process recording

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

Objectives:

After the orientation phase, the nurse will be able to:

Determine why the patient sought help

Establish trust, acceptance, and open communication

Mutually formulate a contract with the patient

Explore patient’s thoughts, feelings, and actions

Identify patient’s problems

Define goals with the patient

Date/ Time/ Venue: November 25, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

NURSE-PATIENT

INTERACTION

RATIONALE OF THE

NURSE’S

COMMUNICATION

TECHNIQUE

ANALYSIS OF THE

PATIENT’S RESPONSE

Nurse: Magandang umaga J.

Ako si Ran. Estudyante ako

mula sa Centro Escolar

University, Manila. Student

nurse mo ako ngayon.

Magkikita at mag-uusap tayo

simula Miyerkules hanggang

Biyernes sa susunod na

linggo, mula alas-siyete

hanggang alas-tres ng hapon.

Mag-uusap ulit tayo bukas ha.

Patient: Opo…Opo…Opo

(with nodding)

Nurse: Puwede ko bang

malaman ang buong pangalan

mo?

Patient: (stated the name)

Therapeutic:

Giving Information

Making available the facts

that the client needs

Use names

Using a person's name

makes her feel more

valued, and introducing

yourself is a basic step in

establishing a therapeutic

interaction.

Therapeutic:

Exploring

Encourages the speaker to

expand upon their

remarks/ question

Patient is conscious and

comprehending

Nurse: Ano ulit ang pangalan

ko J?

Patient: Ran po. (somnolence)

Nurse: Sige. Ako ang student

nurse mo tapos ikaw ang

pasyente.

Patient: Opo.

Nurse: Mag-uusap tayo J ha.

Magkukwentuhan lang tayo.

Patient: Opo. Opo.

Nurse: Alam mo ba kung

anong petsa at araw ngayon?

Therapeutic:

Help to orient

Illness and hospitalization

can be very disorienting

for patients, especially the

elderly.

Therapeutic:

Help to orient



for patients.

Patient is responsive

Patient is drowsy and

comprehending

According to Jung,

perception involves all the

ways of becoming aware

of things, people,

happenings, or ideas.

Judgment involves all the

ways of coming to

conclusions about what

has been perceived. If

people differ

systematically in what

they perceive and in how

they reach conclusions,

then it is only reasonable

for them to differ

correspondingly in their

interests, reactions, values,

motivations, and skills.


Patient: Sabado

Nurse: J Huwebes ngayon.

November 26, 2009.

Patient: (stares only)

Nurse: Ano ulit ang petsa

ngayon J?

Patient: Sabado

Nurse: Huwebes ngayon,

November 26, 2009 J.

Patient: Opo

Nurse: Ilang taon ka na pala J?

Patient: Napulo

Therapeutic:

Presenting Reality

When it is obvious that the

patient is misinterpreting

reality, the nurse can

indicate that which is real.

He does this not by way of

arguing with the patient or

belittling his own

experiences, but rather by

calmly and quietly

expressing her own

perceptions or the facts

Therapeutic:

Asking Direct Questions:

This allows the patient to

try answering a direct

question directly, briefly

and correctly

Therapeutic:

Reframing the question:




and correctly

He is analyzing the

information

Patient had

established/formed fixated

idea with regards


He has a difficulty to

recall personal information

and is often confused.

He has a difficulty to

recall personal information

and is often confused.

Nurse: Anong taon nuong

ipinanganak ka?

Patient: Marso

Nurse: Ano ang birthday mo?

Kelan ka ipinanganak?

Patient: Hulyo, Agosto

Nurse: alam mo ba J kung ano

ang ginagawa mo dito?

Patient: (looses eye contact,

tumingin sa malayo)

Nurse: Anong lugar to J?

Patient: (silence. Spits saliva)..

Ambot

Therapeutic:





and correctly

Therapeutic:

Help to orient



for patients.

Therapeutic:





and correctly

Therapeutic:





and correctly

Therapeutic:

Patient has difficulty in

memory skills

Disoriented to place

Misleading answer

Trying to recall personal

information

Nurse: Saan ka pala nakatira

J?

Patient: sa bahay

Nurse: Saan ka galing na

probinsiya?

Patient: doon

Nurse: Saan yung doon na

sinasabi mo J? Yung lugar

kung saan ka dati nakatira

bago ka napunta dito?

