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PROCESS RECORDING

Resident: Mr. J.V


Age: 21
Diagnosis: schizophrenia undifferentiated
Objective: Establish rapport and a trusting relationship with the client to be able to encourage the patient to verbalize his feelings and
the reason behind them
General Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual
movements or mannerisms were observed
Setting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather
like a park with plenty of plants and the noises are subdued.
Date: January 4, 2010
THERAPEUTIC
RATIONALE AND
VERBAL ( NON VERBAL ) COMMUNICATION EVALUATION
FEELINGS OF NURSE
TECHNIQUE USED
Nurse Patient • Giving This is the Orientation Phase Patient J. was shy at the start,
“Magandang araw Mr. “Ok lang.” (nods, recognition so it is important that I but eventually starts to open
J, ako po si nurse smiles a little but • Offering self establish rapport and a trusting up his previous life to me. He
James, at ako avoids eye contact) • Rapport relationship with my client. doesn’t maintain much eye
makakasama nyo sa building Greeting the client by name contact and frequently forgets
araw na ito. kamusta • Giving shows that you acknowledge information. The objective
ka?” ( open posture, information the patient as an individual, for today was met since the
walking, smiling) and he by responding proves patient had eventually become
that he knows his own name comfortable therefore a good
and is oriented with what’s rapport was established.
happening at the moment. Giving reward made Mr. J
I feel that my patient answered my questions.
responded rather shyly.
“ano ang pangalan “James Villanueva” • Seeking This question does not only
mo?” (Sitting, looking (briefly gazes at me information seek information from the
directly at Mr E.) then looks at his feet) client, this also checks if the
patient is oriented and paying
attention. I feel like the
patient is not comfortable
enough based on his nonverbal
actions.
“ ah, ganun ba. Ilang “15.” (maintains eye • accepting This indicates that the nurse
taon ka na?” contact.) • exploring understands the client. I feel
( maintains eye that Mr. J is not totally
contact; sitting, oriented based on his answer.
leaning forward, nods)

“Saan ka nakatira, “….Silence.”(Gaze at • exploring This question not only checks


bago ka dalhin dito?” his side, leaning back • active listening his memory, this may open
(maintains eye on the chair) new topics for us. I feel that
contact, leaning Mr. J is still not comfortable
forward while sitting) enough based on not
answering my question and on
his non verbal actions.
“anong pangalan ng “Perlita Villanueva” • seeking Since the patient failed to
nanay mo?”( leaning (smiling, leaning back information answer the previous question,
forward, maintaining on the chair) • active listening it’s necessary for me to show
eye contact) the patient that it’s ok. This
will encourage the patient to
respond more. I feel that the
Mr. J is starting to feel
comfortable since he is now
smiling.
“Ano ang niluluto “Pancit.” ( smiling, • exploring This question focuses in the
sayo ng nanay mo?” leaning back on the • active listening Mr. J’s relationship to his
(leaning forward, chair) parent, this will help the client
maintaining eye to talk about his life more.
contact)

“Malapit ka ba sa “Oo. ( smiling, • focusing This question encourages Mr J


nanay mo?” ( leaning leaning back on the • verbalizing the to expand his response earlier.
forward, maintaining chair) implied I feel like, Mr J is fond of
eye contact) • active listening talking about his life and his
parents.

“Nasaan ang nanay at “….silence. (averts • exploring Here, I allowed a significant


