Republic of the Philippines

BATAAN PENINSULA STATE UNIVERSITY

Balanga Campus
Don M. Banzon Ave. Poblacion, City of Balanga, Bataan
(047) 237 – 3003 (047) 237 – 5477
COLLEGE OF NURSING AND MIDWIFERY
09/09/10

Process

Recording

And

Mental

Status

Assessment

(Psychiatric Nursing)

Submitted by:
Mr. Leomar P. Gonzales
Group23 ThFS

Submitted to:
Mrs. Irish Lee
Clinical Instructress

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responsive to socio – economic needs.
Process Recording
Date: September 1, 2010 (Wednesday) (Day 4)
Time: 9:10 am
Therapies: Photo language and Newspaper Therapy
Place: Mariveles Mental Hospita
Phase: Working Phase

I. Personal Data:

Name: Mr. A.G.

Address: Florida Blanca, Pampanga (c/o Elizabeth Baybayon, MSWD)
Age: 23 years old
Gender: Male
Date/ Place of birth: January 18, 1983, Manila, Philippines
Religion: Iglesia Ni Cristo
Place where the patient spent last 15yrs. of life: Jail according to the client
but it was observed that the jail that was stated by the client is, his ward inside the
hospital, and the client was admitted to the hospital 2 years ago.

II. Objectives:

A. Client-Centered Objectives
1. To gain and maintain client’s trust by using therapeutic
communication.
2. To promote proper personal hygiene by means of daily grooming.
3. To facilitate newspaper and photo language therapy to boost or assess
immediate, recent and remote memory.

B. Nurse-Centered Objectives
1. To help client interact or communicate with others inside the group as
socializing agent.
2. To create therapeutic environment by acting as a student nurse
manager.
3. To present reality regarding recalling the events and situations in their
lives.

III. Description of Setting

A. Describe the Set-up/Environment

It was a sunny day; the temperature was warm, with the wind blowing softly.
At around 9:10 in the morning, personal hygiene was rendered to the client at the
pantry. After the grooming, selected therapy like Photo Language and Newspaper
therapy was conducted at the BPSU center. The place is just enough to have
therapy even though the place is quite messy.

B. Describe the Nature, Behavior, Affect and Mood of the client

 It was around 9:10 in the morning, I received Mr. A.G. sitting on the chair in
the ground of the Male Ward A wearing a blue uniform. Mr. A.G. looks mad at
that time while having a conversation with me during the grooming session but
then after gaining trust to me during the therapy, Mr. A.G.’s with a smile on his
face.

IV. Process Recording

Nurse-Client Therapeutic Analysis and

Conversation communication technique Interpretation based on
(including non-verbal used theories
cues)
------Before Grooming----- -------------------------------- --------------------------------
SN: Magandang umaga Giving information - According to King
po, ako po si Leomar (1960), the stress in NPI
Gonzales, estudyante po will occur if more conflict
galing sa BPSU, ako po is experienced. Hence it is
ang magiging student important for the student
nurse nyo simula po nurse to identify their role
ngayong miyerkules, in relation to the patient.
huwebes, biyernes ng
umaga, para pos a ngayong
linggo at hanggang sa
susunod na linggo,
parehong araw po, tuwing
hapon naman po. Kayo po,
anong pangalan nyo?
Mang A:Mang A.G.

SN: Ah ok po, ilang taon Using direct question - Included in the 10

nap o kayo? carative factor of jean
Mang A: 23 Watson is the cultivation
SN: Taga saan po kayo? of sensitivity to one’s self
Mang A: Maynila, sa may and to others. Asking the
mga building. said question will measure
SN: Ano po ang birthday the client’s memory
nyo at san po kayo retention level.
pinanganak?
Mang A: Sa Maynila,
January 18.

SN: Mang A., nasaan po Placing event in time or To relate past event to the
kayo ng taong 1995, 15 sequence present just to gather data
taon na pong nakakalipas regarding his illness.
at ano po ang ginagawa
nyo ng mga panahong
iyon?
Mang A: Nasa kulungan…
SN: Nasa kulungan po? Seeking clarification Include in the 10 carative
Tama po ba ang aking factors of Jean Watson
narinig? (1970), is the cultivation of
Mang A: Oo, ayan yung sensitivity to one’s self and
kulungan oh! to others. Verbalizing what
is observed in the patient
aids in validation and
encourages situation.

SN: Ah... ang tinutukoy Asking direct question To gather data related to
nyo po ay ang inyong the client.
ward... Ilan taon na po ba
kayong namamalagi sa
inyong ward?
Mang A: Mga 2 taon na...

SN: Kung dalawang taon Placing event in time or To relate past event to the
na po, ibig sabihin, wala sequence present just to gather data
pa po kayo dito ng 15 regarding his illness.
years ng nakakalipas.. ang
tanong ko po Mang A.,
nasan po kayo 15 years na
pong nakakalipas? Nung
wala pa po kayo dito?
Mang A: Ah... Nasa
Maynila pa ako…
nagtratrabaho.

SN: Ganun po ba.. Tara po In voicing doubt This therapeutic

Mang A., maghilamos na communication is used
po kayo.. because there is no
Mang A: (Nodding) pertinent data was gathered
including chart reading
that will proved if the
client statement is true or
not.

-----After Grooming-------- -------------------------------- --------------------------------

SN: Tapos na po ba Giving Recognition According to Peplau
kayong magcologne? (1952), a nurse is stranger
Ayan po Mang A., malinis to the patient. It is
at mabango na po kayong therefore important to
tignan. Tara na po sa remind the patient who we
BPSU center. Doon po are and be consistent with
tayo gagawa ng therapy. the information we are
Mang A: (nodding) giving to him to gain their
trust.

-----Newspaper therapy---- -------------------------------- --------------------------------

SN: Mang A., bago po Encouraging Decisions According to Abraham
tayo dumako sa ating Maslows, all needs must
therapy, may mga ilang meet to proceed to the next
katanungan lang po akong level. Respecting client’s
nais tanungin sa inyo. Ayo decision will make client
slang po ba? to meet the 3rd level which
Mang A: (nodding) is love, belongingness and
acceptance.

SN: Ano po ang petsa Asking Direct Question In order for the nurse to
ngayon? know if the client is
Mang A: Di ko alam eh... oriented to the date.

SN: Mang A., ang petsa po Giving Information/ According to King (1960),
ngayon ay September 1, asking direct question the stress in NPI will occur
2010. Mang A., Nasaan po if more conflict is
kayo ngayon? experienced. Hence it is
Mang A: Dito sa important for the student
Mariveles, sa hospital. nurse to identify their role
in relation to the patient.

SN: Tama po. Mang A., Exploring According to abdellah, one

alam nyo po ba kung step in identifying the
anong dahilan ng client’s problem is to
pakakapunta nyo ditto sa continue observing and
hospital? evaluation the patient to
Mang A: Oo, Para identify attitude and cues
magpagamot kasi baliw affecting his behavior.
ako at may epilepsy.

SN: Ok po Mang A., Giving Information It is stated in Kings theory

ngayon naman po, dumako of Goal Attainment(1960),
na po ulit tayo sa inyong that if a nurse with special
therapy. Akin lang po knowledge and skill to
ipapaalala sa inyo ang mga communicates the
parte n gating dyaryo. Ito appropriate information to
po ang frontpage, editorial, the client, mutual goal
entertainment, classified setting and goal attainment
ads, obituary, at sports. will occur
Ang dyaryo po ay
naglalaman ng iba’t- ibang
mahahalagang balita
patungkol sa ating bansa,
ngayon po, ano po ba ang
nais nyong basahin?
Mang A: Ito, basketball.
SN: Sige po basahin nyo
na po.
Mang A: (silence)
SN: (silence)
SN: Mang A., napansin ko Stating observation Having observation will
pong hindi nyo po lead a nurse to explore
binabasa ang dyaryo, client’s feelings and mood.
Tanong ko lang po,
marunong po ba kayong
bumasa?
Mang A: Hindi eh, grade 1
lng natapos ko, may sakit
kasi akong epilepsy kaya
huminto ako.