Patient: Bitano

Nurse: Saan yung Bitano J?





and correctly

Therapeutic:





and correctly

Therapeutic:





and correctly

Therapeutic:





and correctly

Therapeutic:




Patient: Sorsogon

Nurse: alam mo ba kung

nasaan ang Sorsogon?

Patient: sa Mindanao

Nurse: Naaalala mo pa ba ang

mga nangyari bago ka napunta

dito?

Patient: (looses focus, drowsy)

Nurse: Sino ang kasama mo

pagpunta mo dito?

Patient: (focus returned)

Using Broad Opening

Statements The use of a broad

opening statement allows the

patient to set the direction of

the conversation.

Therapeutic:





and correctly

Therapeutic:

Observation:

To help with awareness of

feelings, encourage

verbalization of feelings,

conveys concern and

interest.

Verbalizing Implied Thoughts

and Feelings

The nurse voices what the

patient seems to have

Somnolence

The patient can’t justify

Piaget’s cognitive theory.

According to Piaget, the

formal operational period

is the fourth and final of

the periods of cognitive

development in Piaget's

theory. This stage, which

follows the Concrete

Operational stage,

commences at around 11

years of age (puberty) and

Nurse: J mag-usap pa tayo ha?

Patient: Opo.

Nurse: Okay ka pa?

Patient: Opo.

Nurse: Inaantok ka ba J?

Patient: hindi po

Nurse: Napapagod ka na ba?

Patient: Hindi po.

Nurse: Nag-enjoy ka ba knina

J?

fairly obviously implied,

rather than what he has

actually said.

Therapeutic:





and correctly

Therapeutic:

Exploring or delving further

into a subject or idea:

The nurse should

recognize when to delve

further. If the patient

chooses not to elaborate,

the nurse should respect

the patient’s wishes.

Therapeutic:

Focusing:

It will help the client

expand on a topic

Therapeutic:

continues into adulthood.

In this stage, individuals

move beyond concrete

experiences and begin to

think abstractly, reason

logically and draw

conclusions from the

information available, as

well as apply all these

processes to hypothetical

situations.

It is observable that the

patient has an

inappropriate affect

Some questions with

regards to personal

information can be

answered correctly by the

patient.

Patient: Opo (flat affect)

Nurse: Nag-exercise ka rin ba?

Patient: Opo

Nurse: Kamusta naman ang

pag-ehersisyo mo kanina J?

Patient: Okay lang po

Nurse: Sino pala ang kasama

no J pagpunta mo dito?

Patient: Suseng

Nurse: Kaano-ano mo si

Suseng J?

Patient: nanay

Nurse: Nanay mo siya?

Sequencing:

Helps to identify cause and

effect, recurring pattern of

interpersonal difficulties.

Therapeutic:



The nurse should


further – she should refrain

from probing or prying. If

the patient chooses not to

elaborate, the nurse should

respect the patient’s

wishes. Probing usually

occurs when the nurse

introduces a topic because

she is anxious.

Therapeutic:

Sequencing:




Flight of ideas

a nearly continuous flow

of rapid speech that jumps

from topic to topic, usually

based on discernible

associations, distractions,

or plays on words, but in

severe cases so rapid as to

be disorganized and

incoherent.

Patient is fixated with

certain numbers like 5 and

10.

When we feel safe and

secure in our world then

we begin to seek out

friendships in order to feel

a sense of belonging.

Maslow's third level, the

Patient: Opo

Nurse: Tapos ano ang

nangyari?

Patient: may red na bag, blue

Nurse: Tapos?

Patient: isang bag lang dala

ko, namin

Nurse: Ilang taon ka na dito?

Patient: lima

Nurse: Si Suseng nasaan?

Patient: Doon

Therapeutic:



The nurse should










she is anxious.

Therapeutic:





and correctly

Therapeutic:





and correctly

need for belonging and

love, focuses on our desire

to be accepted, to fit in,

and to feel like we have a

place in the world.

Persons may be called

both mentally retarded and

learning disabled, meaning

that their overall IQ is

lower than average, but

that they have strengths

and weaknesses on various

skills.

Cognitive development is

defined as thinking,

problem solving, concept

understanding, and

information processing

and overall intelligence.

Many mentally retarded

clients have cognitive

weaknesses. Their overall

potential may be lower

than that of their peers and

siblings. They still have

patterns of strengths and

Nurse: Saan yung nanay mo J?

Patient: sa bahay, dun

Nurse: Sa Bitano?

Patient: Opo (nods)

Nurse: may mga gamot ka ba

na iniinom?

