Camille Grace B.

Libunao 3NUR5 RLE4

Initial Interaction Process Analysis

I. PATIENT’S PERSONNAL DATA & MSE

Name: Wilson Torres Age: 34 Birthday:
Marital Status: Married Sex: Male
Address: Laguna
Admission Date and time: 2014
Reason for Admission:
As verbalized by the patient, “kase galit buong pamilya ko sakin”, “kase nagpupumilit ako
lumabas ng bahay”
According to relatives: As seen in the chart, relatives verbalized “nananakit, nagdrodroga,
binabantaan kami na papatayin kami”

Previous Psychiatric History:

Date: initially admitted 2012-2014
Reasons/Diagnosis: As verbalized by the patient “kase umuwi akong lasing tapos nagalit”
Type of Treatment received:

Drug and Alcohol use/abuse: Client admits use of Alcohol and Shabu
Amount:
Frequency: 3 times per week
Duration of past and present use of substance: 20 years of Alcohol, 16 years of Shabu
Date and time of last use: September 2017 (PTA)

Disturbance in patterns of daily living

Sleep: 8 hours but with frequent awakening; patient verbalized “okay naman, mga 8 hours pero
pagising gising ako”
Elimination: Only when has the urge to void
Sexual Activity: N/A
Leisure: Playing basketball
Self-care and hygiene: takes a shower everyday

Spirituality:
Religion: N/A
Beliefs and Practices: N/A

Support Systems: Wife, Friends

Relationships:
Wife: patient described her as someone who is very understanding of him and always forgives
him when he does something wrong
Friends: Patient described them as understanding and often gives advice to him when in need.
However, they too have bad habits of consuming drug, alcohol, etc. However, patient
 denied that his friends encouraged him to use any of these substance and verbalized
that it was his choice

MENTAL STATUS EXAM

General Appearance: Patient is fairly kempt in blue uniform and observes proper hygiene. No
presence of cuts or any lesions, has tattoos on arms, legs, and chest, has a stooping posture
when sitting down, has slow gait.
Behaviors during Interview:
Client was focused most at the time, often staring at one space, occasionally losses focus/gets
distracted; eyes wander to different places and not able to focus on question/topic
Expression of Anger: Punches walls and lashes out anger to family members
Degree of cooperation:
Social Skills:

Amount/Type of Motor Activity:

Levels of Activity:
o Psychomotor Retardation o Tense
o Agitated o Hypervigilance
o Restlessness o Others: _______________
Type of Activity:
o Tics o Compulsion
o Grimaces o Unusual gestures/Mannerisms
o Tremors o Others: ______________
Speech Patterns:
Amount: Talks when asked
Rate:
o Rapid o Loud
o Slow o Soft
Characteristics
o Slurring o Others: _____________
o Stuttering
Description: Patient answers appropriately to questions, answers briefly, needs to be asked to
elaborate on a topic for him to give further information about the topic

Degree of Concentration, Attention Span, and Calculations:

The patient was able to concentrate most of the time but gets distracted sometimes, missing
the question/asking what were we talking about

Orientation:
Time: Oriented “umaga”
Place: Oriented “mental”
Person: Oriented “Wilson”
Memory:
Remote: Was able to remember past experiences in his life
Recent: Was able to remember activities the previous day
Immediate: Was able to repeat the numbers stated

Others
o Blackout o Amnesia
o Confabulation
Thought clarity:
o Coherence o Vagueness
o Confusion
Thought process reflected in speech:
o Blocking o Perseveration
o Circumstantiality o Tangential Ideas
o Echolalia o Ambivalence
o Flight of Ideas o Neologism
o Loose Association o Verbigeration
o Word Salad
Though Content:
o Feelings of hopelessness, o Compulsions
helplessness, worthlessness, guilt o Preoccupations
o Suicidal ideas/plans o Antisocial attitudes
o Homicidal ideas/plan o Blaming of others
o Suspiciousness o Poverty of content
o Phobia o Denial
o Obsessions
Description: The patient was able to answer question appropriately and able to go in detail with
the topic with exploration. Was also able to answer reason for admission and go in detail about
his past

Hallucinations:
o Auditory o Others: ____________
o Visual
Content: Patient denied any presence of halucinations

Delusions:
o Grandeur o Influence
o Religious o Persecution
o Reference o Somatic
Content: Patient denied any presence of delusions
Information and Intelligence: High School Graduate, was able to interpret phrase “kapag may
tyaga, may nilaga”

