Interpersonal Communication Process Recording (Day 2)

OLIVAREZ COLLEGE TAGAYTAY

COLLEGE OF NURSING

Interpersonal Communication Process Recording (Day 2)

Introduction

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 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 patient’s 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 we’ve 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 wasn’t interested for the reason that he didn’t like the song we’ve 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 we’ve done.

Patient name: Luciano Malabanan Date: October 1, 2011

Student name: Nikka F. Gatpandan Time started: 2:00pm – 4:00 pm

Diagnosis: 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 there’s a storm coming. The patient enjoys looking at the surrounding.

Interviewer Technique Used Patient AnalysisMaganda Hapon po.. Respect/Giving Recognition

-therapeuticThe patient nodded at go directly to the faucet for ADL.

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”.

Sige po Tay, mag-toothbrush at maghilamos na po tayo para maging maganda ang inyong pakiramdam.

Suggesting collaboration - therapeutic

The patient started his ADL. 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 Orem’s 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 na po tayo sa Student hall,

Giving Recognition -therapeutic

No responseNon verbal: The patient follows the student nurse.

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)

Dito po tayo umupo Tay. (pointing to the left side of the hall)

Giving information- therapeutic

The patient sits facing me. The patient follows instruction and show interest by maintaining eye to eye contact with the nurse.

Tay, mag e-exercise po muna tayo bago magsimula para masigla ang ating katawan.


The patient nodded. The patient participates actively in the activity. He can do the same movement the leader is doing in front.

Wow, ang galing naman ni tatay mag-exercise, dito na

Giving recognition -therapeutic

The patient follows the student nurse and sits in the chair.

The patient can understand the student nurse instruction.

po ulit tayo sa ating upuan.Tay, naaalala nio pa po ba ako?

Help to orient Opo, si Nikka. The patient answers the question correctly.

Wow, mabuti naman po at naaalala niyo ako. e saan school naman po kami galing?

Giving recognition- therapeuticHelp to orient

Sa Olivares po. The patient answers the question correctly.

Wow, natatandaan niyo po. Kamusta naman po kayo? Ang tulog mo po?

Broad opening - therapeutic Maayos naman ang tulog ko. Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak.

Tay kukunan kop o ulit kayo ng BP, Temperatura ng inyong katawan, pulso at RR nio po?

Asking for permission - therapeutic

The patient nodded. The patient is cooperative to the student nurse.

Normal naman po ang inyong Bp = 120/80 po.

Tay, 36.8 po, wala naman po kayo lagnat. Ok naman po lahat ng VS nio.


Normal naman…

The patient is repeating what I’ve said.

The patient is cooperative to the student nurse.

May gusto po ba kayo pag usapan ngayon?

Broad Openings - therapeutic

No response.

The patient is just starring at the table.

Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak.

Ano po tumatakbo sa isip nio ngayon?(Looking at the client and making observation)

Broad Openings - therapeutic

Wala naman.

Still the patient is starring at the table.

Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak.

Ano po tinitingnan niyo? Questioning - therapeutic Yung Table po. The patient answer the question

Gusto niyo po ba gumamit ng Asking Direct Question - Hindi tinitingnan ko lamang yun Patient is responsive.

table? therapeutic nasa lamesa.Ahh, yun libro po, gagamitin po natin yan mamaya sa activity, tayo po ay magbabasa.

Giving information - therapeutic

Ako po ay marunong magbasa. Patient is responsive.

Mabuti po kung ganon, ano po gusto niyo basahin mamaya?

Asking question - therapeutic

The patient stands up and read the words written at the whiteboard.

The patient can understand and read well.

Wow, ang galing mo naman po, ano po natapos ninyo? Naka-pag kolehiyo po kayo?

Giving recognition- therapeuticExploring- therapeutic

Opo, nakapag kolehiyo po ako.. The patient knows his educational attainment.

Ano po kurso ang iyong kinuha?


Automotive Mechanical The patient is responsive.

E di marunong po kayo gumawa ng sasakyan?

