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Process Recording WMCC

The document summarizes a nurse-patient interaction over 4 days. It includes information about the patient's diagnosis of undifferentiated schizophrenia and goals for each phase of interaction including orientation, working, and termination. The environment for the first interaction is described as a small room that was a little noisy. The patient appeared well-groomed in her hospital gown. The evaluation concludes the interaction was successful in establishing rapport and trust with the participative patient.

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Kris Tejerero
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88 views

Process Recording WMCC

The document summarizes a nurse-patient interaction over 4 days. It includes information about the patient's diagnosis of undifferentiated schizophrenia and goals for each phase of interaction including orientation, working, and termination. The environment for the first interaction is described as a small room that was a little noisy. The patient appeared well-groomed in her hospital gown. The evaluation concludes the interaction was successful in establishing rapport and trust with the participative patient.

Uploaded by

Kris Tejerero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Clients Initials: SL

Age: 44 y/o
Nursing Diagnosis: Undifferentiated Schizophrenia Disturbed Type
Goal of Interaction:
Orientation Phase:
-

To gain rapport with my patient


Establish trust acceptance and open communication
To understand the patients problem

Working Phase:
-

To
To
To
To
To

readily apply the therapeutic activities for self enhancement


help them understand their current mental status
establish confidence upon interaction
promote patients self esteem
gain working trust and relationship

Termination Phase:
-

To gain self-awareness and self-care


To revive discomfort on understanding others

Description of environment: 1st day of interaction


-

The nurse-patient interaction was held in a small room in a house known


as the pantry area. The environment is a little bit noisy because the
quarter was in that area. Yet the patient still feel comfortable and relax.

Appearance of Client:
-

The client was well groomed with her hospital gown.

STUDENT

CLIENT
Hi, good morning. Ako
nga pla si Susan.

INTERPRETATION
Client expresses feeling
of excitement

Hanggang kalian po
kayo rito?.

Client ask for the day of


our stay, she shows
interest and happiness.

Ito ok lang naman.

Client states about her


feelings but shows
sadness on her face.

Ano kasi yun, sinabi


nila sa akin na may
ninakaw daw ako. Pero
hindi ko na matandaan
kung ano yung
ginagawa ko, sabi nila
sigaw daw ako ng
sigaw.

Client is open and


shows willingness to
share about her
concerns.

Salamat po sa iyong
pagbabahagi. Alam niyo
po ban a hindi totoo ang
mga yun? Hindi rin po
kasi maari yun kung
iyong iisipin ng mabuti.
Kailangan po lang natin
ang pinagkaiba ng totoo
sa hindi.

Nararanasan ko
minsan na
naghahallucinate ako.
Minsan nasa isip ko na
marami raw akong pera
at na anak daw ako ng
president.

Client expresses her


problems and about the
experiences she had
when attacks of illness
comes.

Nalulungkot ako na
marinig yun pero alam
mo nanjan naman ang
Diyos.

Alam mob a na nagiisa nalang ako, wala na


kasi akong asawa. Hindi
ko rin alam kung
nasaan ang mga anak
ko.

Client shows emotion of


sadness and concern
about her support
system. She seems
depress and incapable
of coping with stressors.

Buti naman at ganon


pero kung susundin mo
lang yung oag-inom ng
gamot mo, maaaring di

Oo nga eh, pag


nalulungkot ako
tumawatag lang ako sa
kanya, n asana hindi na

Client tells about her


problems and how she
deals with them.

Magandang umaga
po. Ako nga pala si
Whims, ako po ang
iyong magiging
student
nurse.
Nandito po ako sa
loob ng apat na araw.

Kamusts ka namn
ngayon?.

Ano nga palang


dahilan kaya ka
nandito?.

Evaluation:
All in all. My interaction with my patient for me has become successful because
I was able to gain answer for my questions. Establish rapport and trusting
relationship with her. I was satisfied and I think my patient was satisfied. She
seem so participative in every activities and excited in every activities. And I
can say that the interaction I made with my patient was improved a lot.

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