Affect/Mood:
Anxiety level
o Mid o Severe
o Moderate o Panic
Affects:
o Appropriate o Blunted
o Inappropriate o Flat
o Adequate o Labile
o Restricted
Mood:
o Euthymic o Depressed
o Elevated o Labile
Insight: patient was able to verbalize the reason for his admission, “kase galit buong pamilya ko
sakin”, “kase nagpupumilit ako lumabas ng bahay”
o Poor o
o Good o
Judgement:
A situation was given, “kapag po nasa bahay kayo tapos may sunog, ano pong gagawin ninyo”.
Patient answered with “lalabas ako or gigisingin ko mga tao kung meron akong kasama tapos
hihingi ng tulong o tatawag ng bumbero”

Objectives:
Short term: After 1 hour of nurse-patient interaction, the patient will be able to start to
establish rapport and trust, and share some information about him. The Student Nurse will be
able to start to establish rapport and gain the trust of the patient, using therapeutic
communication techniques when interviewing the patient. The patient will also be able to form
understanding that the nurse he is with will be his nurse for the allotted days and he will be able
to form an understanding to the rules and regulations set by the students during nurse-patient
interaction and therapy time

Long term: After 3-4 weeks of nurse-patient interaction, the patient will be comfortable
expressing his feelings, sharing information about his past, and able to share insight and
improve problem solving skills that will improve progress and contribute to the positive change
of behavior in the patient. The student nurse should be able to maintain the trust, rapport, use
of therapeutic communication techniques, help the patient in sharing insights, and help
improve problems solving skills.

Venue, Date, and Time of Interaction:

1. NCMH Pavillion 35 (1), March 16, 2018 9:00 AM
Table of Conversation
Verbatim Accounts
N: Good Morning po sir!
Kumusta naman po kayo
P: Okay naman
N: Sir, since napagusapan na Nurse is setting the topic to be
natin nakaraan yung kabataan talked about today
ninyo, pagusapan naman po
natin yung noong medyo
matanda na kayo. Noong
binata po kayo
P: Sige
N: Ano nga po pala yung
trabaho ninyo bago pa po kayo patient's life prior to
ma admit po?
P: Tricycle Driver
N: Kumusta naman po ba
trabaho ninyo noon, nilang
tricycle driver?
P: Okay naman, masaya
naman kase hindi gaano
nakakapagod. Magaan lang
yung trabaho
Analysis Nurse's Feelings
Nurse is using broad opening Slightly nervous but feeling
to allow patient to freely rather confident because I
express feelings and thoughts have prepared topics for my
patient
Patient replied that he is
feeling okay but is not
expressive of his feelings
unless asked
Patient showed understanding
and willingness for compliance
Nurse is collecting data of the
admission
Patient was able to respond
appropriately, however his
response is only limited to
what is being asked. Patient
also showed awareness and
orientation about his self and
his previous life outside
Nurse is using broad opening
to allow the patient to fully
express his feelings and
thoughts about the topic
Patient answered
appropriately and expressed
his feelings and thoughts
about his previous job
N: Ano po ba yung trabaho na Nurse is exploring the
pinangarap nyo po dati? patient's desires and dreams
to see if there is any
underlying guilt within the
patient

P: Pulis Patient showed understanding

of the question and was able
to answer appropriately

N: Ano naman po ba yung Nurse is further exploring the

dahilan kung ba't ayun yung reason why the patient
napili ninyo na trabaho na wanted to be a police officer
gusto

P: Wala lang, mukang masaya Patient is showing continuous

eh. Saka bata palang talaga
ako, pangarap ko na talaga
maging pulis
understanding to the
questions given and answers
appropriately. Patient was also
seen to be happy when this
topic was brought up and was
more expressive and open to
telling stories

N: Meron po bang nag Nurse is exploring further,

impluensya sainyo para seeing if there are any
gustuhin ninyong maging influences of models that the
pulis? patient may have gotten it
from

P: Wala naman, talagang gusto Patients still showed

ko lang kapag nakikita ko sila. understanding and answered
appropriately to the questions

N: Kapag po ba nakauwi na po Nurse is exploring the

kayo, meron po ba kayong patient's feelings and seeing if
plano para tuparin yung there are any goals set when
kagustuhan ninyo maging discharge is conducted
pulis?

