Sanvictores, Diane Claudette S. 15, 2011 BSN 202/Group8 Delgado
April Ma’am Emy
PROCESS RECORDING Observation prior to interaction The client looks normal because the way he looks and acts during the interaction can be considered normal. He smiles when I called his name and immediately sat in front of me, seems like he is eager to share something about his life. He is very cooperative, and I feel welcomed with the way he interacts with me. He is not shy and was comfortable with what he has been sharing with me. I believe in him because I got what I have been expected him to answer. Nurs Nurse’ e’s s Stat Statem emen entt 1. Magandang hapon po Kuya Jeremy.
2. Ah, pangalan kop o kasi ay Diane Claudette. Galing po sa Claudette yung Clau. (Smiled)
Clie Client nt’s ’s Re Resp spon onse se Magandang hapon naman din Clau! Teka, bakit Clau, eh di ba Diane yung sabi mo nung isang linggo? (looking at my nametag).
Ah talaga? Kaya pala.
3. Binigyan lang po
kame ng limited na minuto para po kayo ay makausap namin.
Ahmm, (thinking deeply).. sabi sakin ng doctor ko,
Inte Interp rpre reta tati tion on and and Analysis Recognize the client Greeting the client by name, indicating awareness of change, noting efforts of the client which shows that the nurse recognizes the client as an individual.
Giving information or a little background about his attending nurse may somehow gain the trust of the client.
Setting contract and limits to let them know what to expect during the interaction.
C.I.’s Comments
Ano po gusto niyo ikwento o mapagusapan natin kuya Jeremy?
undifferentiated schizophrenia schizophrenia yung sakit ko.
4. Sa tingin niyo po, ano po yung dahilan na nandito po kayo ngayon?
5. Opo (nodding), tapos po?
6. Bukod po ba sa insomnia na sinabi niyo, ano pa po yung mga naramdaman o naranasan niyo bago po kayo mapasok
Ganito kasi yun, bago pa ako pumasok dito, may insomnia ako, 7 months akong hirap matulog. Kung makatulog man ako, mga 2:30 na sa medaling araw at magigising din ng alas-sais sa umaga. Ayun, eh yung ate ko pina-check-up pina-check-up ako, may kumausap pa nga sakin na psychiatrist kaso ini-snob ko. Di ko sinasagot mga tanong niya kasi alam ko na psychiatrist nga siya. Oo, may mga naririnig din ako na mga bumubulong sakin.
Broad openings made the client lead interaction/conversation. Client was not hesitant in telling/giving me information about him. Exploring, by asking open ended questions in order to encourage the client to express more fully.
Accepting, this response indicates that the nurse has heard and followed the train of thought. I indicate acceptation to what my client says and for him to continue what he is saying.
Seeking information, the nurse should seek clarification, or additional information
dito?
7. Ano po yung mga
naririnig niyo? Ngayon po ba may mga naririnig pa kayong ganun?
8. Kelan nga po pala kayo napasok dito? Nabasa ko po kasi sa chart niyo na may readmission po. Ano po ang nangyare?
May gusto daw pumatay sakin. Mga ganun, pero ngayon wala na ako naririnig, di naman kasi totoo yung mga yun.
2004 yung unang beses na nadala ako dito. Diba sabi ko pinacheck-up ako ng ate ko, tapos may kumausap sakin na psychiatrist, siguro sinabi ng doctor na yun sa may ari nitong home care na kunin ako sa apartment. Sumama naman ako. Nakalabas ako dito after ng isang taon. Pero 6 days lang ako sa labas, binalik ulit
to validate what the client said. Doing so can help the nurse avoid making assumptions that understanding has occurred when it is not.
Focusing, the nurse should have follow up questions to clarify what he answered in the previous question. The client had an auditory hallucination before; without showing any doubts while he was sharing, and also admitted that what he was hearing before were not real. Placing events in time or sequence. Putting events in proper sequence helps both the nurse and the client to see them in perspective. The client may gain insight into cause and behavior. The nurse may gain information about recurrent pattern or themes in the client’s
9. Ilan po ba kayong mgkakapatid? 10. Ah, so pangalawa pop ala kayo sa bunso. Nasan na po sila ngaun? Eh yung nanay at tatay niyo po?
11. 11. Sa pami amilya lya niyo iyo po ba, may mga may sakit din po? Ano po yung mga sakit na yun?
