De La Salle Medical & Health Sciences

Institute College of Nursing

PROCESS RECORDING

(Interaction Study)
Client’s Initial: P.J. Age: 53 y/o
Nursing Diagnosis: Schizophrenia
Goal of Interaction: Orientation Phase: Acquaint with the patient Date & Time: February 6, 2023
Place & Description of the environment: On the pathway of the male ward, trees and plants are the background view, fine weather, and
temperature. Noise or sound levels are low. Slightly foul odor, pathway is kept clean. In general, it was a calm environment

First Day
NURSE CLIENT NURSING ACTION EVALUATION
As we are approaching the The client seems approachable, To keep him from getting upset, I I realized that, unlike some
venue while waiting for our he smiledat us. was very aware of my nonverbal people, our patient is not scared
client, I felt little nervous and cues and how I used words. or anxious, and he was able to
excitement. Nervous is a way talk to us.
that I may say or do something
that my client wouldn’t want
and excited because this would
be our first day of exposure and
I really want to know how to
deal with individuals like them.

When we were seated, my He was patiently listening to Our started my conversation with I was expecting him to open up or
group and I started my groupmates with flat Roberto by thinking about how he contribute right away, and while
introducing ourselves and told affect. felt, and I treated him with my expectation appears non-
him the activities we are respect, just like I do with therapeutic, I should utilize
going to do for the rest of the everyone else. therapeutic communications next
hours that we are together. time to be more effective.

I asked him “Roberto, kamusta He was distracted while he is It's important to show others and
I made myself available to him
ka? Kamusta ang tulog mo answering “Okay naman po ako, clients that we care about them
in order to reassure him and
kagabi?”. “Nakakain ka ba ng mahimbing ang tulog ko at and want to hear their stories and
concentrated on developing a
maayos?” my voice was soft nakakain naman ako ng understand them. We do this by
connection. I remained silent
and clear. maayos.” He was shaking his showing empathy and making
while briefly showing concern.
hands. ourselves available.
 We observed he has numerous He said, “Kinulam kasi ako tapos To promote comfort, we treated The patient was aware of his
scratch wounds all over his body. nangangati ako ng nangangati” his wounds with the medicinal wounds and is in agreement with
We asked “saan nanggaling yang ointment Calmoseptine. the prescribed meds. After
mga sugat mo?” applying the ointment, he
expresses that he feels relief.

We begin to start the activity One of my groupmates held the Roberto is relaxed and did not
He nodded and made a gesture ball first and told us what makes
therapy called “Ball therapy” is share anything yet, I can see him
while saying “Aba! Syempre” her happy. We encourage broad
like a group session in which smiling through the joy in his
whoever holds the ball he/she opening so that he can also say eyes.
will say an event what makes what makes him happy.
him/her happy. We instructed
Roberto and asked “handa ka na
ba?”

He said, “May asawa ako, si I made myself available to him

When I felt that Roberto is in order to reassure him and
Mylene tapos anak ko si Niño,
comfortable with us, I asked him concentrated on developing a
Pitong taon na sya noong napunta
“may asawa ka ba?”, “may anak connection. I remained silent
ako dito”, “Opo, apat kami at ako
ka ba?”, “Ilan taon na yung anak while briefly showing concern.
ang bunso”
mo?”, “May mga kapatid ka ba?”

“Natatandaan mo ba ang mga

“Opo, sina Victor, Berni at Vicky”
pangalan nila?”
Roberto was calm and
At the end of conversation, we “Lunes ngayon, Martes bukas, e di comprehended our explanations.
bid him goodbye and told her we sa Miyerkules po?” “Salamat po!”
will come back the other day.
“Sige Roberto, uuwi na muna
kami ha, sa susunod na araw
babalik ulit
kami”
IMPRESSION AND PLAN FOR NEXT MEETING:
I was filled with both anxiety and excitement as I prepared to meet my first customer. There was apprehension since I do not know how the client will
react to my presence, nor do I know how successfully I will be able to apply therapeutic communication techniques. Despite this, I felt that the relationship
between my client and I had begun to develop after only a few minutes of talking to one other.
During the second session, I will make an effort to increase my patient's engagement in our activities by employing therapeutic communications and
techniques that are most likely to be successful.

Rhezzy Marie P. Reyes SN’24

Signature over-printed name
Date: February 6, 2023
Second Day
NURSE CLIENT NURSING ACTION EVALUATION
On our next day of duty, I felt Once Roberto noticed us, he The way I interacted with
Still, I was conscious of my
excited to see Roberto this time came right up to our table. nonverbal emotions and used Roberto last time changed this
because I have knowledge how he As with our initial meeting, suitable phrases to anticipate time because I was able to apply
behaves, and I know that he is Roberto seems joyful and at ease. his offense. different therapeutic techniques.
kind and very cooperative. mood. We were able to show him his
reality as we ended our
connection.
After meeting the client, I had The client participated heartily in
the impression that he would be the exercises that the student
able to communicate with us had arranged nurses. He seems to
more comfortably and like to sing, clap, and dance.
effectively. He was energetic
when we were running our
exercise and clap learning
program.
I greeted Roberto then asked “Maayos naman po ako, Ikaw si… I gave him a recognition by
“Kamusta ka Roberto? Ishi” with an asking tone, not sure saying “Wow! Ang galling naman Roberto is now aware of how to
Natatandaan mo pa ba ang if he was correct. talagang natatandaan mo pa handle his stories, ideas, and
pangalan ko? Kami yung ako” feelings as well as how he will be
nanggaling dito noong isang able to deal with these
araw.” manifestations and to
comprehend reality. Roberto was
He was instructed to shoot ping- He nodded as an answer that he able to recognize his true identity
pong balls for two rounds and understood the mechanics of the and realities.
calculate the amount of money game
equal to the scoring of each ring
throughout his activity (different
sizes basket where the client
shooted the balls).

After the game, we moved on to Following careful attention, “Roberto, andito lang kami para
revalidating the data that was participation in our review drills, making sa mga gusto mong
shown in his chart and the data and a summary of the facts. I sabihin ha” by this statement, I
he had provided to us on Monday. could see the reaction through his offered myself.
We told him about his actual eyes. He was sad hearing the fact
racial makeup, family and facing the reality.
background, and life story. We
laid forth his reality for him.
I asked him “naalala mo ba paanoHe answered, “Magkalayo kaming
I sought for clarification, so I
nyo ginawa si Niño?” magkasiping at gamit ang robot
asked “Paanong gamit robot nyo
kung paano nagawa si Niño”. ginawa si Niño?” then I gave him
information that the son he is
I said farewell to him and talking about is not real.
informed him that this would be
our final session.

IMPRESSION:
I think the client benefited from these conversations overall because of their effectiveness. This is clear from the client's improvement in maintaining
eye contact during the talk and from the fact that he stopped tremors with his hands. For me, promoting elaboration and encouraging evaluation was
the most effective treatment strategy. I think this client is aware of some valuable information, but his nervousness prevent s him from participating
fully at times. However, the patient expresses his desire to feel better and pledges to actively participate in his treatment plan more. The patient's
willingness to get better is a sign that this talk has therapeutic significance.

Rhezzy Marie P. Reyes SN’24

Signature over-printed name
Date: February 8, 2023