delayed somtimes 3. Facial Expression jek-jek facial expressions were with congruence to her emotions or reactions. She was quite most of the times. When having our activity she participates with showed happiness on her face. When she feels happy she smiles. C. Behavior () friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive ( ) seductive ( ) indifferent ( ) withdrawn The manner of behaviour Jek-Jek has was friendly. She was friendly to the assigned student nurse and as well as to the other student nurses. D. Nurse-Patient Interaction ( ) cooperative ( ) uncooperative ( ) initially ( ) all throughout Quality: () warm ( ) distant ( ) dependent ( ) hostile ( ) suspicious ( ) talkative

Still on this phase she shows normoactive in activity. She was participative in any activities and games. She does not need assistance in performing.

3. Facial Expression jek-jek facial expressions were with congruence to her emotions or reactions. She was quite most of the times. When having our activity she participates with showed happiness on her face. When she feels happy she smiles. C. Behavior () friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive ( ) seductive ( ) indifferent ( ) withdrawn All of us student nurse notice that Jek-Jek was friendly. She smiles to a student when talked. D. Nurse-Patient Interaction () cooperative ( ) uncooperative ( ) initially ( ) all throughout Quality: ( ) warm ( ) distant ( ) dependent ( ) hostile ( ) suspicious ( ) talkative

Jek-Jek was very cooperative, well responsive and Since the orientation phase up to now, Jek-Jek very vocal. She was able to answer questions asked showed the same attitude, she was still cooperative to her. The quality of interaction that she has and the quality was very warm.

shown us was very warm. She gets to talk a lot and share her experiences whether be good or bad. I. Stream of Talk II. Stream of Talk A. Character ( ) spontaneous ( ) deliberate ( ) blocking ( ) pressured We consider the character of talk that Jek-Jek has a spontaneous and in a right pace. She talks clearly and comprehensively. Sometimes she talks fast. She was able to speak Bisaya, Tagalog and English. B. Organization of Talk ( ) relevant ( ) loose of associations ( ) tangentiality () irrelevant ( ) flight of ideas ( ) neologism () incorrect ( ) circumstantialities ( ) others A. Character () spontaneous ( ) deliberate ( ) blocking ( ) pressured We consider the character of talk that Jek-Jek has a spontaneous and in a right pace. She talks clearly and comprehensively. Sometimes she talks fast. She was able to speak Bisaya, Tagalog and English. B. Organization of Talk ( ) relevant ( ) loose of associations ( ) tangentiality ( ) irrelevant ( ) flight of ideas ( ) neologism ( ) incorrect ( ) circumstantialities ( ) others

Jek-Jek organizations of talk were irrelevant and Jek-Jek organizations of talk were relevant. She some are incorrect because she still believes in the answers most of the questions correctly and presence of her delusions. appropriately. She answers directly with no any flight of ideas or circumstantialities C. Accessibility ( ) good ( ) self- absorbed ( ) defensive () fair ( ) mute ( ) inaccessible Fair accessibility means that the client was able to be involved in a conversation whenever the student nurse initiates the conversation. It was different from good because it was still our first week of interaction with our client III. Emotional State and Reactions A.Mood () euthymic C. Accessibility ( ) good ( ) self- absorbed ( ) defensive ( ) fair ( ) mute ( ) inaccessible We could say that we were able to establish a good trusting relationship with our client. There was a good accessibility between us and Jek-Jek, especially to the assigned student nurse. She communicate very well with us III. Emotional State and Reactions A.Mood () euthymic

( ) depression ( ) euphoria Jek-Jek was euthymic in such way that when the situation calls for being active and happy, she was happy and active. She appears to have initiative and focus to the activities B. Affect ( ) appropriate () inappropriate Quality: () flat ( ) elated ( ) histrionic () blunted ( ) labile ( ) angry ( ) hostile ( ) anxious (

( ) depression ( ) euphoria Jek-Jek was euthymic in such way that when the situation calls for being active and happy, she was happy and active. She appears to have initiative and focus to the activities B. Affect

