You are on page 1of 6

PROCESS RECORDING Description of client: A 65 year old female client.

Sometimes the client expressed suppression during interaction that limits the main points of discussion. Description of environment: well- ventilated environment and well organized during the discussion and activities. Setting: Pavilion 8 Objectives: After the orientation phase, the client will: Be able to establish rapport and trust with the student nurse, be able to get the patients initial data, profile and background, be able to establish the plan of activities and the contract to the patient. ORIENTATION PHASE Therapeutic Technique

Nurse-Patient Interaction Nurse: Magandang araw po Nanay Patient: Magandang Araw din Nurse: Ako po pala si Dennis, mula po ako sa University of Makati, ako ang iyong magiging nurse simula po ngayon hanggang sa biyernes andito po kami mula alas dos ng hapon hanggang alas diyes ng gabi. Patient: ako si Devina Deogracia, 58 taong gulang, nakatira sa Tarlac Nurse: May asawa pa po kayo? Patient: wala na po. Nurse: ibig nyo po bang sabihin ay patay na sya? Patient: opo patay na daw sya, Nurse: Ilan naman po ang mga anak nyo? Patient: 2 po Nurse: eh, gaano na po kayo

Inference or Analysis

Giving Information Offering self

Establishes rapport with the client Assures the client that you are their ready to listen

Restating

Stating back the patients statement in order not to give false hopes

katagal dito nanay? Patient: matagal na.. 7 years na. nung March 5 Nurse: dinadalaw naman po kayo ng mga kapamilya mo? Patient: oo, ung pinsan ko lang. Nurse: talaga ho? Patient: oo, dinalaw nya ako kaso matagal na iyon. Nurse: Alam nyo po ba kung nasaan kayo ngayon? Patient: ako ay nasa pavilion 8, National Center for Mental Health Nurse: ang galing naman nay. Patient: oo magaling na ako. Kelan ba ako makakauwi? Nurse: kelan ka kaya makakauwi? Patient: ewan ko. Nurse: kumusta ka naman dito nay? Patient: malungkot. Naaalala ko palagi ang mga anak ko lalo na pag may mga student nurse dito ( sob) Nurse: ano po ang ginagawa nyo pag nalulungkot kayo? Patient: nagdadasal po. Nurse: may gusto po ba kayong pag-usapan nating dalawa? Giving broad openings Identifying themes identifies the thoughts, feelings and behaviors of the patient encourages the patient to elaborate or give some ideas or feelings that will Reflecting Helps her identify her own feelings Voicing doubt helps the client to arrange her thoughts Helps the patient to recognize reality

Placing the event in time or sequence

Patient: wala na. Nurse: oh sige nay, ako poy nagpapasalamat sa inyong oras at sa inyong partisipasyon. Patient: salamat din anak.

help her express her feelings,

Description of client: A 65 year old female client. Sometimes, client expresses suppression but she can answer the following questions that she recalled. She has dry skin with few lesions on her hands and feet. She can look directly. Description of environment: well ventilated and well organized during the interaction Setting: Pavilion 8 Objectives: After the working phase, the client will: be able to participate with the different activities, be able to express her own insights regarding her mental condition, be able to summarized the learning behavior she has learned Nurse-Patient Interaction Nurse: Nanay Devina magandang hapon po. Patient: magandang hapon din WORKING PHASE Therapeutic Technique Giving Recognition Inference or Analysis To gain the patients trust during the NPI.

Nurse:alam nyo po ba kung anong petsa, araw, buwan at taon ngayon? Patient: opo. Ngayon ay araw ng miyerkules, 08 po March 2011. Nurse: tama po. Eh nasaan po kayo ngayon nay? Patient: sa pavilion 8, national center for mental health Nurse: Eh, kumusta naman ang araw mo nay? Patient: ok naman, masaya. Paggising ko nagligpit ako ng gamit, tapos naligo na ako at kumain. Nurse: nay, paano po kayo napunta dito sa NCMH? Patient: hindi ko nga alam eh. May nagdala sakin dito. Nurse: (silence and maintaining eye to eye

Placing the event or sequence

Helps the client to be attached to reality

Exploring

So that she can use her knowledge to recall what she has done for the whole day

contact) Patient: may sira kasi ang aking utak Nurse: ano pa po? Patient: matagal na ako dito dinala ako dito nung march 5. 7years na ko dito Nurse: ano po ang nararamdaman nyo ngayon at andito kayo sa NCMH? General Leads Helps the client to talk more that can help her express her feelings and emotions. Helps the client to express and interpret her own emotions. Helps us to identify the patients feelings about certain things. Makes her realized the value of life, hope and love Silence Gives client the time to organize thought ang go on

Interpreting

Patient: malungkot. Kasi gusto ko na makasama ang mga anak ko. Kasi dapat paaralin Reflecting ko yung bunso kong anak. Nurse: Masaya ba kayo pag naaalala nyo ang inyong mga anak? Patient: nalulungkot kasi namimiss ko na sila. Nurse: Ano po ang pinakamasayang araw nyo na kasama sila? Ikwento nyo nga po. Patient: masaya kapag nag pipicnic kami dati at kumpleto pero wala yung asawa ko kasi hiwalay kami nun. Nurse: ano po ang gusto nyong pag-usapan natin nay? Gusto nyo po tungkol sa asawa nyo? Patient: wag na yun. Nurse; eh, masaya po ba kayo sa activity natin nung nakaraang araw? Patient: opo, nag socialization pala kami kanina.

Encouraging evaluation

Summarizing

Recalling her happiest moments with her children will help in her learnings.

Giving Broad Openings

Encourages the client to share what she feels and what she wants to talk about Makes her realized the value of life, hope and love

Encouraging evaluation

Nurse: oh. Nagsaya naman po ba kayo? ano po ang gagawin nyo para sumaya din kayo sa socialization naming bukas? Patient: sasali ako sa mga laro at fashion show, kakain din ako ng masarap na pagkain. Nurse: tama nay. Kaya po sa biyernes ay magpaganda kayo at socialization na natin. Patient: oo, sige Nurse: oh nay, hanggang dito na muna po tayo ah. Maraming salamat nay Devina. Patient: sige Dennis, salamat din

Formulating a plan of action

Making plans increases the likelihood that the client will cope more effectively in a similar situation.

Giving Recognition

Appreciation is the best thing that can help the client to have a presence of recognition and will increase her self-esteem.