NPI AND NCP

IN

NCMH
SUBMITTED BY:
Ma. Michelle A. Jandugan

SUBMITTED TO:
Ma’am marilyn Sta. Rita, rn
 PATIENT’S PROFILE

NAME: Remedios B. Palma

DATE OD ADM: February 3, 1997
AGE: 55
CIVIL STATUS: Married
ADDRESS: Camalig Kasiguran, Quezon
DATE OF BIRTH: April 14, 1949
RELIGION: Roman Catholic
DIAGNOSIS: Auditory Hallucination

OBJECTIVE

GENERAL:

 Promotion of mental health and prevention of mental illness.

 Provision of care, treatment and rehabilitation to mentally ill clients.
 Training Education, Research.

SPECIFIC:
 ASSESSMENT

The environment outside the Dormitory has many trees with grassy leaves and has benches where the patient can
sit and relax. The patient is wearing a clean dress that came inside the Dormitory. She is cooperative in all activities and
sometimes in good eye contact when saying something. She is always delaying in reaction in some activities. She has a
slow and soft speech. She has auditory hallucination.
 INTERACTION INFERENCE ANALYSIS

Broad Opening To initiate Broad Communication.

N: Magandang umaga po.
P: Magandang umaga din.

Offering self Making self available and showing interest

N: Ako po c michella Jandugan, estudyante
and concern.
po ng perpetual.
P: Kaw si Michelle.

Focusing Pursuing a topic until its meaning or

N: Opo nay, ano pong pangalan nyo?
importance is clear.
P: Remedios Palma, Remy na lang.

Questioning Using open-ended questions to achieve

N: Ilang taon na po kayo?
relevance and depth in discussion.
P: 34 yrs. Old

Active listening Paying close attention to verbal and

N: Kelan po ang kaarawan niyo?
nonverbal communications, patterns of
P: Hindi ko tanda ang taon pero December
thinking, feelings and behaviors.
26, kasi ang pangalan ng ama ko ay Kristo
at ang ina ko naman ay si Maria.

Empathy Recognizing and acknowledging patients

N: May asawa na po ba kayo? Asan siya?
feeling.
P: Meron, lagi siyang umiinom ng Ginebra
San Miguel, pag nakainom siya kumukuha
siya ng kahoy at ipinapalo niya sa akin ulo
hanggang paa, sabi ko sa kanya wag na
muna sya sumama dun sa kaibigan nya at
wag na muna sya uminom kahit ngayong
araw lang. nagagalit sya sa akin at
hinahampas ako ng kahoy, dinala pa nga
EVALUATION

I evaluate that the patient has violent feeling in her husband and miss her 3 kids. She is traumatizing about what
happen between her and her husband. She cannot remember some details about her self.

CUES NRSG. PLANNING NRSG. RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

SUBJECTIVE: Nutrition After Nursing Discuss eating habits, To appeal to After Nursing
“ Kung ano lang imbalanced less Intervention the including food clients desires or Intervention the
binibigay nila than body patient will be preferences, likes. client
yung ang requirements able to meet intolerances/aversions. demonstrate
kinakain ko, related to foods progressive progressive
basta malinis at that lack of weight gain. Assess drug May be affecting weight gain
hindi panis.” nutrients. interaction, disease appetite, food toward goal.
As verbalized by effects, allergies, use of intake or
the patient. laxatives, diuretics. absorption.

OBJECTIVES: Assess weight, age, Provide

Weak and pale in body build, strength, comparative
looking activity/ rest level. baseline.
Thin body
appearance Use flavoring agents, To enhance food
(lemon and herbs) if satisfaction and
salt is restricted. stimulate
appetite.

Encouraging client to To stimulate

choose foods that are appetite.
appealing.

Promote pleasant, To enhance

relaxing environment, intake.
including socialization
when possible.