P: Hindi na... Patient showed understanding

to the question and answered
appropriately. However, mood
 seemed to lower down that
may imply guilt, sadness,
hopelessness, or any negative
feelings

N: Ano naman po bang dahilan Nurse is further exploring the

kung bakit hindi na? patients feelings and insight
about the situation

P: Eh syempre matanda na ko, Patient showed understanding

saka wala na akong pagasa, to the question and answered
ano ka ba. appropriately. However, mood
seemed to lower down that
may imply guilt, sadness,
hopelessness, or any negative
feelings

N: * nods * To convey understanding and

empathy to the patient using
non verbal communication

N: Uh Diba nga po pala Nurse is trying to introduce

nabanggit ninyo na high school another topic and is verifying
po ang natapos ninyo? the information gotten
previously about the patient's
educational attainment

P: Oo Patient showed understanding

to the question and answered
appropriately but is only
limited to the question

N: Ano naman po bang dahilan Nurse is exploring the reason

kung bakit hindi ninyo of the patient for not
ipinagpatuloy sa collegio? continuing school

P: Ah eh wala eb, nalulong na Patient showed understanding

ako sa droga noon eh. Saka,
wala talaga eh.
to the question and answered
appropriately. However his
response may imply guilt,
regret, sadness, hopelessness
or any negative feelings about
himself
N: Meron pa po ba kayong Nurse is exploring further the
ginusto pa pong curso dati po? desires of the patient

P: Ahh meron naman Patient showed understanding

to the question and answered
appropriately

N: Ano naman po ba yon? Nurse is further exploring

P: Ginusto ko rin maging chef Patient showed understanding

to the question and answered
appropriately

N: Mahilig po ba kayo Nurse is further exploring

magluto?

P: Oo naman Patient showed understanding

to the question and answered
appropriately

N: Ano po ba mga gusto Nurse is further exploring

ninyong niluluto noon po?

P: Mga menudo, adobo. Patient showed understanding

Ganon to the question and answered
appropriately

N: Sa bahay po ba, nagluluto Nurse is further exploring

rin po kayo?

P: Oo, paminsan minsan. Pero Patient showed understanding

asawa ko kase nagluluto eh. to the question and answered
appropriately

N: * nods * To convey understanding and

empathy to the patient using
non verbal communication

N: Edi noong natapos po kayo Nurse is trying to introduce

ng highschool, ano na po bang another topic and is gathering
ginawa ninyo? information about the
patient's demographic data
P: wala tumambay muna ako, Patient showed understanding
tapos nagkatrabaho rin to the question and answered
appropriately

N: Ano na po ba yung una The nurse is exploring

ninyong naging trabaho?

P: Dancer, sa Adonis Patient showed understanding

to the question and answered
appropriately

N: Mga ilang taon po kayo The nurse is exploring to

nung nagsimula po kayo mag identify the duration of his
trabaho doon? work as a dancer that may
affect him

P: Mga 19 Patient showed understanding

to the question and answered
appropriately

N: eh hanggang anong edad The nurse is exploring to

naman po? identify the duration of his
work as a dancer that may
affect him

P: mga 38 Patient showed understanding

to the question and answered
appropriately

N: Ano naman po bang rason Nurse is exploring the

kung bakit ayun po yung napili patient's reason for choosing
ninyong trabaho? an unorthodox job

P: eh wala, madali yung pera Patient showed understanding

doon eh. Sasayaw ka lang, to the question and answered
tapos hindi ka pa pagod. appropriately. His response
also implied that there were
financial issues

N: Napag alaman po ba to ng nurse is exploring if he was

pamilya nyo po? given judgment for having an
unorthodox job
P: Oo, nahuli rin naman
N: Paano po ba nila nalaman?
P: eh laging wala sa bahay
tapos nalaman nila na may
karelasyon ako
N: ano naman po ba naging
reaksyon nila
P: wala sabi ng asawa ko bakit Patient showed understanding
mo to nagawa, ganon
N: ano naman po bang
naramdaman ninyo noong
sinabi nya po iyon?
P: syempre nalungkot. Pero
sinabi ko naman sakanya na
ginagawa ko lang to para
umangat yung buhay namin
N: Eh yung iba nyo pong
pamilya, ano po bang naging
reaksyon nila o sinabi/
P: eh wala sinasabi nila, mag
quit na ko. Nakakahiya daw
Patient showed understanding
to the question and answered
appropriately. Patient was also
noticed to be really calm
about sensitive topics and
answers straight to the point
without hesitation, which may
imply intellectualization
Nurse is further exploring
Patient showed understanding
to the question and answered
appropriately.
Nurse is further exploring to
see how his relative reacted
which may have affected him
to the question and answered
appropriately. Patient was also
noticed to be really calm
about sensitive topics and
answers straight to the point
without hesitation, which may
imply intellectualization
Nurse is exploring how the
patient felt or reacted with
how his relatives reacted
Patient showed understanding
to the question and answered
appropriately.
Nurse is further exploring to
see how his relative reacted
which may have affected him
Patient showed understanding
to the question and answered

