Nursing Process for MAPB
Department of Nursing
GUIDE FOR NURSING PROCESS
Name : Supremo, Jamaine
Villegas, Liezel
Sy, Marionne
Tamares, Geriko
Villanuava, Yen
Section/Group: Group 3 Sub- Group B
Date: September 21 2021
Score:
NURSING HEALTH HISTORY: CLIENTS WITH MALADAPTIVE BEHAVIOR
DATE
September 21, 2021
___________
A. BIOGRAPHICAL DATA
Patient’s Initials:
Address:
Date of Birth:
Occupation:
Source and Reliability
of Information
Sarah
_____________________________
North America
_____________________________
September 21 1966
_____________________________
_____________________________
N/A
The patient and the patient
_____________________________
husband
PATIENT PROFILE
Age:
Race:
55 year old
____________
Caucasian
____________
Female
Sex:
__________
Married
Marital Status: __________
B. MENTAL STATUS EXAMINATION Caucasian
Reason for Admission (in client’s own words, indicates insight):
She verbalized that she has develop emotional stress and under the influence of a drug, and She reported
that stressful situations and substance abuse could aggravate the fragmentation of her personality, she
reported that she had anxiety during a personality state transition. As a result, the patient wants to suicidal
and homicidal, the patient had a previous hospitalized in a mental institution for a significant period at least
two to three times in the past. Multiple aspects of her personalities were also reported
Circle / Underline assessments that apply. When assessment findings are unusual, specify with a
description.
1.
GENERAL BEHAVIOR, APPEARANCE and ATTITUDE
Appearance (Grooming/hygiene):
Appropriate
Disheveled
(dirty,messy)
Open posture
Eye Contact
Eye contact: ______
_______
Describe posture: _________
Unusual for situation(specify)______________________________________
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
General Behavior:
Manipulative Withdrawn
Argumentative Passive
Passive-aggressive
other: Suicidal to homicidal
Isolated
Assertive
Verbally or physically hostile
Aggressive
Motor Activity:
Lethargic
Relaxed
Restless
Pacing
Threatening
Other (specify)___________________________________________________________
2.
CHARACTERISTICS OF SPEECH
Speech Rate:
Slow
Normal
Pressured (fast and difficult to interrupt)
Content of speech is appropriate to situation
Clear
Coherent
Neologisms
Loose associations
Perseveration
Rumination
Slow impoverished speech
Slurred Speech
Flight of ideas
Circumstantiality
Incoherent
Aphasic
Tangentiality
Unusual (specify) ____________________________________
3.
EMOTIONAL STATE
Mood appears to be:
Normal
Depressed
Euphoric
Angry
Irritable
Anxious
Affect: Broad (can express both positive and negative emotion)
Flat
Labile (changeable)
Bland
4.
Blunted
CONTENT OF THOUGHT: SPECIAL PRE0CCUPATIONS AND EXPERIENCES
Thought Process:
Clear
logical
easy to follow
relevant
Confused
rapid flow of thoughts Slowness in thought association
Thought Content:
Delusions
Depersonalizations
Somatic delusions
Illusions
Fantasy
Nihilistic delusions
Obsession
Daydream
Compulsions
Grandiose
Suicidal, homicidal
Suicidal Ideas Homicidal Ideas (ask directly if client feels like hurting self or others)
Hallucinations: None noted Auditory Visual
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
Other
__________________________________________________________________________
5.
ORIENTATION

Oriented to:
Time______________________
Place: ___________________

6.

Person: __________________
Situation: _________________

MEMORY
Cognition: Short-Term Memory
(ask what client had for breakfast):
Intact
Impaired
Long-Term Memory
(ask where client went to school):
Intact
Impaired
7.
(specify)
GENERAL INTELLECTUAL LEVEL
General Grasp of Information: (Ask client to state the last four president or name four known cities in the
Philippines)
Intact
Impaired
Unwilling/unable to answer
Ability to Calculate: (Serial sevens test or simple mathematical ability tests)
Intact
Impaired
Unwilling/unable to answer
Judgement: (problem solving, such as,“What would you do if you were away from home and remembered
that you left the stove turned on?”):
Intact
Impaired
Unwilling/unable to answer
8.