Exploring - therapeutic Opo, marunong po ako gumawa ng sasakyan, mahilig po ako sa sasakyan.

The patient is responsive and knows his capacity.

E yung mga computer o cellphone sira marunong po kayo mag ayos?

Questioning - therapeutic Yung computer yun madami games, tapos yun cellphone yung sa kamay.

The patient knows the use of the gadget that the student nurse is says.

Tay, ilang taon na po kayo dito?

Exploring - therapeutic Matagal na, dalawa beses na ko bumalik dito.

I’ll try to know more about the patient.

Ah, dati po nakalabas na kayo, tapos binalik po ulit kayo dito sa loob?

Restating - therapeutic Opo, dalawa beses na ko nakabalik dito, dati nasa labas po ako.

The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution.

Sa ano po dahilan at ibinalik kayo dito?

Exploring - therapeuticAsking 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

The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution.

wala na sila.Ahh, tinali po kayo, ang kasama nio po pumunta dito ay ang tatay at kuya mo?

Restating - therapeutic Opo, si Kuya duroy at si tatay. The patient still know his past experiences and still recall previous occasion

Saan ka po nakatira? Questioning - therapeutic Sa Talisay Batangas Patient is responsive.Alam mo pa po ang pauwi sa inyo?

Questioning - therapeutic Hindi ko na alam, gusto ko dito na lang. (then he whisper something)

The patient knows his own capacity and knows his limitations.

Ilan po kayo magkakapatid? Questioning - therapeutic 60 po. (then he started to say different names)

Obtaining information and regarding client’s existing family.

Pangalan po yon ng mga kapatid mo?

Questioning - therapeutic Opo, gusto ko na sila Makita. The patient is longing for his siblings.

Namimiss mo na po sila lahat?

Exploring - therapeuticQuestioning - therapeutic

Namimiss ko na. The patient what to see his family.

Kelan ka po huli dinalaw dito?

Asking direct question - therapeutic

Nun april pa. The patient still remembers past events.

April po? Ngayon taon po o nung nakaraan taon pa?

Help to orient - therapeutic Nun isang taon pa. The patients still remember past events.

Isang taon na po pala kayo hindi pinupuntahn dito, matagal na po pala kayo hindi nadadalw.

Restating- therapeutic Gusto ko dalawin nila ako, sabihin mo sa kanila dalawin ako dito.

The patient is longing for his family.

Baka po kasi malayo yung bahay niyo kaya hindi pa po ulit kayo nadadalaw dito.

Giving information - therapeutic

Malayo ang bahay(then the patient start whispering again)

The patient wants to see his family and friends. He wants them to visit him at CCMH.

May asawa po ba kayo? Exploring - therapeutic Meron, si Marieta Obtaining data regarding client’s personal life.

Ilang taon na po yung asawa mo?

Questioning - therapeutic Nun 21 ako, 19 siya The patient somehow remembers details about his wife.

May anak po kayo? Exploring - therapeutic Meron dalawa, Obtaining data regarding

client’s personal life.Babae po o lalaki? Questioning - therapeutic Babae at lalaki The patient is responsive.Ano po pangalan nun babae? Asking question -

therapeuticMargaret The patient is responsive.

E yung lalaki po, ano pangalan?


Franco The patient is responsive.

Ilang taon na po yung mga anak nio?


4000 na sapatos, 2000 damit, 500 sandals

The patient didn’t answer my question instead he’s saying those words and repeating it for 4 times.

Ano po yung sinasabi mo? Questioning - therapeutic Bigyan mo ko ng 4000 na sapatos, 2000 damit, 500 sandals

The patient is asking me to give those things/ stuff.

Napakarami naman po nun, ano po gagawin mo dun?

Exploring - therapeutic Sa amin, hati-hati po kami dito. Ipapamigay ko sa kanila, sa iba naming kasamahan, tapos itatago yun iba.

The patient knows the scarcity of stuff being used for them.

Wow, ang bait nio naman po at gusto ninyo sila bigyan.

Giving recognition - therapeutic

The patient just stares at me and looks around.

