PROCESS RECORDING
Pt’s name: L. L . A. Physician: Dr. S.H. Age: 23 years years old Student Nurse: Nurse: M.T. Sex: Female Diagnosis: Post Traumatic Stress Disorder and Depression
Process Recording # 1 I. OBJECTIVES General: After 2 weeks weeks of SN-client SN-client interaction interaction,, the client client will be able to reorient reorient self self with the environment, have insight on her present condition and develop positive attitude and skills. Specific: After 30-45 30-45 minutes, of SN-client SN-client interaction, interaction, the patient will will be able to: to: 1. establish rapport 2. introduce oneself as the student nurse 3. orient self to date, place, and time 4. cite the purpose and expectation of the interaction 5. identify adaptive coping mechanisms that the client uses when feeling aggressive, anxious, sad, or angry 6. agree as to the date, place and time of the next interaction II. SETTING OF INTERACTION: a. Time: 5:45 PM b. Date: 09/29/12 c. Place: Living room of the client
III. Appearance: She has not yet taken a shower and has not yet changed from the clothes that she slept on last night. She was wearing a fitted stripe black and white shirt and a navy blue short. Her hair seemed semi messy. She has chipped red nail polish on her toes. BEHAVIOR: She was not as attentive and cooperative at first but opened up slowly as the interaction went on. She was slightly shy in the interaction with the student nurse. She would make an eye contact then would look at the ground from time to time with simple hand gestures and with teary eye. COMPREHENSION: Her answers were appropriate and correlated to the questions being asked but there’s sadness behind every answer she speaks. Sometimes she pauses and thinks before she answers, it seems she thinks before she speaks. IMPLICATIONS: She was very responsive to the interaction. She interacted with the student nurse specifically with details but there were moments that the questions make her seem teary eyed and sad. She looks around when the question is being asked and focuses back to the student nurse when she has to answer the question.
Student Nurse’s
Communication The student nurse approaches the patient with the best smile to gain patient’s approval and cooperation. The student nurse sits in the chair near the patient.
Communication Defense Communication Techniques Mechanism
Analysis
(Patient nod to answers questions) Patient answers with a low-toned voice,
Greeting the client by name indicates that the efforts the client has made all show that the nurse recognizes the client as an individual and a person.
Patient’s
Giving recognition
“Maayong buntag Lheslen.”
“Maayong buntag sad.”
“Pwede ko nimu sultian sa imong pangalan”
“Lheslen akong pangalan”
Seeking information
“Lheslen, ako si
“Sige, wala ko
Giving
Client responds with a nod just to make it clear that nothing’s wrong.
To clarify if the patient is aware of whom she is. The student
M.T., ang imong student nurse gikan college of nursing. Naa ko diri karon para makig storya nimo. Hinaut pa unta nga abli tas atong pagstorya sa usag usa. Naa ko diri sa imong tupad para maminaw nimu og maau og mutambag sa ma tambag nako nimu.” Lheslen, karon kay kaila na man ta sa usag usa, mangutano ko, nahibaw ka unsa ta na adlaw og petsa karon?
problema ana,” Lheslen smiles and nodded
Information
nurse is the resource person of the patient. The nurse builds trust with the client by giving information
Patient looked in Asking to the student questions nurse and said, “Sabado man ta karon sa gabii, Septembre bainte nueve.”
The nurse calmly asks the client if he is aware of the date and day of the interaction to assess patient’s memory and level of consciousness to the reality.
“Lheslen, sakto ka na ni ingon ka na Sabada karon sa Septembre 29, 2012.”
(Patient smiles ) “Salamat Anne.”
Giving Information
To be able to bring the patient’s thought and memory into the right way and reality or to the present.
“Lheslen, naa kay ma storya nako karong adlawa? Kung unsa man na imong na feel,
“Kadyot lang sa ha, kay katon kaau akong mata.” (Patient started to get teary
Exploring
Displacement
Any problem or concern should better be understood if explored in depth. She got
naa ko diri para ma minaw nimu og maau”
eyed)
“Unsa man atong buhaton para dili na mag katol imong mata?”
“Okay ra ning akong mata ui. Salamat kaau na ni ari ka diri para naa tawn ko ka storya. Kailangan baya jud ko og ka storya kay lisod kaau na mag inusara lang” “Sakit lang jud kaau stanan, kay maka hinumdom gihapon ko sa iyang gi buhat nako. Pamilya man unta nako siya pero ngano man tawn iya kong gi inan ana?” (She looks down to the ground and with a monotone voice. She repsonded…)
“Cge, ingna ko bisag unsa imong gi hunahuna diha unya mag sturya tang duha ha.”
“Kinsa man Lheslen? Unya gi unsa man ka nya??”
teary eyed, but blamed that her eyes were itchy.
Focusing
Any problem or concern can be better understood if explore in depth.
Focusing
Any problem or concern can be better understood if explore in depth.
Seeking information
“Gi abuse ko unya gi haras ko sa bana sa akong iyaan.”
“Unsa man ang
“Wala sad ko
Focusing
Patient answered in precise manner because she sometimes has difficulty in verbalizing when feeling anxious.
Nurse is trying to know about how Lheslen interacts with Mary Anne. Mary Anne is Lheslen’s closest peer in the house because they are always with each other if they can. Student nurse
hinungdan na gi inan ato ka niya Lheslen?”
kabaw ngano iya toh gi buhat nako. Wala man koi gi buhat nya. Ngano ako jud. ”
encourages the client to concentrate his or her energies on a single point, which may prevent multitude of factors or problems from overwhelming the client.
“Unsa man imo gi buhat pag inan ato nya nimu? Ni sumbong ka sa imong mama o papa o bisag kinsa?”
“Wala man dayon ko ni sumbong kay na hadlok ko kung unsa man iyang buhaton sa akong pamilya. Iya pa lang patiyon. Dili ko ganahan mag apil-apil sa dili kailangan ma apil. Pero pag dugay-dugay, akong gi una sumbongan kay akong mama. Nya ni gakos siya nako og maau. Nag hilak gud ming duha.”
Exploring
Patient maybe just tried not show any feeling because she likes not to show his feelings to other people. But eventually will open up when comfortable.
When patent tends to deal with topics superficially exploring can help them examine the issue fully.
“Naay pa kay lain i.dungag sa imon storya para ma paguwas jud na tanan imong gi bati.”
“Mao ra jud na akong gi bati, sakit jud lang kaau. Dili nako ganahan maka huna-huna kay bati jud kaau siya na feeling. Pero ma okay ra man jud ko.
Broad Openings
Patient does not want anymore to expand any topic that would come from him.
Broad openings make explicit that the client has the lead in the interaction.
Kailangan jud dili lang ko ipa hinumdom” “Kasabot jud ko sa imong gi bati Lheslen. Ganahan ko mag storya pa ta og maau inig balik nako inig ka sunod na Sabado. Mu adto sa ako Lhes, unya mag kita ta balik ha. Kaon na diha para dili ka ma pasmo.”
“Sige. Salamat kaau Anne.”
IV. EVALUATION: Almost all the objectives for this interaction were met. Patient was able to identify the student nurse, he was able to orient himself with the time, date and place of interaction, was able to identify adoptive coping mechanisms that she uses when she is feeling angry, sad, or anxious, and was able to set a contract with student nurse for next interaction. She was also able to tell the student nurse about her past and some background about her feelings and thought about the situation. The client is generally cooperative and responsive with our interaction.
