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PROCESS RECORDING

Pts name: L. A. Physician: Dr. S.H.


Age: 23 years old Student Nurse: M.T.
Sex: Female
Diagnosis: Post Traumatic Stress Disorder and Depression

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

II. SETTING OF 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.

Student Patients Communication Defense Analysis


Nurses Communication Techniques Mechanism
Communication
The student (Patient nod to Giving Client Greeting the
nurse answers recognition responds client by name
approaches the questions) with a nod indicates that
patient with the Patient answers just to make the efforts the
best smile to with a low-toned it clear that client has
gain patients voice, nothings made all show
approval and wrong. that the nurse
cooperation. The recognizes the
student nurse client as an
sits in the chair individual and
near the patient. a person.

Maayong Maayong
buntag Lheslen. buntag sad.

Pwede ko nimu Lheslen akong Seeking To clarify if the


sultian sa imong pangalan information patient is
pangalan aware of
whom she is.
Lheslen, ako si Sige, wala ko Giving The student
M.T., ang imong problema ana, Information nurse is the
student nurse Lheslen smiles resource
gikan college of and nodded person of the
nursing. Naa ko patient. The
diri karon para nurse builds
makig storya trust with the
nimo. Hinaut pa client by giving
unta nga abli tas information
atong pagstorya
sa usag usa.
Naa ko diri sa
imong tupad
para maminaw
nimu og maau
og mutambag sa
ma tambag nako
nimu.
Lheslen, karon Patient looked in Asking The nurse
kay kaila na man to the student questions calmly asks
ta sa usag usa, nurse and said, the client if he
mangutano ko, Sabado man ta is aware of the
nahibaw ka unsa karon sa gabii, date and day
ta na adlaw og Septembre of the
petsa karon? bainte nueve. interaction to
assess
patients
memory and
level of
consciousness
to the reality.

Lheslen, sakto (Patient smiles Giving To be able to


ka na ni ingon ) Information bring the
ka na Sabada Salamat Anne. patients
karon sa thought and
Septembre 29, memory into
2012. the right way
and reality or
to the present.

Lheslen, naa Kadyot lang sa Exploring Displacement Any problem


kay ma storya ha, kay katon or concern
nako karong kaau akong should better
adlawa? Kung mata. be understood
unsa man na (Patient started if explored in
imong na feel, to get teary depth. She got
naa ko diri para eyed) teary eyed,
ma minaw nimu but blamed
og maau that her eyes
were itchy.

Unsa man Okay ra ning Focusing Any problem


atong buhaton akong mata ui. or concern
para dili na mag Salamat kaau na can be better
katol imong ni ari ka diri para understood if
mata? naa tawn ko ka explore in
storya. depth.
Kailangan baya
jud ko og ka
storya kay lisod
kaau na mag
inusara lang
Cge, ingna ko Sakit lang jud Focusing Any problem
bisag unsa kaau stanan, or concern
imong gi huna- kay maka can be better
huna diha unya hinumdom understood if
mag sturya tang gihapon ko sa explore in
duha ha. iyang gi buhat depth.
nako. Pamilya
man unta nako
siya pero ngano
man tawn iya
kong gi inan
ana?
Kinsa man (She looks down Seeking Patient Nurse is trying
Lheslen? Unya to the ground information answered in to know about
gi unsa man ka and with a precise how Lheslen
nya?? monotone voice. manner interacts with
She because she Mary Anne.
repsonded) sometimes Mary Anne is
has difficulty Lheslens
Gi abuse ko in verbalizing closest peer in
unya gi haras ko when feeling the house
sa bana sa anxious. because they
akong iyaan. are always
with each
other if they
can.

Unsa man ang Wala sad ko Focusing Student nurse


hinungdan na gi kabaw ngano iya encourages
inan ato ka niya toh gi buhat the client to
Lheslen? nako. Wala man concentrate
koi gi buhat nya. his or her
Ngano ako jud. energies on a
single point,
which may
prevent
multitude of
factors or
problems from
overwhelming
the client.

Unsa man imo Wala man Exploring Patient When patent


gi buhat pag dayon ko ni maybe just tends to deal
inan ato nya sumbong kay na tried not with topics
nimu? Ni hadlok ko kung show any superficially
sumbong ka sa unsa man iyang feeling exploring can
imong mama o buhaton sa because she help them
papa o bisag akong pamilya. likes not to examine the
kinsa? Iya pa lang show his issue fully.
patiyon. Dili ko feelings to
ganahan mag other people.
apil-apil sa dili But
kailangan ma eventually
apil. Pero pag will open up
dugay-dugay, when
akong gi una comfortable.
sumbongan kay
akong mama.
Nya ni gakos
siya nako og
maau. Nag hilak
gud ming duha.

Naay pa kay Mao ra jud na Broad Openings Patient does Broad


lain i.dungag sa akong gi bati, not want openings
imon storya para sakit jud lang anymore to make explicit
ma paguwas jud kaau. Dili nako expand any that the client
na tanan imong ganahan maka topic that has the lead in
gi bati. huna-huna kay would come the interaction.
bati jud kaau from him.
siya na feeling.
Pero ma okay ra
man jud ko.
Kailangan jud
dili lang ko ipa
hinumdom

Kasabot jud ko Sige. Salamat


sa imong gi bati kaau Anne.
Lheslen.
Ganahan ko
mag storya pa ta
og maau inig
balik nako inig
ka sunod na
Sabado. Mu
adto sa ako
Lhes, unya mag
kita ta balik ha.
Kaon na diha
para dili ka ma
pasmo.

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.

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