SN: Ah ganon po ba, sige Offering self To gain client’s

po, kung gusto ninyo ako cooperation, you must gain
na po ang magbabasa para first his trust by offering
sa inyo, gusto nyo po ba? yourself.
Mang A: (nodding)

SN: Ang balitang ito po ay Giving information/ According to abdellah, one

patungkol sa labanan ng Exploring step in identifying the
dalawang kuponan sa client’s problem is to
basketball, ang USA at ang continue observing and
Brazil, na kung saan po ay evaluation the patient to
muntikan ng matalo ng identify attitude and cues
Brazil ang USA sa iskor na affecting his behavior.
80-78. Ang USA po ay
isang malakas na kuponan
pagdating sa larong
basketball. Mang A.,
ngayon po, ang aking
katanungan ay, ano po
bang dahilan at napili nyo
poi tong balitang ito?
Mang A:Ah, kasi mahilig
akong maglaro ng
basketball simula noong
bata pa ako.

SN: Ganon po ba, Asking Question To gather info regarding

naglalaro din po ba kayo his favorite sports from his
ng ibang laro? past life.
Mang A: Naglalaro din,
computer, tatsing, pero
paborito ko basketball.

SN: Ano po ang dahilan at Encouraging Comparison According to Abdellah,

mas napili nyo po ang nurses must help
larong basketball kaysa sa individual in developing a
ibang laro? comprehensive plan. In the
Mang A: Masaya kasama comprehensive nursing, it
ko mga kaibigan ko, is stated that nurses can
nanalo kami tapos ililibre help direct the works of
kami ng softdrinks. others.

SN: Sino naman po ang Exploring According to abdellah, one

nagturo sa inyo? Tatay nyo step in identifying the
po ba? client’s problem is to
Mang A: Hindi, bata pa continue observing and
lang ako, namatay na sya, evaluation the patient to
kaibigan ko lang nagturo identify attitude and cues
sa akin. affecting his behavior.

SN: Nabanggit nyo pong Seeking clarification Helps the client to clarify
namatay ang tatay nyo, their own thoughts and
tama po ba ang aking maximize mutual
narinig? understanding between the
Mang A: Oo nurse and the client.

SN: Ganun po ba, eh ang Asking Question To gather data from his
nanay nyo po, nasan na? past life regarding his
Mang A: Wala na, bata pa family
lang ako iniwan na nya
ako.

SN: Ganon po ba, sige po General leads It helps nurse to explore

magkwento pa po kayo client’s feeling and it
patungkol sa inyong allows client to verbalize
buhay. his feelings.
Mang A: Grade 1 lang
natapos ko, kasi may
epilepsy ako, tapos, iniwan
din ako ng nanay ko, mga
5 yrs/old ako namatay ang
tatay ko kaya inampon ako
ng amo nya. Taga linis ako
ng bus at tumutolong din
ako sa pagmemekaniko.
Natuto din ako magrugby
kasi tinuruan ako ng mga
kaibigan ko. Kaya doon na
rin ako nagsimulang
masiraan ng ulo.

SN: Nabanggit noy po na Identifying participants To explore if his

iniwan kayo ng inyong ina, and relationship significant others has
Ano po ang naramdaman contribution to his illness
ninyo?
Mang A: Medyo galit,
naiinggit din ako sa ibang
bata kasi nag-aaral sila.
SN: Ganon po ba, sige po, Summarization It is stated by Orlando
malapit na kasing (1980), that individuals
maggroup dynamics, have their own subjective
pwede nyo po bang ibuod perceptions and feeling
ang ating mga that may not be observed
napagusapan? directly. Therefore, it is
Mang A: basketball at important to set the client
saka buhay ko. know their perception are
accepted and heard to
encourage verbalization of
thoughts.

-----Photo -------------------------------- --------------------------------

Language-------- Exploring/ encouraging According to abdellah, one
SN: Mang a, nakapilina po evaluation step in identifying the
ba kayo ng larawan? Tara client’s problem is to
po, upo po tayo doon. continue observing and
SN: Mang A, maaari nyo evaluation the patient to
po bang sabihin kung ano identify attitude and cues
po ang nais sabihin ng affecting his behavior.
inyong napiling larawan?
Mang A: Ito baskeball, at
saka ito mga tao,
nagbubuhat ng bahay.
Encouraging expression To explore client’s feeling
SN: Maari nyo po bang why he chooses the two
sabihin ang dahilan ng pictures, whether it has
inyong pagpili sa larawang significant relation
iyan? regarding his life.
Mang A: Ito kasi mahilig
ako sa basketball, Masaya
kasi kasama ko mga
kaibigan ko. Ito naman,
gusto ko kasi magtayo ng
bahay ko sa maynila.
Encouraging comparison According to Abdellah,
SN: Ganon po ba, kung nurses must help
papapiliin kayo sa individual in developing a
dalawang larawan nay an, comprehensive plan. In the
ano po ang mas pipiliin comprehensive nursing, it
ninyo? is stated that nurses can
Mang A: Itong bahay, kasi help direct the works of
gusto ko din magtayo ng others.
bahay.
Encouraging description To explore whether
SN: Ok po, may gusto po of perception client’s has a abstract
ba kayong sabihin tungkol thinking about the picture.
sa larawang inyong napili?
Mang A: Itong bahay, may
mga taong nagbubuhat,
 sumisilong sila.
Asking Direct question To know if the client
SN: Alam nyo po ba ang knows that thing in the
tawag sa ganyan? picture.
Mang A: Hindo ko alam.
Giving information It is stated in Kings theory
SN: Bayanihan po ang of Goal Attainment(1960),
tawag dyan. May mga that if a nurse with special
taong tumutulong upang knowledge and skill to
mailipat ang isang bahay. communicates the
Pinapakita po nayn ang appropriate information to
pagagakaibigan. the client, mutual goal
Mang A: (silence) setting and goal attainment
will occur

Summarization It is stated by Orlando

SN: Ngayon po mang A., (1980), that individuals
Maari nyo po bang ibuod have their own subjective
ang ating napagusapan? perceptions and feeling
Mang A: Basketball at that may not be observed
bahay. directly. Therefore, it is
important to set the client
know their perception are
accepted and heard to
encourage verbalization of
thoughts.

Reinforcement As Stated in the domain

SN: Maraming salamat concepts of Orlando, one
Mang A., bukas po ulit, goal of nursing is
gagawin naman po natin improvement in client’s
ang creative arts therapy. behavior. Feedback
Babalik na po tayo sa encourage client to pursue
inyong ward… salamat po. positive behavior.
Mang A: Salamat din.

V.1 Theme Identification

A. Content Theme- The focus of the 1st conversation is all about newspaper therapy
where we talked about his favorite sports and we also talked about his past life. We also
talked about the photo language therapy, where the client interprets his feelings
regarding to the picture.

B. Interaction Theme- At first, there are some resistance between our conversations
where I can’t get his cooperation. But then, afterwards, after the client gain trust, he
opens a lot to me making our conversation more productively, where he answer my
entire question relevant.
C. Mood Theme- At first, as what I’ve observed to my client, clients looks mad while
I’m talking to him. But then, during the therapy, I observed that patient looks happy
where I think he gain trust to me.

V.2 Nursing Diagnosis

- Risk for loneliness r/t loss of family

VI. Nursing Interventions

Ernestine Wrendenbeck (1964) stated that nursing skills are made up

of a variety of actions and characterized by harmony of movement, precision, and
effective use of self. It is important to let the client know that the nurse is available for
the client and is willing to listen. The effective use of self lessens the feeling of
loneliness or being alone and at the same time; it allows the nurse to identify possible
harm the client may do to himself due to situation. It also give nurses a great
opportunity to gain client’s cooperation during the whole course of the treatment by
letting him understand that the health care team’s action are carried out to achieves a
specific clients-centered purpose rather than completion of skills itself being end goal.