The patient is thinking and maybe unwinds his mind.

Ano po paborito nio pagkain?


Siopao, tsaka yun pansit, spaghetti.

The patient is responsive.

Ano naman po ulam nio kanina?


Pansit at embutido. The patient still notice the meals they ate at lunch time.

Madami po ba kayo nakain? Asking question- therapeutic

Madami ako nakain. The patient seems restating what I’ve asked. Maybe he didn’t understand what I’m asking because he is pre-occupied of different things,

Nakailang kanin po kayo? Nakarami po kayo?


Hindi isa lang po, The patient still knows how to count numbers.

Ah, sabay- sabay po kayo kumakain?


Opo, sabay sabay kami kumain, tigi-tigisa kami ng plato at baso. (the patient is looking at the TV)

The patient is cooperative and responsive.

Nanunuod po kayo ng TV? Exploring - therapeutic Opo The patient is still responsive.

Asking Direct Question - therapeutic

Ano po pinanuod nio kagabi? Exploring - therapeuticAsking Direct Question - therapeutic

Balita po. The patient is somehow updated with the current things happening outside the CCMH.

E di alam nio po may bagyo ngayon?


Wala po bagyo. The patient is disoriented.

Meron po padating na bagyo mamaya gabi, tingnan nio po mahangin po sa labas at umaambon.

Giving Information - therapeutic

May bagyo pala mamaya. The patientsunderstands what the student nurse is trying to explain.

Sino naman po paborito ninyo artista?


Si Lanie Mercado po.. The patient recognizes names of our local artist.

E lalaking artista po? Asking Direct Question - therapeutic

Si Robin Padilla po. The patient recognizes names of our local artist.

Tay, magsisimula na po ang ating activity, making po kayo mabuti sa mga kwento kasi magtatanong kami mamaya.

Giving Information - therapeutic

The patient nodded and sits on his designated place.

The patient understands the student nurse instruction. And He participates in the activity by giving feedback and moral lesson of the story.

After the activity..Wow, galing nit ay sumagot.Tay, kakain na po tayo, magdadasal po muna tayo bago magsimula kumain.

Giving recognition - therapeutic The patient sits in the chair and

waits for his food.They pray before they started to eat.

After eating,Kamusta naman po ang lasa ng pagkain ngayon? masarap po ba?

Seeking Information - therapeutic

Opo, masarap naman. He is happy on the food that the nurse gives to him and he was satisfied.

Nabusog naman po kayo? Seeking Information - therapeutic

Opo busog po ako. He was satisfied with the food.

Tay wala po kami bukas, ang Giving information - Sa lunes, martes? The patient is clarifying when

balik po naming ay sa huwebes na po ulit,

therapeutic we will return in the CCMH.

Wala po, Huwebes na po kami babalik, bali apat na araw pa po bago mag-huwebes.

Giving information – therapeuticSetting limits- therapeutic

Ahh.. The patient seems to understand what the student nurse is trying to explain.

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..


The patient nodded. The patient understands the student nurse instruction.

Patient name: Luciano Malabanan Date: October 6 2011

Student name: Nikka F. Gatpandan Time started: 2:30pm – 4:00 pm

Diagnosis: Place conducted: Bayanihan Hall

Perception to the client: The patient looks irritated.

Perception to the environment: The environment was cold and windy because of the rainy weather conditions.

Interviewer Technique Used Patient AnalysisMaganda Hapon po.. Respect/Giving Recognition

-therapeuticThe patient nodded at go directly to the faucet for ADL.

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”.

Sige po Tay, mag-toothbrush at maghilamos na po tayo para maging maganda ang inyong pakiramdam.

Suggesting collaboration - therapeutic

The patient started his ADL. 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 Orem’s 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 na po tayo sa Student hall,

Giving Recognition -therapeutic

No responseNon verbal: The patient follows the student nurse.

Silence or long pause in communication may indicate different things.(Vedebeck 2nd

Edition)Dito po tayo umupo Tay. (pointing to the left side of the hall)


The patient sits facing me. The patient follows instruction and show interest by maintaining eye to eye contact with the nurse.