() appropriate ( ) inappropriate Quality: ( ) flat ( ) elated ( ) histrionic ( ) blunted ( ) labile ( ) angry ( ) hostile ( ) anxious others ( ) others Upon the observation of the student nurses, JekJek affect was appropriate. Her facial expressions were with congruence to her feelings and verbal cues. She shows seriousness most of the time when no one is conversing her. C. Depersonalization and Derealization ( ) present ( ) absent Our client was not detached from herself to reality. She was able to understand that she was a human being with multiple functions and feelings. She was also aware of her environment. With this we can say that depersonalization and derealisation were not present D. Suicidal Potential ( ) present ( ) absent The chart of our client says that she does not have a suicidal or homicidal potential. Jek-Jek was already excited about whats her life would be after she will be discharged

Upon the observation of the student nurses, JekJek affect was inappropriate. Her facial expressions were with flat and blunted. She shows seriousness most of the time when no one is conversing with her. C. Depersonalization and Derealization ( ) present () absent Our client was not detached from herself to reality. She was able to understand that she was a human being with multiple functions and feelings. She was also aware of her environment. With this we can say that depersonalization and derealisation were not present D. Suicidal Potential ( ) present () absent The chart of our client says that she does not have a suicidal or homicidal potential. Jek-Jek was already excited about whats her life would be after she will be discharged

IV. Thought Control A,Perception ( ) present ( ) absent There was absent of neither hallucination nor illusions. Her thoughts are relevant. Jek-Jek perceived through her senses and well interpreted by her brain. B. Delusions () present ( ) absent There were persecutory delusions noted because our client still thinks that someone is following her and would kill her. She has suspicious belief of others. C. Ideas of Reference ( ) present ( ) absent Jek-Jek does not associate herself to an external event. She knows the things or happenings that she was not involved with. D. Preoccupations and Ruminations ( ) present () absent

IV. Thought Control A,Perception ( ) present () absent There was absent of neither hallucination nor illusions. Her thoughts are relevant. Jek-Jek perceived through her senses and well interpreted by her brain. B. Delusions ( ) present ( ) absent No any type of delusions was observed. She has selfcontrol and she was oriented to reality.

C. Ideas of Reference ( ) present () absent Jek-Jek does not associate herself to an external event. She knows the things or happenings that she was not involved with. D. Preoccupations and Ruminations ( ) present () absent

There was no over centering of thought content on There was no over centering of thought content on particular ideas observed to Jek-Jek. She does not particular ideas observed to Jek-Jek. She does not repetitively say things of what was in her mind. repetitively say things of what was in her mind. Jek-Jek feels protected when she is inside the New Day Recovery Center E. Deja vu and Jamais Vu E. Deja vu and Jamais Vu ( ) present ( ) present ( ) absent () absent There was never a time in which our client shared or talked about certain events that have not yet occurred that she find familiar nor the other way around. V. Neurovegetative state Dysfunction A.Sleep ( ) normal There was never a time in which our client shared or talked about certain events that have not yet occurred that she find familiar nor the other way around. V. Neurovegetative state Dysfunction A.Sleep () normal

( ) MNA ( ) DFA ( ) hypersomia ( ) EMA () interrupted sleep

( ) MNA ( ) DFA ( ) hypersomia ( ) EMA ( ) interrupted sleep

According to Jek-Jek on the first 3 days upon In this phase our client Jek-Jek sleeping pattern being admitted to NDRC she cant sleep at night. was normal. But as days goes by Jek-Jek has a normal sleeping pattern. She sleeps more than 7 hours. B. Appetite B. Appetite Our client has a fair appetite. She cant eat well and consume her meals during the first days of admission because of her depression and the onset of her condition was still at its peak. C. Diurnal Variation Jek-Jek follows and participates on the schedule of activities that the institution provided for them. She does always her actual daily living activities. She also participates in our daily activities and program. D. Weight Jek-Jek initial weight was 46 kg. E. Libido Our client has a good appetite. She was able to consume the entire foods served every meal of the day. She can immediately finish eating her food and drink right away. She was not anorexic nor did experience volemia C. Diurnal Variation Jek-Jek follows and participates on the schedule of activities that the institution provided for them. She does always her actual daily living activities. She also participates in our daily activities and program. D. Weight The weight of our client was increase to 48 kg. E. Libido

We would consider her libido as normal. She was We would consider her libido as normal. She was not sexually preoccupied. not sexually preoccupied. VI.General Sensorium and Intellectual Status VI.General Sensorium and Intellectual Status A.Orientation A.Orientation