Aside from therapeutic use of self, we can also identify strategies to

expand the world isolated. There may be special gathering in the hospital or there may
be activity programs like therapies.

VII. Summary and Evaluation

Around 9 o’clock in the morning, I received Mr. A.G. from male ward
A, where I assist him in terms of grooming at grooming area. We start a conversation
talking about his personal profile while walking. At the BPSU center, we started our
therapy. The group dynamics was lead by our facilitator which is our co-student nurse.
After that, we started our first therapy, the “newspaper therapy”. Mr. A.G. selects some
news at the newspaper which is all about basketball. Our conversation focus on that
game and some of his past experience. After that therapy, another group dynamics was
held. Then the second therapy, which is the Photo Language therapy, was started. Mr.
A.G. picks two pictures where I get some data regarding his life. Around 11am, the
therapy was finished. Lastly, Mr. A.G. returns to his ward.

VIII. References
-Psychiatric Nursing Handouts
-Psychiatric-Mental Health Nursing fifth edition by Videbeck
-NANDA
 Psychotherapy

I. Newspaper therapy
- Types of therapy where the psychiatric nursing uses newspaper as a material just for
the nurse to assess client’s immediate memory also including his comprehensive ability.

*Purpose of the Therapy*

1. Assess client’s comprehensive ability.
2. Assess client’s immediate memory.
3. To inform client recent news.

*Procedures*
1. There will be a group dynamics where the facilitator will discussed some information
about the therapy.
2. After the group dynamics, each student nurse will pick their clients for 1 on 1
conversation about the newspaper.
3. After reading the newspaper by the client, there will be a conversation for the
evaluation.
4. After the therapy, the client will return in the group dynamics for further assessment.
*Analysis and Interpretation*

Mr. A.G. chooses the sports page especially the news that talks about
basketball. Mr. A.G. tells that he likes basketball especially if he is with his friends. By
this statement, we can says that Mr. A.G. does not want to be alone, based on him, his
father died and his mother left him alone making him to find friends. Mr. A.G. has no
knowledge or skills in terms of reading.
II. Photo Language Therapy
- Technique of psychotherapy that uses photos to help client express their feelings that
they cannot express. It also assesses client perception regarding the pictures.

*Purpose*
1. To help client express their feelings by use of photos.
2. To encourage client to verbalize thoughts and experienced related to their selected
photos.
3. To provide a diversion activity to the client who cannot verbalize their feelings.

*Procedure*
1. There will be a group dynamics where the facilitator will discussed some information
about the therapy.
2. After the group dynamics, each student nurse will pick their clients for 1 on 1
conversation about the Photo Language therapy.
3. The client will choose two pictures and they will talk about it together with his
student nurse.
4. After the conversation, the client will return to the group dynamics for the
summarization.
*Analysis and Interpretation*

Mr. A.G. chose 2 pictures; one is playing basketball and the other is
“bayanihan”. Client chose basketball because that is his favorite sports and he want to
have friends. He also chose “bayanihan” because he wants to build his own house
someday together with his family.
Date and time: September 2, 2010; 9:00am; Thursday (Day 5)
Therapy: Expressive Arts Therapy
Place: Mariveles Mental Hospital
Phase: Working Phase

I. Client’s Name: Mr. A.G.

II. Objectives:
A. Client-Centered Objectives
1. To discover client’s ability in terms of creativeness.
2. for the client to express his feelings through expressive arts therapy.
3. for the client to recall his past life as what he designs to the therapy.
4. To maintain his trust to his Student Nurse.

B. Nurse-Centered Objectives
1. To interpret output made by the client.
2. To explore client’s feelings regarding the therapy.
3. To maintain client’s trust to his student nurse.

III. Description of Setting

A. Describe the Set-up/ Environment

September 2, Thursday morning, it was a rainy day making the set-up or place
empty (no people walking around inside the hospital). The therapy was conducted at
BPSU center. The three groups were combined to conduct the expressive arts therapy
making the place or set-up crowded and not enough to conduct good therapy.

B. Describe the Nature, Behavior, Affect and Mood of the client

Around 9 o’clock in the morning, I received Mr. A.G. at the male ward A,
wearing his blue uniform well groomed. I observed that Mr. A.G. is not in good mood
which is evidenced by his mad face. But then, during the therapy, he smiles at me
showing that he is enjoying the activity.

IV. Process Recording

Nurse-Client Therapeutic Analysis and

Conversation Communication Interpretation
SN: Magandang umaga po Giving Recognition According to Peplau
Mang A., naaalala nyo pa (1952), a nurse is stranger
po ba ako? to the patient. It is
Mang A: Hindi therefore important to
remind the patient who we
are and be consistent with
the information we are
giving to him to gain their
trust.
SN: Ganun po ba. Ako po Giving information According to king (1960),
Si leomar Gonzales, yung stress in NPI will occur if
student nurse nyo conflicts are experienced.
kahapon, noong umaga po. Hence it is important for
Mang A: (silence) the student nurses to
identify their more in
relation to the client.

SN: Mukhang bagong ligo Stating Observation Include in the 10 carative

po kayo ah… factors of Jean Watson
Nagtoothbrush nap o ba (1970), is the cultivation of
kayo? sensitivity to one’s self and
Mang A: Hindi Pa to others. Verbalizing what
SN: Tara po mang A., is observed in the patient
Magtoothbrush po muna aids in validation and
kayo. encourages situation.

----After Grooming-------- -------------------------------- ---------------------------------

SN: Pagkatapos nyo pong Giving information It is stated in Kings theory
magpulbos, pupunta nap o of Goal Attainment(1960),
tayo sa BPSU center that if a nurse with special
upang isagawa ang knowledge and skill to
Expressive therapy. Ang communicates the
therapy po na iyon ay appropriate information to
ginagawa gamit ang palito the client, mutual goal
ng posporo kung saan ay setting and goal attainment
ididikit nyo poi to sa isang will occur
papel.
Mang A: (nodding)
SN: Tara na po.

----During therapy--------- -------------------------------- ---------------------------------

SN: Ito po ang papel, Giving information For the client to be
pandikit at palito ng oriented on how to do the
posporo, dyan nyo po therapy.
ididikit ang palito para po
gumawa ng kahit anong
maisipan nyo.
Mang A: (nodding)
SN: Pakidikit na po…

---After therapy------------- -------------------------------- ---------------------------------

SN: Ayan po.. ang ganda Giving recognition Peplau identified the basic
naman po ng inyong nature of nursing as an
binuo… interpersonal process
Mang A: (smile) noting efforts of the client
has made shows that the
nurse recognize the client
as a person
SN: Maaari nyo po bang Encouraging For the client to explain his
sabihin sa akin ang inyong collaboration work more abstractly
ginawa?
Mang A: Ah ito bahay, ito
bundok, ito puno ng niyog,
at ito naman araw.

SN: Mang A., maaari nyo According to abdellah, one

po bang sabihin ang Exploring step in identifying the
dahilan kung bakit iyan po client’s problem is to
ang inyong nabuo? continue observing and
Mang A: Iyan kasi lagi evaluation the patient to
kong nakikita. Ayun yung identify attitude and cues
bundok oh.. ayun din yung affecting his behavior.
bahay…

SN: yun lang po ba General Leads For the client to expound

dahilan? Pagpatuloy nyo his thoughts
pa po..
Mang A: Oo.

SN: Hindi nyo po ba Asking close-ended Included in the 10 carative

naaalala ang inyong question factor of jean Watson is the
pamilya habang binubuo cultivation of sensitivity to
po yang bahay? one’s self and to others.
Mang A: Hindi. Asking the said question
will measure the client’s
memory retention level.

