Our Lady of Fatima University

COLLEGE OF NURSING
Antipolo City

National Center for Mental Health

Psychiatric Health Nursing

Submitted by:
Arthur Jammes B. Ornias

Submitted to:
Mrs. Kristine Joy Anonuevo, RN MAN
Clinical Instructor
PROCESS RECORDING: February 4, 2019 (Monday)

I. Profile
Name: Juan Jacob
Address: San Juan
Status: Single

II. Objectives
a. General
To be able to:
 Establish rapport and a trusting relationship with the patient
 Discuss the contract to the patient
 Determine the type of psychiatric disorder of the patient through interview and observation
 Assess the behavior, thoughts process and content, affect, emotional state, sensorium and intellectual process of the patient
 Apply therapeutic communication that we learned during our lecture.

b. Specific
To be able to:
 Introduce myself to the patient.
 Create a good therapeutic communication
 Present reality whenever the need arises
 Show interest and sincerity to the patient
 Gather further information about the patient
 Encourage the patient to verbalize feelings and the reason behind them
 Attend to the patient’s needs

II. Setting
The nurse-patient interaction took place in a spacious area in Pavilion 11, just outside the ward was a bungalow structure where we seated. There was a
considerable distance between the student nurses and their respective patients. The working atmosphere was calm and therapeutic.

PROCESS RECORDING: February 4, 2019 (Monday)

 VERBAL NON-VERBAL THERAPEUTIC ANALYSIS NURSE’S FEELINGS
TECHNIQUE
N: Good morning po. Ako si student nurse Jammes. Ano po Patient looked directly Providing information Paying close attention to what I was surprised upon receiving my
ang pangalan niyo? to my eye, held a the patient says and observing patient from the ward as he
P: Juan Jacob. Pero Jacob nalang po sir. considerable time for Active listening both verbal and non-verbal cues. expressed a great interest on
N: So bago po tayo magsimula, gusto ko lang po ipaalam na eye contact. Patient is having to communicate. He held a
nandito kaming mga studyante ng OLFU Antipolo Campus. surprisingly good at Maintaining eye contact and positive affect and showed that he
Mag co-conduct kami ng mga interviews kada Monday keeping eye contact. making verbal remarks to clarify is friendly and sociable.
hanggang Wednesday sa bawat lingo, mula ngayon, and encourage further
hanggan 2 weeks after next week. communication
P: Okay po.
N: Taga saan po kayo?
P: Ay taga San Juan lang ako. Alam mo kung saan yun? Sa
may greenhills banda yung bilihan ng sapatos.
N: Ah oo. Madalas nga napapadaan ako dun. So dun ka
lumaki o sa iba?
P: Ah doon nako lumaki.
N: Ganun ba. Pamilyado ka na ba?
P: Ay nako, hindi pa po sir. Hahaha.
N: Pero may pamilya ka pa ba – magulang, mga kapatid?
P: Oo meron. Si mama ko nga kanina bumista e haha.
N: Oh okay yan ah. Kumusta naman paguusap niyo?
P: Ayun. Ayaw niya pa ako kunin e. Haha. Paguwi daw ni Broad opening To have an insight on his thought To initiate discussion, while at the
papa ko siya daw kukuha sakin. Di ko nga alam kung bakit Exploring content; to assess the connection same time allowing the patient to
e. Okay naman na ako e. Hahaha. Patient’s facial Asking relevant questions on his thoughts and to evaluate if determine what will be discussed.
N: Ano naman ang sabi sayo ng Doctor? expressions and the patient has thought
P: Okay naman na daw ako. Hinihintay ko nalang masundo gestures were disturbances.
e. Hahahaha. appropriate for what
N: So napansin ko may mga tattoo ka. Ano ibig sabihin ng he was saying. He
mga ito? usually smiles and
P: Ito? Haha ay wala yan. laughs like a child
N: Pwede ko Makita? before he speaks.
P: Oo. Hahaha
N: Ayos yan ah. Si Jesus bay an? Bakit bulag yung isang
mata?
P: Ah kasi inaasar ako dati. Mukha daw kasing banlag, so
ayun, pinagawa ko nalang na bungo yung kalahati. Hahaha.
N: Pero napaka creative ah haha gusto ko nga rin sana mag
patattoo e. Ano tingin mo?
P: Ewan ko e. Minsan kasi parang sana wala nalang ako
tattoo. Kasi iba tingin sakin e.
N: Ah so kumbaga parang phase o may panahon lang talaga
na gusto moa ng tattoos?
P: Oo. Pero andiyan nay an e. Hahaha kaya go with the flow
lang.
N: May iba ka tattoo maliban jan?
P: Sa likod ng ulo ko may 666 at 777.
N: Bakit naman 666 at 777?
P: Wala lang. Kasi diba parang cipher. Parang kailangan
pang idecode.
N: Ah ganun ba? E yang nasa gilig ng mga mata mo?
P: Cross at tsaka ano, yung parang bulaklak na pang good
luck.
N: Ah. Clover? Pang good luck nga daw. Exploring To have an insight on his thought I failed to focus the patient to talk
P: Oo kasi nabasa ko yan e. Yung parang sa Celtics. Good Patient looked around Paraphrasing content; to assess the connection only about one topic at a time. I
luck daw. the area when he was Reflection on his thoughts and to evaluate if tried to re-focus him but his
N: Ano naman ang kinahuhumalingan mo? thinking of what he Restating the patient has thought speech was very rapid.
P: Poetry. Mahilig ako magsulat. Nakasulat na nga ako ng has to say. General Leads disturbances.
rap ditto sa loob e. Kasi February lang ako napunta dito. Pag
labas ko nga plano ko maglabas ng isang kanta lang e.
N: Parinig naman ako ng mga nasulat mo. Tungkol saan ba
ito?
P: Parang cipher. Decode mo mga salita ganun. Idol ko kasi
yan si 2pac.
N: Sample nga.
P: I put my middle fingers up. You can’t be mad at me.
Because you can’t even pray for me. Because it’s all
blasphemy. You got to decipher, cipher, hidden messages
before I make this bloody mess. You cant see the best only
what’s less – of me.
N: Magaling. Pero napansin ko medyo may halong negatibo
sa rap mo. Ano ang tumatakbo sa isip mo nung nagsulat ka
nito?
P: Ah kasi di ko naman alam bat ako kasama dito. Sama
sama lang sa mga pasabog ganun. Go with the flow lang.
Kasi parang nag iba yung isip ko. Parang yung mundo,
nagging pula at blue. Tas parang naghalo? Parang ganun e.
Hirap i-explain hahaha. Exploring To have an insight on his thought This time, I was able to maneuver
*At this point, we were instructed to say our goodbyes as Paraphrasing content; to assess the connection our conversation by asking him to
we end the nurse-patient interactions.* Reflection on his thoughts and to evaluate if elaborate what he said earlier
Restating the patient has thought
General Leads disturbances.

Summarizing Contract has been restated for I clarified to the patient that our
 the patient to remember session for that day has already
come to an end and told him the
N: Sige Jacob. Maguusap nalang tayo ulit sa September 9. schedule of our succeeding
Bye at salamat sa panahon mo. meetings.
P: Sige po. Salamat din po sir.

V. EVALUATION:
Good rapport was established upon meeting the patient. Overall appearance was nice and clean. Nothing stood out as unhygienic. He seemed to be smarter or
more capable mentally compared to most of the patients in the lineup. More substantial reports will be done upon further interviewing and observation of the client in the
weeks to come.