The document provides background information on a 55-year-old female patient named Carmencita and objectives for her treatment which include helping her distinguish reality from delusions. It then describes interactions between the nurse and patient where the patient describes delusional thoughts about insects in her skin and people searching for her. The nurse uses reflective listening and questions to understand the patient's perceptions while reassuring her and keeping her focused on reality.
The document provides background information on a 55-year-old female patient named Carmencita and objectives for her treatment which include helping her distinguish reality from delusions. It then describes interactions between the nurse and patient where the patient describes delusional thoughts about insects in her skin and people searching for her. The nurse uses reflective listening and questions to understand the patient's perceptions while reassuring her and keeping her focused on reality.
The document provides background information on a 55-year-old female patient named Carmencita and objectives for her treatment which include helping her distinguish reality from delusions. It then describes interactions between the nurse and patient where the patient describes delusional thoughts about insects in her skin and people searching for her. The nurse uses reflective listening and questions to understand the patient's perceptions while reassuring her and keeping her focused on reality.
The document provides background information on a 55-year-old female patient named Carmencita and objectives for her treatment which include helping her distinguish reality from delusions. It then describes interactions between the nurse and patient where the patient describes delusional thoughts about insects in her skin and people searching for her. The nurse uses reflective listening and questions to understand the patient's perceptions while reassuring her and keeping her focused on reality.
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Leslie Loredo BN3A
NURSE PATIENT INTERACTION
I. Background Information
A. Name: Carmencita
B. Sex: Female
C. Age: 55
D. Civil Status: Divorced
E. Educational Attainment: College Graduate, BS in Secondary Education
F. Occupation: None
G. Religion: Roman Catholic
H. Address: Brgy. Granada, Bacolod City
II. Objectives
A. General Objectives (Long Term – duration of the exposure)
Patient-centered 1. The patient will be able to function and perform ADL’s without being distracted by any persistent delusional thoughts Nurse-centered 1. The student nurse will be able to provide interventions that will enable patient to perceive reality and delusional thoughts
B. Specific Objectives (Short Term – daily)
Patient-centered: 1. The patient will be able to recognize the environment correctly
2. The patient will be able to verbalize thoughts and feelings without
having any delusions for at least 5 minutes Nurse-centered 1. The nurse will be able to establish trust and rapport with the patient
2. The nurse will be able to recognize and empathize with the feelings of the patient III. Actual Entry
(Pre-orientation and Orientation Phase) “Hi ma’am, mayong “Mayong aga” Giving recognition - Patient nods his head aga” shows courtesy and respect to patient as a fellow human being.
“Updan ta lang ka di “geh” Offering self – lets the Patient’s facial
expression is neutral pungko ma’am ah.” patient know that you are there while she is buying time to interact
“.....” “Maano kamo d sbong Silence - allows patient to Patient looks calm nurse haw?” think. Also, the attitude therapy of passive friendliness should be applied since the patient is paranoid therefore, wait for the patient to approach you before starting the interaction. Patient looks around and avoids eye “Ma’am ako gali si “Ah cge, Ako si Giving information – contact while talking Leslie, student nurse Carmencita” allows patient to be aware mo sbong. Bale ma of the purpose of istorya lang ko sa imo interaction and to provide ma’am ah. information to make better Mamangkot lang sa choices imo ginabatyag kag kung kamusta ka na.”
