Sanvictores, Diane Claudette S.

April
15, 2011
BSN 202/Group8 Ma’am Emy
Delgado
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.

Nurse’s Statement Client’s Response Interpretation and C.I.’s Comments

Analysis
1. Magandang hapon po Magandang hapon  Recognize the client
Kuya Jeremy. naman din Clau! Teka,  Greeting the client by
bakit Clau, eh di ba name, indicating
Diane yung sabi mo awareness of change,
nung isang linggo? noting efforts of the
(looking at my client which shows that
nametag). the nurse recognizes the
client as an individual.
2. Ah, pangalan kop o
kasi ay Diane  Giving information or a
Claudette. Galing po Ah talaga? Kaya pala. little background about
sa Claudette yung his attending nurse may
Clau. (Smiled) somehow gain the trust
of the client.

3. Binigyan lang po  Setting contract and

kame ng limited na Ahmm, (thinking limits to let them know
minuto para po kayo deeply).. sabi sakin ng what to expect during
ay makausap namin. doctor ko, the interaction.
 Ano po gusto niyo undifferentiated  Broad openings made
ikwento o mapag- schizophrenia yung the client lead
usapan natin kuya sakit ko. interaction/conversation.
Jeremy?  Client was not hesitant
in telling/giving me
information about him.

 Exploring, by asking
4. Sa tingin niyo po, ano open ended questions in
po yung dahilan na Ganito kasi yun, bago order to encourage the
nandito po kayo pa ako pumasok dito, client to express more
ngayon? may insomnia ako, 7 fully.
months akong hirap
matulog. Kung
makatulog man ako,
mga 2:30 na sa
medaling araw at
magigising din ng  Accepting, this
5. Opo (nodding), tapos alas-sais sa umaga. response indicates that
po? the nurse has heard and
Ayun, eh yung ate ko followed the train of
pina-check-up ako, thought.
may kumausap pa nga  I indicate
sakin na psychiatrist acceptation to what my
kaso ini-snob ko. Di ko client says and for him
sinasagot mga tanong to continue what he is
niya kasi alam ko na saying.
6. Bukod po ba sa psychiatrist nga siya.
insomnia na sinabi  Seeking
niyo, ano pa po yung Oo, may mga naririnig information, the nurse
mga naramdaman o din ako na mga should seek clarification,
naranasan niyo bago bumubulong sakin. or additional information
po kayo mapasok
 dito? to validate what the
client said. Doing so can
help the nurse avoid
making assumptions
that understanding has
7. Ano po yung mga May gusto daw occurred when it is not.
naririnig niyo? pumatay sakin. Mga
Ngayon po ba may ganun, pero ngayon  Focusing, the
mga naririnig pa wala na ako naririnig, nurse should have follow
kayong ganun? di naman kasi totoo up questions to clarify
yung mga yun. what he answered in the
previous question.
 The client had an
auditory hallucination
before; without showing
any doubts while he was
sharing, and also
8. Kelan nga po pala 2004 yung unang admitted that what he
kayo napasok dito? beses na nadala ako was hearing before were
Nabasa ko po kasi sa dito. Diba sabi ko not real.
chart niyo na may pinacheck-up ako ng
readmission po. Ano ate ko, tapos may  Placing events in
po ang nangyare? kumausap sakin na time or sequence.
psychiatrist, siguro Putting events in proper
sinabi ng doctor na sequence helps both the
yun sa may ari nitong nurse and the client to
home care na kunin see them in perspective.
ako sa apartment. The client may gain
Sumama naman ako. insight into cause and
Nakalabas ako dito behavior. The nurse may
after ng isang taon. gain information about
Pero 6 days lang ako recurrent pattern or
sa labas, binalik ulit themes in the client’s
 ako. Pano, inom at behavior or
sigarilyo nanaman. relationships.
Kaya yun, eh may  The client is very
9. Ilan po ba kayong sari-sari store ako na comfortable of what he
mgkakapatid? pinamana sakin ng is sharing. He is serious
bunso namin. and his reactions are
10. Ah, so related with what he is
pangalawa pop ala Pito kaming talking.
kayo sa bunso. Nasan magkakapatid, pang-
na po sila ngaun? Eh anim ako.
yung nanay at tatay
niyo po? May mga sari-sarili na  Seeking
silang pamilya information
ngayun. Wala na ang
nanay at tatay, pero
11. Sa pamilya niyo natatanda na sila  Exploring. Any
po ba, may mga may nung namatay sila, si problems or concern can
sakit din po? Ano po nanay 1996 namatay, be better understood if
yung mga sakit na si tatay 2004. explored in depth.
yun?  The client seems
Madalas highblood. to remember everything
Ako din eh, my about his family.
hypertension ako.
Pero dahil sa  Exploring. Any
maintenance na problems or concern can
gamot, bumaba yung be better understood if
BP ko. explored in depth.
12. Talaga po kuya Nga pala, pwede na
 The client also
Jeremy? Ayos po yun! daw ako lumabas
manifests hypertension
Ano naman po ang anytime, hinihintay
as such with his family.
balak niyo o mga nalang yung pag-
dapat gawin pag sundo sakin ng ate ko.
labas niyo?
 Dahil lahat ng mga
kapatid ko may kanya  Formulating a
kanyang pamilya na, plan, it may be helpful
gusto ko rin naman for the client to plan in
magkaroon ng sariling advance for what he is
pamilya. Gusto ko rin to do in the future.
sana mag-business o  Definite plans
kaya mgoperate ng increase the good
jeepney sa probinsya chances that the client
namin sa Romblon. At will cope more
siyempre, wala na ring effectively in similar
13. Opo (smiles), inom-inom o sigarilyo, situation.
sige lang kuya at iinumin ko sa oras  The patient
Jeremy, magkwento ang mga gamot ko knows that what he did
ka lang. maganda para maging mas in the past were wrong
ang mga plano mo maayos pa ako. and is willing to change,
ah.. got plans how to handle
the same situation in the
Oo eh, namimiss ko na future.
din kasi yung labas.
Gusto ko na gawin
yung mga gawain ng
isang normal na tao.  General Leads
indicate that the nurse is
14. Ganito kuya Jeremy, listening and following
sabi po ng doctor what the client is saying
ninyo, ang sakit niyo without taking away the
daw po ay initiative for the
undifferentiated interaction. They also
schizophrenia. Bago encourage the client to
po kayo pumasok dito Tama ka dyan Clau, continue if he is hesitant
kayo po ay may salamat sa iyong or uncomfortable about
insomnia, at may pakikinig sa akin. the topic.
mga naririnig na Ako’y natutuwa at
bumubulong sainyo. Masaya dahil sa inyo.  Summarizing
Naadmit po kayo  The nurse
nung 2004 at reiterates and identifies
nakalabas tapos ng the main points of the
isang taon, 6 days total interaction.
lang po kayo sa labas  This helps the
dahil sa bisyo po. client, review the
Pero ngayon, handa interaction and hear
na po kayo magbago how his communication
at may magagandang has been perceived by
plano para sa future others.
niyo pos a labas.  The client is very
Tama po ba yun? 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 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 of the Environment:

We conducted our second NPI inside MTHC’s activity area. The
surrounding was clean, quiet, together with the other client’s with their
respective nurses doing NPI too.

Objectives:
After 15 minutes of second interaction, I will be able to:
1. Gather more information about my client
2. Set priorities in determining my client needs
3. Encourage my client to 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
enthusiastically shares the story of his life within that 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 with lots of paper 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.