tatay mo ngayon?” gaze, a bit teary eyed, • active listening time to pass, it will give Mr. J
( leaning forward, sitting but fidgeting • use of silence the opportunity to collect his
maintaining eye with the hem of his thoughts and gain insight. I
contact) shirt, leans forward) feel like my patient has finally
opened a sensitive topic, he
has shown slight behavioral
changes when he responded to
the question.
“Ano ang pangalan ng “Erfren Villanueva • exploring The main thought of what Mr.
tatay mo?” (smiling, teary eyes, • active listening J previously acts was call
(maintaining eye avoiding eye contact) attention to this topic. This
contact, open posture; will also indicate that I am
leaning forward) actively listening to what he is
saying
“Anong trabaho ng “Pintor.” (smiling, • exploring This encourages Mr. J to
tatay mo?” glances briefly, • active listening expand his previous response
( maintaining eye scratches his head, so that I will gain better
contact, open posture) leans back) insight and understanding to
what he is saying. I feel that
Mr. J is trying to conceal
whatever emotions this topic
has brought to him.
“Wow, eh di “…Hindi ko • active listening This basically encourages my
tinutulungan mo siya? alam.”(not looking at • offering patient to continue his story
( open posture, me, blank expression, general leads telling. I feel the patient still
maintining eye leaning back) disoriented.
contact,)

“tinutulungan mo b “Oo.”( smiles, briefly • active This basically encourages my


siya magpinta?” looks at me) listening, patient to continue his story
(maintaining eye • offering telling.
contact, open posture) general leads

“Ilan kayong “Apat.” (smiles and • active listening This will help both me and the
magkakapatid?” looks at me) • exploring patient to see the whole event
( maintaining eye in perspective. I feel like he is
contact, open posture) trying to hide his emotions.
“pang ilan ka sa “Hindi ko alam.” • active listening This will help both me and the
inyong ( maintains eye • focusing patient to see the whole event
magkakapatid?” contact, responded in perspective. I feel like the
(maintaining eye nonchalantly) said question has had a very
contact, open posture) strong impact on Mr. J.

“Ano pangalan ng “pancit…..”(maintains • active listening This question will enable Mr.
mga kapatid mo?” eye contact, • focusing J. to analyze the question in
(maintaining an eye responded detail and of course, expand
contact and open nonchalantly) the current topic. But I think I
posture) need to use the reward
punishment during the
conversation.
“nasabi mong pancit? “…silence” (leans • active listening This will help me and the
Ano ang dahilan sa back) • exploring patient o see the whole thing
pagsabi mo ng in perspective. I think the
pancit?”(leaning client has more emotions and
forward, maintaining negative feelings about the
eye contact, open current topic.
posture)
“nasabi mong pancit “gutom….”(blank • encouraging This encourages Mr. J. to
dahil….”(maintaining expression, avoiding expression continue what he is saying and
eye contact, open eye contact) • providing to express his feelings
posture) general leads regarding to the ‘pancit’. . So
• active listening by verbalizing this, the
discussion is less obscure.
“paano ka magugutom “….pancit”(blank • focusing This question focuses on what
eh kakakain mo expression, avoiding • active listening the client means with the word
lang.”(maintaining eye eye contact) • sharing “pancit”. Also, it focuses on
contact, open posture) perception the feelings of the client

“o sige bibigyan kita “oo.”(blank • verbalizing the Mr. J directly portrays what he
ng pancit pagkatapos expression,avoiding implied really feels, so by merely
kuwentuhan mo ko.” eye contact) • active listening giving food to the client let
(maintaining eye • focusing him answering my questions.
contact, open posture)

“ano ang “Masaya.”(blank • focusing This focuses on the client’s


nararamdaman mo pag expression, avoiding • active listening feeling during that moment. It
kumakain ka ng eye contact) • encouraging encourages the expression of
pancit?”(maintaining expression Mr. J’s feelings.
eye contact, open
posture)

“dib a sabi mo kanina “Oo”(smiles, eye • exploring This question encourage the
nilulutuan ka ng nanay contact, waving his • active listening patient to expand the story
mo ng pancit, masarap hands) regarding with his relationship
ba siyang magluto ng to his parent.
pancit?”(maintaining
eye contact, open
posture)
“ah, ganun “oo”(smiles, scratches • accepting
ba!”(smiles, open his head)
postures, leans
forward,nodding)

