special institution-sta. ana1

8/7/2019 special institution-sta. ana1

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Centro Escolar UniversityCollege of NursingMendiola, Manila

In partial fulfillment of the requirements

In

NCM 104

Special InstitutionSta. Ana Elementary School

MR

(Mental Retardation)

Submitted by:

Daez, Mark Steven R.

BSN 3A /Group 3A

Submitted to:

Mr. Jeffrey Castillo

Clinical Instructor


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CHAPTER 1: OBJECTIVES

At the end of 16 hours of exposure, the student will be able to:

1. Assess the adaptive functioning of the client during the orientation

phase

2. Assess the developmental tasks of the client during the orientation

phase

3. Determine the different characteristics of the client.

4. Observe the different learning skills of the client.

5. Know and understand what are the different psychiatric disorders

especially mental retardation and autism

6. Integrate the significance of nurses role in caring for clients with

special needs

7. Develop insights in the related learning experience

8. Establish rapport with the mentally challenged client

9. Care for the mentally challenged client

10. Assist in the activities of daily living and in the program of the institution

during the working phase

11. Prepare for program culmination during the termination phase or the

socialization day

12. Be familiarizing with the set-up of the institution.

13. Integrate the 3 principles of nursing care to the mentally challenge

clients.

14. Make use of proper therapeutic communication with the clients.


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MANIFESTATION

Prenatal causes: the configuration and the size of the head offer clues to avariety of conditions, such as microcephaly, hydrocephalus, and Downsyndrome.hypertelorism, a flat nasal bridge, prominent eyebrows, epicanthal folds, cornealopacities, retinal changes, low-set and small or misshapen ears, a protrudingtongue, and a disturbance in dentition, a high-arched palate, uncommon ridgepatterns and flexion creases on the handother clinical manifestations of other disorders associated with mental retardationlike Down syndrome, phenylketonuria, fetal alcohol syndrome, etc.

BEHAVIOR

Surveys have identified several clinical features that occur with greater frequencyin persons who are mentally retarded than in the general population. These features,

which can occur in isolation or as part of a mental disorder, include hyperactivity, lowfrustration tolerance, aggression, affective instability, repetitive and stereotypic motorbehaviors, and various self-injurious behaviors. Self-injurious behaviors seem to bemore frequent and more intense with increasingly severe mental retardation.

PLAY

INTERACTIVE PLAYOne of the most prevalent problems among persons who are mentally retarded is asense of social isolation and social skills deficits. Thus, improving the quantity andquality of social competence is a critical part of their care.

NURSING INTERVENTION

1. Assess all children for signs of developmental delays.

2. Administer prescribed medications for associated problems such as anticonvulsantsfor seizure disorders, and methylphenidate (Ritalin) for attention deficit hyperactivitydisorder.

3. Support the family at the time of initial diagnosis by actively listening to their feelings

and concerns and assessing their composite strengths.

4. Facilitate the childs self-care abilities by encouraging the parents to enroll the child inan early stimulation program, establishing a self-feeding program, initiating independenttoileting, and establishing an independent grooming program (all developmentallyappropriate).


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5. Promote optimal development by encouraging self-care goals and emphasize theuniversal needs of children, such as play, social interaction and parental limit setting.

6. Promote anticipatory guidance and problem solving by encouraging discussionsregarding physical maturation and sexual behaviors.

7. Assist the family in planning for the childs future needs (e.g. Alternative to homecare, especially as the parents near old age); refer them to community agencies.

8. Provide child and family teaching

Identify normal developmental milestones and appropriate stimulating activitiesincluding play and socialization.Discuss the need for patience with the childs slow attainment of developmentalmilestones.Inform parents about stimulation, safety and motivation.

Supply information regarding normal speech development and how to accentualnonverbal cues, such as facial expression and body language, to help cuespeech development.Explain the need for discipline that is simple, consistent and appropriate to thechilds .Review an adolescents need for simple, practical sexual information thatincludes anatomy, physical development and conception.Demonstrate ways to foster learning other than verbal explanation because thechild is better able to deal with concrete objects than abstract concepts.Point out the importance of positive self-esteem, built by accomplishing smallsuccesses in motivating the child to accomplish other tasks.

