Process Recording

PROCESS RECORDING

Resident: Mr. J.VAge: 21Diagnosis: schizophrenia undifferentiatedObjective: Establish rapport and a trusting relationship with the client to be able to encourage the patient to verbalize his feelings and the reason behind themGeneral Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual movements or mannerisms were observedSetting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather like a park with plenty of plants and the noises are subdued. Date: January 4, 2010

VERBAL ( NON VERBAL )THERAPEUTIC

COMMUNICATION TECHNIQUE USED

RATIONALE AND FEELINGS OF NURSE

EVALUATION

Nurse Patient Giving recognition

Offering self Rapport

building Giving

information

This is the Orientation Phase so it is important that I establish rapport and a trusting relationship with my client. Greeting the client by name shows that you acknowledge the patient as an individual, and he by responding proves that he knows his own name and is oriented with what’s happening at the moment. I feel that my patient responded rather shyly.

Patient J. was shy at the start, but eventually starts to open up his previous life to me. He doesn’t maintain much eye contact and frequently forgets information. The objective for today was met since the patient had eventually become comfortable therefore a good rapport was established. Giving reward made Mr. J answered my questions.

“Magandang araw Mr. J, ako po si nurse James, at ako makakasama nyo sa araw na ito. kamusta ka?” ( open posture, walking, smiling)

“Ok lang.” (nods, smiles a little but avoids eye contact)

“ano ang pangalan mo?” (Sitting, looking directly at Mr E.)

“James Villanueva” (briefly gazes at me then looks at his feet)

Seeking information

This question does not only seek information from the client, this also checks if the

patient is oriented and paying attention. I feel like the patient is not comfortable enough based on his nonverbal actions.

“ ah, ganun ba. Ilang taon ka na?” ( maintains eye contact; sitting, leaning forward, nods)

“15.” (maintains eye contact.)

accepting exploring

This indicates that the nurse understands the client. I feel that Mr. J is not totally oriented based on his answer.

“Saan ka nakatira, bago ka dalhin dito?” (maintains eye contact, leaning forward while sitting)

“….Silence.”(Gaze at his side, leaning back on the chair)

exploring active listening

This question not only checks his memory, this may open new topics for us. I feel that Mr. J is still not comfortable enough based on not answering my question and on his non verbal actions.

“anong pangalan ng nanay mo?”( leaning forward, maintaining eye contact)

“Perlita Villanueva” (smiling, leaning back on the chair)

seeking information

active listening

Since the patient failed to answer the previous question, it’s necessary for me to show the patient that it’s ok. This will encourage the patient to respond more. I feel that the Mr. J is starting to feel comfortable since he is now smiling.

“Ano ang niluluto sayo ng nanay mo?” (leaning forward, maintaining eye contact)

“Pancit.” ( smiling, leaning back on the chair)


This question focuses in the Mr. J’s relationship to his parent, this will help the client to talk about his life more.

“Malapit ka ba sa nanay mo?” ( leaning forward, maintaining eye contact)

“Oo. ( smiling, leaning back on the chair)

focusing verbalizing the

implied active listening

This question encourages Mr J to expand his response earlier. I feel like, Mr J is fond of talking about his life and his parents.

“Nasaan ang nanay at tatay mo ngayon?” ( leaning forward, maintaining eye contact)

“….silence. (averts gaze, a bit teary eyed, sitting but fidgeting with the hem of his shirt, leans forward)

exploring active listening use of silence

Here, I allowed a significant time to pass, it will give Mr. J the opportunity to collect his thoughts and gain insight. I feel like my patient has finally opened a sensitive topic, he has shown slight behavioral changes when he responded to the question.

“Ano ang pangalan ng tatay mo?” (maintaining eye contact, open posture; leaning forward)

“Erfren Villanueva (smiling, teary eyes, avoiding eye contact)


The main thought of what Mr. J previously acts was call attention to this topic. This will also indicate that I am actively listening to what he is saying

“Anong trabaho ng tatay mo?” ( maintaining eye contact, open posture)

“Pintor.” (smiling, glances briefly, scratches his head, leans back)


This encourages Mr. J to expand his previous response so that I will gain better insight and understanding to what he is saying. I feel that Mr. J is trying to conceal whatever emotions this topic has brought to him.

“Wow, eh di tinutulungan mo siya? ( open posture, maintining eye contact,)

“…Hindi ko alam.”(not looking at me, blank expression, leaning back)

active listening offering

general leads

This basically encourages my patient to continue his story telling. I feel the patient still disoriented.

“tinutulungan mo b siya magpinta?” (maintaining eye contact, open posture)

“Oo.”( smiles, briefly looks at me)

active listening,

offering general leads

This basically encourages my patient to continue his story telling.

“Ilan kayong magkakapatid?” ( maintaining eye contact, open posture)

“Apat.” (smiles and looks at me)

active listening exploring

This will help both me and the patient to see the whole event in perspective. I feel like he is trying to hide his emotions.

