Process Recording and Theme Identification

August 25, 2010

10:30 am

Place: under the tree, beside the canteen

Orientation phase

I. Personal data

Name of the patient: A. A.

Address: #874 bldg. Arlegui St. Quiapo, Manila

Age: 28 years old

Gender: female

Date of birth/place: January 07, 1982/ Cotabato City, Mindanao

Religion: muslim

Place where patient spent her last 15 years: Cotabato City, Mindanao

II. Objectives

Client-centered objectives:

• To established trust through the use of various therapeutic

communication techniques

• To encouraged verbalization of thoughts and feelings

 • To improved active socialization and reduced anxiety

Nurse-centered objectives:

• To analyzed and interpret every behavior being manifested by the

patient

• To attend mental health care for the patient

• To develop positive coping behavior through therapeutic

communication techniques

III. Description of the setting

Set-up/ environment:

It was a sunny day, around 10:30 in the morning, August 25th, 2010.

We received our client from the female ward with the supervision of Mr.

Iris Flores. As we received our patient, we proceed to the pantry for

grooming. After attending the client’s proper hygiene routine we went

under the trees beside the canteen area for the substantial conversation.

The setting was enough convenient for a conversation accompanied by

the beautiful and breath-taking mountain views. There’s enough sunlight

 thrusting to the branches of the trees. Calm and quiet surrounding enough

to set a good mood for our client.

Nature, behavior, affect and mood of the client:

During the conversation, the client was coherent and approachable.

She kept on smiling and grinning as we go along the conversation. She

had answered all the questions consistently although sometimes the

conversation and or the answers are just being repeated and far from the

thought of the question. She had a positive coping behavior as we talked

about her past experiences and what she had before.

IV. Process Recording

Therapeutic Analysis and

communication Interpretation
Nurse-patient Interaction
techniques used

Sn: “magandang umaga Giving recognition According to

po Aling A.A.” Sullivan’s

interpersonal theory

by addressing
P: “magandang umaga
someone’s name
din.”
shows that nurse

recognized the client

 as a person to be able

to build friendship

towards the client.

Sn: “ako po pala si Aira Giving information Make the available

at sya naman si vangie, facts the client need

kami po ang to established trust

makakasama nyo bilang and cooperation

nurse sa loob ng 3

linggo.”

P: “ah ikaw si aira at

ikaw si vangie, sige alam

ko na.”

Sn: “ ano po ba ang Encouraging To make clear if the

buong pangalan nyo?” elaboration client has refreshed

her memory
Seeking clarification

P: “Ana Alamada.”

Sn: “ilan taon nap o ba Asking question To gain information

kayo?” from the therapy than

the client did in order

P: “28 years old.”
to maintain an

effective verbal
 communication

Sn: “kalian po ang Asking question To gain information

birthday nyo?” from the therapy than

the client did in order

to maintain an
P: “January 07, 1982”
effective verbal

communication

Sn: “alam nyo po ba ang Seeking clarification To make clear if the

araw at petsa natin client has refreshed

ngayon?” her memory

P: “Miyerkules ngayon,

kaso yung date hindi ko

alam pero alam ko year

2010 na.”

Sn: “taga-saan po Asking question To gain information

kayo?” from the therapy than

the client did in order

to maintain an
P: “Quiapo, Manila sa
effective verbal
874 bldg. Arlegui street
communication
Quiapo, Manila.”

Sn: “gaano nap o kayo Asking question To gain information

katagal dito?” from the therapy than

the client did in order

to maintain an
P: “bale mag-siyam na
effective verbal
buwan na ako dito.”
communication

Sn: “may asawa po ba Asking broad open- Asking goal directly

kayo?” ended question questions that helps

the client to focus in

Focusing
specific area of
P: “wala pa single ako.”
concern.