9. Encourage the prevention of mental retardation

Encourage early and regular prenatal care.Provide support for high risk infants.

Administer immunizations, especially rubella immunization.Encourage genetic counselling when needed.Teach injury prevention both intentional and unintentional

THERAPY

Certain skills are important to adaptive behavior, such as:

Daily living skills, such as getting dressed, using the bathroom, and feedingoneselfCommunication skills, such as understanding what is said and being able toanswerSocial skills with peers, family members, spouses, adults, and others


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MEDICATION

If seizure disorder is present, antiseizure medications

DIAGNOSTIC PROCEDURE

An assessment of age-appropriate adaptive behaviors can be made usingdevelopmental screening tests. The failure to achieve developmental milestonessuggests mental retardation.

The following may be signs of mental retardation:

y Abnormal Denver Developmental Screening Test (DDST)Here in the Phils. (MMDST)

MMDST- is a test utilized in pediatric patients to determine their physical and mentalskills. the nurses will assist in developing motor skills among toddlers and young

patients

Purposes

Measures developmental delaysEvaluates 4 aspects of development

Aspects of developmentPersonal-socialFine-motor adaptiveLanguage

Gross motor behaviorAdaptive behavior score below averageDevelopment way below that of peersIntelligence quotient (IQ) score below 70 on a standardized IQ test

Laboratory tests to help detect metabolic and genetic disorders. Imaging tests, such as

computed tomography (CT) or magnetic resonance imaging (MRI), may be performed

to look for structural problems within the brain. An electroencephalogram (EEG) records

the brain's electrical activity and is used to evaluate a child for possible seizures. A

chromosome analysis, urine and blood tests, and x-rays of bones can also help rule outsuspected causes of MR/ID.


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Psychosexual

Theory of

Sigmund

Freud

Latent-

7-12 years

- Childs libido or

energy is diverted to

more concrete type

of thinking

-no obvious

development.

-he accepts and

can do all things

given to him.

In relation with my client,

his libido is concentrated

in his activities rather than

on his genital. He is active

in school by participating

well in class.

Psychosocial

Theory of Erik

Erickson

Industry vs.

Inferiority

7-12 yrs

- child learns how to

do things well

- the client can

do things well in

his own ways.

In relation with my client,

child shows competency as

evidenced by participating

well in the class as his

teacher called him to read or

answer in front of his

classmates but not as good

compared with his other

classmates because

sometimes, he needs

supervision or help of his

classmates in answering

some question of his

teacher. He is also not

confident in answering some

question of his teacher that

leads to guidance,

supervision at dependencyof the child. But if we talk

about classroom works, he

is responsible in a way that

hes the one who dispose

the garbage of the

classroom every end of their

class.

Cognitive

Theory of

Jean Piaget

Concrete

Operational

thought- he can count

up to 100 and

Some of the

developmental task in this


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reversibility-

cause and effect

y Have concept of

longer situation

constancy

despite of

transformation.

.

Interpersonal

Theory of

Harry Sullivan

-- Social subordination

- obey parental-like

authority

-extends from the

patterning of

preferred genital

activity through

unnumbered

educative and

deductive steps to

the establishment of

a fully human or

mature repertory of

interpersonal

relations, as

permitted by

available

opportunity, personal

and cultural

-The main focus as a

juvenile is the need for

The client has a

good

relationship with

his classmate

and to hismentors. He can

take good care

of himself.

One of the task on this

stage of Sullivan theory was

social subordination or

obeying parental-like

authority. In relation with my

client, he can obey

commands by authorities

like his teacher and older

age that him by reading forparticipation in the class,

and following instructions

like the drawing activity that

the CEU students and other

activities during the

socialization.He also has a

good interaction with his

classmates because he can

easily mingle with them and

he also has a good

interaction with them.