ABSTRACT THINKING
(interpretation of proverbs, such as “What does it mean when they say,‘The early bird gets the worm’?”):
Abstract
9.
Concrete
Unwilling/unable to answer
INSIGHT EVALUATION
(Ask client whether they feel the need of treatment, and how they explain the symptoms)
If the client feels irritability, suicidal and homicidal thoughts, if client feels like hurting self or others
_______________________________________________________________________
Mental Status Examination was adapted from Mental Health Nursing 2nd ed by Eby and Brown. 2009 and Contemporary Psychiatric-Mental
Health Nursing 2nd ed by Kneisl and Trigoboff. 2009
C. OTHER SOURCES
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
Client Profile: Sarah
Name: (Optional)
Gender: female
Age:55 years old
Diagnosis: Dissociative identity disorder (DID)
Description of the Interaction Setting:
During encounter with the client with different personalities under emotional stress and under the
influence of a drug, Multiple aspects of her personalities were reported, a personality of a sevenyear-old child, a personality that would behave as a teenager, and another that acted like a female
person in addition to her normal 55-year-old personality.
Environment:
The environment was quiet and secure.
Goal:
The goal for the client is to fully express his feelings.
Student’s Verbal
Statement
Student’s
Non- Verbal
Statement
Client’s
verbal
Statement
Client’s
Non- verbal
Statement
Communication
Technique used
Good afternoon,
ma’am, may I know
what happened?
Relaxed
open posture;
smiling,
leaning
forward,
maintaining
eye contact
Hi ma’am, I
am Sam
Milby, 55
years old. I
feel like there
are a lot of
people who
eants to listen
to me ah, I
appreciate
you all
ma’am. But I
think I am not
doing good
lately because
my family
members told
me I have
multiple
personalities
and
Open
posture;
relaxed, eye
contact
(Seeking
information)
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Evaluation/
Analysis of
the
Interaction
Seeking
information to
clarify what is
overly
significant or
confusing
Nursing Process for MAPB
Department of Nursing
Hello sir, I am
Marionne Sy, I am a
psychiatric nurse here,
and I will be taking
care of you, so please
don’t hesitate to share
with us your feelings
and your experiences.
What we will do sir, is
that we will listen to
you so we could better
understand your
situation and I
promise that any
information that you
will share will be kept
private and
confidential and will
remain between the
healthcare providers
that are involved in
your treatment. What
do you feel today?
What are the different
personalities that your
family told you that
you have?
Head tilt for
curiosity and
genuinely;
leaning
forward, eye
contact
Relaxed
posture;
leaning
forward, eye
contact
sometimes I
become
violent even
to people
whom I am
close to when
I am
transitioning
these
personalities.
I am sad
because I do
not know
what is
happening to
me and why
this happens
to me.
They said that
my
personality
becomes a
seven-yearold child that
would show
the same
interests and
choices that
includes
becoming
moody or
self-arrogant.
In this state, I
hurt myself if
I don’t meet
my wants.
Also, my last
personality is
my normal
state in which
I am very
comfortable
nurse. You
Open
posture;
relaxed, eye
contact
(Offering Self)
Offering the
self
emphasizes to
the patient that
they are
valued and lets
them know
that they are
not alone, and
that someone
is willing to
give them
their time and
attention. This
also helps
them boost
their mood.
Open
posture;
relaxed, eye
contact
(Exploring)
When clients
deal with
topics
superficially,
exploring can
help them
examine the
issue more
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
know what,
I’ve got an
anxiety attack
during the
transition of
my
personality
because I do
not know
when it will
happen, and I
do not know
that it
happened.
But my
family told
me that the
transition of
my
personality
happens often
when I am in
stressful
situations and
when I take
marijuana or
cocaine,
especially if
I’m with my
friends.
You mean, you have 4
different personalities
in which you are
transitioned into
different ages?