“sige ituloy na lang “ah, oh cge”


natin bukas, balik na
tayo sa loob”

PROCESS RECORDING

Resident: Mr. J.V


Age: 21
Diagnosis: schizophrenia undifferentiated
Objective: To continue encouraging the patient to express feelings and formulate a plan of action
General Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual
movements or mannerisms were observed
Setting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather
like a park with plenty of plants and the noises are subdued.
Date: January 11, 2010
THERAPEUTIC
RATIONALE AND
VERBAL ( NON VERBAL ) COMMUNICATION EVALUATION
FEELINGS OF NURSE
TECHNIQUE USED
Nurse Patient • giving Greeting the client shows
“magandang umaga “…silence”(smiling, recognition that the nurse acknowledges Mr. J is more comfortable
po, ako po ulit ang nodding) • offering self the client as a person. today and has shared some
nurse ninyo para sa significant information,
araw na ito”(smiling, feelings and experience to
briefly touches the me. He even summarized
shoulder) the whole conversation and
“Nag aaral ka ba bago “Oo”(smiling, hand • Exploring This will help the client seemed to have realized the
ka dalhin gestures) examine the topic more fully mistake he did before. He
dito?”(sitting, open came up with a plan that he
posture, maintaining intended to carry out after
eye contact) his hospitalization at
“san ka nag “aklan”(eye contact, • Exploring By giving follow up National center for Mental
aaral?”(leaning open posture) • Active questions to the client, the health.
forward, open listening nurse shows that he is
posture,maintaining listening and that it urges the
eye contact) client to continue.
“eh di madami kang “hindi ko • focusing This will also indicate to the
kaibigan sa alam”(nodding, smiling) • Active client that the statement was
school?”(eye contact, listening communicated effectively.
open posture)
“sino ang pinaka “Si Jp”(responds • Exploring The nurse can better
malapit sayo na nonchalantly) • Active understand superficial topics
kaibigan?”(eye listening if it is explored by delving
contact,open posture) deeper into the subject.
“mabait ba si Jp?”(eye “….silence”(scratches • Focusing The client is encouraged on a
contact, open posture) his head) • Active single topic and indicates
listening that the nurse is listening.

