OLIVAREZ COLLEGE TAGAYTAY COLLEGE OF NURSING
Interpersonal Communication Process Recording (Day 2)
Introduction WORKING PHASE At this point, the clients problems are identified and solutions are explored, applied and evaluated. The focus of the assessment and of the relationship is the clients behavior and the focus of the interaction is the clients feeling. General Objectives: To readily apply the therapeutic activities for self enhancement To help them understand their current mental health status To prevent them from harming their self To promote mind set for easy recovery To reduce anxiety
Specific Objective as a student: To overcome resistance behavior To provide physical cleaning To create good therapeutic binding To reduce level of fear
To make him realize that there is hope in life To promote self-actualization
Specific Objective for patient: To promote patients self-esteem To provide high level of trust To establish confidence upon interaction To promote self enhancement through life confession experience To gain working trust relationship
Summary: On the second and third day of handling my patient, I gained his trust and he started sharing his ideas and thoughts. He also tells stories about his past life. In the activities weve prepared for them, he actively participates in reading therapy. And he conceptualizes his own moral lesson of the story. Though sometimes his answered is a little bit far from the story at least he tries his best to cooperate with the other members of the group. On our third day we had sing Anak by Freddie Aguilar and Kapaligiran by Asin for our music therapy, but he wasnt interested for the reason that he didnt like the song weve pick and choose. And for play therapy we had banana relay and hep hep hooray. But in the banana relay he participates well and his group won. And the hephep hooray game is one of his favorite and most known games. He won the last game and I see him very happy with the result. Evaluation: At the end of the working phase, the patient was able to verbalize his feelings and emotions and was able to tell his story why he was admitted at CCMH. He knows his current situation and he feels sad for not being with his family. The patient also express his talents in different ways and facilitate his learning thru different activities weve done.
Patient name: Luciano Malabanan Student name: Nikka F. Gatpandan Diagnosis:
Date: October 1, 2011 Time started: 2:00pm 4:00 pm Place conducted: Student hall
Perception to the client: The patient looks calm. He leads the way on where we are going to stay for NPI. When he sits down, he started to talk. Perception to the environment: The environment was cold and windy because theres a storm coming. The patient enjoys looking at the surrounding.
Interviewer Maganda Hapon po..
Technique Used Respect/Giving Recognition -therapeutic
Patient The patient nodded at go directly to the faucet for ADL.
Sige po Tay, mag-toothbrush at maghilamos na po tayo para maging maganda ang inyong pakiramdam.
Suggesting collaboration therapeutic
The patient started his ADL.
Analysis Showing respect is an important factor in effective communication. Greeting a client by name shows that the nurse recognizes the client as a person, as an individual. It does not carry the notion of value, of being good or bad. The patient is following task given. This indicates that the patient knows and aware of his daily routine, therefore the patient was able to perform self-care. Dorothea Orems self-care theory states that self-care is
where an individual performs independently throughout of life to promote and maintain personal well being.
Tapos na po kayo Tay? Punta Giving Recognition na po tayo sa Student hall, therapeutic
No response Non verbal: The patient follows the student nurse.
Dito po tayo umupo Tay. (pointing to the left side of the hall) Tay, mag e-exercise po muna tayo bago magsimula para masigla ang ating katawan. Wow, ang galing naman ni tatay mag-exercise, dito na
The patient sits facing me.
The patient nodded.
Giving recognition therapeutic
The patient follows the student nurse and sits in the chair.
Silence or long pause in communication may indicate different things. The client may be depressed and struggling to find the energy to talk. Sometimes pauses indicate the client is thoughtfully considering the question before responding. At times. The client may seem to be lost in his or her own thoughts and not paying attention to the nurse. It is important to allow client sufficient time to respond even of it seems like a long time. (Vedebeck 2nd Edition) The patient follows instruction and show interest by maintaining eye to eye contact with the nurse. The patient participates actively in the activity. He can do the same movement the leader is doing in front. The patient can understand the student nurse instruction.
po ulit tayo sa ating upuan. Tay, naaalala nio pa po ba ako? Wow, mabuti naman po at naaalala niyo ako. e saan school naman po kami galing? Wow, natatandaan niyo po. Kamusta naman po kayo? Ang tulog mo po? Tay kukunan kop o ulit kayo ng BP, Temperatura ng inyong katawan, pulso at RR nio po? Normal naman po ang inyong Bp = 120/80 po.
Help to orient Giving recognitiontherapeutic Help to orient Broad opening - therapeutic
Opo, si Nikka. Sa Olivares po.
