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Chapter I

Personal Data
Name

Sex

Age

Address

Civil Status

Birth date

Birthplace

Religion

Nationality

Date Admitted

Time Admitted

Admitted Doctor

Diagnosis

General data

History of Present Illness:


Mental status examination:
Neurologic Examination:

Cranial Nerves
I.
II.
III.. so on and so on

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Motor System:
Limbs
Trunk

5/5

5/5

5/5

5/5

Stance
Gait
Rombergo

Reflexes
J.J
B.J
S.J
T.J
Plantar

Sensational
Pain & Touch
Temperature

100

100

100

100

Vibration
JPS
Two point Descrimination

Chapter II
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Process Recording (Karl Angel B. Fabe, SN-SJIT)

Process Recording No. 1


Orientation Phase
Description of Phase:
Problem defining phase
Starts when client meets nurse as stranger
Defining problem and deciding type of service needed
Client seeks assistance ,conveys needs ,asks questions, shares
preconceptions and expectations of past experiences
Nurse responds, explains roles to client, helps to identify problems and to use
available resources and services
I. Goal Interaction
To gain rapport of my patient.
Establish trust, acceptance, and open communication
To be able to become acquainted of my patient.
To understand the patients problems.
To demonstrate genuine care and understanding.
To mutually formulate a contract with the patient
II. General Objectives
To distinguish the sickness of the client thru the observation done.
To reduce the anxiety felt by the client towards the nurse.
To discuss the contract to my patient.
To explore patients thoughts, feelings, and actions
III. Short-term Objectives
To be able to introduce myself to my patient and getting to know one another.
To show interest and sincerity to my patient.
To gain trust from my patient.
To observe and assess my patients personality.

Process Recording (Karl Angel B. Fabe, SN-SJIT)

IV. Description of the Environment


The environment was calm and therapeutic aided with props to promote joyous
atmosphere. The breeze of the wind makes the patient feel comfortable and relaxing.
There is slight noise but tolerable.
Nurse-Patient Interaction (NPI) Orientation Phase
NPI

Inference

Rationale

N: Magandang hapon sa iyo


P: Magandang hapon po
N: Ano po ba ang pangalan mo?
P: Marimar po.

Broad Opening

To establish openended
communication

N: Ako nga pala po si Karl Angel


Fabe. Isang student nurse ng
Saint Joseph Institute of
Technology po sa Butuan City.
Simula po ngayon, araw-araw
na tayon magkakasama at paguusapan
natin ang iyong talambuhay.
P: Ano pong gusto mong
malaman?
N: San ka po nakatira?
P: Sa Bicol po.

Giving Information

To gain rapport and


trust

Offering Self

To accommodate her
thoughts and giving a
free expression of
thoughts and feeling

Exploring

To have an idea on
her present illness
and help analyze her
situation

N: Anung araw ngayon?


P: Lunes po.
N:May asawa ka ba?
P:Opo Patay na
N:Ano naalala mo?
P: Yung anak ko sa Bicol
N: Masaya ka bas a taas?
P: Oo.. Masaya kasi may mga
nurse na nag-aalaga sa amin
at saka may libreng pagkain
dito.
N: Minsan ba nalulungkot ka?
P: Hindi naman kasi marami kami
dito at kayo pumupunta dito.

Process Recording (Karl Angel B. Fabe, SN-SJIT)

N: Salamat po sa iyong tiwala sa


paglahad ng mga bagaybagay..
P: Walang anuman po
N: Pagod ka na ba ate?
P: Opo.
N: Okay sige. Pahinga ka
na ate Marimar. Hintayin
lana muna natin ang iba
na matapos ha.
P: Opo.

Recognition

To build confidence
and increase her
self-esteem

V. Evaluation of Interaction
At the end of the conversation, the patient held smile and was confident to
confess a part of her life in summary. The patient used healthy words in mind easily
understandable by healthy mental state. She did said her favorite songs and artist as
well as her work before she was admitted at the said institution. She was responsive
and accommodating with frequent praise on physical looks on her nurse. In addition, the
patient lapses often on some topics which are not good in mental state.