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CHAPTER 5: ADAPTIVE FUNCTIONING:

a. Communication- The client blurts out inappropriate comments, show his

emotions without restraint, and act without regard for consequences. He

doesnt seem listening when spoken to and lacks eye contact during

conversation.. He uses simple words when communicating. He speaks and

understands simple English. He uses Filipino as a medium of communication.

b. Self-care- the client is well groomed upon observation.

c. Social interaction- he often interrupts conversations or others' activities. He

is friendly and has good interaction with others.

d. Self direction- He has difficulty processing information as quickly and

accurately as others and struggles to follow instructions. The client is easily

distracted, miss details, forget things, and frequently switch from one activity

to another.

e. Functional academic skills-. He has trouble completing or turning in

homework assignments alone and needs supervision. He has hard time

answering his teachers question when asked. But excels in doing school

projects and works.

f. Work- the client has difficulty focusing on one thing. He easily becomes

bored with a task after only a few minutes, unless he does something

enjoyable. He also has difficulty focusing attention on organizing and

completing a task or learning something new. But accepts tasks given to him.

g. Leisure- He likes to watch television and play computer games.

h. Health- The client seems to be too skinny. Most likely, he is in below normal

weight. He is neat. He also likes to eat fruits. He practices good hygiene.


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CHARACTERISTICS OBSERVED NOT OBSERVED

Affect isolation

Unrelatedness to others

Twiddling behaviour

Inconsistent

developmental maturity

Self destructive

behaviour

Temper tantrums/

anxiety

I/you apparent

confusion

Concrete thinking

Perceptual

inconsistencies

Immediate and delayed

echolalia

Orderliness

Physical uncoordination


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Physical Description

Patient is in small frame body built. He has a smooth rhythmic gait,

appropriately dressed and no malodorous scent noted. No obvious physical

deformities. Skin is in normal racial tone and nails are long and dirty. Hair is black

in color. Ears are aligned on the patients eyebrows and no deviations found.

Eyes are straight normal. He has a flat nose bridge. No other deformities found

CHAPTER 8: NURSE-PATIENT INTERACTION

ORIENTATION PHASE

Definition: It is during the orientation phase that the nurse and the patient

meet. The tasks in this phase of the relationship are to establish a climate of

trust, understanding, acceptance, and open communication and formulate a

contract with the client.

Objectives: After the orientation phase, the student nurse will be able to:

y Establish trust and rapport with the client;

y Establish a contract with the client;

y Initially identify problems of the client that are needed to

intervene;

y

Explore patients feeling, perceptions, thoughts, and actions;and

y Define mutual, specific goals with the patient.

Date: January 20, 2011

Time: 9:30 a.m.

Venue: Sta. Ana Elementary School


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pat ent s presence s e t y

the nurse.

Nurse: Ako si kuya Mark

Steven Daez. student

nurse po ng Centro

Escolar University sa

Mendiola. Eto ang unang

araw naming ditto sa

school niyo. Hanggang

dito kami bukas. Anu

naman ang pangalan

mo?

Nurse: Pakiulit nga po

ang pangalan ko?

Patient: J.C.

Patient: Kuya Mark!

Giving information: To give

details that the patient needs

to know in order to gain

patients trust andcooperation. The nurse also

sets the time frame of

working with the client.

Nurse: Ikaw si J.C. ?

Ilang taon ka na?

Patient: (blocking.....)

8 po.

Restating: This restatement

lets the client know that he

communicated the idea

effectively. This encourages

the client to continue.

Questioning: To gain basic

information about the client.


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nakatira?

Nurse: Saan dun?

Nurse : okay

Patient : Sa bahay

namin.



Exploring: To examine the

issue more fully.

Nurse: Nasaan mga

pamilya mo?

Patient: Nasa bahay

po naming.



Nurse:May kapatid ka

ba? Eh yung mga

kapatid mo? Asan sila?

Nurse: Ilan kayong

magkakapatid?

Nurse: ahh. 3 kayo?

Pang ilan ka? Ikaw ba

yung bunso?

