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PROCESS RECORDING I OBJECTIVES OF THERAPEUTIC COMMUNICATION: To promote understanding and to help establish a constructive relationship between the nurse

e and the client. II PATIENTS PROFILE: Salazar, Gregoria 47/ Female She has a husband and 3 sons (Still needs Clarification*) Seen at Angeles City. Carried by Social worker III HISTORY OF HOSPITALIZATION: The client was admitted to the hospital last Oct. 23, 07. Accompanied by social worker from Angeles City, upon entering the emergency room she is experiencing delusions. The social worker stated that Gregoria was seen in a market wandering around then a concerned citizen noticed her and reported to the municipal office. Upon examining, the doctor found out that she has skin allergies and skin lesions which is to be found an fungal infection. She was transferred immediately to the Pavilion 3 for further observation. She was given Chlorpromazine 200mg as prescribed by the physician. IV PRESENT MSE: Upon first impression the client was well groomed and dressed with slight foul odor on her head, has no cosmetics on her body. Her age seems to fit for her body and image. Upon sitting the client has no signs of difficulty on sitting. She seems to smile rarely. The client was hypo activity with some waxy flexibility for when Im interviewing her. I did not observe any facial grimacing when I talked to her. The client is cooperative but sometimes I have to restate my statements for her twice. She is seemed to be friendly. I noticed that sometimes the client has poverty in speech when Im asking her about something. The clients speech was slightly slow but it was tolerable. The client was seemed to be happy at all times. Her affect was appropriate for the situations.

The client has no hallucinations and delusions during every conversation with her. I noticed that the client is using echolalia rarely. The clients attention span was very short even in a 30mins to 45mins of talking to them. She was oriented to time and place where she belong. The client can make rational decisions most likely in games and activities. In evidence of letting them choose the rules in the activity. Most likely they are very aware of the consequences when they violated any rule, which gregoria understands. As far as I handled gregoria as my patient she cares for her fellow patients with the evidence of sharing her spare foods. When gregoria was telling me about her past I was amazed how she can recall the informations that she had given to me. Though at first Im not satisfied with her answers because on the first place I havent seen her chart at first. Then I already clarified that information when I already read the charts and surprisingly gregoria has a good memory even though she is mentally ill. I am not sure thought with one single information that she relay to me that she has sons and husband. I already asked Sir Bon but he said that they are still confirming it. V PRESENT DIAGNOSIS: The client is diagnosed with undifferentiated schizophrenia.




ANALYSIS OR RATIONALE -Giving acknowledgment provides a comforting feeling or acceptance that you like to communicate to the client.

Magandang hapon po!Kamusta naman po kau mam gregoria?

Mabuti naman ako , Masaya.

Oh sige. Ako nga Ako nga po pala si Limuel S. Detillo, Student Nurse po ng Our lady of Guadalupe, ako nga pop ala ang magiging nurse nyu para sa araw na ito hangang sa susunod na byernes. Kami po ay nandito ng mga bandang alas-3 ng hapon hangang alas 8 ng gabi. Kukunin lang po namen kau pag nandyan po si sir bon. Wala naman. pala si gregoria Salazar 47.

Giving Information Setting the contract 1st before anything else will be the baseline of the interaction between the nurse me and mam gregoria

Providing broad openings -It makes the client more comfortable

Anu pong gusto nyu pag usapan Wala naman. Offering general

and anxious free because the client

ngaung araw mam?

Leads and focusing

chose the topic. Focusing on the

Maari nyu po bang sabihin ang dahilan at wala po kaung gustong pagusapan? Oo. Offering Self

clients concern makes them feel that we are concern while using offering general leads encourages the client to voice out

As the conversation is going, I noticed that Sige po mam gregoria andito lang po ako sa tabi nyu, kung gusto nyu pong mag kwento maari nyu po akong kausapin. mam gregoria was very anxious and uncomfortable so I decided to offer myself to her when she likes to tell me something. This is normal upon the first meeting with the client though.

Kasi nga me sakit ako. *after a few minutes I decided to ask some questions. Ano po ba ang dahilan at napasok po kau ditto sa mental? Yung social worker ang nagdala sakin, dati kasi pakalat kalat ako, tapos dinala ako dito. Exploring deep and asking questions can give me some rational informations about the clients background and history regarding on Placing the event in time / Exploring

why she was brought Sinu po ang nagdala sa inyo dito? Dinala ako sa pavilion 3 tapos ginamot ako tapos nilipat ako dito. Offering General Leads here and its is also one key to asses if mam gregoria is aware of the situation. Asking her questions -Pagkatpos po? Mabuti naman Masaya! Masaya kasi madaming pagkaen Masaya naman Kamusta maman po kau dito sa hospital?l -Anu po ang dahilan at masya kau dito? Anu po bang nararamdaman nyu ngaung araw na to? Collaborating and making her know that Im interested will be Maraming salamat po mam, sana po ay madami kaung matutunan at ma I share sakin para rin poi to sa inyu mam the one of the most vital parts of our relationship, encouraging her to collaborate makes the working process Suggesting Collaboration ako ngaun. Refocusing is one of the main factors here because mam gregoria was seemed to be sad when she was stating her past and asking her about her current situation and feeling alleviates her self esteem. Encouraging Description of Perceptions Refocusing/ Encouraging Description of Perceptions that can make her verbalize is therapeutic. To lessen anxiety and to make her feel that Im interested in her story.

more easy to handle.