(smiling)

Sn: “eh may pamilya pa Encouraging Encouraging client to

po ba kayo?magulang? elaboration tell something about

mga kapatid?” herself. Interaction is

very beneficial in

relationship to other
P: “oo, nasa Quiapo
people through what
sila, 4 kami
client’s sees and
magkakapatid 4 kami
remember.
mga babae. Pang-tatlo

ako sa magkakapatid

panganay si ate marissa,

2nd si ate myra tapos

bunso si jehan.”
Sn: “papaano po kayo Asking question According to jean

napunta dito?” Orlando, to provide or

Seeking clarification
to gain information

from the therapy than

P: “nahuli ako ng pulis
the client did in order
kasi nagtitinda ako sa
to maintain an
bangketa sa Quiapo,
effective verbal
tapos kinuha ako ng
communication
DSWD dinala ako dito,

bahay ampunan raw

ditto eh.”

Sn: “alam nyo po ba Asking question To gain information

kung nasaang lugar from the therapy than

kayo?” the client did in order

to maintain an

effective verbal
P: “oo, Mariveles,
communication
Bataan. Malayo sa’min.”

Sn: “aling A.A. gusto Offering one’s self Showing concern and

nyo po bang lagyan ko interest making one’s

kayo ng lipstick?” self available. The

nurse should assist

the individual sick or

P: “oo, sige.”
well, in the
 performance of those

activities contributing

to their healthcare

Sn: “kaya nyo po bang Offering one’s self Showing concern and

maghilamos mag-isa? interest making one’s

gusto nyo po ba self available. The

tulungan ko kayo?” nurse should assist

the individual sick or

well, in the
P: “kaya ko naman mag-
performance of those
isa.”
activities contributing

to their healthcare

Sn: “ano pong ginagawa Asking broad open- Encourage client to

nyo noong nakaraang 15 ended questions tell something about

taon?” herself. Interaction is

very beneficial in

relationship to other
P: “nag-aaral ako, high
people through what
school na’ko nun tapos
client’s sees and
nung ma-stop ako
remember.
nagbalik na ko sa Manila

tinulungan ko na lang

magtinda si nanay ko.”

Sn: “hanggang saan

lang po ba ang natapos

nyo?”

P: “3rd year high school”

Sn: “anu-ano po yung

tinda nyo?”

P: “damit, bag at mga

sapatos.”

Sn: “ano pa po iba

nyong ginagawa?”

P: “gumigimik kami sa

gabi ng mga friends ko;

tapos madalas kami

 mag-outing nila ate

marissa at myra.”

Sn: “naaalala nyo pa po Summarizing Provide the client a

ba ang mga pangalan concise resume of

naming?” what has transpired it

helps them to

evaluate and review

P: “ay ano na nga
all issues.
ba?”(smiling)

Sn: “next week po Giving information Shares information

makakasama nyo kami regarding on the

uli bilang student nurse client’s health care

Aling A.A. inaasahan po and well being.

naming ang inyong

kooperasyon.

P: (nodding)

V. Theme Identification

Content theme:
 The nurse-patient interaction focused primarily about the client’s

feelings and thoughts about herself. Allowing the client to open everything

about her past experiences and what she had before. Encouraging the

patient to verbalize her present thoughts and feelings about her loved-

ones and the life that she had before. The client can recall everything from

her past and her life outside the institution. She was actually a bit

functional.

Interaction theme:

The client was coherent and approachable during the

conversations; she had consistently answered all the questions, although

we’ve found some flaws regarding her answers. She can recall everything

right away. And she can also follow instructions very well.

Mood theme:

Upon receiving the client, she seemed to be so happy and

addressed us with a simple smile. Even during the grooming session she

had cooperatively finished her hygiene with of course our assistance. The

conversation went good although there are some parts wherein she just

repeat it and copy from what we have said.

 Nursing diagnosis:

Disturbed thought process related to psychological conflicts such

as how to earn large amount of money as evidenced by inconsistency of

answers.

Excerpts: statement 1 – “single ako.”

Statement 2 – “may asawa ako si Kevin kinasal kami.”

VI. Nursing Interventions

We had established nurse-patient interaction, to gain trust and

cooperation from our client. We introduced ourselves and set our

boundaries, including the contract. We also attended her hygiene needs

with of course our assistance. We encouraged the client to verbalize her

thoughts and feelings through therapeutic communication techniques. And

lastly, we tend to develop a positive coping behavior through active

socialization such as asking her for a walk and exposing her to a good

environment.