Based on Watson theory

SN: oh sige po, tanong ko Focusing there is independency and
lang po sa inyo, saan nyo integration of the parts and
po ba gusto magtayo ng elements of thoughts and
bahay? behavior that make up the
Mang A: Sa may syudad, system, hence it is
sa may maraming important to help the client
building. identify his own thoughts
and feelings to gain better
understanding of him.

Include in the 10 carative

SN: Mang A., napansin Stating Observation/ factors of Jean Watson
kop o kanina na ang Seeking Clarification (1970), is the cultivation of
inyong bahay na ginawa sensitivity to one’s self and
ay malapit sa bundok. to others. Verbalizing what
Tama po ba? is observed in the patient
Mang A: Oo.. aids in validation and
encourages situation.

According to abdellah, one

SN: Eh sabi nyo po na Exploring step in identifying the
mas gusto nyong tumira sa client’s problem is to
syudad, eh ano pong continue observing and
dahilan at malapit poi to sa evaluation the patient to
bundok? identify attitude and cues
Mang A: wala lang, mas affecting his behavior.
gusto ko talaga sa syudad,
lagi ko lang kasi nakikita
yung bundok at saka
mahirap gumawa ng
building eh…
According to abdellah, one
SN: Ganun po ba? Eh sino Exploring step in identifying the
naman po gusto nyo isama client’s problem is to
sa binuo nyong bahay? continue observing and
Mang A: Wala, ako evaluation the patient to
lang… identify attitude and cues
affecting his behavior.

According to Abraham
SN: Ayaw nyo po bang Encouraging Decisions Maslows, all needs must
isama ang pamilya nyo o meet to proceed to the next
magulang? O kaya asawa? level. Respecting client’s
Mang A: Wala na sila, decision will make client
patay na.. asawa? Pwedi to meet the 3rd level which
rin kung mayaman na is love, belongingness and
siguro ako. acceptance.

Included in the 10 carative

SN: Ganon po ba, Asking Close-ended factors of Jean Watson is
matanong ko lang po, may Question the cultivation of
asawa na po ba kayo o sensitivity to one’s self and
nanligaw na po ba kayo? to others. Asking the said
Mang A: Hindi pa question will measure the
client’s memory retention
level.

Asking the meaning or

SN: Ganon po ba, ahm.. Encouraging Expression important of something
noong nagagawa po kayo may lead to self disclosure.
ng ating therapy, ano po Thus identifying the
ang inyong naramdaman? problems of the client.
Mang A: Masaya.
According to abdellah, one
SN: Sa anong kadahilanan Exploring step in identifying the
po? client’s problem is to
Mang A: Wala kasi ito continue observing and
yung mga nakikita ko ditto evaluation the patient to
sa hospital. identify attitude and cues
affecting his behavior.
 According to Abdellah,
SN: Kung papapiliin po Encouraging Comaprison nurses must help individual
kayo, gusto nyo pa po in developing a
bang bumalik sa inyong comprehensive plan. In the
tahanan o ditto na lang comprehensive nursing, it
mamalagi? is stated that nurses can
Mang A: Sa dati, kaso help direct the works of
hindi na ako pwedi others.
bumalik doon, baliw kasi
ako.
Through this question, I
SN: Ano po ang Encouraging description will explore or know if the
nararamdaman ninyo sa of perception client wants to go back in
tuwing maaalala nyo po his home.
ang dati nyong tirahan?
Mang A: Malungkot
According to abdellah, one
SN: Sa ano pong Exploring step in identifying the
kadahilanan. client’s problem is to
Mang A: Wala, basta. continue observing and
evaluation the patient to
identify attitude and cues
affecting his behavior.

This aid having in depth

SN: Ok po, ano po ang Encouraging Evaluation understanding of client’s
inyong natutunan sa ating thoughts of feelings. As
ginawang therapy? stated by Levine (1989),
Mang A: natutong human being must be
magdikit at gumawa ng aware and must be able to
bahay. contemplate objects,
condition and situation.

Reviewing the main points

SN: Ok po, bago po natin Summarizing of discussions and making
tapusin ang ating therapy, appropriate conclusions
maaati nyo po bang ibuod will help the client
ang ating pinagusapan? remember what was
Mang A: Ayun, tungkol sa discussed and its
ginawa ko, sa bahay. significance.

As Stated in the domain

SN: Tama po. Ngayon po Reinforcement concepts of Orlando, one
ay babalik na po tayo sa goal of nursing is
ating grupo at pagkatapos improvement in client’s
po nun ay babalik na po behavior. Feedback
kayo sa inyong ward. encourage client to pursue
Nawa po ay natuwa po positive behavior.
sayo sa ating ginawa,
magkikita po ulit tayo
bukas ng umaga. Salamat
po sa inyong kooperasyon.
Mang A: Salamat din.

V.1 Theme Identification

A. Content Theme- The focus of our conversation is all about the expressive art
therapy. We talked about his output, his feelings towards to our activity and his
reasons why did the client do that thing which I can relate it to his past life.

B. Interaction Theme- Mr. A.G. interacts to me well and logically even though that
there are some things that he didn’t want to open with me. He answers all my
questions with his concrete thinking, meaning to say that, his work doesn’t have
meaning to him; instead it’s only an observation to his surroundings.

C. Mood Theme- The client feels mad when I received him. Maybe because he is
tired to what he is doing before I received him. But then, doing his therapy, he feels
happy, maybe because of what he’s doing. He smiles while doing hi activity.

V.2 Nursing Diagnosis

- Risk for injury r/t deficit on support measure as evidence by bare feet
walking.

VI. Nursing Interventions

According to Sullivan (1953), the goal of treatment as the establishment of

satisfying interpersonal relationships. The therapist provides a corrective interpersonal
relationship for the client. Sullivan coined the term participant observer for the
therapist’s role, meaning that the therapist both participates in and observes the
progress of the relationships. In order for the nurse to gain patient’s trust and
cooperation for the progressive therapy, he must use therapeutic communication.

VII. Summary and Evaluation

After receiving Mr. A.G. at around 9 o’clock in the morning, we start our
expressive art therapy. Mr. A.G made a house, sun, tree and mountain using
matchstick where he explained that he made that things because that is his observation
to his surroundings. Mr. A.G.’s work is not correlated to his past life, instead, its
focus to his environment inside the hospital. While doing his activity, Mr. A.G. Seems
happy in what he is doing.

VIII. References

- Psychiatric-Mental Health Nursing by Videbeck

- Psychiatric Nursing Handouts
- NANDa
 Psychotherapy

I. Expressive Arts Therapy

- Technique use to evaluate client’s ability in terms of arts and to assess
client’s feelings and perception towards the activity. This therapy is done using
a matchstick as a material.

*Materials*
Matchstick
Glue
A4 Bond paper

*Goals*
1. Evaluate client’s ability in terms of arts
2. Assess client’s feelings and perception towards the activity.

*Procedure*
1. There will be a group dynamics that will lead by facilitator to explain the
therapy.
2. The student will give the necessary equipments needed for the therapy and
will instruct the client about the procedure.
3. After the activity, the student nurse will have conversation with his client.
4. The nurse will get the output of his client and record all the necessary data
regarding to his client.
*Evaluation*
Mr. A.G. made a house, sun, mountain and coconut tree because these things
are based on his observation to his environment. This therapy shows that client’s
output has no significant relation to his past life, instead, it focus on his present life
inside the hospital.
Date and time: September 3, 2010; 9:00am; Friday (Day 6)
Therapy: Role Play Therapy
Place: Mariveles Mental Hospital
Phase: Working Phase

I. Client’s Name: Mr. A.G.

II. Objectives:

A. Client-Centered Objectives:
1. for the client to develop abstract thinking from concrete thinking
2. for the client to recognize the difference between fiction and reality
3. for the client to gain moral values
4. To maintain his trust from his student nurse

B. Nurse-Centered Objectives:
1. for the nurse to assess client’s cognitive ability
2. for the nurse to maintain trust of his client
3. for the nurse to gain skills in assessing client using MSA.

