Nursing Process Recording

UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA
Alabang- Zapote Road, Pamplona Las Pinas City
Course Requirement for the Subject
Related Learning Experience 104
NURSE PROCESS RECORDING
Submitted To: Dr. Felipe Naval Escao, R.N., R.M., M.A.N., DPSVI Clinical Instructor Submitted By:
Viejo, Mary Antonette L. BSN 4U
September 23, 2009
DEMOGRAPHIC DATA Clients Initials: E.M. Age: 24 years old Sex: Male Address: Pangasinan Source of Information: the client and his chart Impression: Schizophrenia, aresidual Date Admitted: November 8, 2004 Date of History Taking: September 15, 2009 Name of Institution: Cavite Center Mental Hospital
NURSE PATIENT INTERACTION

ORIENTATION PHASE
Statement of Goals & Objectives: At the end of the orientation phase, the student nurse would be able to: 1. establish rapport with the client 2. establish trust through open communication 3. determine the clients chief complaint 4. help the client identify the problem Description of the Setting: The setting is a quiet and calm environment. It was raining on the day the interaction was to take place. There were a lot of huts in the venue and some buildings for the wards. The setting where the interaction will take place is at the social hall. It was spacious enough to accommodate the clients. The outside environment has a lot of trees and plants. Feelings and Thoughts of the Student Nurse before the NPI The student nurse was quite anxious and afraid of meeting with the client. She didnt know what would be the best approach to the client and was thinking of what kind of response would the client have towards her.
NURSES RESPONSE Magandang hapon po! Ako po si Mary, ang student nurse niyo ngayong hapon. Kayo po ba si Eric?
CLIENTS RESPONSE oo
ANALYSIS OF PATIENTS RESPONSE The client answered the question with a flat affect and has eye to eye contact with the student nurse
ANALYSIS OF NURSES RESPONSE The student nurse approached the client in a friendly manner
INFERENCES The student nurse was trying to establish rapport with the client, but it seemed that the client was not interested and had a flat affect every time he would respond. The student nurse happily assisted and guided the client and this helped the client be free from harm and provided safety The student nurse was trying to help the client be independent and self reliant by giving him tasks to do. The client was able to accomplish all tasks given to him , but he still lacks initiative and motivation. The student was trying to help the client do decision making for himself and this helped the client be able to
Pila po muna kayo at pupunta po tayo sa social hall
no verbal cues & no changes in facial expression
It seems that the client is uninterested in talking with the student nurse
The student nurse assisted the patient and made sure he was safely guided
Eric, ito po ang toothbrush mo at toothpaste. Magsisipilyo ka para malinisan ang ngipin at bibig mo.
No verbal cues, but he was able to hold the toothbrush and brush his teeth
The client did not respond but he was able to follow instructions given by the student nurse
The student nurse helped the client establish ability to do activities of daily living
Gusto mo rin ba maghilamos? oo The client still had flat affect and no verbal response, but he was able to accomplish the task given by the student nurse No verbal The nurse provided suggestions for the client to do decision making
Ang galing mo naman, nagawa mo ang maghilamos mag-isa!
no verbal cues
NURSE PATIENT INTERACTION

WORKING PHASE
Goals & Objectives: At the end of the working phase, the student nurse would be able to: 1. explore insight, judgment, stressors and feelings 2. recognize and work through resistance to therapy 3. assess implementation of coping mechanism 4. prepare the client for the termination phase Description of the Setting: The setting is a quiet and calm environment. It was raining on the day the interaction was to take place. There were a lot of huts in the venue and some buildings for the wards. The setting where the interaction will take place is at the social hall. It was spacious enough to accommodate the clients. The outside environment has a lot of trees and plants. Feelings and Thoughts of the Student Nurse before the NPI The student nurse was not that anxious and afraid of interacting with the client anymore since she established rapport with the client. It was more easier and relieved than before interacting with the client for the first time.
NURSES RESPONSE Eric, magdrawdrawing ka ng kahit anong gusto mo i-drawing. Ito ang krayola mo at papel
CLIENTS RESPONSE The client didnt have any verbal cues and he got the paper and crayons
ANALYSIS OF PATIENTS RESPONSE The client still responded with a flat affect. He didnt start right away with the drawing. He was observing first the other clients before he did his drawing The client responded when being asked and still with a flat affect. He was able to express what he was feeling. The client was also able to write his name after drawing The client did not have any verbal response but was able to eat his food and drink his juice
ANALYSIS OF NURSES RESPONSE The student nurse assisted the client in drawing by giving him the paper and crayons
INFERENCES The student nurse was trying to let the client express his feelings and emotions through drawing
Eric, tapos kana magdrawing? Bakit ito yung na drawing mo?
Bahay naming ito. Gusto ko na umuwi.
The student nurse was trying to know what the client was thinking or feeling by asking the client to do some art works
The student nurse was trying to know the emotions and feelings of the client by the art work. The client was able to do the task and was able to express what he felt.
Ito na po yung tinapay at juice mo
The client accepted it and consumed the food and drink
The student nurse gave food to the client to provide nourishment to their body and gain trust from the client
The student nurse was able to give food and drink to the client and gain his trust. The client follows the instructions of the student nurse and accepts things or food from the student nurse

Nursing Process Recording

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UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA

Alabang- Zapote Road, Pamplona Las Pinas City

Course Requirement for the Subject

Related Learning Experience 104

NURSE PROCESS RECORDING

September 23, 2009

NURSE PATIENT INTERACTION

Pila po muna kayo at pupunta po tayo sa social hall

no verbal cues & no changes in facial expression

Ang galing mo naman, nagawa mo ang maghilamos mag-isa!

NURSE PATIENT INTERACTION

Eric, tapos kana magdrawing? Bakit ito yung na drawing mo?

Bahay naming ito. Gusto ko na umuwi.

Ito na po yung tinapay at juice mo

The client accepted it and consumed the food and drink

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