Professional Documents
Culture Documents
Process Recording # 1
I. OBJECTIVES
General:
After 2 weeks of SN-client interaction, the client will be able to reorient self
with the environment, have insight on her present condition and develop positive
attitude and skills.
Specific:
After 30-45 minutes, of SN-client interaction, the patient will be able to:
1. establish rapport
2. introduce oneself as the student nurse
3. orient self to date, place, and time
4. cite the purpose and expectation of the interaction
5. identify adaptive coping mechanisms that the client uses when feeling
aggressive, anxious, sad, or angry
6. agree as to the date, place and time of the next interaction
a. Time: 5:45 PM
b. Date: 09/29/12
c. Place: Living room of the client
III. Appearance:
She has not yet taken a shower and has not yet changed from the clothes that
she slept on last night. She was wearing a fitted stripe black and white shirt and a navy
blue short. Her hair seemed semi messy. She has chipped red nail polish on her toes.
BEHAVIOR:
She was not as attentive and cooperative at first but opened up slowly as the
interaction went on. She was slightly shy in the interaction with the student nurse. She
would make an eye contact then would look at the ground from time to time with simple
hand gestures and with teary eye.
COMPREHENSION:
Her answers were appropriate and correlated to the questions being asked but
theres sadness behind every answer she speaks. Sometimes she pauses and thinks
before she answers, it seems she thinks before she speaks.
IMPLICATIONS:
She was very responsive to the interaction. She interacted with the student nurse
specifically with details but there were moments that the questions make her seem teary
eyed and sad. She looks around when the question is being asked and focuses back to
the student nurse when she has to answer the question.
Maayong Maayong
buntag Lheslen. buntag sad.
IV. EVALUATION:
Almost all the objectives for this interaction were met. Patient was able to identify
the student nurse, he was able to orient himself with the time, date and place of
interaction, was able to identify adoptive coping mechanisms that she uses when she is
feeling angry, sad, or anxious, and was able to set a contract with student nurse for next
interaction. She was also able to tell the student nurse about her past and some
background about her feelings and thought about the situation. The client is generally
cooperative and responsive with our interaction.