III. Description of Setting

A. Describe the Set-up/ Environment

September 3, 2010, Friday, at around 9 o’clock in the morning, role
play therapy was conducted at BPSU center, near the coconut tree. It was a fair and
sunny day were it can boost the energy of each client to do therapy more
effectively.

B. Describe the nature, behavior, affect and mood of the client

Around 9 o’clock in the morning, I received Mr. A.G. sitting on the
chair I n the male ward. During the grooming and the role play therapy, I’ve observed
that Mr. A.G.’s mood is in good mood with a smile on his face. I was amazed
that Mr. A.G. remembers my name because last past 2 days, Mr. A.G. didn’t
recognize my name.

IV. Process Recording

Nurse- client relationship Therapeutic Analysis and

communication used Interpretation
SN: Magandang umaga po Giving Information According to Imogene
Mang A., ako po yung King (1960), nursing is a
student nurse nyo process of action, reaction
kahapon. Makakasama and interaction whereby
nyo pa po ako sa susunod nurse –client share
na linggo, sa araw po ulit information about their
ng miyerkules, huwebes at perception in the nursing
biyernes, tuwing hapon action situation.
poi yon.

SN: Naalala nyo pa po ba Giving Recognition According to Peplau

ako? (1952), a nurse is a
Mang A: Oo, (smiled) stranger to the patient. It is
kaw si Mar. therefore, important to
remind the client who we
are and be consistent with
the information we are
giving them to gain their
trust.

SN: Ako po ay nagagalak Giving Recognition According to Peplau

at naaalala nyo pa po ang (1952), he identified the
aking pangalan basic nature of nursing as
Mang A: (smiled) an interpersonal process
noting efforts to the client
has made shows that the
nurse recognizes the client
as a person. Thus rapport is
built by demonstrating
acceptance.

-------After Grooming----- -------------------------------- ---------------------------------

SN: Mang A., napansin Making observation Include in the 10 carative

kop o na nakangiti po kayo factors of Jean Watson
ngayon. Ano po ang (1970), is the cultivation of
dahilan ng inyong sensitivity to one’s self and
pagngiti? to others. Verbalizing what
Mang A: Masaya ako, kasi is observed in the patient
may gagawin ulit tayong aids in validation and
therapy. encourages situation.

SN: Tama po kayo, ang Giving Information It is stated in Kings theory

gagawin po nating therapy of Goal Attainment(1960),
ngayon ay role play that if a nurse with special
therapy na kung saan knowledge and skill to
makikinig po kayo ng communicates the
gagawin naming dula appropriate information to
dulaan, tapos po may ilan the client, mutual goal
po akong itatanong sa inyo setting and goal attainment
pagkatapos ng therapy. will occur
Mang A: (nodding)

-------After Role Play------ -------------------------------- ---------------------------------

SN: Ngayon pong tapos na Asking Direct Question Asking questions about the
ang ating therapy, maaari therapy will assess
nyo po bang sabihin kung patient’s ability in terms of
ano po ang pamagat ng memory including his
aming ginawang dula- immediate recall.
dulaan?
Mang A: Ampalaya

SN: A ng buong pamagat Encouraging decisions According to Abraham

po ay “Alamat ng Maslows, all needs must
Ampalaya”, Ngayon po, sa meet to proceed to the next
lahat po ng gumanap na level. Respecting client’s
gulay, sino po ang pinaka decision will make client to
nagging paborito nyo? meet the 3rd level which is
Mang A: Si ampalaya. love, belongingness and
acceptance.

SN: Sa ano pong Encouraging Evaluation This aid having in depth

kadahilanan at napili nyo understanding of client’s
si ampalaya? thoughts of feelings. As
Mang A: mapait kasi sya. stated by Levine (1989),
human being must be
aware and must be able to
contemplate objects,
condition and situation.

SN: Sige po, sabihin nyo General Leads To encourage client to

pa po kung ano pong express his feelings toward
dahilan at ampalaya ang to the object and to explore
napili nyo. more of his reasons.
Mang A: Mapait at
sinasama sa ulam.

SN: Mang A., maaari nyo Encouraging According to Abdellah

po bang maikumpara ang Comparison (1965), nurses must help
nagging buhay nyo sa the individual in
isang ampalaya? developing a
Mang A: Ahm.. Masarap comprehensive plan in the
saya, mapait, masarap comprehensive nursing
igulay. skills, it is stated that
nurses can help direct the
work of others.

SN: Hindi po iyon ang Encouraging According to Abdellah

tanong ko, ang sabi kop o, Comparison (1965), nurses must help
paano nyo maikukumpara the individual in
ang sarili nyo sa isang developing a
ampalaya? Naging comprehensive plan in the
mainggitin din po ba kayo comprehensive nursing
dati? skills, it is stated that
Mang A: Hindi naman ako nurses can help direct the
nagging maiingitin. work of others.

SN: Mang A., sabi nyo po Seeking Clarification Helps the client clarify
sa akin na hindi po kayo their own thoughts and
nagging mainggitin, tama maximize mutual
po ba ang aking narinig? understanding between the
Mang A: Oo. nurse and the client.

SN: Sabi nyo po dib a sa Encouraging Expression According to Abdellah

akin dati, namatay ang (1965), one of the steps in
tatay nyo at iniwan kayo identifying the client’s
ng inyong nanay, problem is to continue
nakaramdam po ba kayo observing and evaluating
ng inggit sa ibang bata the patient to identify
dahil sa nangyari? attitude and cues affecting
Mang A: Nakaramdam his behavior.
din, Pero hindi na ngayon.

SN: Pag-usapan po natin Focusing As stated by Watson, there

ang inyong ina, Galit pa is interdependency and
po ba kayo sa kanya? integration of the parts and
Mang A: hindi naman, elements of thoughts and
nagtatampo lang ako. behavior that make up the
system. Hence, it is
important to help the client
identify his thoughts to
gain better understanding
of himself.

SN: Ganon po ba Mang Encouraging Decisions According to Abraham

A., gusto nyo pa po bang Maslows, all needs must
Makita at makasama ang meet to proceed to the next
inyong ina kung bibigyan level. Respecting client’s
kayo ng pagkakataon? decision will make client to
Mang A: Hindi na, nasa meet the 3rd level which is
malayo na yung mga yun love, belongingness and
ngayon. acceptance.

SN: Ngayon po Mang A., Summarizing It is stated by Orlando

malapit na pong matapos (1980), that individuals
ang ating pag-uusap, have their own subjective
maaari nyo po bang perceptions and feeling
sabihin kun ano ano ang that may not be observed
ating napag-usapan? directly. Therefore, it is
Mang A: Si ampalaya at si important to set the client
nanay ko. know their perception are
accepted and heard to
encourage verbalization of
thoughts.

SN: Tama po Mang A., Reinforcement As stated in the domain

Salamat po sa inyong concept of Orlando (1980),
kooperasyon. Magkikita one goal of nursing is
po ulit tayo next week. improvement in client’s
Miyerkules po ng Hapon. behavior. Feedback
Mang A: Salamat din encourage client to pursue
or continue positive
behavior.

V.1 Theme Identification

A. Content Theme- the focus of conversation between me and Mr. A.G. is all about
the role play therapy which is all about the “legend of the Bitter gourd.” We talked
about if he can compare himself to the said vegetable. We also talked about his
mother.

B. Interaction Theme- Mr. A.G. answers some of my questions illogically by

answering me not related to our topic. But then, some of my questions were answered
correctly.

C. Mood Theme- Mr. A.G. seems happy since I received him from his ward up to the
last part of our conversation. He enjoys watching our role play.

