Process Recording No.

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Clients Initials: L.E. General Objective: To develop understanding on patients situation by verbal and nonverbal communication. Specific Objectives: a. To develop skills in interacting with my patient both long and short term goals. b. To understand the needs of my patient both therapeutic and non therapeutic. c. To be able to recognize behavioral changes on my patient. d. To be able to manage problems appropriately. e. To be able to gain trust from my patient. Appearance of the client: Patient is a bit skinny; her hair is cut short, has an oily face and carries a bag with her all the time. Patient has halitosis and yellow teeth. Patient dresses herself usually in a t-shirt pairing it with shorts. Patients fingernails are long and dirty as well as her toe nails with faded pedicure. Date: January 27, 2012

Description of the Environment: Patient says Di ko ganahan diri. referring to the facility because its crowded and noisy. As Ive observed the facility is too small, facilitating the entire patient staying there and its not condusive on their wellness. They sleep on bed made of steel without any coverings or any mattresses while some patients sleeps on chairs or worst in the floor.

Evaluation of the interaction: Patient was able to trust me eventually. Patient answered my questions very well but there are still times that shes being hesitant and some answers are so limited. I was able understand patients situation and her concern of really going home. I have also developed the understanding of my patient through verbal and non verbal communication. And Im able to understand patients behavior too.

References: Boyd, Mary Ann, PhD, DNS, RN, APRN, BC 2008 Psychiatric Nursing: Contemporary Practice 4th Edition Southern Illinois University Edwardsville Edwardsville, IL Shives, Louise Rebraca Basic Concepts of Psychiatric-Mental Health Nursing Beck, Jyoti RN, RM, DPN RINPAS Nursing Process in Psychiatric Nursing Ranchi, India

Student Nurse Good Morning!

Client Good Morning! with a good eye contact and a sweet smile on her face.

Inferences Giving Recognition

Interpretation Pt is responsive.

Ako diay si Jane Jane Marie Cruz ako ang imong as pt reads my student nurse gikan name. sa UV.

Proving Information

Pt is reads my name for reassuring.

Unsa imong ngan?

Lynitz Eran. smiles.

Proving Information

Pt states her name.

Pila na imong edad Lynitz?

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Offering General Leads

Pt gives accurate information.

Kumusta imung adlaw Lynitz?

Ok ra. With good eye contact.

Giving Broad Openings

Pt limits her response.

Kanus-a ka na Pagka November admit diri Lynitz? 11

Offering General Leads

Pt gives accurate information.

Nganong na admit man pod ka diri Lynitz?

Nangaway man Giving Broad gud ko sa among Openings silingan. Smiles.

Pt recalls passed events.

Nganong Kay mga libakira nangaway man pod man kaau. Says ka? angrily.

Giving Broad Openings

Pt recalls passed events and feelings.

Student Nurse Ge unsa pod ka nila pag libak Lynitz

Client Ana sila na naa nasad ang tulo ka boang ai!

Inferences Giving Broad Openings

Interpretation Pt recalls passed events.

ahh! Niya wa diay nimu napugngan imu kaugalingon na di mangaway?

Wala, ambot ngano. Asks herself.

Giving Broad Openings

Pt explains reasonably.

Ika pila na diay ni Ika tulo na sugod nimung admit diri pag-19 nako. Lynitz?

Providing Information

Pt says its her 3rd time to be admitted but in her chart states its already her 4th time. Pt gives affirmation.

Aw ikatulo na Oo nods. diay nimu Lynitz.

Restating

Unsa diay nahitabo pag kinaunhan nimong admit diri?

Naibog man gud kaayo ko sa pan mao to akong gebu-ak ang bildo sa bakery.

Offering General Leads

Pt was aware of what she did and can still recall.

Mangutana ko bahin sa imong pamilya ha?

Nods.

Accepting

Pt gives affirmation.

Kinsa imo kauban Akong mama og sa balay? akong anak. With good eye contact.

Providing Information

Pt willingly responded.

Student Nurse Pila na pod edad sa imong anak?

Client Tres na.

Inferences Providing Information

Interpretation Pt willingly responded.

Nods.

Mag kuwatro nato Using Silence ig February.

Pt added.

Naa kay bana Lynitz? Asa man siya ron?

Oo . Wa ko kahibaw asa to.

Giving Broad Openings

Pt answers with no hesitation.

Ngano man?

Wa na naman Offering General siya ni uli sa amo. Leads Says it in a low voice.

Pt is unhappy while responding the question.

Nods.

Kato man tong wa ko ni kuyog niya sa Davao, sukad ato wa na siya ni uli.

Using Silence

Pt tries to elaborate what really happened.

Nods.

Nakakita man ko niya katong na koy lakaw kuyog akong anak, naa siya kauban babae.

Using Silence

Pt starts to share a lot more on her personal life.

Ni unsa raman ka?

Wala ra.

Giving Broad Openings

Pt responds shortly.

Student Nurse May gani wa ka mangaway niya.

Client Smiles. Wa man sad.

Inferences Giving Recognition

Interpretation Pt was aware that she did the right thing.

Niya love pa nimo siya?

Di na oi bahala Giving Broad nato siya, di nako Openings atong Jomar., Tabi-an man kayo to si Jomar, mura man tog bayot og baba. Strongly emphasized.

Pt verbalized a strong affirmation on the question but she wasnt able to maintain an eye contact.

Kinsa imo mga amiga diri Lynitz? changing the topic.

Si Jenny og sila Alona .

Proving Information

Pt responded shortly.

Kana diay siya miga mo ana niya? pointing one of the patient.

Ah kana si _____ mana siya, maldita mana siya. Looking at the patient.

Proving Information

Pt recognizes the pts name and by her bad attitude.

Kana siya? pointing to other patient.

Si _______, ok Proving raman na siya. In Information ana ra jud na siya sige lakaw-lakaw. Looking at the patient.

Pt recognizes the pt name and by the things that pt commonly does.

Student Nurse Nods.

Client Naa na ang social worker, excuse sa ha.

Inferences

Interpretation

Providing decision Pt is eager to tell making the social that she wants to go home.

Hello Lynitz! 10 Nods. O sige AM na manguli amping. God nami kita lang niya Bless! smiles. ta balik sunod sa sunod semana ha.

Providing Information

Pt responsive and understands.

God Bless pod! Smiles. smiles.

Pt understands.

Cruz, Jane Marie G. BSN III-A Group 3 Center of Behavioral Sciences