Nurse: Ikaw ba ung

drinowing sa sa papel

kanina?

Patient: Pumasok po

sila.

Patient: 3 po kami.

Patient: opo.

Patient: Hindi po.

Bunso namin yun.


issue more fully.


issue more fully.




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Nurse: Eh si tatay?

Nasaan?

Nurse: Pumapasok din si

tatay? Eh si nanay?

Patient: Pumasok din

po.

Patient: Nasa bahay

mo kasama niya lola

ko po.

Restating: This restatement








issue more fully.

(patient goes out the

room and dispose

garbage can)

Nurse: Wow! Ansipag

mo naman.

Nurse: Lagi mo bang

ginagawa yan?

Patient: (big grin

smile)

Patient: Opo. kase

ako lang po ang may

gusto nito. Ayaw ng

mga classmates ko.

Giving recognition-

acknowledging, indicating

awareness




issue more fully.

Nurse: Okay. Yun lang

muna sa araw na to. Oh,

Bukas ah? Andito kami

ulit. May mganakahandang mga

Patient: Okay po!!! Accepting: To indicate the

nurse has heard and


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Nurse : o sige JC. Anu

na nga pala ulit

pangalan ko ?

Nurse : Miguel ba

pangalan ko ? Ano na

nga ulit pangalan ko?

Kuya ?..

Nurse: Kuya Mark!?

Nurse: Yes. Sige

salamat sayo JC. Inggat

ka sa pag uwi.

Patient : (blocking).

Miguel !

Patient: Kuya.

(blocking)

Patient: (repeats)

Kuya Mark!

Patient : Salamat din

po !







Exploring: To examine theissue more fully.

WORKING AND TERMINATION PHASE

Working Phase

Definition: This is the right time to gather all the data you need. It is the time

when the client must have trust to the nurse. This is the phase in which the client

actively participates to all the activities.


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y Identify existing psychiatric nursing problems.

Termination Phase

Definition: This is the last day of the therapeutic relationship. This is the time

to remove all the attachment and let them reflect for all the activities that was

done.Objectives: After the termination phase, the student nurse will be able to:

y Establish reality of separation; and

y Evaluate goals if they are met.

Date: January 21, 2011

Time: 10:00 a.m.

Venue: Sta. Ana Elementary School

Nurse Patient Rationale of the Nurses

Communication

Techniques

Nurse: Hi JC. Magandang

umaga sa iyo.

Patient: hello kuya!

Magandang umaga

din.

Giving Recognition: This is

to provide acknowledgment

and awareness. Greetingthe client shows that the

patients presence is felt by

the nurse.

Nurse: Andito nanaman

ako para makipaglaro

sayo. Ayos ba sayo yon? Patient: Opo!

Giving information: To give

details that the patient

needs to know in order to


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Nurse: Oo naman.

Patient: Kuya,

Magtatapon po ulit

tayo ng basura

mamaya ah?

Accepting: To indicate the

nurse has heard and

followed the train of thought.

Nurse: May mga kaibigan

ka ba dito?

Nurse: Pala kaibigan ka

pala.

Patient: Meron po.

Sila Daniel, Mac

Arthur, at Rafael

Patient: opo (smile)

Accepting: To indicate the

nurse has heard and

followed the train of thought.



Nurse: Anong gusto

mong maging paglaki

mo?

Nurse: Bakit gusto mong

maging pulis?

Nurse: Wow!. Ang galing

mo naman.

Patient: Maging pulis

po. Kasama ko

Rafael, Daniel at Mac

Arthur.

Patient: Para po di po

maging traffic sa

kalsada.

Patient : (smile)



Focusing: To encourage the

client to concentrate his

energies on a single point.

Giving Recognition: This is

to provide acknowledgment

and awareness. Greeting

the client shows that the

patients presence is felt by

the nurse.


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Nurse: Kung naalala mo,

ano yung pinadrawing

namin?

Patient: (Blocking...)

(stared blankly and

slient)

Exploring: Delving further to

a subject or idea.



or idea.