(Working Phase) The patient is talking calmly “Kamusta man gali “Subong okay, okay Giving broad openings - ang ginabatyag mo man ah. Gaabot abot allow patient to take ma’am? “ lang galing nga initiative in introducing the mabatyagan ko nga topic gagululuwa naman ang mga sapat sakon panit”
The patient shows her
“Tuod tuod gid sa ya arms while she is talking “Indi gid ko ya kapati nurse. Katol katol pa Voicing doubt – to help nga may gaguluwa nga na kung mag gwa na patient recognize if she is mga insekto sa imo sila. Tan awa bala ho, thinking based on reality or nga panit ma’am.” ang ulo sang isa daw she is having delusional maulhot na.” thoughts The patient looks anxious and sounds “Ay gali ka ma’am. “ Kalain lain gid ya sa helpless Kabudlay gid guru sa pamatyagan nurse. Encouraging description imo nga amo na Kung sa iban gani, of perceptions - to achieve gakabatyagan mo makakita lng tanga, relevance and depth in ma’am no?” grabe na ang kulba, discussion ano nalng ko ya nga ga inulhot nlng sila kag naga gwa sa lawas ko. Nadamakan ko pero wala ko mahimo kay ara nagid sila ya sa Patient is looking at sulod ka lawas ko” the floor while talking
“Makainchindi gd ko “Mayo man kay may
sang imo ginabatyag nakainchindi sa akon. Empathy – recognizing ma’am” Abi ko gani daw patient’s feelings lessens buang nako d nga anxiety gapanumdom kag Patient said in a low makakita sang indi voice as she puts her amo “ index finger on her lips “... ma’am pwede mo “Ari di sa hospital eh. ya mahambal sa akon Pero hipos lang, indi Asking question - to have kung diin kita sbong?” mag gahod kay may an in depth discussion to nagapangita sa akon. the patient’s situation Halin pa ni sila sa balay, nagasulod gid sila ya. Patyon ko knu nila, kami sang akon Patient said using a bata. Nakulbaan gid ko loud voice in a gani. Indi mo pagsugid panicky manner nga ari ko d ha” “Sin o man ni sila nga mga tawo nga “Indi nurse. Indi ko nagapangita sa imo gid ni sila kilala. Exploring – to delve ma’am? Kilala mo Nakibot lang man ko further into the idea man sila? Pwede mo gani pagbigtaw ko maistorya sa akon?” sang annligad, nagsulod na sila sa balay kag ginapangita Patient calmed down ko nila! Waay ko ya sala nga nahimo sa bisan sin o!” “Indi magkakulba ma’am, wala d sang “Hay ambot lang may masakit sa imo. nurse. Indi ko gd ya Giving information – to Ari kita sa lugar kung mapunggan nga mag allow patient to be at ease sa diin safe ka gd. panic.” with the knowledge that she Wala sang tawo nga is in a safe place Patient said in despair magsulod di nga indi kilala ka pasyente kag sang staffs.”
“Ma’am balik ta sa ginabatyag mo. Kung “Huo eh. Mas mayo mag-abot namn b nga nalng nga mapatay ko Focusing– pursuing to the mag gululuwa namn kaysa ma topic until the thought is ang mga insecto nga experiensyahan ko ni clear hambal mo sa imo adlaw adlaw. Tan awa panit, may gasulod bala panit ko ho. man sa paminsaron mo Sunog na tungod kay nga tapuson nalng ang ginabanyusan ko mga kabuhi mo?” bulong para Patient is anxious and resentful magkalamatay ang mga sapat, pero wala gd ya. Mas mayo guru nga ako nalng mapatay para maglinong man “Mas mayo nalng nga ko.” Patient has a neutral mapatay ka para expression. makabatyag ka “Huo eh, ano pa ang linong? Amo na pulos mabuhi kung Reflecting – to allow hambal mo ma’am?” sagay man lng ko patient to identify feelings pasakit sa kondisyon and thoughts “Makainchindi gd ko ko sbong.” sang imo ginabtyag ma’am. Akig sa imo “Pabay e da ah, waay sitwasyon subong kag naman gd ko sang Empathy – to acknowledge nasubuan ka kay waay mahimo. Indi ko na ni the feelings of the patient ka sang may mahimo” palibugan. Tigulang Patient nods her head naman ko. and waves her hand Daw kanami ka landong sang puno sa gwa, malakat ko to (Termination Phase) nurse.”
“Cge ma’am, salamat
gd sang imo oras para mag istorya sa akon. “sige nurse, salamat Kung kinanglan mo man.” Giving information – to sang maistorya, provide patient information mintras ari pa kami d for better options and nga student nurse, decisions hambala lang ko ma’am kay mamati gd ko sa imo.”
IV. Evaluation: (For daily requirement, evaluate specific objectives only)
Patient-centered: 1. The patient was able to recognize the place and the environment by saying “Ari di sa hospital eh”. Goal met.
2. The patient was able to verbalize thoughts and feelings but was mixed with delusional thinking “Subong okay, okay man ah. Gaabot abot lang galing nga mabatyagan ko nga gagululuwa naman ang mga sapat sakon panit” Goal unmet. Nurse-centered 1. The nurse was able to establish trust and rapport with the patient as the patient approached her and shared her thoughts and feelings. Goal met.
2. The nurse was able to recognize and empathize with the feelings of the patient “Makainchindi gd ko sang imo ginabtyag ma’am. Akig sa imo sitwasyon subong kag nasubuan ka kay waay ka sang may mahimo.” Goal met.
Name: Gerald Age: 3 Years Old Current Diagnosis: Imperforate Anus Nursing Care Plan Cues/Clues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
Name: Gerald Age: 3 Years Old Current Diagnosis: Imperforate Anus Nursing Care Plan Cues/Clues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