“pang ilan ka sa inyong magkakapatid?” (maintaining eye contact, open posture)

“Hindi ko alam.” ( maintains eye contact, responded nonchalantly)

active listening focusing

This will help both me and the patient to see the whole event in perspective. I feel like the said question has had a very strong impact on Mr. J.

“Ano pangalan ng mga kapatid mo?” (maintaining an eye contact and open posture)

“pancit…..”(maintains eye contact, responded nonchalantly)


This question will enable Mr. J. to analyze the question in detail and of course, expand the current topic. But I think I need to use the reward punishment during the conversation.

“nasabi mong pancit? Ano ang dahilan sa pagsabi mo ng pancit?”(leaning forward, maintaining eye contact, open posture)

“…silence” (leans back)

active listening exploring

This will help me and the patient o see the whole thing in perspective. I think the client has more emotions and negative feelings about the current topic.

“nasabi mong pancit dahil….”(maintaining eye contact, open posture)

“gutom….”(blank expression, avoiding eye contact)

encouraging expression

providing general leads

active listening

This encourages Mr. J. to continue what he is saying and to express his feelings regarding to the ‘pancit’. . So by verbalizing this, the discussion is less obscure.

“paano ka magugutom eh kakakain mo lang.”(maintaining eye contact, open posture)

“….pancit”(blank expression, avoiding eye contact)

focusing active listening sharing

perception

This question focuses on what the client means with the word “pancit”. Also, it focuses on the feelings of the client

“o sige bibigyan kita ng pancit pagkatapos kuwentuhan mo ko.” (maintaining eye contact, open posture)

“oo.”(blank expression,avoiding eye contact)

verbalizing the implied


Mr. J directly portrays what he really feels, so by merely giving food to the client let him answering my questions.

“ano ang nararamdaman mo pag kumakain ka ng pancit?”(maintaining eye contact, open posture)

“Masaya.”(blank expression, avoiding eye contact)

focusing active listening encouraging

expression

This focuses on the client’s feeling during that moment. It encourages the expression of Mr. J’s feelings.

“dib a sabi mo kanina nilulutuan ka ng nanay mo ng pancit, masarap ba siyang magluto ng pancit?”(maintaining eye contact, open posture)

“Oo”(smiles, eye contact, waving his hands)


This question encourage the patient to expand the story regarding with his relationship to his parent.

“ah, ganun ba!”(smiles, open

“oo”(smiles, scratches his head)

accepting

postures, leans forward,nodding)

“sige ituloy na lang natin bukas, balik na tayo sa loob”

“ah, oh cge”

PROCESS RECORDING

Resident: Mr. J.VAge: 21Diagnosis: schizophrenia undifferentiatedObjective: To continue encouraging the patient to express feelings and formulate a plan of actionGeneral Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual movements or mannerisms were observed

Setting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather like a park with plenty of plants and the noises are subdued. Date: January 11, 2010




EVALUATION

Nurse Patient giving recognition

offering self

Greeting the client shows that the nurse acknowledges the client as a person.

Mr. J is more comfortable today and has shared some significant information, feelings and experience to me. He even summarized the whole conversation and seemed to have realized the mistake he did before. He came up with a plan that he intended to carry out after his hospitalization at National center for Mental health.

“magandang umaga po, ako po ulit ang nurse ninyo para sa

araw na ito”(smiling, briefly touches the

shoulder)

“…silence”(smiling, nodding)

“Nag aaral ka ba bago ka dalhin

dito?”(sitting, open posture, maintaining

eye contact)

“Oo”(smiling, hand gestures)

Exploring This will help the client examine the topic more fully

“san ka nag aaral?”(leaning forward, open

posture,maintaining eye contact)

“aklan”(eye contact, open posture)

Exploring Active

listening

By giving follow up questions to the client, the nurse shows that he is listening and that it urges the client to continue.

“eh di madami kang kaibigan sa

school?”(eye contact, open posture)

“hindi ko alam”(nodding, smiling)

focusing Active

listening

This will also indicate to the client that the statement was communicated effectively.

“sino ang pinaka malapit sayo na kaibigan?”(eye

contact,open posture)

“Si Jp”(responds nonchalantly)

Exploring Active

listening

The nurse can better understand superficial topics if it is explored by delving deeper into the subject.

“mabait ba si Jp?”(eye contact, open posture)

“….silence”(scratches his head)

Focusing Active

listening

The client is encouraged on a single topic and indicates that the nurse is listening.

“May dala kong biscuit dito, bibigyan

kita tapos kuwentuhan mo ko, lagi mo bang kasama si Jp?”(eye

contact, open posture)

“…Oo, biscuit”(smiling) Exploring Active

listening

Since the patient failed to answer the previous question, it’s necessary for me to show the patient that it’s ok. This will encourage the patient to respond more. The nurse used reward punishment for the patient to respond.