“May dala kong “…Oo, biscuit”(smiling) • Exploring Since the patient failed to
biscuit dito, bibigyan • Active answer the previous
kita tapos kuwentuhan listening question, it’s necessary for
mo ko, lagi mo bang me to show the patient that
kasama si Jp?”(eye it’s ok. This will encourage
contact, open posture) the patient to respond more.
The nurse used reward
punishment for the patient to
respond.
“lagi kayong “Oo, • Restating Repeating a key word that
magakasama?”(eye basketball”(smiling) • Active captured the attention of the
contact, open posture) listening patient, provides validation
and confirmation that there
was an effective
communication.
“naglalaro kayo ng “Oo”(hand gestures, • Active This is a follow up remark to
basketball?”(eye smiling) listening encourage the client to
contact, open posture) • Focusing continue with the story.
“tapos…”(eye contact, “basketball tapos kain • Offering This is a follow up remark
open posture) kame madame”(leans general leads that encourages the patient to
back) • Active continue talking and
listening expanding the topic.
“saan kayo naglalaro “Sa bahay, • Exploring This let’s the client know
at kumakain?”(eye basketball”(pointing to • Active that the statement was
contact, open posture) the court,nodding) listening communicated effectively.
“Hindi tayo puwedeng “bicuit.” ( scratches his • Disapproving This focuses on disapproving
maglaro ng basketball head, leaning backward) • Active what the clients want to do. I
kasi wala tayong listening feel that Mr. J change his
bola.”(open posture, behavior after disapproving
eye contact) what he wants to do.
“sige bibigyan kita “Oo, Pulis, • Accepting This indicates that the nurse
tapos sasagutin mo army”(scratches his • Exploring understands the client but is
yung mga tanong ko, head, smiling) • Active non judgemental in nature.
diba ang papa mo listening
pintor? Ikaw ano gusto
mong maging?”(open
posture, eye contact,
nodding)
“May kilala ka bang “army, si Andrew”(leans • Exploring Certain topics will be better
pulis o army?”(open back, avoids eye • Active understood if it is explored
posture, eye contact) contact) listening by delving deeper into the
subject.
“army ba si “Hindi ko • Exploring Repeating a key word the
Andrew??”(leans alam.”(smiling, avoids • Active patient has said, provides
back, eye contact, eye contact) listening validation and confirmation
open posture) • Restating that there was an effective
communication.
“Ano ang dahilan at “Hellicopter.”(smiling, • Exploring Certain topics will be better
gusto mong maging nodding) • Active understood if it is explored
pulis o army?” listening by delving deeper into the
(eye contact, open subject.
posture)
“gusto mong sumakay “ayaw, hindi ako • Summarizing Summarization brings out
sa hellicopter At gusto marunong, baka • Active the important points of the
mong maging mahulog ako.”(briefly listening discussion and to increase
army”(eye contact, looks at me) the awareness of the client. It
open posture) also provides a sense of
closure for the whole
conversation.
“di ba sabi mo apat “bunso”(smiling) • Exploring Certain topics will be better
kayong • Active understood if it is explored
magkakapatid,pangilan listening by delving deeper into the
ka?”(eye contact, open subject
posture)
“anong pangalan ng “….pajong, mac at • Active This is a follow up remark to
mga kapatid mo?”(eye bongbong.”(maintains listening encourage the client to
contact, open posture) eye contact) • Focusing continue with the story.
“malapit ka ba sa “Oo, • focusing The client is encouraged on a
kanila?”(eye contact, biscuit”(maintaining eye single topic and indicates
smiling) contact, smiling) that the nurse is listening.
“ah.. ganun ba! Sige, “sige”(smiling, nodding) • Accepting
balik na ulit tayo sa
loob. Tuloy na lang
natin bukas yung
usapan natin.”
(eye contact)

PROCESS RECORDING

Resident: Mr. J.V


Age: 21
Diagnosis: schizophrenia undifferentiated
Objective: To properly terminate the whole interaction between the nurse and the patient
General Appearance: the patient is wearing the hospital gown. He avoids eye contact and wore a blank facial expression. No unusual
movements or mannerisms were observed
Setting of Interaction: An open area outside the ward, with considerable distance from other nurse and patient. The place was rather
like a park with plenty of plants and the noises are subdued.
Date: January 12, 2010

THERAPEUTIC
RATIONALE AND
VERBAL ( NON VERBAL ) COMMUNICATION EVALUATION
FEELINGS OF NURSE
TECHNIQUE USED
Nurse Patient • Giving Greeting the client shows that
“kamusta po ang “ok naman, recognition the nurse acknowledges the The whole interaction with Mr.
activity ngayong masaya”(smiling, patient as a person E ended with appreciation from
araw?’ (smiling, open nodding) both of us.
posture)
“ngayon na kasi ang “salamat, paalam
huling araw namin sayo.
dito, gusto ko sanang babye”(smiling,
mag pasalamat sa oras nodding)
at partisipasyon
mo”(smiling, briefly
touches the arm)

Mood and affect

Patient J.V is a shy type person. It seems that he is guilty on what happened in his life. He has a poor eye contact, and I can see
in his facial expression that he is not at ease when we talked about his condition.

Speech

He is normally responsive to cues. There is also a time that he is whispering.


Perceptual disturbance

He is not experiencing any hallucinations and delusions during our interaction.

Thought

He is shifting to one topic from one subject to another in a somewhat related way.

Sensorium and Cognition

He is oriented to date and time. He is conscious and alert. He knows what they ate in breakfast, lunch and dinner before our
interaction. He is good in drawing and coloring. He can read and write.

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