Process Recording No 1
Process Recording No 1
Process Recording No 1
1 Orientation Phase Description of Phase: Problem defining phase Starts when client meets nurse as stranger Defining problem and deciding type of service needed Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and expectations of past experiences Nurse responds, explains roles to client, helps to identify problems and to use available resources and services Personal Data: Name: R.R Address: Age: 59 y/o Gender: Male Date of birth/place: Religion: Catholic Place where patient spent his last 10 years:
I. Goal Interaction To gain rapport of my patient. Establish trust, acceptance, and open communication To be able to become acquainted of my patient. To understand the patients problems. To demonstrate genuine care and understanding. To mutually formulate a contract with the patient II. General Objectives To distinguish the sickness of the client thru the observation done. To reduce the anxiety felt by the client towards the nurse. To discuss the contract to my patient. To explore patients thoughts, feelings, and actions
Mark Andrew Castelo Gaerlan III. Short-term Objectives To be able to introduce myself to my patient and getting to know one another. To show interest and sincerity to my patient. To gain trust from my patient. To observe and assess my patients personality. IV. Description of the Patient The patient sits calmly and always smiling. He is dressed in green uniform from the Institution. His hair was wet but kept clean and fixed. His teeth are crooked. His eye are a bit droopy and squinted but keeps good eye contact.
V. Description of the Environment The environment was calm and therapeutic. The dining room was clean and isolated. Fans were on to keep the room cool and comfortable. Light was adequate from the ceiling and the sun through the window. There is slight noise but tolerable.
Rommel, I will be your student nurse from today, tomorrow, next Thursday and Friday. How are you today?
Ok Smiling
Imparting Information.
Make the available facts the client need to established trust and cooperation
Im fine
According to Sullivans interpersonal theory by addressing someones name shows that nurse recognized the client as a person to be able to build friendship towards the client. Questioning was used to keep the conversation going and on the right tract. This question opened open communication about the objective. (Therapeutic)
Are you Filipino? Yes, both of my parents are Filipino. You speak English well are you from the States? Smiling Yes I live in California for 4 years.
The client is engaging me with his own questions, therefore giving me a hint that he is interested.
Mark Andrew Castelo Gaerlan How old are you now? What did you use to do when you live here in the Philippines? During whos term? (nodding) Im 59 years old I worked at the Commelect. Questioning. Active Listening Exploring Wanting to get more information the client responds directly Questioning allowed me to find out what about being alone is appealing to him. (Therapeutic)
During Marcos, but I resigned after he was removed. I lived in Quezon City, Project 6 behind SM North My dad is from Bicol and My mother is from Pampanga. I have(counts with his fingers) 7 brothers and 6 sisters. Im the third from the eldest.
Smiling
I ask the patient to clarify what he meant by thinking more clearly. (Therapeutic)
Wow (I smile) are you the eldest or youngest? Holidays must be really fun since you have a huge family. Do you have kids?
I dont (answered laughingly) Its complicated The client opens up but is still
We have group therapies in the other room, like cooking, watching TV, eating. I like Sea world, The Rock, any movies with Nicholas Cage, Jean Claude Van Dam, Bruce Willis,. Noodles, bicol express, filipino foods I like siopao, siomai, Chinese foods. (pauses looks up and counts with his fingers, he mumbles at first) 10 years
Probing/Questionin g.
The client opens up more and engages me about how excited he is about the movies.
I felt that questioning about the origination of his social behavior may have been helpful in determining the cause. (Therapeutic)
Smiling
What do you usually cook during therapies? What kind of food do you like eating? How long have you been here?
Smiling
Probing/Questionin g.
The patient began to pull back at this point due to the directness of my questioning. I should have broken up the questioning with other forms of communication. (Therapeutic) At this point the patient became very nervous. I do think it was in part about his
Smiling
Probing/Questionin g.
Mark Andrew Castelo Gaerlan discharge. This question should have been reworded to be more of an open question in which he could have elaborated.
Most of them are in the States, only three are left here in the Philippines We eat, but mostly talk with my doctor.
I see. When he visits what do you guys usually do? About what?
My discharge, but I follow my brothers wishes. (Looks away and mumbles) it personal The client answers embarassed
Well. --, Were going to start our activities. It was very nice to meet you.
Ok.
smiling
Terminating interaction.
I wish I had more time to speak with this patient, but I feel that I was able to keep up a conversation well and use the therapeutic techniques I have learned so far.
The client seemed happy and satisfied, willing to continue our interaction the next day.
Mark Andrew Castelo Gaerlan VI. Evaluation of Interaction At the end of the conversation, the patient kept his smile and was confident about telling me a part of his life and family. The patient was able to express his feelings and ideas well. I feel that he is comfortable about talking to me and is willing to divulge things about his life. He understands where he is and accepts it. He is very accommodating and often laughs with me. The patient portrays interest in meeting again.