Patient: oo, kanina

Nurse: Ano daw yun J?

Patient: aspilit, isa lang

Patient: gamot, gamot,

(showed both arms)

Nurse: may asawa ka naba J?

Therapeutic:

Sequencing:




Therapeutic:

Sequencing:



interpersonal difficulties

Therapeutic:

Acknowledging the patient’s

Feeling:

The nurse helps the patient

to know that his feelings

are understood and

weaknesses in their

development and may do

very well with certain

types of learning.

Adaptive skills are the

skills needed for daily life

and include the ability to

produce and understand

language

(communication); home-

living skills; use of

community resources;

health, safety, leisure, self-

care, and social skills; self-

direction; functional

academic skills (reading,

writing, and arithmetic);

and work skills.

Patient: wala

Nurse: Nakatapos ka na ba ng

elementary o high school J?

Patient: oo, elementary

Nurse: Hanggang anong grade

natapos mo?

Patient: Grade 1

Nurse: ano pala palagi mo

ginagawa dito J?

Patient: Toothbrush (acting),

ligo, kain

Nurse: Tuwing umaga?

accepted and encouraged

him to continue expressing

them. If communication is

to be successful, it is

essential that the nurse

accept the thoughts and

feelings her patient is

expressing.

Include the patient

You must remember that

patient care should be

collaborative and include

the patient in decision

making whenever

possible. The patient often

feels at the mercy of the

system, but you can help

him find ways to feel in

control.

Patient: kain

Nurse: kapag hapon?

Patient: tulog

Nurse: ano ang gusto mong

pagkain J?

Patient: monggo’

Nurse: ano ang kinain mo

kanina?

Patient: monggo

Nurse: Masarap ba J?

Patient: Opo

Nurse: ano ang mga ayaw mo

kainin?

Patient: monggo, kanin, apple

Nurse: Di ba sabi mo gusto

mo ng monggo knina?

Nurse: Usap ulit tayo bukas

ha!

Patient: Opo.

WORKING PHASE


At this point, the client’s problems are identified and solutions are explored,

applied and evaluated. The focus of the assessment and of the relationship is the client’s behavior

and the focus of the interaction is the client’s feelings.

Objective:

After the working phase, the nurse will be able to:

Explore relevant stressors for the patient

Promote patient’s development of insight and use of constructive coping

mechanisms

Overcome resistance behavior

Date/ Time/ Venue: November 26, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

NURSE-PATIENT

INTERACTION

RATIONALE OF THE

NURSE’S

COMMUNICATION

TECHNIQUE

ANALYSIS OF THE

PATIENT’S RESPONSE

Nurse: Magandang umaga sa

yo J!

Patient: Magandang umaga

din po.

Nurse: Ano ulit ang pangalan

ko J?

Patient: (Kran)

Therapeutic:

Use names:


makes her feel more




interaction.

Therapeutic:

Help to orient

Patient is disoriented to

time, place and person

MEMORY AND

ATTENTION. Memory

deficiencies interfere with

learning rote material such

as days of the week,

months of the year, and

times tables. Basic facts

are hard to remember and

there is a lack in

Nurse: Ran ako

Patient: Ran

Nurse: Kamusta naman ang

tulog mo J?

Patient: Maayos

Nurse: eh ang gising?

Patient: ayos

Nurse: Anong araw pala

ngayon J?

Patient: Martes

Nurse: J, Biyernes ngayon.

Ang petsa ay November 27,

2009.



for patients.

Therapeutic:

Using Broad Opening

Statements:

The use of a broad

opening statement allows

the patient to set the

direction of the

conversation. Give the

patient an opportunity to

begin expressing himself.

In using a broad opening

statement, the nurse

focuses the conversation

directly on the patient and

communicates to him that

she is interested in him

and his problems. Upon

sensing that the patient

may have a need, the nurse

can use a broad opening

statement to initiate

discussion, while at the

same time allowing the

patient to determine what

will be discussed.

Therapeutic:

knowledge of general

information. There are

deficits in attention that

interfere with ability to

focus and concentrate on

tasks.

The patient can’t justify

Nurse: Anong araw ang

sumunod sa Biyernes?

Patient: Martes

Nurse: Kung Biyernes ngayon,

ano ang araw bukas? Bukas

ay?

Patient: Martes

Nurse: Sabado bukas J.

Sundan mo ko ha.

