CAPITOL MEDICAL CENTER COLLEGES, INC. #4 Sto.

Domingo Avenue, Quezon City

COLLEGE OF NURSING PROCESS RECORDING #1 (Orientation Phase)

Name: OFELIA CANETE__ Age: _N/A_ Address: __#248 Lavedes, General Luna, Quezon___ Dateof Birth: _N/A_ Date of Admission: __July 17, 1993__ Educational Attainment: _N/A_ Diagnosis: __Schizophrenia, Manageable, Undifferentiated__ Setting: __Pavillion 5 National Center for Mental Health Date/Time of Interaction: __September 3, 2013 / 10:30 AM__

DESCRIPTION OF THE PATIENT Patient is wearing a red orange dress with NCMH label on it, no underwear and is wearing a pair of white slippers. Patient preceded the conversation in a blunt affect. She has no dentures. She is complaining about the scabies at her back, irritated on it and gradually scratches it. She breathes rapidly. Due to her appearance, patient seems to be old despite not knowing her age. Patient answers accurately but some are incorrect and unrelated to the question. In the middle of conversation, there are some evidence of flight of ideas and answers on a tangent. Patient often answers in a different dialect. She cant maintain eye to eye contact. DESCRIPTION OF ENVIRONMENT The interaction was held in Pavillion 5, with chairs arranged separately from each of the students with their reapective patients. The area was noisy and is sometimes distracting the flow of conversation with the patient. OBJECTIVES To establish rapport To reorient patient with the correct proper time, date and place To be able to recognize the clinical manifestations of the clients condition and accept behaviour To listen for patients concerns

NURSE

THERAPEUTIC TECHNIQUE

PATIENT

ANALYSIS

Magandang umaga po, ako po si Anne ang inyong student nurse.

Giving recognition & Giving information Giving recognition Seeking information Broad opening

Magandang umaga.

Ang bango naman po natin.

Ate Anne.

To greet the patient by name, to indicate awareness of change, to note the efforts the patient has made--these and other similar indications by the nurse show that she recognizes the patient as a person, as an individual.

Kayo naman po,ano po ang pangalan ninyo? Kamusta naman po Aling Ofelia? Ahh.. ilang taon na po kayo?

Ako po si Ofelia Canete. Okay naman po.

Seeking information Seeking information

Hindi ko alam.

Saan po kayo nakatira?

Sa Lavedes, General Luna, quezon. Galing ako sa Infirmary. May mga doktor, may mga patay. Si Vicente Marasigan. Dalawa. Anak ng pinsan ko. May tatlo akong kapatid. Dalawa. Si Erlinda, Francisco, Amelia. Pangalawa po. Ang tatay ko nagtuba sa dagat. Hindi ko po alam.

May asawa po ba kayo? May anak po ba kayo?

Seeking information Seeking information Restating

Anak po ng pinsan niyo?

Pang-ilan po kayo? Ang mga magulang niyo po? Paano naman po ang nanay niyo?

Seeking Clarification Seeking information Seeking information

Alam niyo po ba kung nasaan kayo?

Seeking information

Dito sa hospital, sa mental. Galing ako dun, doon sa infiramary tapos dinala ako dito. Dinala ako nung dalawang araw.

Kailan pa po ba kayo nandito?

Seeking information

Pwede niyo po bang sabihin kung anong araw ngayon? Ngayon po ay Martes, September 3, 2013. Anong araw po ulit?

Seeking information Giving information

Hindi po.

Martes.

(Silence)

Using silence

Makati. (Scratches and exposes her back with scabies.) Bigyan mo ako ng tsinelas, hindi akin ito e. Kakain ako ng tinapay. Sasayaw?

Huwag niyo po kakamutin, magsusugat po yan. Alam niyo po ba kung anong size ng paa ninyo? Mamayang hapon po ay magkikita tayo ulit dahil may mga aktibidad po tayong gagawin. Opo. May mga palaro din po tayo. At may pagkain at juice po kaming ibibigay. Opo, Aling Ofelia! Maraming salamat po! Bye!

Giving information Seeking information Giving information

Giving information

Masaya yun!

Accepting and Summarizing

Bye bye po!