V.2 Nursing Diagnosis

- Risk for injury r/t absence of foot wear as evidence by bare feet.

VI. Nursing Interventions

Nursing skills is made up of variety of actions and characterized by harmony

of movement, precision and effective use of self as what Ernestine Wredenback
(1964), stated. It is important for the client to know that someone is willing to listen to
all his concern about himself. Someone he can trust on and can solve regarding his
feeling of loneliness, etc. By gaining client’s trust, nurse will also gain his cooperation
to perform all therapy well that can help client to decrease his anxiety and for the
nurse to assess client’s psychophysiologic aspects.

It is also stated by Orem’s Self Care Deficit Theory that, we as nurses should
assist others in provision and management of self care to maintain or improve human
functioning at home level of effectiveness. Through instructing them to their activities
of daily living well, we can improve them for a better one.

VII. Summary and Evaluation

Around 9 o’clock in the morning, I received Mr. A.G. starting his day with
grooming. Then we proceed to the BPSU center to do his role play therapy. Through
that therapy, I assess and evaluate his cognitive ability showing a result that Mr. A.G.
has concrete and sometimes illogical thinking than in abstract or logical ones.

VIII. Reference:
-Psychiatric Nursing handouts
- Psychiatric –Mental Health Nursing, Fifth edition by Videveck.
 Psychotherapy

I. Role Play Therapy

- technique which the nurses will prepare a role playing to evaluate client’s cognitive
thinking ability towards the said therapy and to test their memory especially
immediate recall.

*Goals*
1. Assess client’s cognitive thinking ability
2. To test their memory especially immediate recall
3. To relate the role play to their past life.
4. To give differentiation between fiction and reality

*Procedure*
1. Through a group dynamics, the facilitator will give information about the therapy.
2. The nurse will perform role play.
3. Afterwards, clients will go their respective student nurses for further assessment.
4. Lastly, they will go back to a group dynamics.

Evaluation:

Mr. A.G. enjoys watching the role play that was presented by the student
nurses. He choose “Ampalaya” as his favorite vegetables and character in the reason
that it is bitter but then, Mr. A.G. didn’t show any abstract thinking regarding that
character and cannot relate the characteristic of the said vegetables to his life. As our
conversation regarding the bitter gourd goes by, there is a point where we talked
about his mother if he feels some bitterness towards his mother, then he answer me
that he is not bitter and angry anymore against his mother.
Date and time: September 8, 2010; 2:30pm; Wednesday (Day 7)
Therapy: Dance Therapy
Place: Mariveles Mental Hospital
Phase: Working and Pre-termination phase

I. Client’s Name: Mr. A.G.

II. Objectives
A. Client-Centered Objectives
1. Maintain client’s trust to his student nurse.
2. for the client to discover his talent in dancing.
3. For the client to gain skill in terms of following procedure especially those
steps that he will learn from his student nurse.

B. Nurse-Centered Objectives
1. To gain skills in handling mental ill patient especially in teaching steps in
dance therapy.
2. To maintain client’s trust for better result of the therapy.
3. To assess client’s perception about the dance therapy.

III. Description of Setting

A. Describe the Set-up/ Environment

September 8, at around 2:30pm where I received Mr. A.G. from his ward. The
environment seems wet and slippery just because it was a cloudy day with slightly
rain. The set up of the therapy was conducted at BPSU center where it seems
conducive for the dance therapy.

B. Describe the Nature, Behavior, Affect and Mood of the Client

I received Mr. A.G. at around 2:30pm at male ward. I observed that Mr. A.G.
is in good mood which is evidence by a big smile on his face, maybe because of the
near event which is the grand socialization day.

IV. Process Recording

Nurse-Client Therapeutic Analysis and

Conversation Communication Interpretation
SN: Magandang hapon po Giving Recognition According to Peplau
Mang A., naaalala nyo pa (1952), a nurse is stranger
po ba ako? to the patient. It is
Mang A: Oo,.. ahm… kaw therefore important to
si Mar. remind the client who we
are and be consistent with
the information we are
giving to them to gain their
trust.

SN: Tama po, Mang A., Stating Observation/ According to abdellah, one
napansin kop o na Masaya exploring step in identifying the
kayo ngayon, ano po ba client’s problem is to
ang dahilan? continue observing and
Mang A: Wala lang, evaluation the patient to
malapit na kasi ang grand identify attitude and cues
socialization natin. affecting his behavior.

SN: Tama po Mang A., Giving information/ According to King (1960),

malapit na ang grand Setting Limits stress in NPI will occur if
socialization natin, at dahil conflict is experienced
po doon, hanggang bukas nurses to identify the more
nyo na lang po kami on relation to the patient.
makakasama, sa susunod
po na linggo, iba nap o ang
hahawak sa inyo, hindi
nap o ako, pero BPSU pa
rin po.
Mang A: Oo nga eh,
nasabi na rin yan ng
student nurse ko kaninang
umaga.

SN: Mang A., tanong ko Asking close-ended Included in the 10 carative

lang po, alam nyo po ba question factors of Jean Watson is
ang gagawin nating the cultivation of
therapy ngayong hapon? sensitivity to one’s self
Mang A: Oo, dance and to others. Asking the
therapy. said question will measure
the client’s memory
retention level.

------After Grooming------ -------------------------------- --------------------------------

SN: Mang A., ngayon po - By giving client an
ay sasayaw tayo, susundan Giving information, the client will
nyo po muna kaming information/asking direct be aware to what he is
sumayaw, tapos po, question been going to do and by
mamaya, sabay-sabay nap asking question related to
o tayong sasayaw kasama his feelings regarding the
nap o ang musika. Mang therapy is use to explore
A., sabik nap o ba kayong his feelings.
sumayaw?
Mang A: Medyo…

-----After therapy----------- --------------------------------

SN: Mang A., Mukha Through the use of this
pong pinagpapawisan -------------------------------- two therapeutic
kayo, nag-enjoy po ba - communication, I can
kayo sa ating ginawang Stating observation/ explore client’s feelings
therapy? Asking question toward the therapy.
Mang A: Medyo, kaso
mahirap, kaw din
pinagpapawisan.

SN: Mang A, dib a po, According to Abdellah,

kaninang umaga ay nurses must help
kumanta po kayo kasama individual in developing a
ng inyong student nurses, Encouraging Comparison comprehensive plan. In the
ano po ba mas gusto nyo, comprehensive nursing, it
sumayaw o kumanta? is stated that nurses can
Mang A: kumanta kasi help direct the works of
mas madali. others.

SN: Sinabi nyo pong mas Helps the client to clarify

gusto nyo kumanta, tama their own thoughts and
po ba ang aking narinig? maximize mutual
Mang A: Oo, mahirap kasi Seeking Clarification understanding between the
yung step ng sayaw eh… nurse and the client.

SN: Ok po, anu-ano It helps client to recall all

naman po mga alam nyong songs that he knows from
kanta? his past life.
Mang A: “Bakit nga ba Asking Question
ang puso”

SN: Ah, “kung mula sa For the client to expound

puso” ang title po ng his thoughts.
kantang iyan. Ano pa po?
Ituloy nyo pa po. General Leads
Mang A: yung “Halik”

SN: Mukha pong marami Reviewing the main points

kayong alam na kanta ah.. of discussions and making
Mang A., malapit na pong appropriate conclusions
matapos ang ating Summarization will help the client
paguusap. Maaari nyo po remember what was
bang ibuod ang ating mga discussed and its
napagusapan? significance.
Mang A: Ah yung kanta at
sayaw. Pati na rin yung
grand socialization.

---After Group Dynamics- --------------------------------

SN: Mang A., babalik nap As Stated in the domain
o kayo sa inyong ward, concepts of Orlando, one
nawa po ay natuwa kayo -------------------------------- goal of nursing is
sa ating ginawa, magkikita Reinforcement improvement in client’s
pa po ulit tayo bukas sa behavior. Feedback
ating grand socialization encourage client to pursue
ng umaga. positive behavior.
Mang A: Ok salamat din
sayo.