Relaxed
posture;
leaning
forward, eye
contact
Yes, nurse
that’s what
happens to
me, but I
didn’t know
that it
happened.
My family
will just tell
me after the
transition of
my
personality
fully. Any
problem or
concern can be
better
understood if
explored in
depth.
Open
posture;
relaxed, eye
contact
NCM117- Care of Clients with Maladaptive Patterns of Behavior
(clarifying)
Clarifying to
understand
message
accurately
unclear. To
clarify the
senders
meaning.
Nursing Process for MAPB
Department of Nursing
We understand your
situation now Sir.
Moving on, let us
proceed with the
assessment. I'll be
asking you a few
questions; I'd
appreciate it if you
could answer them
truthfully.
Relaxed
posture;
leaning
forward, eye
contact
When is your
birthday?
Relaxed, Sit
squarely
facing the
patient with
an open
posture and
establishing
eye contact
Relaxed
posture;
leaning
forward, eye
contact
Relaxed
posture;
leaning
forward, eye
contact
What time is it now?
Where are you now?
when I’m in
my normal
state.
I will nurse.
Open
posture;
relaxed, eye
contact
(accepting)
Accepting lets
the client
acknowledge
that they heard
the other and
lets her other
client know
that the client
is taking him
seriously,
making him
more likely to
be receptive to
care.
Providing
information
guides and
opens to the
client
strategies and
possible
solutions to
their problem.
Doing this
also guides
September
21, 1966
Open
posture;
relaxed, eye
contact
(Asking relevant
question)
Ask relevant
questions to
seek
information
needed for
making
decision.
It is 11:11 in
the morning
Open
posture;
relaxed, eye
contact
(Seeking
information)
: I am here in
the hospital
talking with
the
psychiatric
Open
posture;
relaxed, eye
contact
(Seeking
information)
Seeking
information to
clarify what is
overly
significant or
confusing
Seeking
information to
clarify what is
overly
significant or
confusing
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
Why do you think you
are here?
Relaxed
posture;
leaning
forward, eye
contact
What did you have for
breakfast?
Relaxed
posture;
leaning
forward, eye
contact
What was the school
that you had last
attended?
Relaxed
posture;
leaning
forward, eye
contact
Can you name 4 know
cities in the
Philippines?
Relaxed
posture;
leaning
forward, eye
contact
Can you subtract 100
by 7?
What would you do if
you were away from
home and
remembered that you
left the stove turned
on?
What does it mean
when early bird gets
the worm?
nurse about
my problem.
It is because I
have been
experiencing
multiple
personalities
and I need
medical help
about my
situation now.
I can’t
remember
nurse, maybe
I didn’t take
breakfast, or I
don’t know
nurse
Uhmmmm, I
can’t
remember
nurse
Open
posture;
relaxed, eye
contact
(Seeking
information)
Seeking
information to
clarify what is
overly
significant or
confusing
Open
posture;
relaxed, eye
contact
(Seeking
information)
Seeking
information to
clarify what is
overly
significant or
confusing
Open
posture;
relaxed, eye
contact
(Seeking
information)
Cebu City,
Manila City,
Iligan City
and Ozamiz
City
Open
posture;
relaxed, eye
contact
(Seeking
information)
Relaxed, Sit
squarely
facing the
patient with
an open
posture and
establishing
eye contact
Relaxed
posture;
leaning
forward, eye
contact
93, 86, 79, 72
Open
posture;
relaxed, eye
contact
(Seeking
information)
Seeking
information to
clarify what is
overly
significant or
confusing
Seeking
information to
clarify what is
overly
significant or
confusing
Seeking
information to
clarify what is
overly
significant or
confusing
I will go
home and
turn it off
Open
posture;
relaxed, eye
contact
(Seeking
information)
Relaxed
posture;
leaning
forward, eye
contact
This means
that the
people who
starts early
can maximize
Open
posture;
relaxed, eye
contact
(Seeking
information)
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Seeking
information to
clarify what is
overly
significant or
confusing
Seeking
information to
clarify what is
overly
Nursing Process for MAPB
Department of Nursing
the potential
outcome.
significant or
confusing
Seeking
information to
clarify what is
overly
significant or
confusing
Why do you feel like
you need to get a
treatment?
