CAPITOL MEDICAL CENTER COLLEGES, INC. #4 Sto.

Domingo Avenue, Quezon City

COLLEGE OF NURSING PROCESS RECORDING #3 (TERMINATION PHASE)

Name: OFELIA CANETE__ Age: _N/A_ Address: __#248 Lavedes, General Luna, Quezon___ Dateof Birth: _N/A_ Date of Admission: __July 17, 1993__ Educational Attainment: _N/A_ Diagnosis: __Schizophrenia, Manageable, Undifferentiated__ Setting: __Pavillion 5 National Center for Mental Health Date/Time of Interaction: __September 9, 2013 / 11:00 AM__ DESCRIPTION OF THE PATIENT Patient is wearing a red orange dress, without underwear and is wearing a pair of brown slippers. Patient recognizes me by my face. Patient answers accurately but some are incorrect and unrelated to the question. In the middle of conversation, there are some evidence of flight of ideas and answers on a tangent. Patient often answers in a different dialect. Patient easily forgets what is being taught to her. Patient maintains good eye contact throughout the conversation. DESCRIPTION OF ENVIRONMENT The place was again held at the Pavilion 5 - Function Room, with our chairs separated from each other with the patients together with their corresponded student nurses. OBJECTIVES Bring a therapeutic end to the relationship. Review feelings about the established rapport. Evaluate progress towards goal. Establish mechanisms for meeting future therapy needs. Summarize entire communication and follow-up treatments.

NURSE

THERAPEUTIC TECHNIQUE

PATIENT

ANALYSIS

Magandang umaga po Aling Ofelia.

Giving recognition

Magandang umaga po.

To greet the patient by name, to indicate awareness of change, to note the efforts the patient has made--these and other similar indications by the nurse show that she recognizes the patient as a person, as an individual. This allows patient to take the initiative in introducing the topic. It gives the patient the chance to elaborate details as possible.

Kamusta naman po kayo? Ano po nararamdaman niyo ngayon sa mga ginawa natin? Kwentuhan niyo po ako.

Giving broad openings Exploring

Mabuti naman po. Masaya po kasi kumanta, nagsayaw at naglaro po kami. Masaya po kami nandito kayo. Opo. Masaya. Bukas po ulit kasama namin kayo? Ganun ulit ang gagawin? Salamat.

Masaya din po ako kasi napasaya namin kayo.

Restating

This restatement gives evidence to the patient that an idea has been communicated effectively. It indicates that the nurse has heard and has followed the trend of thought. Informing the patient of the facts when he asks questions builds up trust as well. To reorient patient for the correct time and date. To give patient a greater body of knowledge and making facts available which client needs.

Opo.

Accepting

May handaan po tayo bukas at may mga palaro po ulit. Aling Ofelia, alam niyo po ba kung anong araw ngayon? Ngayon po ay ang araw ng Lunes, September 9, 2013. Kahapon po ay ang birthday ni Mama Mary, September 8. Mabuti naman po.

Giving information Exploring Giving information Giving information Accepting

Martes. Hindi ko po alam. Naalala ko po yun. Nagsimba po kami.

Nagdasal po kami. It indicates that the nurse has heard and has followed the trend of thought Nagpunta kami sa simbahan. Seeking to make clear that which is not meaningful or that which is vague.

Ano pa po ang ginawa niyo kahapon?

Seeking clarification

Saan po kayo nagsimba?

Exploring

Dun sa tatay ko nagbebenta ng tuba. Yung nanay ko pinainom ng alak yung kapatid ko, namatay. Si Amelita, namatay yun e. Tatlo sila.

It tests whether the nurse is really interested enought to look further. Organizing and summing up which has gone before.

Nabanggit niyo po na nagbebenta sya ng tuba. Magkano po ang kinikita niya sa isang araw? Sino po sa mga kapatid niyo ang namatay? Pang-ilan niyo pong kapatid si Amelita? Pangatlo po?

Summarizing

Exploring

It let the patient elaborate detail as possible. Seeking to make clear that which is not meaningful or that which is vague.

Seeking clarification Restating

Opo. Dun ako sa Infirmary,nakatali ako dun. Hindi masarap ang pagkain, kaya hindi ako kumakain. Adobong baboy. Ayoko noon, gusto ko isda. Hindi din ako pinapaliguan. Ako lang nagpapaligo sa sarili ko. Bilhan mo ako ng panty, wala akong panty, masakit kapag umuupo. Puti po at bulaklakin. Hindi ko po alam. Opo.

This restatement gives evidence to the patient that an idea has been communicated effectively

Anu-ano po ba ang mga pagkain doon? Maganda po ang isda, hindi po nakkahigh blood.

Restating

Giving information

Needed information that will assist the patient to understand his problem and the situation. Silence in itself often encourages the patient to verbalize if it is an interested, expectant silence. Clarification should be sought at each step of the way. To see whether the nurse is really interested enough to look further or as if to say that nothing of importance has ever happened in their lives It is an especially useful technique when the patient jumps rapidly from one thought to another.

(silence)

Using silence

Ano po gusto niyong kulay at kung anong size po kayo. Ang size niyo po? Osige po. Itatantsya ko na lang po kung ano ang size na magkakasya sa inyo. Maraming salamat po, Aling Ofelia! bye bye po!

Seeking clairification Exploring Focusing

Giving recognition

Bye bye din po.

EVALUATION Patient was happy about todays activity and imparts what she feels. She answers my questions but some of her answers are not related to the questions.