Nurse: Lunes

Patient: Lunes

Nurse: Martes

Patient: Martes

Giving Information

Studies have shown that a

major cause of anxiety or

discomfort in hospitalized

patients is lack of

information or

misconceptions about their

condition, treatment, or

hospital routines. When

the patient is in need of

information to relieve

anxiety, form realistic

conclusions, or make

decisions, this need will

often be revealed during

the interaction by

statements he makes. By

providing such

information as she

prudently can, admitting

and finding out what she

doesn’t know, or referring

the patient to someone

who can assist him, the

nurse can do much to

establish an atmosphere of

helpfulness and trust in her

relationship with the

patient.

Piaget’s cognitive theory








Operational stage,








logically and draw





situations.

Nurse: Miyerkules

Patient: Miyerkules

Nurse: Huwebes

Patient: Huwebes

Nurse: Biyernes

Patient: Biyernes

Nurse: Sabado

Patient: Sabado

Nurse: Linggo

Patient: Linggo

Therapeutic:

Using Broad Opening

Statements:

The use of a broad

opening statement allows

the patient to set the

direction of the

conversation. Give the

patient an opportunity to

begin expressing himself.

Therapeutic:

Sequencing:




Therapeutic:

Sharing Observations

Patient is responsive.








Operational stage,




Nurse: Anu-ano pala mga

ginawa mo ngayong umaga?

Patient: Kain, toothbrush, ligo

Nurse: Ano yung mga kinain

mo?

Patient: Spanish

Nurse: Spanish bread?

Patient: Opo

Nurse: masarap ba?

Patient: Opo

Nurse: pag-usapan natin ang

drawing mo kanina.

Patient: iskindi (ice candy)

The nurse shares with the

patient observations

regarding behavior. The

patient who has a need is

often unaware of the

source of this distress, or

reluctant to communicate

it verbally. However, the

tension or anxiety created

by his need creates energy

which is transformed into

some kind of behavior,

Therapeutic:

Sequencing:



interpersonal difficulties

Reflecting:

In reflecting, all or part of the patient’s statement is repeated to encourage him to go on. Reflecting can be overused, and the patient is likely to become annoyed if his own words or statements are continually repeated to him





logically and draw





situations.

Patient is responsive and answers questions with comprehension.

Nurse: ice candy yung

drawing mo?

Patient: Opo.

Nurse: Anong meron sa ice

candy at yun ang dinrawing

mo?

Ang ice candy ay?

Patient: matamis, lamig

Nurse: ano pa?

Patient: tigas, tamis

Nurse: may naalala ka ba sa

ice candy?

Patient: (silence)

Therapeutic:



The nurse should recognize when to delve further – she should refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect the patient’s wishes. Probing usually occurs when the nurse introduces a topic because she is anxious

Therapeutic:




MEMORY AND

ATTENTION. Memory







there is a lack in






tasks.

MEMORY AND

ATTENTION. Memory





Nurse: paborito mo ba ang ice

candy?

Patient: Opo.

Nurse: ano ang paborito mo na

lasa ng ice candy?

Patient: monggo

Nurse: Anu-ano pala ang mga

kulay ng ice candy? Diyan sa

drawing mo J?

Patient: (Points on the lines

while identifying its colors,

with some mistakes)

Nurse: (corrects the mistakes)

Nurse: okay J, very well.

Magaling!


and correctly



there is a lack in






tasks.

Nurse: Nagtitinda ka ba dati

ng ice candy J?

Patient: Hu..

Nurse: Pagod ka na ba J?

Patient: Opo.

Nurse: Okay sige. Pahinga ka

na J. Hintayin lana muna natin

ang iba na matapos ha.

Patient: Opo.

TERMINATION PHASE


The nurse terminates the relationship when the mutually agreed goals are met, the

patient is discharged or transferred or the rotation is finished. The focus of this stage is the

growth that has occurred in the client and the nurse helps the patient to become independent and

responsible in making his own decisions. The relationship and the growth or change that has

occurred in both the nurse and the patient is summarized.

Objective:

During the termination phase, the nurse will be able to:

Establish reality of separation

Review progress of therapy and attainment of goal

Mutually explore feelings of rejection, loss, sadness, and anger and related

behaviors

Date/ Time/ Venue: December 3, 2009 at National Center for Mental Health, Pavilion 1

Ward 9

Nurse-Patient Interaction Rationale of the Nurse’s Communication Technique

Analysis of the Patient’s Response

Nurse: Magandang umaga sa yo J.