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Process Recording No. 2


Working Phase
Description of Phase:
At this point, the clients problems are identified and solutions are
explored, applied and evaluated. The focus of the assessment and of the relationship is
the clients behavior and the focus of the interaction is the clients feelings.
VI. Goal Interaction

To establish confidence upon interaction


To promote patients self-esteem
To provide high level of trust
To promote self enhancement through life confession experience
To gain working trust and relationship

VII. General Objectives

To readily apply the therapeutic activities for self enhancement


To help them understand their current mental health status
To promote mind set for easy recovery
To reduce the level of anxiety
To prevent them from harming their self

VIII. Short-term Objectives

To make her realize that there is hope in life


To promote self-actualization
To reduce the level of fear
To provide physical cleaning
To create a good therapeutic binding

To overcome resistance behavior

IX. Description of the Environment


The working atmosphere was good. Everyone is active on their respective
activities. The patient did verbalized that she was excited on that days activity. There
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Process Recording (Karl Angel B. Fabe, SN-SJIT)

was a presence of slight noise coming from other schools session. The weather was
hot but then tolerable. The environment was therapeutic as evidenced by the patient
understanding during the interaction.
Nurse-Patient Interaction (NPI) Working Phase
NPI
N: Magandang umaga po
Sa yo ate Marimar!

N: Ano ulit ang pangalan ko

Inference
Use Name

Help to orient

Marimar?

Rationale
Using a person's name
makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.
Illness and hospitalization
can be very disorienting for
patients.

P: Kran po!
N: Carl ako
P: Carl
N: Kumusta kana Marimar?
P: Okey lang p
N: Anung araw ngayun po
ate marimar?
P: Martes po.
N: Nag-almusal ka na?
P: Opo.. kumain ako ng
Tinapay, nagligo at
Nagtoothbrush

Broad Opening

To establish open-ended
communication

N: Galing, Masarap ba
yun?
P: Oo.. kani-kanina lang..

Accepting

To prevent negative
feedbacks and thoughts on
her mind

N: May gusto ka bang


sabihin sa akin?
P: Yung ano lang.. yung
tungkol sa asawa ko.
N: Anong tungkol kay
asawa mo?
P: Namatay siya pati anak
kung tatlo sa Bicol
N: Napanu po sila ate
Marimar?
P: Namatay lang, Hindi ko
alam kung bakit

Exploring

To have an idea on her


present illness and help
analyze her situation

Process Recording (Karl Angel B. Fabe, SN-SJIT)

N: Kalimutan mo na po un..
P: Medyo nakalimutan ko
na..
N: Ganyan po ate Marimar!
Pagod ka na ba ate?
P: Opo.
N: Okay sige. Pahinga ka
na ate Marimar. Hintayin
lana muna natin ang iba
na matapos ha.
P: Opo.

Presenting Reality

To promote easy
understanding on the
problem

X. Evaluation of Interaction
At the end of the working phase interaction, the patient was confident in herself
as evidenced by sharing her thoughts which are unlikely in the previous interactions.
She also added that she learned a lot during remotivation. In this phase, the patient
expresses her thoughts freely without fear. Furthermore, she sing and dance graciously
without anxiety.

Process Recording No. 3


Termination Phase
Description of Phase:
8

Process Recording (Karl Angel B. Fabe, SN-SJIT)

The nurse terminates the relationship when the mutually agreed goals are met,
the patient is discharged or transferred or the rotation is finished. The focus of this stage
is the growth that has occurred in the client and the nurse helps the patient to become
independent and responsible in making his own decisions. The relationship and the
growth or change that has occurred in both the nurse and the patient is summarized.
XI. Goal Interaction

To evaluate the patients readiness of oneself


To develop independent care
To gain self-awareness and self-care
To prevent interdependency of the patient to the nurse
To relieve discomfort on understanding others

XII. General Objectives

To protect patient from harming herself


To stabilize her good mental health or state of mind
To increase her level of independence
To establish a hopeful life outside the institution
To regain self respect

Establish reality of separation


Mutually explore feelings of rejection, loss, sadness, and anger and related
behaviors
XIII. Short-term Objectives

To make her realize that there is hope in life


To promote self-actualization
To reduce the level of fear
To provide physical cleaning
To create a good therapeutic bonding

XIV. Description of the Environment


The weather was calm and sunny. The termination phase was quite more joyous
and active since it is the last time to interact with them. Every patient cooperated and
tried their best to achieve the goals in that particular activity. At the end, they are quite
sad on that farewell but then as they verbalize that they are thankful that we had them.

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Nurse-Patient Interaction (NPI) Termination Phase


NPI
N: Magandang umaga po
Sa yo ate Marimar!