V.1 Theme Identification

A. Content Theme- Our discussion was focused on the therapy that we’ve done. Mr.
A.G. stated that he loves to sing than to than to dance, because of the reason that
dancing is more difficult than singing. The therapy that was conducted is the dance
therapy.

B. Interaction Theme- Mr. A.G. interacts with me in a good manner, where he can
recall his past favorite songs. He also answers all my questions correctly.

C. Mood Theme- Within our conversation, Mr. A.G. shows a good mood which is
evidenced by a smile on his face. He enjoys dancing even though that he like to sing
than to dance.

V.2 Nursing Diagnosis

- Risk for deficient fluid volume r/t over perspiration.

VI. Nursing Interventions

Based on Virginia Henderson’s definition of the unique function of nursing,

she defines nursing as “Assisting the individual, sick or well, in the performance of
those activities contributing to health or its recovery.” Based on this statement, we
nurses must assist our client in doing such a thing in the sense that our client should
not be dependent on us.

Another is that, According to Peplau, we must used therapeutic

communication just to gain their trust and cooperation in doing such thing like
conducting a group therapy.

VII. Summary and Evaluation

Around 2:30 in the afternoon, I received Mr. A.G. in male ward. We

conducted dance therapy. Mr. A.G. shows interest in dancing well in fact, he loves to
sing than to dance as he stated in our conversation. Mr. A.G. didn’t follow the steps
correctly but then I observed that he tries his best to the therapy. We also talked about
his favorite songs when he was an adolescent.

VIII. Reference
-Scribd.com
-Psychiatric Nursing Handouts
-NANDA
-Psychiatric- Mental Health Nursing by: Videbeck
 Psychotherapy

I. Dance Therapy
- It is a group therapy where the client will mimic or follow steps from their student
nurses with music.

*Goal*
1. Assess if the client can follow direction through copying some steps from their
student nurses.
2. It serves as recreation for the client for them to recall if they do dance in their past
life.

Procedure:
1. The facilitator will inform the entire client regarding the procedure in dance
therapy.
2. All students will teach their client about the step with out music.
3. After the rehearsal, all nursing students together with their client will dance with
music.
4. After the dance therapy, the client will go to his student nurse to have a talked
about the therapy and for summarization.
5. Lastly, there will be a group dynamics again for the whole evaluation.

Evaluation:

While doing the therapy, I observed that Mr. A.G. enjoys dancing. He states to
me that those steps that we teach to him are hard for him to follow, but then he enjoys
it. He said that he loves to sing than to dance because singing is more easy than
dancing. He also recalls some of his favorite songs in his past life.
Date and time: September 9, 2010; 9:00am; Thursday; Day 8
Therapy: Grand Socialization
Place: Mariveles Mental Hospital
Phase: Termination Phase

I. Client’s Name: Mr. A.G.

II. Objectives:

A. Client-Centered Objectives
1. Maintain client’s trust.
2. The client will verbalize his feelings regarding Grand Socialization
3. The client will be inform that this is the last day that he will be handle by
his student nurse.

B. Nurse-Centered Objectives
1. The nurse will assess client’s feelings regarding Grand Socialization.
2. The nurse will inform client regarding termination phase.
3. The nurse will demonstrate how to socialize with others to his client.

III. Description of Setting

A. Describe the Set-up/Environment

September 8, 2010, Thursday, around 9 o’clock in the morning, grand
socialization was conducted at the ruins. It was a fair and sunny day where it can
boost the energy of each client to cooperate in the grand socialization.

B. Describe the Nature, Behavior, Affect and Mood of the Client

Around 9 o’clock in the morning, Mr. A.G. was bought by his 2 other student
nurses in the ruins for grand socialization. While having a snack, I talked to Mr. A.G.
to assess his feelings towards the grand socialization and informed him about the
termination phase. I observed that Mr. A.G. is in good mood, and happy because he
cooperates well in our event.

IV. Process Recording

Nurse- client relationship Therapeutic Analysis and

communication used Interpretation
--Having Snack in Grand
Soc---------------------------- -------------------------------- --------------------------------
SN: Mang A., magandang Giving Recognition According to Peplau
umaga po, kamusta po (1952), a nurse is a
kayo? Natatandaan nyo pa stranger to the patient. It is
po ba ako? therefore, important to
Mang A: Oo, kaw si Mar. remind the client who we
are and be consistent with
the information we are
giving them to gain their
trust.
SN: Ako po ay natutuwa at Giving Recognition According to Peplau
naaalala nyo pa po ako (1952), he identified the
hanggang sa last day kop o basic nature of nursing as
ditto sa Mental hospital an interpersonal process
bilang student nurse nyo. noting efforts to the client
Mang A: (smiled) has made shows that the
nurse recognizes the client
as a person. Thus rapport
is built by demonstrating
acceptance.

SN: Napansin kop o Stating Observation Include in the 10 carative

kanina na Masaya kayo factors of Jean Watson
habang naglalaro kayo sa (1970), is the cultivation of
ating grand soc. Ano po ba sensitivity to one’s self and
ang dahilan? to others. Verbalizing what
Mang A: Masaya, kasi is observed in the patient
grand soc ngaun, sumali aids in validation and
ako sa maraming laro kahit encourages situation.
1 beses lang ako nanalo.

SN: Alam nyo po ba kung Asking Direct Question To assess if the client is
anong araw ngayon? aware regarding the date
Mang A: Hindi eh. and time.

SN: Ngayon po ay Giving It is stated in Kings theory

huwebes, September 8, Information/Setting of Goal Attainment(1960),
2010, at ngayon po ang Limits that if a nurse with special
huling araw na ihahandle knowledge and skill to
kop o kayo ditto sa Mental communicates the
Hospital. Iba na po ang appropriate information to
hahawak sa inyo sa the client, mutual goal
susunod na linggo, pero setting and goal attainment
BPSU students pa rin po will occur
sila.
Mang A: Ah…

SN: Mang A., masarap po Encouraging Evaluation According to abdellah, one

ba ang pagkain na step in identifying the
inihanda naming sa inyo? client’s problem is to
Mang A: Oo, masarap. continue observing and
evaluation the patient to
identify attitude and cues
affecting his behavior.

SN: Mang A., pagkatapos Summarization Reviewing the main points

po ng grand soc., ako po of discussions and making
ang maghahatid sa inyo sa appropriate conclusions
inyong ward, bago po ang will help the client
lahat, nais ko pong remember what was
ipabuod sa inyo ang ating discussed and its
napag-usapan. significance.
Mang A: Grand soc., at
saka yung huling araw nyo
rito.

-------After------------------- -------------------------------- --------------------------------

SN: Mang A., maraming Reinforcement As Stated in the domain
salamat po sa inyong concepts of Orlando, one
cooperasyon at tiwala, goal of nursing is
nawa po ay nagenjoy kayo improvement in client’s
sa ilang linggong kasama behavior. Feedback
nyo po ako, ingat po! encourage client to pursue
Mang A: Salamat din. positive behavior.

V.1 Theme Identification

A. Content Theme- The focus of our conversation is all about the grand socialization
and termination phase. We talked about his feelings regarding the event and also I
informed him that this is the last time that I will handle him. He shows his
cooperation to the event making him to enjoy the grand soc.

B. Interaction Phase- Mr. A.G. answerws all my questions relevant to the topic.

C. Mood Theme- Mr. A.G. seems happy since I was received him up to the point that
I accompanied him going to his ward. He enjoys playing with his co-client in the
grand soc.

V.2 Nursing Diagnosis

- Risk for loneliness r/t termination phase

VI. Nursing Intervention

According to Peplau’s Interpersonal theory, in termination phase, the nurse

must inform his client regarding that this is the last time that he will handle the client.
By the use of therapeutic communication while having a conversation, the client will
accept that he will not see anymore his nurse and another nurse will handle him.
Through acceptance, the client will be no longer experience loneliness regarding of
that event.