Patient: Gandang umaga din po.

Therapeutic:

Use names


The patient is conscious.

The patient talks rapidly.

Adaptive skills are the

Nurse: Kumusta ang tulog mo?

Patient: Ok lang.

Nurse: Maayos ba naman ang gising?

Patient: Opo.

Nurse: Anu-ano ang mga ginawa mo kanina?

Patient: toothbrush, ligo, kain

Nurse: Ano ang kinain mo J?

Patient: tinapay

Nurse: masarap ba J?

Patient: Opo.

Nurse: nabusog ka ba?

Patient: (nods)

Nurse: Pag-usapan natin J yung tungkol sa niyog. Ano nga ang mga parte ng niyog?

Patient: dahon

makes her feel more




interaction.

Therapeutic:

Using Broad Opening

Statements:

The use of a broad opening statement allows the patient to set the direction of the conversation. Give the patient an opportunity to begin expressing himself.

Therapeutic:

Focusing:

It will help the client

expand on a topic

Therapeutic:



The nurse should







skills needed for daily life

and include the ability to

produce and understand

language

(communication); home-

living skills; use of

community resources;

health, safety, leisure, self-

care, and social skills; self-

direction; functional

academic skills (reading,

writing, and arithmetic);

and work skills.

Cognitive development is

defined as thinking,

problem solving, concept

understanding, and

information processing

and overall intelligence.

Many mentally retarded

clients have cognitive

weaknesses. Their overall

potential may be lower

than that of their peers and

siblings. They still have

patterns of strengths and

weaknesses in their

development and may do

very well with certain

Nurse: Ahh. Magbigay ka nga ng isang gamit ng dahon.

Patient: bubong

Nurse: Ano pa J? Magsabi ka pa nga ng isang parte pa ng puno ng niyog?

Patient: puno

Nurse: Anong gamit ng kahoy ng niyog J?

Patient: bahay.

Nurse: Oo. Ginagamit nga to sa paggawa ng bahay.

Nurse: Puwede ka bang magkuwento ng tungkol sa mga magulang at mga kapatid mo J?

Patient: …

Nurse: Namimiss mo ba sila J?

Patient: …

Nurse: Ano ulit pangalan nung nanay mo?




she is anxious.

Therapeutic:

Sequencing:




Therapeutic:

Focusing:

It will help the client expand on a topic

Therapeutic:





and correctly

types of learning.

MEMORY AND

ATTENTION. Memory







there is a lack in






tasks.








Operational stage,


Patient: Suseng

Nurse: Ano naman ang pangalan ng tatay mo J?

Patient: Mario

Nurse: Ang mga kapatid mo? Naaalala mo ba mga pangalan nila?

Patient: Ricoy, Marichu

Nurse: Nasaan na sila ngayon J?

Patient: Ambot.

Nurse: Napaano pala yang mga sugat mo sa kamay J?

Patient: kadena

Nurse: Sino ang nagkadena sa yo J?

Patient: nanay

Nurse: Ano daw ang dahilan ni Suseng dahil kinadena ka nya? May nagawa ka ba na kasalanan?

Patient: Ambot lang.

Therapeutic:

Acknowledging the patient’s

Feeling:

The nurse helps the patient

to know that his feelings

are understood and

accepted and encouraged

him to continue expressing

them. If communication is

to be successful, it is

essential that the nurse

accept the thoughts and

feelings her patient is

expressing.







logically and draw





situations.

MEMORY AND

ATTENTION. Memory







there is a lack in

Nurse: Ano pa ang mga nangyari J. Sige magkuwento ka pa. Makikinig ako.

Patient: Kinulong ako.

Nurse: Kinulong ka J?

Patient: …

Nurse: Ano ang naramdaman mo?

Patient: Nagalit.

Nurse: Kanino ka nagalit?

Patient: Suseng

Nurse: Tapos ano na ang nangyari?

Patient: Ambot.

Nurse: J huling beses na pala kita makakausap ng ganito.

Patient: …

Nurse: Socialization na bukas at huling araw na rin na pupunta ako dito bukas.






tasks.








Operational stage,








logically and draw





Patient: ….

Nurse: May gusto ka pa ba na sabihin o ikuwento sa akin?

Patient: Wala na.

Nurse: Sige J. Hintayin na lang natin ang iba na matapos.

situations.

process recording

Documents

direct patient

information patient

responsive patient

hospitalization patient

facts patient

remarks question patient

responsive nurse

memory skills patient