Process Recording

  • June 2020
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I.

Demographic Data Name: Virgilio Extra

Age: 28 y/o

Sex: Male

Impression: Schizophrenia Undifferentiated II.

Working Phase: A. Statement Of Goals and Objectives By the end of the working phase the patient will: •

View the student nurse as honest, open and concerned about his welfare



View the student nurse as a competent professional capable of helping



Maintain a therapeutic relationship with the student nurse



Explore his thoughts and feelings

B. Description of setting The nurse patient interaction happened around 9am. The weather was slightly cloudy and a bit humid. Our activity was held at their quadrangle and we were in what seems like a cat walk. I was sitting on the bench and my patient is in front of me with a space of half a meter. Though it was a bit noisy because we are all talking at the same time, the patient was cooperative and replies in an audible manner. C. Thoughts and feeling of the nurse before Nurse Patient Interaction I felt slightly nervous even though we already met because we will never know how a mentally ill person will suddenly behave, so therefore they are very unpredictable. But my nervousness is very minimal because I already had an prepared

experience handling a mentally ill patient. I was more of excited because of the activities that we will do. We games and therapies that they will definitely enjoy.

Nurse’s Response

Patient’s Response

Inferences

“Hello po! Naalala nyo pa po ba ako?”

Oo, ikaw si Gladys

The patient is able to recall my name and is able to retrieve recent memories.

“tama po! (claps)

The patient smiles

Anong araw na po ngayon?

Miyerkules na ngayon

The patient feels his verbalizations are recognized The patient is aware of the day during NPI

Anong buwan na po?

September, mali, october na pala nayon 2009 na

Anong taon? Nasaan po kayo? Galing naman ni Kuya Extra, nasagot lahat” (claps) Kamusta naman po kayo? May naririnig pa po ba kayong mga boses ngayon?

Ako ay nasa Mandaluyong sa Pavilion 11 The patient smiles again

The patient is aware of the month during NPI The patient is aware of the year during NPI The patient is aware where he is. The patient feels his verbalizations are recognized

Ok lang naman ako

The patient is able to state his overall feeling Wala na naman. Dati The patient verbalizes that he does not meron pag nakakalabas ako experience any auditory hallucinations dito.

Ilang taon na po ba kayo dito?

13 years na akong pabalikbalik dito.Kapag nasa labas na kasi ako hindi na ako umiinom ng gamot tapos gumagamit na ulit ako ng shabu.

The patient can still recall the past events that took place in his life and the reason that he comes and go in the institution

Punta po tayo dyan sa drawing nyo, ano po yang

Puno ng niyog ang iginuhit ko

The patient is able to describe what he drew

Communication Technique

Giving recognition

Orienting patient to time, place and person

Giving Recognition

na-drawing nyo? Ano po naalala nyo sa niyog?

Naalala ko ang Cebu. Kasi malaki ang lupain namin dun. May sampung ektarya ng puno ng niyog kami dun. Maliit lang yun. Kasi naghihirap na kami kaya naibenta na na yung iba naming lupain

The patient was able to recall where he grew up. But he is showing grandiosity in his response.

Sino po sa magulang nyo ang taga-Cebu?

Yung nanay ko. Mayaman kasi yung lolo ko dun dun sa sampung ektaryang lupa namin may bundok pa doon.

The patient was able to recall that his mother was the one who came from Cebu. His grandiose delusions are still demonstrating.

Namimiss nyo na po bang umuwi ng Cebu?

Oo, matagal na kasi akong hindi umuuwi dun eh.

The patient misses the place where he grew up

Kailan po ba kayo huling umuwi ng Cebu?

Matagal na eh, di na kasi ako pinabalik dun kasi yung mga kaibigan ko din doon adik.

The patient verbalizes that it has been a long time since he came home to Cebu, he was not allowed by his parents because his friends there are drug addicts.

Sa kanila po ba kayo natutong gumamit ng ipinagbabawal na gamot?

Oo. Sila nagtro sa akin na mag-marijuana muna tapos gumamit na rin kami ng shabu.

The patient remembers that his friends Consensual Validation from Cebu are the ones who taught him to use illicit drugs

Malaki po pala ang lupa nyo, sampung ektarya po ba? Tama ba ang pagkakarinig ko?

The patient firmly believes that his family Restating owns 10 hectares of land

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