PROCESS RECORDING

Clients initials: EA Age: 31 years old Nursing Diagnosis: Disturbed thought processes related to inadequate support system as evidenced by distractibility. Goal of Interaction: To improve communication process and establish reality-based information. Description of environment: The conversation happened outside the room of the client. The ambiance outside was good because of the air and the trees surrounding the area. Sometimes theres an offensive odor but most of the time, there was none. The place is quiet enough for the client to be comfortable. Appearance of the Client: The client was wearing the designated shirt of the institution which is the blue in color. He looks neat except his nails look dirty. STUDENT CLIENT INTERPRETATION

Good morning My Good morning name is Monique and I will (smile and establish eye-tobe the assigned nurse to eye contact; nodding) you We will be here until Friday and we will be having activities that will help you enhance your condition. (Maintaining eye-to-eye contact and speaking softly) a. Offering self b. Giving information

The client looks like in the mood but he was shy.

The client was able to listen carefully and remain contact me.

Hmmm.. so, how old are you?.. How are you here and how long have you

Im 32 years old,..Im good and happy hereIve been here for 8monthsIm from

The client responds to the question.

been staying here?..And by the way, where are you from? (Maintains eye-to-eye contact while sitting)
a. Exploring

Palawan, I was born there and grew up in the same place.. (remains eye contact ; smiling)

The client gives short answer then suddenly become silent.

So, youve been here for 8 months I would like to ask, what you are doing here...? What did you do? (maintaining eye contact; sitting in front of the client) a. Seeking information b. Restating

Yes,The warden in the jail get me here and no one is with meYou know what, my head is aching at that time, I cant sleep well at night, thats why Im here (eye contact at first but started to lean her head right and left)

The client was able to open up, and then becomes distracted as Ive started asking few questions.

Oh, how come that thing happened?...And what is the reason that lead you to be in jail? Did you do something wrong?... (still in eye contact; speaking softly) a. Suggesting collaboration b. Exploring

I dont knowits just that I cant sleep...Ahhmm, none, I didnt do anything wrong...I just felt my head aching, then I started to seek doctor while inside the jail, and suddenly they brought me here.. (smiling; glance at first then distracted again)

The client doesnt seem to trust: he looks suspicious.

The client also seems ashamed.

Ahh, so how long did you

From 1995...hmmm, I mean

The client seems confused at

stay in Palawan Jail?.. What are your feelings with regards to what happen, tell me how do you feel at that time..? (eye contact; sitting;) a. Encouraging expression

2005 to 2008 I was there I felt very sad and my mother got angry to me... (Eye contact started to establish again.)

first.

The client started expressing his feelings.

Ahhmm. Mr.EA,its okay if youre having a hard time expressing your feelings, Ill just stay here and wait until you open up to me,, Im here to listen, and I assure that everything that we will talk about will just be for the two of us.. (lean forward; remains eye-to-eye contact) a. Encouraging description or perception b. Encouraging expression c. Offering self

Theres no problem, Im okay here except that I got bored sometimes because there was nothing to do here.. (eye-to-eye contact; smiling)

The client was trying to express his feelings about his condition.

The client started to feel comfortable.

Oh, looks like youre bored here..i would like to ask you again, is there any reason that lead you to

You know what, Im really sad at that time, I really miss my family.. Hmm..i was drunk that time, Im not in

The client was able to trust and disclose his feelings.

jail?.. Tell me everything, Ill listen.. You look very shy, dont worry you can trust me. (speaking softly; maintains eye contact; sitting in front of the client) a. Offering self b. Making observations c. Restating

normal state, I throw a stone in the glass window of an office.. I was accused an attempted murder, thats why I put up to jail.. (smiling with low voice tone; consistent eye-to-eye contact)

He looks comfortable.

Youre accused an attempted murder..So, do you know whose office is that? Do you have any problem with that person? (eye contact still) a. Exploring b. Restating

Yes, I do know the owner of The client looks sad at first but the office.. but I dont have then relieved when he start any problem or conflict with expressing himself. that person..Its just that I am drunk at that time...You know what; I really regret what happened to me, if I were given a chance, I would start all over again. I want to go back to Palawan when Im discharge here and I will get back to work. (eye-to-eye contact; speak softly)

So, youre willing to start all over again..Thats good to hear..hmmm, when do you start drinking alcohol? Is there someone who influences you?..Where are your family?..Whose with

I started drinking when I graduated from high school...I hooked up with my friends...My parents were in Palawan as well as my relatives...I dont have someone here in Manila, Im

The client feels sad while telling stories about his life.

you here in Manila?.. (still sitting in front of the client; speaking gently and softly)
a. Exploring

alone, and since I got here, I dont see any one of them, I dont have any news from them..I missed them.. (eye contact remains)

Its good to hear that you were able to graduate from high school..but on the other side being alone here, makes you feel sad and missed them so much..Thats why we are here to help you to at least lessen or reduce those sad feelings that you have and also to help you guys to improve your condition in that case, you should participate in our activities so that you will have fun.. (eye contact; smiling) a. Reflecting b. Giving Information c. Giving Recognition

Yes, Mam... Thank you for being here and helping us...I will surely join and participate in your activities... (smiling; eye contact)

The client shows interest.

The client looks happy now and relieved.

Evaluation: AE was able to at least improve his communication skill. He manages to express his feelings and open up about his condition. I think, after this conversation, AE will feel like he has someone to trust and talk to. His expression change from being suspicious and confused into being comfortable. For me, it was an effective interaction though sometimes, AEs answer has no connection at all. But anyway, he learns to trust other people and was able to connect events that happen to him in the end.