Tay, mag e-exercise po muna tayo bago magsimula para masigla ang ating katawan.


The patient nodded. The patient participates actively in the activity. He can do the same movement the leader is doing in front.

Wow, ang galing naman ni tatay mag-exercise, dito na po ulit tayo sa ating upuan.

Giving recognition -therapeutic

The patient follows the student nurse and sits in the chair.

The patient can understand the student nurse instruction.

Tay, naaalala nio pa po ba ako?

Help to orient Opo, si Nikka. The patient answers the question correctly.

Wow, mabuti naman po at naaalala niyo ako. e saan school naman po kami galing?

Giving recognition- therapeuticHelp to orient

Sa Olivares po. The patient answers the question correctly.

Wow, natatandaan niyo po. Kamusta naman po kayo? Ang tulog mo po?

Broad opening - therapeutic Maayos naman ang tulog ko. Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak.

Tay kukunan ko po ulit kayo ng BP, Temperatura ng inyong katawan, pulso at RR nio po?

Asking for permission - therapeutic

The patient nodded. The patient is cooperative to the student nurse.

Normal naman po lahat Tay, wala po kayo lagnat.


Normal naman… The patient is cooperative to the student nurse.

The patient is repeating what I’ve said.

Tay, ngayon po tayo ay magkakaroon ng music therapy at play therapy, gusto mo po ba kumanta?

Asking Question - therapeutic

Opo, gusto ko kumanta. The patient is excited for the music therapy.

Ano po gusto nio kantahin? Asking Question - therapeutic

Yun po when the smoke is going down.

The patient wants to sing his favorite song.

Naku tay, anak po at kapaligiran po ang kakantahin natin ngayon, alam mo po ba yun?

Asking Question- therapeutic

The patient nodded. And look far away.

The patient is not interested with the song that the student nurse pick.

Music Therapy started…

Tay,tara na po sa unahan, kakanta na po tayo, galingan niyo po huh.

Suggesting collaboration-therapeutic

The patient moves his chair in front.

The patient understands the student nurse instruction and sit in front together with his co-patients.

Tay,kanta din po kayo. Sabayan niyo po sila.

Suggesting collaboration- therapeutic

The patient just nodded. Then watch the surroundings.

The patient is showing dislike about the song, he is not cooperating and he just holds his slippers and watches the surroundings.

After music therapy, we had the banana relay..

Tay, maglalaro naman tayo, galingan niyo po huh.. (one of my groupmates explain and demonstrate the proper way in playing the banana relay therapy)

Suggesting collaboration- therapeuticGiving information- therapeutic

The patient nodded. The patient shows interest in the games.

After playing..Wow,ang galing ni Tay Giving recognition- No response. The patient is tired because of

tumakbo, ang bilis. therapeutic the game.Tay, hephep Hooray naman tayo, alam niyo po ba yun laruin?

Asking question- therapeutic

Opo mam.The patient demonstrates how to play the hephep Hooray.

The patient is knowledgeable about the mechanics of the said game.

After playing Hephep Hooray..Wow tay, ang galing niyo naman po, kayo po ang nanalo, ang premyo niyo po ay bukas na po naming ibibigay.

Giving recognition - therapeutic

Sige po.. The patient is happy with the result and excited for the reward.

Tay, pahinga po muna kayo, mamaya po kakain na po tayo.


Sige po. The patient understands what is the student nurse instructed.

Tay, kakain na po tayo, magdadasal po muna tayo bago magsimula kumain.

Suggesting Collaboration- therapeutic

The patient led the prayer. The patient still knows how to pray.

After eating..Nabusog po ba kayo Tay?

Seeking Information - therapeutic

Opo. The patient gives two thumbs up.

The patient is satisfied with the food.

Tay, pabalik na po tayo ngayon sa ward, yun tsinelas po iiwan niyo po ulit sa akin, bukas po kakanta at sasayaw po kayo huh?


The patient nodded. The patient is looking forward for the next activities.

Documents

Interpersonal Communication Process Recording (Day 2)