Leolene Grace G Bautista

N311 Group A

National Center for Mental Health Pavillion 5 Chronic Female Ward

Process Recording Name: Susan Fuentes Age: 35 Address: c/o Caloocan City Social Welfare Department, Kalookan City Civil status: N Religion: Catholic History of Present Illness: 1 day prior to admission, patient was seen by the staff of CSWD wondering along monumento, looking filthy and disturbed. Patient refused to change clothes. Patient was noted to be irrelevant when asked with questions about herself. Patient was also noted to be mumbling to herself. Due to the above condition, patient was escorted and was brought to our institution and admitted. Educational attainment: Occupation: Sleeping pattern: Sleeps at short interval Eating pattern: patient eats 3x a day Admitting Diagnosis: t/c psychosis, NOS Date of Admission: October 21, 2009

(Orientation Phase) Goal Interaction: To establish rapport with the patient To gather significant information about the patients history of present illness To be effective in expressing interest/ concern for patient/ family To provide health care information General Objectives: To stabilize her good mental health or state of mind To establish a hopeful life outside the institution Mutually explore feelings of rejection, loss, sadness and anger that are related to behaviors To regain self respect Description of the Environment: The setting of the NPI took place in the lobby of Pavillion 5. The nurse and the patient are seated and facing each other with a distance of 3-4 feet. The place is clean, neat and wellventilated. Activities: Exercise (dance: buttercup) Action Song (roll over the ocean) Play therapy (the boat is sinking) Nurse Magandang umaga po Patient Magandang umaga din po, Ako si Susan Fuentes Therapeutic Communication Giving Recognition Rationale Includes acknowledging and indication awareness. To show that the nurse that recognizes client as an individual or as a person Includes acknowledging and indication awareness. To show that the nurse that recognizes client as an individual or as a person Making oneself available on unconditional basis, thereby increasing

Ako naman po si Grace ng Global City Innovative College, ako po pala magiging student nurse niyo Makakasama niyo po ako sa loob ng 4 na araw ...

(smiles)

Giving Recognition

Opo

Offering self

Aware po ba kayo sa ginagawa natin ngayon? Pang 21 po?

Opo, pang 21 na student nurse kana na kilala ko Opo, lahat po sila mababait sa akin. Binibigyan di ako ng pagkain

Encouraging description of perceptions Restating

Ano po ba yung paborito niyong pagkain? Hindi po pwede yun, ako po inyong nursing student lamang pero wag po kayo magalala meron naman po kayong merienda pagkatapos natin magusap. Ano po gusto niyong pagusapan natin ngayon? Ano po tungkol sa nanay niyo? Ampon po? Ilan po ba kayo magkakapatid?

Spaghetti po saka friend chicken, pwede mo ba ko dalhan nun? Talaga po Sige po (simles)

Encouraging Expression Setting limitations

clients feelings of self worth. Asking the client to verbalize what is being perceived This let the client know whether or not expressed statement has been understood and gives her the chance to continue or to clarify if necessary Encourages the client to make her own appraisal rather than the opinion of others Letting the client know the limitations of the client

Hmmmm tungkol sa nanay ko.. Si mama celia mabait sa akin kahit na ampon lang ako. Opo, walo po kami. Mga pang apat po ako

Ilang taon na po ba kayo?

53 ?? ay hindi .. 54 .. Pinanganak po ako nung 1968.

1968? Di ba dapat po 1957 dahil kayo po ay 54 na ?

Ahh opo

Allows the client to take the initiative introducing the topic. Offering general leads Offers the client encouragement to continue. Restating This let the client know whether or not expressed statement has been understood and gives her the chance to continue or to clarify if necessary Placing the event in Clarifies the time or sequence relationship of events in time so that the nurse and client can view them in perspective. Presenting reality The nurse defines reality for the client when she has a

Giving broad openings

Meron po ba kayong asawa?? Anak ?? Hindi po kayo binibisita?

Meron po, kaso hindi na nila ako binibisita Oo, naghiwalay na kasi kami ng asawa ko saka di ko na alagaan ang mga anak ko ng maayos Namatay na kasi yung tatlo, dahil sa kapabayaan ko tapos yung dalawa may mga pamilya na ngayon. Pati sarili ko nagagawa kong saktan (shows me her right hand and right feet with incomplete fingers) Opo (seems irritated already) Opo

Exploring Restating

Paano po nasabi na ganoon nga po kayo?

Exploring

misperception of the time/date. Delivering further into a subject, experience, or relationship. This let the client know whether or not expressed statement has been understood and gives her the chance to continue or to clarify if necessary Delivering further into a subject, experience, or relationship. Gives the client the opportunity to collect and organize thoughts

(silence)

Using silence

Buti po di na po yan lumala? Tila ayaw nyo na pong pagusapan yun, nagugutom ka na po ba?

Exploring Making Observation And Giving recognition

Delivering further into a subject, experience, or relationship. Verbalizing what is observed or perceived. Allows the client to take the initiative introducing the topic

Evaluation: Goal partially met. The patient is responsive during interaction. She was able to express her thought and feeling spontaneously with the question but she has poor eye contact. She usually looks far away. The interaction was still effective because it showed that I was interested in listening to her stories and displayed an active interest in her condition.