Relaxed
posture;
leaning
forward, eye
contact
I feel like I
need a
treatment
because I’m
affecting the
lives of the
people
around me,
which is I
don’t like,
and I want to
maintain my
normal state
in which I am
very
comfortable.
Open
posture;
relaxed, eye
contact
(Seeking
information)
How do you explain
your symptoms?
Relaxed
posture;
leaning
forward, eye
contact
Open
posture;
relaxed, eye
contact
(Asking relevant
question)
Ask relevant
questions to
seek
information
needed for
making
decision.
You’ve mentioned
earlier that you
become violent even
to the people that you
are close to? How do
you handle that kind
situation?
Relaxed
posture;
leaning
forward, eye
contact
I have 4
different
personalities
with different
ages. I
become
violent when
I’m
transitioning
from one
personality to
another.
To be honest
nurse, I was
arrested in the
past because
of that. I was
also isolated
and restrained
by being
locked in the
room, they
also
hospitalized
me in the
mental
institution for
Open
posture;
relaxed, eye
contact
(clarifying)
Using the
clarification
important to
check and
understand a
message
accurately,
and to clarify
a client
message
meaning.
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Nursing Process for MAPB
Department of Nursing
How many times that
situation occurred?
Relaxed
posture;
leaning
forward, eye
contact
Upon hearing your
situation
Mr. Sam your
treatment will
include psychotherapy
with cognitive
behavioral therapy
addressing stress and
substance use
disorder.
Psychotherapy will
help you eliminate or
control troubling
symptoms for you to
function better and
this can also increase
your well-being and
will promote healing
to you. The
psychotherapeutic
treatment will last for
at least six months,
and I will also give
you escitalopram as
prescribed by the
doctor which can help
you reduce your
anxiety symptoms.
How are you, Mr.
Sam?
Relaxed
posture;
leaning
forward, eye
contact
Relaxed
posture;
leaning
forward, eye
contact
a significant
period which
make me sad.
So, I think I
didn’t handle
that correctly
I think twice
or thrice.
Open
posture;
relaxed, eye
contact
(Asking relevant
question)
Thank you,
NURSE.
Open
posture;
relaxed, eye
contact
Giving
information)
The anxiety
pills that the
doctor
prescribed,
was really
helpful to me
and the stress
that I
Open
posture;
relaxed, eye
contact
Giving Broad
Openings)
NCM117- Care of Clients with Maladaptive Patterns of Behavior
Ask relevant
questions to
seek
information
needed for
making
decision.
The facts
improve the
client's
understanding
of a topic by
informing her.
Since the
patient was
being hesitant,
this allows the
patient to lead
the
conversation
and prompts
Nursing Process for MAPB
Department of Nursing
You will be required
to visit here for
follow-ups as this will
help us know if the
prescribed treatment
plan is effective to
you and this will make
your situation better.
This will also increase
the likelihood of a
positive outcome
Call me when you
need help. I am
always here to talk
with you about your
problem. Thank you.
Relaxed
posture;
leaning
forward, eye
contact
Relaxed
posture;
leaning
forward, eye
contact
felt became
better
however my
condition did
not drastically
change and is
almost the
same 6
months ago.
Okay nurse,
I’ll take note
of that. Thank
you
Sure, I will
thank you
again nurse.
him to explain
his feelings
and emotions.
Open
posture;
relaxed, eye
contact
(Giving
information)
The facts
improve the
client's
understanding
of a topic by
informing her.
Open
posture;
relaxed, eye
contact
(Offering Self)
Offering the
self
emphasizes to
the patient that
they are
valued and lets
them know
that they are
not alone, and
that someone
is willing to
give them
their time and
attention. This
also helps
them boost
their mood.
NCM117- Care of Clients with Maladaptive Patterns of Behavior