VII. Summary and Evaluation

The patient was very cooperative on the conducted conversation.

During the conversation and grooming process, she was able to execute
 instructions and did it well. She had a consistent happy and jolly mood and

had a good hygiene as to what we had observed.

We gained her trust and she did verbalize everything about

her thoughts and feelings. She had opened everything about her past

experiences and shared her life before. As we go along, the client had a

bit positive outlooks.

August 31, 2010

9:30 am

Inside the Lazareto de Mariveles

Working phase

I. Name of the client: Aling A.A.

II. Objectives

Client-centered:

• To motivate the client’s expressionism towards a positive coping

• To encourage verbalization of feelings and thoughts

• To establish positive coping behaviors while relating client’s past

experience about the therapies

Nurse-centered

• To assess well the client’s ability to cope positively through such

therapies like newspaper/ music and art

 • To have a clear outlook about the client’s abstract reasoning

capacity

• To establish a good assessment regarding the consistency of the

client’s given information from pre-interaction to working phase

III. Description of the setting

Set-up/ environment:

It was a humid day with rain showers, around 9:30 in the morning, August

31st, 2010.

We’ve fetched our client from female ward with the supervision of Mr. Iris

Flores. As we received our client, we’d proceed to the pantry as usual for the

grooming. After the client’s usual proper hygiene routine, we went to the Lazareto

ruins, wherein it’s not too convenient actually for our client to concentrate but in

spite of the ambience our client was still in a good mood. She just enjoyed the

humid weather and felt the essence of the historic ruins. We’ve started the

therapies with the newspaper partitions and reading it, then we’ve continued the

therapy with hand painting accompanied by a slow and fast music as well.

Nature, behavior, affect and mood of the client:

Still, the client was coherent and approachable. During the therapies, our

client seemed to enjoy everything. Just like before she kept on smiling and

grinning, and can cope positively. She’d also related her works to her past
experiences. And this time she’s better than what she was on our pre-interaction

phase.

IV. Process recording

Therapeutic Analysis and

Nurse-patient interaction communication interpretation

techniques used
Sn: “good morning po Giving recognition According to Sullivan’s

Aling AA.” interpersonal theory by

addressing someone’s

P: “good morning din name shows that nurse

(smiling)” recognize the client as a

person to be able to build

friendship towards the

client
Sn: “kamusta po kayo?” Asking question To gain information for an

effective verbal

P: “okay naman.” communication

Sn: “kaya nyo po bang Encouraging decision Provide independency

mag-toothbrush mag- and autonomy to the

isa?” client. Respect the

autonomy its necessary

P: “Oo kaya ko” since it foster self-esteem

 and independency on

decision-making
Sn: “ano pong part ng Asking question Showing concern and

dyaryo ito?gusto nyo po Offering oneself interest making one self

bang basahan naming available

kayo?”

P: “editorial, hindi na ako

na lang (smiling)”
Sn: “aling AA ‘gang next Giving information Make the available facts

week na lang po tayo the client need to

magkakasama” establish trust and

cooperation

P: “ay next week na

lang.”
Sn: “ano pong part ang Asking broad open- Encourage ct. to open

nabasa nyo sa dyaryo?” ended question something herself.

Interaction is very

P: “sa showbiz at beneficial in relationship

classified ads.” to other people through

what ct. sees and

remembers.
Sn: “ano po ang Asking broad open- Encourage ct. to open

naaalala/nararamdaman ended question something herself.

nyo habang binabasa po Interaction is very

‘yan?” beneficial in relationship

to other people through

P: “naaalala ko nung what ct. sees and

nag-aabroad din ako as remembers.

domestic helper”
Sn: “ano po ang ibig Asking broad open- Encourage ct. to open

sabihin ng ipininta nyo?” ended question something herself.

Interaction is very

P: “yung may isda, beneficial in relationship

paborito ko kasi bangus to other people through

at tilapia tapos bundok at what ct. sees and

mga puno maganda remembers.

kasing tanawin tapos

yung bahay dream house

ko kasi yun”
Sn: “oh aling AA ako si Summarizing Providing the ct. a

Aira at sya si Vangie ha, concise resume of what

bukas po uli kita tayo.” has transpired it helps

them to evaluate and

P: “oo sige bukas.” review all issues.