12. Tala alaga po kuya Jeremy? Ayos po yun! Ano naman po ang balak niyo o mga dapat gawin pag labas niyo?
ako. Pano, inom at sigarilyo nanaman. Kaya yun, eh may sari-sari store ako na pinamana sakin ng bunso namin. Pito kaming magkakapatid, panganim ako. May mga sari-sarili na silang pamilya ngayun. Wala na ang nanay at tatay, pero natatanda na sila nung namatay sila, si nanay 1996 namatay, si tatay 2004. Madalas highblood. Ako din eh, my hypertension hypertension ako. Pero dahil sa maintenance na gamot, bumaba yung BP ko. Nga pala, pwede na daw ako lumabas anytime, hinihintay nalang yung pagsundo sakin ng ate ko.
behavior or relationships. The client is very comfortable of what he is sharing. He is serious and his reactions are related with what he is talking.
Seeking information
Exploring. Any problems or concern can be better understood if explored in depth. The client seems to remember everything about his family.
Exploring. Any problems or concern can be better understood if explored in depth. The client also manifests hypertension hypertension as such with his family.
13. Opo (smiles), sige lang kuya Jeremy, magkwento ka lang. maganda ang mga plano mo ah..
Dahil lahat ng mga kapatid ko may kanya kanyang pamilya na, gusto ko rin naman magkaroon ng sariling pamilya. Gusto ko rin sana mag-business o kaya mgoperate ng jeepney sa probinsya namin sa Romblon. At siyempre, wala na ring inom-inom o sigarilyo, at iinumin ko sa oras ang mga gamot ko para maging mas maayos pa ako.
Oo eh, namimiss ko na din kasi yung labas. Gusto ko na gawin yung mga gawain ng isang normal na tao. 14. Ganito kuya Jeremy,
sabi po ng doctor ninyo, ang sakit niyo daw po ay undifferentiated schizophrenia. schizophrenia. Bago po kayo pumasok dito kayo po ay may insomnia, at may
Tama ka dyan Clau, salamat sa iyong pakikinig sa akin.
Formulating a plan, it may be helpful for the client to plan in advance for what he is to do in the future. Definite plans increase the good chances that the client will cope more effectively in similar situation. The patient knows that what he did in the past were wrong and is willing to change, got plans how to handle the same situation in the future.
General Leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. They also encourage the client to continue if he is hesitant or uncomfortable about the topic.
mga naririnig na Ako’y natutuwa at bumubulong bumubulong sainyo. Masaya dahil sa inyo. Naadmit po kayo nung 2004 at nakalabas tapos ng isang taon, 6 days lang po kayo sa labas dahil sa bisyo po. Pero ngayon, handa na po kayo magbago at may magagandang plano para sa future niyo pos a labas. Tama po ba yun?
Summarizing The nurse reiterates and identifies the main points of the total interaction. This helps the client, review the interaction and hear how his communication has been perceived by others. The client is very eager for what in the future for him. He also seems happy because he shared to me a glimpse from his life.
PROCESS RECODING NO.2 (WORKING PHASE)
Name: Fabella, Jeremy Address: 3436 M. Torres St., Bacood Sta. Mesa Age: 47 y/o Sex: Male Educational Attainment: College Student Date of NPI: April 14, 2011 Setting: Mother Teresa Home Care
Description Description of the Patient: Mr. Fabella looked calm on our second meeting. He was wearing a white t-shirt and short pants with his slippers on. He is approachable and is eager to be interviewed. Description Description of the Environment: We conducted our second NPI inside MTHC’s activity area. The surrou surroundi nding ng was clean, clean, quiet, quiet, togeth together er with with the other other client client’s ’s with with their their respective nurses doing NPI too. Objectives: After 15 minutes of second interaction, I will be able to: 1. Gather more information information about my client 2. Set priorities priorities in determining my my client needs needs 3. Encourage my client to express express more fully about his life. Evaluation: I was able to build trust and rapport with my patient since our first meeting, that’s why it had been easy for me to ask him questions and got what I’m expecting from him to answer. He was not hesitant at all and enthus enthusias iastic ticall ally y shares shares the story story of his life life withi within n that that short short span of our interaction. Comments with regard to CI: We had our post conference right after our NPI, OT and Play therapy with Ma’am Delgado. She keeps on reminding us to be right with what we are doing. Though we have been bombarded bombarded with lots of paper works works to do; she would still listen to our concerns and give us guidance and counseling during our remaining time of our stay there in the area.