The patient answers the question correctly. The patient answers the question correctly.
Maayos naman ang tulog ko.
Asking for permission therapeutic
The patient nodded.
Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak. The patient is cooperative to the student nurse.
Normal naman The patient is repeating what Ive said.
The patient is cooperative to the student nurse.
Tay, 36.8 po, wala naman po kayo lagnat. Ok naman po lahat ng VS nio. May gusto po ba kayo pag usapan ngayon?
Broad Openings therapeutic
No response. The patient is just starring at the table. Wala naman. Still the patient is starring at the table. Yung Table po. Hindi tinitingnan ko lamang yun
Ano po tumatakbo sa isip nio ngayon? (Looking at the client and making observation) Ano po tinitingnan niyo?
Broad Openings therapeutic
Questioning - therapeutic
Gusto niyo po ba gumamit ng Asking Direct Question -
Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak. Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak. The patient answer the question Patient is responsive.
table? Ahh, yun libro po, gagamitin po natin yan mamaya sa activity, tayo po ay magbabasa. Mabuti po kung ganon, ano po gusto niyo basahin mamaya? Wow, ang galing mo naman po, ano po natapos ninyo? Naka-pag kolehiyo po kayo? Ano po kurso ang iyong kinuha? E di marunong po kayo gumawa ng sasakyan? E yung mga computer o cellphone sira marunong po kayo mag ayos? Tay, ilang taon na po kayo dito? Ah, dati po nakalabas na kayo, tapos binalik po ulit kayo dito sa loob?
therapeutic Giving information therapeutic
nasa lamesa. Ako po ay marunong magbasa.
Patient is responsive.
Asking question therapeutic Giving recognitiontherapeutic Exploring- therapeutic Asking question therapeutic Exploring - therapeutic
The patient stands up and read the words written at the whiteboard. Opo, nakapag kolehiyo po ako..
The patient can understand and read well. The patient knows his educational attainment. The patient is responsive. The patient is responsive and knows his capacity. The patient knows the use of the gadget that the student nurse is says. Ill try to know more about the patient. The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution. The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution.
Automotive Mechanical Opo, marunong po ako gumawa ng sasakyan, mahilig po ako sa sasakyan. Yung computer yun madami games, tapos yun cellphone yung sa kamay. Matagal na, dalawa beses na ko bumalik dito. Opo, dalawa beses na ko nakabalik dito, dati nasa labas po ako.
Questioning - therapeutic
Exploring - therapeutic Restating - therapeutic
Sa ano po dahilan at ibinalik kayo dito?
Exploring - therapeutic Asking Question therapeutic
Kasi sabi nila ipapa-check up lang ako, tapos sumunod ako sa jeep. Kasama ko tatay at kuya ko. Pagdating dito may nilagay sakin na gamot tapos tinali ako. Dito at dito (point to his hands and feets). Tapos paggising ko
Ahh, tinali po kayo, ang kasama nio po pumunta dito ay ang tatay at kuya mo? Saan ka po nakatira? Alam mo pa po ang pauwi sa inyo? Ilan po kayo magkakapatid?
Restating - therapeutic
wala na sila. Opo, si Kuya duroy at si tatay.
Questioning - therapeutic Questioning - therapeutic
Questioning - therapeutic
Sa Talisay Batangas Hindi ko na alam, gusto ko dito na lang. (then he whisper something) 60 po. (then he started to say different names) Opo, gusto ko na sila Makita. Namimiss ko na. Nun april pa.
Pangalan po yon ng mga kapatid mo? Namimiss mo na po sila lahat? Kelan ka po huli dinalaw dito? April po? Ngayon taon po o nung nakaraan taon pa? Isang taon na po pala kayo hindi pinupuntahn dito, matagal na po pala kayo hindi nadadalw. Baka po kasi malayo yung bahay niyo kaya hindi pa po ulit kayo nadadalaw dito. May asawa po ba kayo? Ilang taon na po yung asawa mo? May anak po kayo?
Questioning - therapeutic Exploring - therapeutic Questioning - therapeutic Asking direct question therapeutic Help to orient - therapeutic Restating- therapeutic
The patient still know his past experiences and still recall previous occasion Patient is responsive. The patient knows his own capacity and knows his limitations. Obtaining information and regarding clients existing family. The patient is longing for his siblings. The patient what to see his family. The patient still remembers past events.
Nun isang taon pa.