Giving information Shares information

regarding on the clients

health care and well

being.
V. Theme identification

Content theme

The therapies focused primarily about the expression of feelings

and thoughts through reading newspaper also thru hand painting

accompanied by a slow/fast music. Allowing the client to express her

feelings about her past experiences. Encouraging the client to establish a

positive expression and coping behaviors. The client recalls and relates

her pasts and everything she had before.

Interaction theme:

The client was still coherent and approachable just like before,

during the pre-interaction phase. She had consistently recalled and related

her experiences to what she did during the therapy. She did well this time

than before, she smiled and seemed to be so positive as we went through

the therapies.

Mood theme:

During the therapy, she seemed to be so happy and very

cooperative. She had delivered her works with a smile. Especially,

regarding the assumptions of her hand painted works. She was so positive

and behaving well all throughout the therapy.

Nursing diagnosis:
 Effective treatment therapies related to positive coping behavior as

evidenced by consistent cooperation and positive outlooks.

Excerpts: statement 1 – “may dream house ako, kasi gusto ko

magkakasama kami ng buong pamilya ko”

VI. Nursing interventions

We had established nurse-patient interaction, to gain trust and better

cooperation from the client. We again introduced ourselves and set our

boundaries. We also attended the usual hygiene needs of the client during the

grooming process, with of course our assistance. We’d prepared therapies such

as newspaper/ music and art for her to develop more about her positive coping

behaviors and also to allow her to express her thoughts and feelings. It is also for

her active socialization allowing her to mingle with others.

VII. Summary and evaluation

The client was very cooperative on the conducted therapies. During the

therapies, she was able to execute instructions well. She had a consistent happy

mood as to what we had observed all throughout the therapy.

We gained her trust and had oriented her again about us. She did

consistently express herself throughout the therapies. She can recall faster

although still there are some parts of flaws regarding her answers. But all in all

she had a positive coping about her pasts.

September 01, 2010

9:30 am

Inside the Lazareto de Mariveles

Working phase

I. Name of the client: Aling A.A.

II. Objectives

Client-centered:

• To established positive coping behaviors while relating client’s past

experience about the therapies

• To encourage verbalization of feelings/thoughts

• To enhanced the client’s memories about the past including her

previous daily routine

Nurse-centered:

• To assessed well the client’s ability to cope positively through such

therapies like role identification/photo language

• To established a good assessment regarding the consistency of the

client’s given information from pre-interaction to working phase

• To identify the usual routines of the client before the said

confinement, for us to have a vivid outlook of her past experiences

and if it has something to do with her present illness

III. Description of the setting

 Set-up / environment:

It was a humid day, around 9:30 in the morning, September 1 st,

2010.

As usual we’ve fetched our client from the female ward with the

supervision of Mr. Iris Flores. We then proceed to the pantry for the daily

grooming. After attending her hygiene, we went to the Lazareto ruins,

wherein we had two therapies which is the role identification and the photo

language. We’ve set-up a big clock for the role identification, and on the

other side was a long table with full of different pictures lined up for them

to picked during the photo language therapy.

Nature, behavior, affect and mood of the client:

The patient just like the usual, she was coherent and approachable.

During the therapies our client seemed to like everything. Just like before,

she kept on smiling and grinning, during the role identification she kept on

smiling on what she was acting, while doing that she was explaining her

previous routines. She can still cope positively as we went along the

therapy. During the photo language her reasoning before, which is the

music and art therapy was matched with what she had reasoned

regarding the picture of a house and a happy family.