(Working Phase) Goal Interaction: To promote self-esteem and self-worth of the patient To maintain the established trust during the orientation phase To provide opportunity for clients self-actualization To increase clients view of oneself General Objectives: To implement the therapeutic communication techniques for a more effective communication process To explore the patients feelings, thoughts and emotions regarding several triggers To decrease clients anxiety To increase trust to the nurse Description of the Environment: The setting of the NPI took place in the lobby of Pavillion 5. The nurse and the patient are seated and facing each other with a distance of 3-4 feet. The place is clean, neat and wellventilated. The NPI lasted for 10 minutes. Activities: psychodrama, cognitive therapy, re-motivation therapy, nutrition therapy calisthenics music and art therapy Nurse Magandang umaga, Susan Patient Magandang umaga rin po newspaper reading bugtong and salawikain occupational therapy action song health advisory. Rationale

Kamusta naman po kayo? Ano naman po gusto niyong pagusapan natin ngayon?

Okay naman po Hmmm.. Meron pala akong kapatid. Si Pablo. Pinatay kaming magkakapatid.

Includes acknowledging and indication awareness. To show that the nurse that recognizes client as an individual or as a person Giving broad Allows the client to openings take the initiative introducing the topic. Offering general leads Offers the client encouragement to continue.

Therapeutic Communication Giving recognition

Pinatay po?

Oo, pinatay niya kami.

Restating

Hindi po kayo pinatay dahil kasama po kita ngayon at nakakausap pa.

(silence)

(nodding) Opo masama po iyon, kaya po ikaw magpakabait po kayo ha?

Opo, dahil sa binuhay pa po ako ng Panginoon. Saka naparusahan na rin yung kapatid ko na yun dahil masama ang yung ginawa niya. Saka nararapat lang na parusahan siya kasi masama yung ginawa niya. Di ba masama po pumatay? Opo

Presenting reality

This let the client know whether or not expressed statement has been understood and gives her the chance to continue or to clarify if necessary. The nurse defines reality for the client when she has a misperception of the time/date. Gives the client the opportunity to collect and organize thoughts Conveys an attitude of reception and regard.

Using silence

Accepting

Evaluation: Goal partially met. The patient was able to express her thought although the topic was not that therapeutic. She seems quiet while the activities were conducted but I still encourage her to participate which she actually did.

(Termination Phase) Goal Interaction: To provide an appropriate evaluation regarding the clients view of oneself To facilitate clients self empowerment To prevent interdependency of the client to the nurse General Objectives: To protect client from harming herself To stabilize her good mental health or state of mind To increase her level of independence To establish a hopeful life outside the institution Establish reality of separation To regain self respect Mutually explore feelings of rejection, loss, sadness, and anger that are related to behaviors Description of the Environment: The setting of the NPI took place in the lobby of Pavillion 5. The nurse and the patient are seated and facing each other with a distance of 3-4 feet. The place is clean, neat and wellventilated. The NPI lasted for 15 minutes. The Grand Socialization was held beside the lobby (garden). Activities: Grand Socialization Day Nurse Susan, Kamusta naman po kayo? Patient Okay naman po ako (smiles) Therapeutic Communication Giving recognition Rationale Includes acknowledging and indication awareness. To show that the nurse that recognizes client as an individual or as a person Allows the client to take the initiative introducing the topic. Allows the client to take the initiative introducing the topic This let the client know whether or not expressed statement

Ano naman po masasabi niyo tungkol sa grand socialization natin kanina? Tila nga po kayo ay nabusog sa pagkain in yong kinain? Spaghetti at fried chicken? Di ba mga paborito mo iyon?

Masaya po, maraming pagkain Opo, kasi ang sarap sarap ng spaghetti at ng fried chicken. Opo, ang sarap sarap po. Nagpapasalamat po ako sa Panginoon

Giving broad openings Giving recognition Restating

at narito kayo at dininig ang aming mga hiling. (silence) (smiles) Bihira lang po kasi kami makakain ng masasarap. Saka tuwing NPI lang po kami nakakain nito. Opo, huling araw niyo na po sa amin. Using silence

has been understood and gives her the chance to continue or to clarify if necessary Gives the client the opportunity to collect and organize thoughts. Clarifies the relationship of events in time so that the nurse and client can view them in perspective. Asking the client to verbalize what is being perceived

Di ba pang apat na araw na po natin ngayon?

Placing the event in time or sequence

Bago po tayo magkahiwalay, meron pa po akong mga katanungan sa inyo.. naaalala niyo pa po ba yung mga activities na ginawa natin noon?

Ano pa po?

Talagang naaalala niyo pa po lahat ng mga ginawa natin. Marami po ba kayong natutunan? (smiles)

Opo,nung nung miyerkules po. Anu, nagbasa po ng balita, nagbigay po ng mga bagay na panglinis sa katawan tapos kumanta, saka nagbugtong bugtungan, saka nagdesign ng box Tapos kahapon, gumawa kami ng sandwich na palaman na itlog saka mayonnaise, nagdrawing, nanuod ng drama Opo, makakatulong po yun pag lumabas na ko Saka nagpapasalamat po ako na naging nurse po kita, ipinagdadasal ko po na sana makapasa po kayo ng board at sana po naramdaman niyo yung pagmamahal na binigay po naming sa

Encouraging description of perceptions

Offering general leads Offers the client encouragement to continue.

Giving broad openings

Allows the client to take the initiative introducing the topic. Gives the client the opportunity to collect and organize thoughts

Using silence

(smiles) nagpapasalamat din po kami sa apat na araw na nakasama namin kayo kahit po kami ay natuto rin habang kasama kayo, sana po balang araw makita na po naming kayo nasa labas at magaling na.

inyo at ganun din po kayo sa amin. Maraming salamat po ulit. (smiles)

Giving recognition

Allows the client to take the initiative introducing the topic

Evaluation: Goal met. The patient knows the limitations and roles of the nurse. She was really eager to participate with the activities in the socialization. She seems to enjoy everything on our last day and thanks us a lot for it.