Jek-Jek was well oriented to time, place and Jek-Jek was well oriented to time, place and persons around her. She was oriented to every time persons around her. She was oriented to every time of the day of the day. She also asks of when will be our next visit or to what will be our therapy for the next activity. B. Memory B. Memory In terms of remote memory, Jek-Jek was able to recall certain important events from her past. She has a good memory as she was able to recall even the dates and years of her lifes happenings. She also has a good and recent memory. In terms of remote memory, Jek-Jek was able to recall certain important events from her past. She has a good memory as she was able to recall even the dates and years of her lifes happenings. She also has a good and recent memory. Before we start our

C. Attention Span Jek-Jek has a good attention span. She does not easily get bored. During our programs, she just stayed in her seat and enjoyed each of the happenings or activities. She participates very well and listens attentively. D. General Information Jek-Jek was not aware of the latest news because they cannot watch TV frequently. But we the student nurse render latest news Jek-Jek can always recall the news of what we have said. E. Abstract Thinking Ability Jek-Jek abstract thinking ability was good. When we ask her what she can say about our daily motto her answers were relevant to the motto. F. Judgement and Reasoning ( ) unimpaired () impaired

activity we always asked her of what did she do before we went to her and she answered that she ate her lunch and then sleep. C. Attention Span Jek-Jek has a good attention span. She does not easily get bored. During our programs, she just stayed in her seat and enjoyed each of the happenings or activities. She participates very well and listens attentively. D. General Information Jek-Jek was not aware of the latest news because they cannot watch TV frequently. But we the student nurse render latest news Jek-Jek can always recall the news of what we have said. E. Abstract Thinking Ability Jek-Jek abstract thinking ability was good. When we ask her what she can say about our daily motto her answers were relevant to the motto. F. Judgement and Reasoning ( ) unimpaired ( ) impaired

Her judgement and reasoning were impaired. She Her judgement and reasoning were impaired. She manifests those signs of delusions. manifests those signs of delusions. VII.Insight VII.Insight () unimpaired () impaired ( ) intellectual ( ) true Clients insight was impaired because she talks much of the delusions she experienced and she believes that her delusions really exist. VIII.Summary of MENTAL STATUS EXAMINATION A.Disturbances ( ) presentation ()stream of talk ( ) thought of control ( ) insight ( ) neurovegetative dysfunction ( ) general sensorium and intellectual status () unimpaired ( ) impaired ( ) intellectual ( ) true Clients insight was impaired because she talks much of the delusions she experienced and she believes that her delusions really exist. VIII.Summary of MENTAL STATUS EXAMINATION A.Disturbances ( ) presentation ( ) stream of talk ( ) thought of control ( ) insight ( ) neurovegetative dysfunction ( ) general sensorium and intellectual status

( ) emotional state and reaction Our client looks according to her age. She does not have any difficulty in uttering words. Her thought were relevant. She expresses her feelings and emotions in an appropriate manner. B. Diagnosis Category () functional ( ) organic ( ) psychotic ( ) non-psychotic Jek-Jek disorder is considered functional. There were no organic or anatomical abnormalities or disorder that Jek-Jek has. C. DSM IV-R Diagnosis Axis I- None Axis II- Persecutory type Axis III- None Axis IV- Psychosocial Problem Jek-Jek was lack of trust to other people due to the experienced delusions. By this our client tens to isolate herself from the society. Our client was introvert she does not express her feeling. Axis V- GAF is 92 (90-95) absent or minimal symptom (e.g mild anxiety); good functioning in all areas, interested and involved in a wide range of activities; socially effective; generally satisfied with; no more than everyday problems or concerns. She has much contact with her family.

( ) emotional state and reaction Our client looks according to her age. She does not have any difficulty in uttering words. Her thought were relevant. She expresses her feelings and emotions in an appropriate manner. B. Diagnosis Category () functional ( ) organic ( ) psychotic ( ) non-psychotic Jek-Jek disorder is considered functional. There were no organic or anatomical abnormalities or disorder that Jek-Jek has. C. DSM IV-R Diagnosis Axis I- None Axis II- Persecutory type Axis III- None Axis IV- Psychosocial Problem Jek-Jek was lack of trust to other people due to the experienced delusions. By this our client tens to isolate herself from the society. Our client was introvert she does not express her feeling. Axis V- GAF is 92 (90-95) absent or minimal symptom (e.g mild anxiety); good functioning in all areas, interested and involved in a wide range of activities; socially effective; generally satisfied with; no more than everyday problems or concerns. She has much contact with her family.