IV. Process recording

Nurse-patient interaction Therapeutic Analysis and

communication interpretation

techniques used
Sn: “magandang umaga Giving recognition According to Sullivan’s

po Aling A.A” interpersonal theory by

addressing someone’s

P: “good morning name shows that nurse

(smiling)” recognize the client as a

person to be able to build

friendship towards client

Sn: “kamusta po kayo?” Asking question To gain information for an

effective verbal

P: “ayos naman ako.” communication

Sn: “linisin ko po ang Offering ones self Showing concern and

sugat nyo?” interest making oneself

available

P: “hindi na, pahingi na

lang ng alcohol”
Sn: “ano po ang Asking broad open- Encouraging the client to

naaalala nyo habang ended question open about her feelings

ginagawa nyo ang and thoughts.

therapy? Interaction is very

beneficial in relationship

P: “masaya kong buhay to other people through

sa bahay, kasama ang what client sees and

family ko.” remembers

Sn: “sinu-sino po ba ang

namimiss o naaalala nyo

sa family nyo?”

P: “si nanay ko at sina

ate Marissa, maalaga

kasi si nanay ko.

Sn: “ano po ang Asking broad open- Encouraging the client to

masasabi nyo sa napili ended question open about her feelings

nyong pictures?” and thoughts.

Interaction is very

P: “ah, ito masaya kasi beneficial in relationship

‘tong family sa picture to other people through

kaya ito ang napili ko what client sees and

dahil sa’min masaya din remembers

kami, lagi kami nagbi-

beach at nagkakainan.”
Sn: “oh aling A.A baka Summarizing Provides a concise

kalimutan mo nanaman resume of what has

ang pangalan naming transpired it helps the

ha?” client to evaluate and

review all issues

P: “hindi na (smiling),

ikaw si Aira at sya si

Vangie.”

V. Theme identification

Content theme:

The therapies focused about the verbalization of feelings and

thoughts through identification of their previous routines also through

photo language wherein she had to recall and refresh her memories.

Allowing the client to expressed her feelings and or her outlooks about her

routines before her confinement. Encouraging the client to have a positive

coping about the pasts.

Interaction theme

The client was coherent and approachable. She had consistently

refreshed her memories of her previous life. She had consistently relate

and reasoned out positively. And she had really did well all throughout the

therapies, even during the substantial conversations.

Mood theme:

During and after the therapies the client seemed to be happy and

very cooperative. She had delivered her works positively. Even during the

assumptions of the therapies. She has passed out everything positively.

 Nursing diagnosis:

Effective treatment regimen/therapies related to positive coping

behavior as evidenced by consistent cooperation and positive outlooks.

Excerpts: statement 1 – “masaya kasi ‘tong family sa picture kaya ito

ang napili ko dahil sa’min masaya din kami

lagi kami nagbi-beach at nagkakainan.”

VI. Nursing interventions

We had established nurse-patient interaction, to gain trust and better

cooperation from our client. We gave information about the pre-termination.

We also attended her hygiene needs; we’d prepared another therapy such

as photo language and role identification for her better development

regarding her coping behaviors. And also to allow her to expressed her

thoughts and feelings. We’d also go through a conversation for us to assess

her consistency about the data she had given to us.

VII. Summary and evaluation

The patient was very cooperative on the conducted therapies. During

the therapies, she was able to execute instructions well. She had a

consistent approach as to what we had observed all throughout the therapy.

 We gained her trust and had oriented her again about us. She did

express herself well during and after the therapies. She copes well

throughout the therapy.

September 06, 2010

3:00 pm

Inside the Lazareto de Mariveles

Pre-termination phase
 I. Personal data

II. Objectives

Client-centered:

• To encourage verbalization of feelings/thoughts

• To improved active socialization and reduced anxiety

• To established trust through the use of various therapeutic

communication techniques

Nurse-centered:

• To analyzed and interpret every behavior being manifested by the

patient during and after the therapies

• To established a good assessment regarding the consistency of the

client’s given information from pre-interaction to pre-termination

phase

• To develop positive coping behavior through therapeutic

communication techniques

III. Description of the setting

Set-up/ environment:
 It was a sunny day, around 3 o’clock in the afternoon, September 6,

2010.

We received our client from the female ward with the supervision of

Mr. Iris Flores. As we received our patient, we proceed to the pantry for

grooming. After attending the client’s proper hygiene routine we went to

the Lazareto ruins wherein we had set-up a movie theater for the cinema

therapy. We had played a movie entitled “SUPERMAN: Returns”. We had

darkened the area for good visualization of the movie projector. We also

provided snacks and refreshments during the movie viewing.