N: eh ano naman po bang
anramdaman po ninyo sa
sinabi nila?
P: wala totoo naman,
nakakahiya. Pero kaylangan
kase, kasi mahirap yung buhay,
saka madali pera doon.
N: nabanggit nyo po diba na
nagkaron kayo ng karelasyon,
ano naman po ba yung dahilan
kung bakit kayo nagkagusto
sakanya
P: hindi ko naman sya
nagustuhan. Adonis kase yun
eh, kaya naibibigay sakin kung
ano man gustuhin ko
N: naghiwalay na po ba kayo?
P: oo
N: ano naman po bang dahilan Nurse is further exploring
kung bakit kayo naghiwalay?
P: eh wala, di na natiis yung
appropriately. Patient
responded in a way which may
be implied to have guilt or
negative emotions towards
self
Nurse is exploring how the
patient felt or reacted with
how his relatives reacted
Patient showed understanding
to the question and answered
appropriately. Patient
responded in a way which may
be implied to have guilt or
negative emotions towards
self
Nurse is further exploring and
focusing on another detail the
patient mentioned about the
situation
Patient showed understanding
to the question and answered
appropriately. Patient was also
noticed to be really calm
about sensitive topics and
answers straight to the point
without hesitation, which may
imply intellectualization.
Nurse is further exploring
Patient showed understanding
to the question and answered
appropriately.
Patient showed understanding
ugali ko. Masyado daw matigas to the question and answered
yung ulo ko
N: ano naman po bang
naramdaman ninyo noong
naghiwalay kayo?
P: wala, nalungkot sympre.
Kase may pinagsamahan rin
kami, saka mabait sya.
Binibigay nya lahat ng gusto
ko. Ayun nalungkot
N: * nods *
THERAPY TIME
Adult education therapy about Patient cooperated and
sportsmanship
Occupational therapy about
making shawarma
N: Sir, kumusta naman po ba
yung mga therapy?
appropriately. Patient
responded in a way which may
be implied to have guilt or
negative emotions towards
self. But patient showed good
insight because he was able to
recognize if he did something
wrong
Nurse is exploring how the
patient felt or reacted to the
situation mentioned
Patient showed understanding
to the question and answered
appropriately. Patient
responded in a way which may
be implied to have guilt or
negative emotions towards
self. But patient was able to
recognize emotions well about
the situation
To convey understanding and
empathy to the patient using
non verbal communication
responded well in both
therapies. Followed
instructions corrected,
needing little guidance and
answered the evaluative
questions conveying
understanding and learning
from the therapies
nurse is using broad opening
questions to reevaluate the
patient on a more personal
level to make the client
 express his feelings and
thoughts more since rapport is
established between nurse
and patient

P: ayun, masaya naman. Patient showed understanding

Marami akong natutunan. of the therapies and it showed
Namiss ko tuloy maglaro ng that the patient was affected
basketball tapos positively because it made him
nakapagbaliktanaw reminisce about his days

N: ganon po ba, mabuti naman Nurse is giving encouraging

po at marami kayong the patient to listen to
natutunan therapies for more new
knowledge

N: kumusta naman po ba nurse is evaluating how the

nararamdaman nyo ngan? patient feels and exploring

P: mabuti naman. Nakakagaan Patient is expressing his

ng pakiramdam kase may feelings about verbalizing and
nakakausap ako, di tulad doon his statement can be used as
sa ward na walang ginagawa an evaluation that talking
makes him feel better

N: ganon po ba, sige po. Wag nurse is giving the patient

lang po kayo mahihiya reassurance that she is willing
magsabi o magkwento sakin to listen to the patient the not
dahil handa naman po ako judge
makinig lagi

END OF INTERACTION

Summary of Patient Interaction

On the second week of interacting with my patient, I can say that I have really
established rapport with him because he was able to share a lot of information with me. I still
see him as somehow intimidating since he is not really vocal unless asked with many questions.
But sometimes, if a question has caught his interest he is really vocal and open with his stories
and makes me feel confident that I am handling my patient well.

I see that my patient has guilt or negative feelings towards himself because in today's
interaction and even the previous days, he mentions phrases like “eh ako kase”, “matigas kase
ulo ko eh” and the likes. The patient was also able to open up freely to me needing to be asked
follow up questions for him to give more details. It was also seen that his focus is better
compared to previous days wherein he will forget my question and drift off.

To summarize, I am still nervous when interacting with him but I feel more confident
because he is starting to take initiative on some topics. He was also able to talk about sensitive
topics about his life easily, not showing any signs of distress (unlike the first day). However, it
may be interpreted that he is intellectualizing his situation since he is not expressing a lot of
emotions and answers factually. Other than that, I see a great improvement in our relationship
as a nurse and patient and learned a lot of things about him