“lagi kayong magakasama?”(eye


“Oo, basketball”(smiling)

Restating Active

listening

Repeating a key word that captured the attention of the patient, provides validation and confirmation that there was an effective communication.

“naglalaro kayo ng basketball?”(eye


“Oo”(hand gestures, smiling)

Active listening

Focusing

This is a follow up remark to encourage the client to continue with the story.

“tapos…”(eye contact, open posture)

“basketball tapos kain kame madame”(leans

back)

Offering general leads

Active listening

This is a follow up remark that encourages the patient to continue talking and expanding the topic.

“saan kayo naglalaro at kumakain?”(eye


“Sa bahay, basketball”(pointing to

the court,nodding)

Exploring Active

listening

This let’s the client know that the statement was communicated effectively.

“Hindi tayo puwedeng maglaro ng basketball

“bicuit.” ( scratches his head, leaning backward)

Disapproving Active

This focuses on disapproving what the clients want to do. I

kasi wala tayong bola.”(open posture,

eye contact)

listening feel that Mr. J change his behavior after disapproving what he wants to do.

“sige bibigyan kita tapos sasagutin mo

yung mga tanong ko, diba ang papa mo

pintor? Ikaw ano gusto mong maging?”(open posture, eye contact,

nodding)

“Oo, Pulis, army”(scratches his

head, smiling)

Accepting Exploring Active

listening

This indicates that the nurse understands the client but is non judgemental in nature.

“May kilala ka bang pulis o army?”(open posture, eye contact)

“army, si Andrew”(leans back, avoids eye

contact)

Exploring Active

listening

Certain topics will be better understood if it is explored by delving deeper into the subject.

“army ba si Andrew??”(leans back, eye contact,

open posture)

“Hindi ko alam.”(smiling, avoids

eye contact)

Exploring Active

listening Restating

Repeating a key word the patient has said, provides validation and confirmation that there was an effective communication.

“Ano ang dahilan at gusto mong maging

pulis o army?”(eye contact, open

posture)

“Hellicopter.”(smiling, nodding)

Exploring Active

listening

Certain topics will be better understood if it is explored by delving deeper into the subject.

“gusto mong sumakay sa hellicopter At gusto

mong maging army”(eye contact,

open posture)

“ayaw, hindi ako marunong, baka

mahulog ako.”(briefly looks at me)

Summarizing Active

listening

Summarization brings out the important points of the discussion and to increase the awareness of the client. It also provides a sense of closure for the whole

conversation.“di ba sabi mo apat

kayong magkakapatid,pangilan ka?”(eye contact, open

posture)

“bunso”(smiling) Exploring Active

listening

Certain topics will be better understood if it is explored by delving deeper into the subject

“anong pangalan ng mga kapatid mo?”(eye contact, open posture)

“….pajong, mac at bongbong.”(maintains

eye contact)

Active listening

Focusing

This is a follow up remark to encourage the client to continue with the story.

“malapit ka ba sa kanila?”(eye contact,

smiling)

“Oo, biscuit”(maintaining eye

contact, smiling)

focusing The client is encouraged on a single topic and indicates that the nurse is listening.

“ah.. ganun ba! Sige, balik na ulit tayo sa loob. Tuloy na lang natin bukas yung

usapan natin.”(eye contact)

“sige”(smiling, nodding) Accepting

PROCESS RECORDING

Resident: Mr. J.VAge: 21Diagnosis: schizophrenia undifferentiatedObjective: To properly terminate the whole interaction between the nurse and the patientGeneral Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual movements or mannerisms were observedSetting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather like a park with plenty of plants and the noises are subdued. Date: January 12, 2010




EVALUATION

Nurse Patient Giving recognition

Greeting the client shows that the nurse acknowledges the patient as a person

The whole interaction with Mr. E ended with appreciation from both of us.

“kamusta po ang activity ngayong

araw?’ (smiling, open posture)

“ok naman, masaya”(smiling,

nodding)

“ngayon na kasi ang huling araw namin

dito, gusto ko sanang mag pasalamat sa oras

at partisipasyon mo”(smiling, briefly

touches the arm)

“salamat, paalam sayo.

babye”(smiling, nodding)

Mood and affect

Patient J.V is a shy type person. It seems that he is guilty on what happened in his life. He has a poor eye contact, and I can see in his facial expression that he is not at ease when we talked about his condition.

Speech

He is normally responsive to cues. There is also a time that he is whispering.

Perceptual disturbance

He is not experiencing any hallucinations and delusions during our interaction.

Thought

He is shifting to one topic from one subject to another in a somewhat related way.

Sensorium and Cognition

He is oriented to date and time. He is conscious and alert. He knows what they ate in breakfast, lunch and dinner before our interaction. He is good in drawing and coloring. He can read and write.

Process Recording

Documents

Transcript of Process Recording