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Process Recording

Orientation Phase
Prepared by:
Apurado, Kim B.
Barol, Bona Ruth
Submitted to:
Asst. Prof. Noyme Lour Abegil
L. Laviste
July 13, 2014
Demographic data:

Patients Name: Manaban, Kevin Age: 21 years old
Birthday: May 6, 1993 Sex: Male
Civil Status: Single Nationality: Filipino
Address: Poblacion Pamplona, Negros Oriental Occupation: None
Date and Time of Admission: May 2, 2014, 11:50 AM Ward: Isolation B, Cell #7
Medications: Fluphenazine Decanoate cc
Chlorpromazine 100mg BID
Apidin 2mg BID
Diagnosis: Suicidal/Escape Tendency
General Impression:
The client is awake, oriented to time, person, and place however responds slowly to questions asked. He listens attentively to questions asked and responds
appropriately. Furthermore, he is cooperative in behavior and dressed appropriately for the weather and place. Hygiene is good with clean skin and nails. Posture
is erect with steady and coordinated gait. He manifests poor eye contact to the student nurses. His speech is comprehensible and responds appropriately to topics


Learning Objectives:

Within the nurse-patient interaction, the student nurse shall:

1. Establish rapport to the patient appropriately
2. Initiate contract setting containing time, place, date, and duration of the interaction to the patient properly
3. Clarify nurses role and responsibilities to the patient sufficiently
4. Clarify nurses expectations to the patient appropriately
5. Become aware of transference and countertransference issues consciously
6. Mutually agree on goals to accomplish with the patient properly
7. Converse about the confidentiality of the interaction to the patient
8. Discuss the terms of termination to the patient correctly
9. Identify patients problems thoroughly
10. Examine patients thoughts, feelings, and actions adequately

Client-centered Objectives:

Within the nurse-patient interaction, the patient will be able to:

1. Express thoughts and feelings to the student nurses genuinely
2. Identify goals with the student nurses correctly
3. Communicate problems to the student nurses appropriately
4. Convey expectations to the student nurses accurately
5. Clarify patients role in the interaction with the student nurses appropriately
6. Maintain trust to the student nurses properly
7. Verbalize any concerns to the student nurses
8. Shares information about self and his relationships towards other people to the student nurses appropriately

Nurses Thoughts and feelings:

Attaining our devised goals is one of our concerns as student nurses but this doesnt mean to overshadow the quality of nursing care we are going to carry
out toward our patient. We desire to accomplish contract setting and to establish an atmosphere of which trust, acceptance, and open communication can grow. A
major emphasis during the first few encounters with our patient is on providing an atmosphere in which trust and understanding, or rapport, can grow.
Furthermore, a contract emphasizes patients participation and responsibility because it shows that we do something with the patient rather than for the patient.
We also aim to clarify about our role as student nurses and the responsibilities of both the patient and us within the course of the interaction so to set a working
scope through which a nurse-patient relationship should deal with. The patient needs to know about the student nurses and the purpose of the meetings, as well.
Conveying expectations, both from the patient, and us is also one of our aims to accomplish, as well as awareness of both transference and countertransference
in the interactions. We are driven to investigate patients thoughts, and feelings in accordance to his actions in order to be aware of his problems. Moreover, we
aspire to articulate patients problems, and mutually agree, together with our patient, on goals to be established. Conditions of termination should also be
introduced and the guarantee that all information coming from the client will remain confidential and only those who are involve in his care will obtain such
information should also be converse about while maintaining a therapeutic atmosphere. The patient has a right to know who else will be given the information
shared with us and that the information may be shared with specific people, such as our clinical instructor, the physician, the staff, or other student nurses in our
conferences. The patient also needs to know that the information will not be shared with relatives, friends, or others outside the treatment team, except in extreme
situations. Safeguarding the privacy and confidentiality of individuals not only is our ethical obligation but also is a legal responsibility as well.

Seating arrangement:


Our conversation revolved around establishing an atmosphere of trust, understanding, acceptance, and open communication and formulating a contract
Observation of seating arrangements and use of space by patients can provide valuable information to the nurse, clarifying not only the nurses
assessment of the patient but also the way in which the nursing intervention should be implemented. In all settings, chairs need to be arranged so that
conversation can take place in normal tones of voice and eye contact can be comfortably maintained.

As shown in the figure above, the patient was seated on his bead inside his cell, lateral to the student nurses. Furthermore, the student nurses were
seated on the chair approximately 4 feet away and were facing him at 45 angle. Space provides another clue to the nature of the relationship between two
people. It must be examined based on sociocultural norms and customs. Distance should be 4 6 feet apart (social zone) in order to maintain therapeutic
communication and most comfortable to the student nurse and the client. People feel more comfortable with smaller distances when communicating with
someone they know rather than with strangers (Northouse & Northouse, 1998). The nurse-patient interaction may be threatened if one invades the others
personal or intimate zone, which can result in tension, irritability, fidgeting, or even flight.

In our interaction, the student nurses observes an acceptable posture, tend towards the client when he speaks in a muffled voice to show interest in the
interaction between the student nurses and the patient. Arms and legs remain uncrossed and direct eye contact was maintained to convey willingness in
listening to what the patient say. The student nurses appeared relax and comfortable.


with the patient. Establishing a contract was a mutual process in which the participation of our patient was needed as fully as possible. We clarified our roles and
responsibilities as student nurses, as well as our expectations towards the patient and the importance of his cooperation throughout the interaction. Clarifying
patients expectations was also asked, too. We told him about our weekly visitations to him and the time we will be having our interaction. Terms of termination
were also discussed to the patient. Assurance of patients confidentiality and that only those people who are involve in his care, as well as our clinical instructor
and classmates, will know the conversations between us and the patient. He verbalized that he is fine with condition of the confidentiality of his personal
information. Furthermore, we conversed about his problem however, he is denied that he was troubled by it. Family members and his relationship to them were
the next that we talked about. His interrelation to his family was good. This is important in providing for the continuity and comprehensiveness of patient care. We
also discoursed about his past experiences especially his first year in college. He talked about his vices in college together with his friends and the outcomes of his
actions. We further assure our patient that we are open to whatever problems he has in mind. We then bid farewell to our client after the 45-minute interaction.


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