Nature, behavior, affect and mood of the client:

IV. Process recording

Nurse-patient Therapeutic Analysis and

Interaction communication interpretation

techniques used
Sn: “kamusta ka naman Asking question To gain information for an

aling AA?” effective verbal

communication

P: “ayos naman ako”

Sn: “hanggang Giving information Shares information

wednesday na lang tayo regarding on the client’s

magkakasama, health care and well

magpagaling kayo ha being

aling AA.”

P: “oo salamat ha.

Magpapagaling ako para

sa family ko at para

makasama ko na sila

uli(smiling)”
Sn: “naaalala nyo pa ba Summarizing Providing the client a

kung sino kami aling concise resume of what

AA?” has transpired it helps

them to evaluate and

P: “oo ikaw si vangie at review all issues.

sya si aira dati pang-

umaga kayo eh”

Sn: “aling AA manunood Giving information Shares information
tayo ng movie ha” regarding on the client’s
health care and well
P: “talaga sana love being
story”(smiling)
Sn: “superman:returns Giving information Shares information
po ang title yung bago regarding on the client’s
nap o yun.” health care and well
being
P: “ah gwapo din
(smiling)”

V. Theme identification

Content theme: The therapies focused primarily about the development of

the client’s active socialization and reducing anxiety. Allowing the client to
unwind for awhile. Encouraging the client to verbalize about her thoughts

and feelings regarding the said activity.

Interaction theme: The client was coherent and approachable as usual.

She had enjoyed the movie and had recalled something on her past while

watching the movie. She had been actively participating and mingling with

the others.

Mood theme: The client was happy and enjoying the therapy. She was still

coherent and very approachable. She had refreshed her memories from

her pasts experiences. She had also opened up about what she was

feeling about the movie concept. We can say that the therapy was

effective.

Nursing diagnosis:

Effective treatment therapies related to positive coping behavior as

evidenced by consistent cooperation and positive outlooks.

Excerpts: statement 1 – ““oo salamat ha. Magpapagaling ako para sa

family ko at para makasama ko na sila

uli(smiling)”

statement 2 - “masaya kasi maganda yung movie tsaka naalala ko dun sa

part na may airplane nung nag-aabroad ako dati.”

 VI. Nursing interventions

We had established nurse-patient interaction, to gain trust and better

cooperation from our client. We gave information about the pre-termination.

We had prepared cinema therapy for her better interaction with the others.

And also to allow her to expressed her thoughts and feeling; to reduce some

anxiety. We’d also go through a conversation for us to assess her

consistency about the data she had given to us from pre-interaction to pre-

termination phase.

VII. Summary and evaluation

The patient was very cooperative on the conducted therapies. During the

therapies, she was able to execute instructions well. She had a consistent

approach as to what we had observed all throughout the therapy.

We gained her trust and had oriented her again about us. She did express

herself well during and after the therapies. She copes well throughout the

therapy.

September 07, 2010

3:00 pm

At the student center, beside the canteen

Pre-termination phase

VIII. Personal data

IX. Objectives

Client-centered:

Nurse-centered:

X. Description of the setting

Set-up/ environment:

Nature, behavior, affect and mood of the client:

XI. Process recording

Nurse-patient Therapeutic Analysis and

Interaction communication interpretation

techniques used

XII. Theme identification

Content theme:

Interaction theme:

Mood theme:
 Nursing diagnosis:

XIII. Nursing interventions

XIV. Summary and evaluation

September 08, 2010

9:00 am

Inside the Lazareto de Mariveles

“Grand Socialization day”

Termination phase

XV. Personal data

 XVI. Objectives

Client-centered:

Nurse-centered:

XVII. Description of the setting

Set-up/ environment:

Nature, behavior, affect and mood of the client:

XVIII. Process recording

Nurse-patient Therapeutic Analysis and

Interaction communication interpretation

techniques used

XIX. Theme identification

Content theme:

Interaction theme:

Mood theme:

Nursing diagnosis:

XX. Nursing interventions

XXI. Summary and evaluation