Nurses' Notes (Psychiatric Exposure) - 1
Nurses' Notes (Psychiatric Exposure) - 1
Romeo A Orcajada
Jr.
Surname First Name M.I. Age Sex Civil Status Admission
No. Attending Physician
Schizophrenia BCMHCC
Diagnosis Room/Ward
NURSES NOTES
Date Time Nurse’s Notes
06/28/22 7:00 AM Received patient awake and alert; standing and walking aimlessly inside
his cellar.--------AALA
Displayed an appearance with ungroomed hair, uncut nails, but clean
clothes Dried rheum was found on the corners of the eyes. --------AALA
Appears to be vocal and responds to greetings of SN.--------AALA
7:20 AM Visited and checked by Dr. Orcajada with new orders. --------AALA
8:00 AM Established rapport with SN during NPI session. Due to a fungal infection
between the upper legs, patient was unable to participate in the morning
circle and hataw.--------AALA
Exhibited a one word vocal communication towards SN. Patient does not
initiate a topic or verbal communication towards SN but responds to
inquiries with a low audible voice.--------AALA
Delusions were noted; talking alone. --------AALA
Polydipsia was observed.--------AALA
9:00 AM The communication was flat. Responds in one to two words at all times.
Maintaining eye contact while engaging in a manipulative act and
coercion; requesting clothes.--------AALA
Therapeutic communication done.--------AALA
Safety and comfort done.--------AALA
10:00AM Snacks were given. --------AALA
11:30 AM Vital signs was taken by the staff.
No complaints made throughout the shift. --------AALA
Endorsed to the next SN on duty. --------AALA