The patients still remember past events. Gusto ko dalawin nila ako, The patient is longing for his sabihin mo sa kanila dalawin ako family. dito. Malayo ang bahay (then the patient start whispering again) Meron, si Marieta Nun 21 ako, 19 siya The patient wants to see his family and friends. He wants them to visit him at CCMH. Obtaining data regarding clients personal life. The patient somehow remembers details about his wife. Obtaining data regarding
Giving information therapeutic Exploring - therapeutic Questioning - therapeutic
Exploring - therapeutic
Babae po o lalaki? Ano po pangalan nun babae? E yung lalaki po, ano pangalan? Ilang taon na po yung mga anak nio?
Questioning - therapeutic Asking question therapeutic Asking question therapeutic Asking question therapeutic
Babae at lalaki Margaret Franco 4000 na sapatos, 2000 damit, 500 sandals
clients personal life. The patient is responsive. The patient is responsive. The patient is responsive. The patient didnt answer my question instead hes saying those words and repeating it for 4 times. The patient is asking me to give those things/ stuff. The patient knows the scarcity of stuff being used for them.
Ano po yung sinasabi mo? Napakarami naman po nun, ano po gagawin mo dun?
Questioning - therapeutic Exploring - therapeutic
Wow, ang bait nio naman po at gusto ninyo sila bigyan. Ano po paborito nio pagkain? Ano naman po ulam nio kanina? Madami po ba kayo nakain?
Giving recognition therapeutic Asking question therapeutic Asking question therapeutic Asking questiontherapeutic
Bigyan mo ko ng 4000 na sapatos, 2000 damit, 500 sandals Sa amin, hati-hati po kami dito. Ipapamigay ko sa kanila, sa iba naming kasamahan, tapos itatago yun iba. The patient just stares at me and looks around. Siopao, tsaka yun pansit, spaghetti. Pansit at embutido. Madami ako nakain.
The patient is thinking and maybe unwinds his mind. The patient is responsive. The patient still notice the meals they ate at lunch time. The patient seems restating what Ive asked. Maybe he didnt understand what Im asking because he is preoccupied of different things, The patient still knows how to count numbers. The patient is cooperative and responsive. The patient is still responsive.
Nakailang kanin po kayo? Nakarami po kayo? Ah, sabay- sabay po kayo kumakain? Nanunuod po kayo ng TV?
Asking question therapeutic Asking question therapeutic Exploring - therapeutic
Hindi isa lang po, Opo, sabay sabay kami kumain, tigi-tigisa kami ng plato at baso. (the patient is looking at the TV) Opo
Asking Direct Question therapeutic Ano po pinanuod nio kagabi? Exploring - therapeutic Asking Direct Question therapeutic E di alam nio po may bagyo ngayon? Meron po padating na bagyo mamaya gabi, tingnan nio po mahangin po sa labas at umaambon. Sino naman po paborito ninyo artista? E lalaking artista po? Tay, magsisimula na po ang ating activity, making po kayo mabuti sa mga kwento kasi magtatanong kami mamaya. After the activity.. Wow, galing nit ay sumagot. Tay, kakain na po tayo, magdadasal po muna tayo bago magsimula kumain. After eating, Kamusta naman po ang lasa ng pagkain ngayon? masarap po ba? Nabusog naman po kayo? Tay wala po kami bukas, ang Asking Direct Question therapeutic Giving Information therapeutic
Wala po bagyo. May bagyo pala mamaya.
The patient is somehow updated with the current things happening outside the CCMH. The patient is disoriented. The patientsunderstands what the student nurse is trying to explain. The patient recognizes names of our local artist. The patient recognizes names of our local artist. The patient understands the student nurse instruction. And He participates in the activity by giving feedback and moral lesson of the story. They pray before they started to eat.
Asking Direct Question therapeutic Asking Direct Question therapeutic Giving Information therapeutic
Si Lanie Mercado po.. Si Robin Padilla po. The patient nodded and sits on his designated place.
Giving recognition therapeutic
The patient sits in the chair and waits for his food.
Seeking Information therapeutic
Opo, masarap naman.
He is happy on the food that the nurse gives to him and he was satisfied. He was satisfied with the food. The patient is clarifying when
Seeking Information therapeutic Giving information -
Opo busog po ako. Sa lunes, martes?
balik po naming ay sa huwebes na po ulit, Wala po, Huwebes na po kami babalik, bali apat na araw pa po bago maghuwebes. Tay, pabalik na po tayo ngayon sa ward, yun tsinelas po iiwan niyo po ulit sa akin, tapos ibibigay ko po ulit pagbalik namin sa huwebes..
therapeutic Giving information therapeutic S...