N: Ano ulit ang pangalan ko

Inference
Use Name

Help to orient

Marimar?
P: Kran po!
N: Carl ako
P: Carl
N: Kumusta kana Marimar?
P: Okey lang p
N: Anung araw ngayun po
ate marimar?
P: Merkules po.
N: Nag-almusal ka na?
P: Opo.. kumain ako ng
Tinapay, nagligo at
Nagtoothbrush
N: Naalala mo pa yung mga
pinag-usapan natin po?
P: Ah.. yung tungkol sa
buhay ko?
N: May gusto ka pa bang
ilahad sa akin?
P: Oo.. gusto ko sa nang
umuwi na sa amin..
N: Magpagaling ka po..
sundin mo lang mg
autos ng nurse at doctor
dito.. nang sa ganun
makalabas ka.
P: okey po.
N: Eto na po pala ang huli
nating pagkikita..
magpakabait po kayo
dito ha? Tandaan mo
lagi yung mga itinuro
naming sayo araw-araw.
10

Rationale
Using a person's name
makes her feel more
valued, and introducing
yourself is a basic step in
establishing a therapeutic
interaction.
Illness and hospitalization
can be very disorienting for
patients.

Broad Opening

To establish open-ended
communication

Exploring

To have an idea on her


present illness and help
analyze her situation

Presenting Reality

To promote easy
understanding on the
problem

Process Recording (Karl Angel B. Fabe, SN-SJIT)

P: Opo.. tatandaan ko po..


XV. Evaluation of Interaction
At the end of the termination phase, the patient understand her current situation
and wants to improve as verbalized by gusto ko nang umuwi at magsimula ulit. She
freely expresses her thoughts and feelings. The patient was seldom on crying and
expressing negative thoughts. During the interaction the patient wont lapse every single
word that she wants to clarify.

Chapter III
Music Appreciation and Interpretation Approach
A. Happy Songs
Black depression and anxiety
Red dominating behavior
Single Drawing represents selfish motives
11

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Indecisive line insecurity and selfishness


Huge Head open seen in grandiose paranoid evidence of aggressiveness, high
fantasy, high level of self-esteem which is usually associated with chronic
alcoholism
Two Shapes Put Together represents dependency to someone

B. Sad Songs
Red dominating behavior
Single Drawing represents selfish motives
Indecisive Line insecurity and selfishness
Huge Head open seen in grandiose paranoid evidence of aggressiveness, high
fantasy, high level of self-esteem which is usually associated with chronic
alcoholism

Attached Drawing

List of Prioritized Psychiatric Nursing Diagnosis


NURSING DIAGNOSIS

12

RANK

RATIONALE

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Disturbed Thought Processes


related to developmental delay
of cognition as evidenced by
cognitive dissonance

Impaired Verbal
Communication related to
impaired cognitive abilities as
evidenced by loose association
of ideas

Impaired Social Interaction


related to impaired thought
processes as evidenced by
dysfunctional interaction with
others

Self-Care Deficit, Bathing and


Hygiene related to mental
delay as evidenced by inability
to bathe himself

13

Based on Carl Jung's Theory of


Psychological Types, perception involves
all the ways of becoming aware of things,
people, happenings, or ideas. Judgment
involves all the ways of coming to
conclusions about what has been
perceived. If people differ systematically in
what they perceive and in how they reach
conclusions, then it is only reasonable for
them to differ correspondingly in their
interests, reactions, values, motivations,
and skills.

According to Karen Horneys Theory on


Personality, moving away from people:
The final possible consequence of a
neurotic is a personality style filled with a
social behavior and an almost indifference
to others. If they don't get involved with
others, they can't be hurt by them. While
it protects them from emotional pain of
relationships, it also keeps away all
positive aspects of relationships. It leaves
them feeling alone and empty.

According to Sullivans Interpersonal


Theory, the need for friendship and need
for sexual expression get combined
during late adolescence. In this stage a
long term relationship becomes the
primary focus. Conflicts between parental
control
and
self-expression
are
commonplace and the overuse of
selective inattention in previous stages
can result in a skewed perception of the
self and the world.

Dorothea E. Orem's Self-Care Deficit


Nursing Theory states that nursing is
required because of the inability to
perform self-care as the result of
limitations.

Process Recording (Karl Angel B. Fabe, SN-SJIT)

Risk for Injury related to


delayed developmental age

14

Self-harm is listed in the Diagnostic and


Statistical Manual of Mental Disorders
(DSM-IV-TR) as a symptom of borderline
personality disorder and depressive
disorders.
Because of a delay on the gross and fine
motor skills, as well as how the patient
perceives things and events, the patient is
at great risk of physical injury.

Process Recording (Karl Angel B. Fabe, SN-SJIT)