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Process-Recording (NCMH)

The document is a process recording of a nurse-patient interaction with a 62-year-old male diagnosed with undifferentiated schizophrenia. The nurse aimed to build trust, encourage open dialogue, and evaluate communication skills, successfully creating a comfortable environment for the patient to share his thoughts and feelings. The evaluation highlights the nurse's effective use of active listening and open-ended questions, leading to a productive conversation about the patient's life and emotional state.

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cristine.echave.mnl
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48 views3 pages

Process-Recording (NCMH)

The document is a process recording of a nurse-patient interaction with a 62-year-old male diagnosed with undifferentiated schizophrenia. The nurse aimed to build trust, encourage open dialogue, and evaluate communication skills, successfully creating a comfortable environment for the patient to share his thoughts and feelings. The evaluation highlights the nurse's effective use of active listening and open-ended questions, leading to a productive conversation about the patient's life and emotional state.

Uploaded by

cristine.echave.mnl
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Process Recording

I. Demographic data:
● Name: R.A.M
● Sex: Male
● Civil status: Married
● Age: 62
● Diagnosis: Undifferentiated Schizophrenia
● Date/Time: 8/30/24 (10:30 AM)

II. Objectives for the Interaction:


1. Build trust to make the patient feel comfortable and respected.
2. Encourage open dialogue where the patient feels safe to share their thoughts and
concerns.
3. Evaluate their interactions, improve communication skills, and enhance patient
care.

III. Nurse-Client interaction:

Nurse Patient Analysis

Verbal Nonverbal Verbal Nonverbal Themes Analysis

What do Asked ”Rudolph na Relaxed Content: Responsive,


you prefer questions lang or body and Identity cooperative
to be while Dudong” remain in Awareness
called? making eye eye
contact. contact.

What has Look at the “Nasa huwisyo Maintains Reality Gives


happened patient naman ako at direct eye Orientation information,
in your life while nakikipag contact. open
recently? talking; interact sa Interaction: communica-
both arms kapwa. Kain, Patient's tion, positive
are on the tulog, lang voice is demeanor
table. tapos kanta expressive,
kanta kami dun. with a varied
Ngayon na lang tone, and is
ako nag parlor smiling.
games ulit
matagal akong
nabakante.”
Did you Look at the “Na-depress Maintains Insight into Therapeutic
know the patient ako. Ayun lang. direct eye Challenges relationship
reason why while Na refresh ako contact.
you are talking; tapos ginamot Interaction:
staying both arms yung psychosis Opens up and
here? are on the ko” shares
table. experience
with nurse

Do you get Leans “May insomnia Leans Sleep Active


well and forward and ako. Naglalakad forward to Disturbances listening
get enough clarifies the lakad lang ako hear the
sleep? question. para makatulog. question
What did May energy and
you do to naman ako pero maintains
help you kailangan ko ng eye
sleep? Do dugo kasi contact.
you feel anemic ako.”
fatigued?

Do you feel Nods “Hindi naman. Maintains Composed Actively


anxious reassuringly Basta may direct eye confidence participate,
about other and gamot, tubig, contact. questioning
things? maintains pagkain Interaction:
eye contact. Answers and
Do you fear “Oo naman repeats the
anything? (pause) sa same
Diyos, takot ako question
magkasala sa
Diyos.
Naniniwala ba
kayo doon?”

What Leans ”Nung grade 6 Upright Sense of Persistent,


activities slightly kumakanta ako, posture and Hopefulness positive
kept you toward the naging active active outlook
busy in the patient and ako sa singing, engage-
past? What speaks kasama ako ment.
are your slowly. noon sa banda.
hobbies? Mahilig ako sa
motor at
automobile.
Naglalaro ako
ng basketball,
volleyball,
football, at
soccer.

Kung
ano-anong
trabaho ang
pinasok ko,
pero walang
asenso. Hindi
ko alam kung
bakit, masipag
naman ako
magtrabaho.
Sana magbukas
ulit ang doors
for opportunity.
Hanggang may
buhay, may
pag-asa”

Do you still Listens ”Wala na, tagal Speaks and Interpersonal Willingness
have attentively na, separated na shares Relationship to
contact or kami, nawalan openly; communicate
connection ng gana ang both arms Mood: , emotional
with your wife ko sa akin on the table sorrow comfort
children nung nadepress Interaction:
and ako. Hindi ko Freely
family/relat na sila (family communi-
ives? and relatives) cates with
nakakausap, nurse
matagal na,
kaya tayo-tayo
na lang yung
nag uusap.”

IV. Evaluation:

The nurse demonstrated exceptional ability in building trust with the patient, which was evident through the patient's
relaxed manner and willingness to engage. The respectful and compassionate approach employed by the nurse
helped create an environment where the patient felt valued and respected, significantly contributing to the comfort
level of the patient throughout the conversation. The nurse effectively facilitated open communication by using
open-ended questions and active listening, which allowed the patient to freely express his emotions. The patient
actively participated in the conversation, helping the nurse to fully understand his current mood.

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