Nurse: Hindi mo na ba

maalala? Diba, bahay at

pamilya mo yung

drinowing mo kahapon?

Yun nga ba?

Patient: ayy. Oo nga

pala. Opo yun po.



(showed the art work of

the client)

Nurse: Di ba eto yung

drinowing mo kahapon?

Patient: (smile)



Nurse: di ba pinapasulat

ko sayo dito sa drawing

mo ang pangalan mo?

Nurse: di ba. Ang

pangalan mo ay J.C.?

Bakit mga letrang

JOIYYPOA ang sinulat

mo?

Nurse: Ganito mo ba

isulat ang pangalan mo?

Patient: Opo.

Patient: (smiling and

staring blankly at the

drawing)

Patient: Hindi po.

Exploring: Delving further to

a subject or idea.




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mo? Sige tutulungan kita

Nurse: Gayahin mo tong

mga letrang ito ah?.

(taught how to write the

clients name)

Nurse: Ngayon, alam mo

na kung paano isaluat

pangalan mo ah?

Nurse: welcome!!

(client followed)

Patient: Opo! Salamat

po!

offering to share, to strive,

to work together with the

client for his benefit.

Nurse: So dito na

nagtatapos ang pag-

uusap natin. Kaya gaya

ng pinangako ko kanina,

maglalaro tayo.

Nurse: kaya mamayang

socialization, sasali ka

ah? Okay ba yon?

Nurse: Apir tayo!

Patient: yehey!!

Patient: opo!

Patient: Apir!

Giving information: making

available the facts that the

client needs to know.

Suggesting collaboration:

offering to share, to strive,

to work together with the

client for his benefit.


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The benefits of regular physical activity for individuals with mental retardation are

numerous, including increased strength and endurance, better weight

maintenance and reduced risk of many diseases. Heart disease is a common co-

morbidity in persons with mental retardation, so health care providers need to

make efforts to reduce the common risk factors for heart disease in their patients

with mental retardation. The key to maximizing the benefits of exercise is to help

the individual follow a well-designed program that accommodates his or her

specific needs and limitations.

Getting Started

y Talk with the individual's health care provider before starting an exercise

program and ask for specific concerns about the patient doing exercise.

y The primary goal of exercise training is to find activities that the individual

enjoys and that is within his or her functional capabilities. Additional goals

include body fat and weight loss and improved muscle strength and

aerobic capacity.

y If the individual's fitness level is low, start with shorter sessions (10 to 15

minutes) and gradually build up to 30 minutes of aerobic activity, 5 days

per week.y Recommended activities include swimming, walking and indoor cycling.

y Strength may have important ramifications for vocational productivity and

independence. A twice-per-week strength-training program using

machines with one to three sets of exercises for the major muscle groups,

with 10 to 15 repetitions, is recommended.

y Help create a structured environment by following a standard routine that

is consistent and rewarding for the individual. Reward systems and

positive reinforcement are particularly effective for helping the individual

adhere to the program.

y Activities set to music increase adherence and are particularly effective,

as are community-based exercise programs.

Exercise Cautions

y Exercise should always be supervised.

y While strength-training gains may be apparent within 10 to 12 weeks, it

may take considerably longer (four to six months) to observe

improvements in cardiorespiratory endurance.


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If your health care provider has not cleared you for independent

physical activity and would like you to be monitored in a hospital setting or

a medical fitness facility, you should exercise only under the supervision of

a certified professional.

CHAPTER 10: LEARNING INSIGHTS

Special children must be treated so special.

Mentally incapacitated individuals are not to be afraid of or someone to

make laugh and fun of. We must treat them as normal individuals instead.

Special education is of great help for those mentally challenged people. It

enhances the way they interact with the people around them. I would like to

recommend to those parents with those who have a child of the same cases to

send their child into special institutions that has the capacity to enhance their

childs potential and the correct way of dealing, handling their situation andteaching them. As a registered nurse hopeful, teachers on that institution really

opened my heart and my mind to be dedicated to my duty and serve the Filipino

people with all my heart first.

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