VII. Summary and Evaluation

Around 9 o’clock in the morning, Grand Socialization was conducted at the

ruins. Mr. A.G. came with his two other student nurses. Mr. A.G. cooperates in almost
all games in that event. He won 1 times out of 4 games but then he feels happy. Mang
A., verbalized his feelings regarding the grand soc, and he shows acceptance
regarding termination phase.
VIII. Reference
- Psychiatric Nursing Handouts
-Psychiatric-Mental Health nursing, Fifth edition by Videbeck
-NANDA
 Psychotherapy

I. Grand Socialization- is event conducted as a part of termination phase where all

clients will group as one to have an entertainment that will lead by the nurses.

*Goals*
1. Teach client how to socialize with others.
2. To give entertainment.
3. To inform client about the termination phase.

*Procedure*
1. The grand soc will be lead by the student nurses of different committee and there
will be two MC to give entertainment to the client.
2. The different committee will do therir assigned task; food committee; games;
aftercare; invitation and program; sounds; and decoration.
3. After the event, there will be a conversation between the student nurse and the
client for the termination phase.
4. The client will return to their ward accompanied by the student nurse.

Evaluation
Mr. A.G. shows energy in the grand soc. He cooperates to different games winning 1
game out of 4 games. But then eventhough he loses to other games, still, he is happy.
Mr. A.G. shows acceptance regarding the termination phase.
 MENTAL STATUS ASSESSMENT

Legend:
Δ- Has, or oriented, possesses
Ω-Has no, not oriented, or do not possesses

Name: Mr. A.G.

Age: Male Ward A

Orientation:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Person Δ Ω Δ Δ Δ
Place Δ Δ Δ Δ Δ
Date Ω Ω Ω Ω Ω
Time Ω Ω Ω Ω Ω
Situation Δ Δ Δ Δ Δ

Analysis and Interpretation:

Day4: Mr. A.G. is oriented in terms of person, place, and situation. He answers me
correctly when I asked him about the person, place and situation but then, Mr. A.G. is
not oriented in date and time.

Day 5: Mr. A.G. is oriented in terms of place, and situation. He answers me correctly
when I asked him about the place and situation but then, Mr. A.G. is not oriented in
person, date and time. He didn’t recognized me when I asked him who am i.

Day 6: Mr. A.G. is oriented in terms of person, place, and situation. He answers me
correctly when I asked him about the person, place and situation but then, Mr. A.G. is
not oriented in date and time.

Day 7: Mr. A.G. is oriented in terms of person, place, and situation. He answers me
correctly when I asked him about the person, place and situation but then, Mr. A.G. is
not oriented in date and time.

Day8: Mr. A.G. is oriented in terms of person, place, and situation. He answers me
correctly when I asked him about the person, place and situation but then, Mr. A.G. is
not oriented in date and time.

Theories:

-According to Hildegard Peplau’s Interpersonal theory, one of the signs that aclient
gain trust to his nurse is by recognizing and remembering the name of his nurse which
is caused by a good Nurse-Client interaction.

-It is also stated in Pschoanalytic theory coined by Sigmund Freud that if a person
over used his defense mechanism just to protect his ego will result in forgetting other
things which can decrease his level of awareness like Mang A. which are not oriented
to the date and time.

-According to Martha Roger’s concept of science of unitary human beings, and

principles of homeodynamics, nursing interventions seek to promote harmonious
interaction between persons and their environment, strengthen the wholeness of the
individual and redirect human and environmentak patterns or organization to achieve
maximum health. And one of the sign the a client return to his maximum health is to
be oriented in person, place, time, situation and date as a part of psychological
aspects.
Defense Mechanism:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
a. Repression Δ Δ Δ Δ Ω
b. Suppression Ω Ω Ω Ω Ω
c. Regression Ω Ω Ω Ω Ω
d. Fixation Δ Δ Δ Δ Ω
e. Denial Ω Ω Ω Ω Ω
f. Displacement Ω Ω Ω Ω Ω
g. Conversation Ω Ω Ω Ω Ω
h. Identification Ω Ω Ω Ω Ω
i. Intellectualization Ω Ω Ω Ω Ω
j. Introjections Ω Ω Ω Ω Ω
k. Projection Ω Ω Ω Ω Ω
l. Rationalization Δ Δ Δ Δ Ω
m. Sublimation Ω Ω Ω Ω Ω
n. Substitution Ω Ω Ω Ω Ω
o. Symbolism Ω Ω Ω Ω Ω
p. Undoing Ω Ω Ω Ω Ω
q. Reaction Ω Ω Ω Ω Ω
Formation
r. Fantasy Ω Ω Ω Ω Ω

Analysis and Interpretation:

Day 4: Mr. A.G. was observed having repression, fixation, denial and rationalization
as his defense mechanism to protect his ego.
Repression was used by Mr. A., just to protect his emotion and by
forgetting the bad things happen to him when he was in adolescence and childhood
days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation
where he was fixate to the time when he was 5 years old which he is with his father.
Denial was also used because he said that he is not angry to his mother who is
contradicted to his facial expression. He also used rationalization by giving me some
reasons telling that he is not angry to his mother

Day 5: Mr. A.G. was observed having repression, fixation, denial and rationalization
as his defense mechanism to protect his ego.
Repression was used by Mr. A., just to protect his emotion and by
forgetting the bad things happen to him when he was in adolescence and childhood
days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation
where he was fixate to the time when he was 5 years old which he is with his father.
Denial was also used because he said that he is not angry to his mother who is
contradicted to his facial expression. He also used rationalization by giving me some
reasons telling that he is not angry to his mother

Day 6: Mr. A.G. was observed having repression, fixation, denial and rationalization
as his defense mechanism to protect his ego.
 Repression was used by Mr. A., just to protect his emotion and by
forgetting the bad things happen to him when he was in adolescence and childhood
days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation
where he was fixate to the time when he was 5 years old which he is with his father.
Denial was also used because he said that he is not angry to his mother who is
contradicted to his facial expression. He also used rationalization by giving me some
reasons telling that he is not angry to his mother

Day 7: Mr. A.G. was observed having repression, fixation, denial and rationalization
as his defense mechanism to protect his ego.
Repression was used by Mr. A., just to protect his emotion and by
forgetting the bad things happen to him when he was in adolescence and childhood
days just to decrease his anxiety. Through this repression, Mr.A. Also used fixation
where he was fixate to the time when he was 5 years old which he is with his father.
Denial was also used because he said that he is not angry to his mother who is
contradicted to his facial expression. He also used rationalization by giving me some
reasons telling that he is not angry to his mother

Day 8: Mr. A was observed negative to all items listed above.

Theories

-According to Sigmund Freud, defense mechanism is used by an individual to protect

their ego and just to decrease their anxiety.

-According to Han Seyle’s Stress theory, to cope up with the stress, there are some
mechanisms that a person must use like defense mechanisms.

-According to Callista Roy’s Adaptation theory, he viewed humans as

biopsycholosocial beings constantly interacting with changing environment and who
cope with their environment through biopsychosocial adaptation mechanism
Extrapyramidal Symptoms:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Pseudoparkinsonism
1. Masklike face Ω Ω Ω Ω Ω
2. No swinging of arms Ω Ω Ω Ω Ω
3. Hesitancy of speech Ω Ω Ω Ω Ω
4. Decreased muscle Ω Ω Ω Ω Ω
strength
5. Shuffling gait Ω Ω Ω Ω Ω
6. Drooling Ω Ω Ω Ω Ω
7. Fine intention tremors Ω Ω Ω Ω Ω
Acute Dystonic Reaction
1. Muscle spasm of jaw, Ω Ω Ω Ω Ω
tongue, neck, eyes
2. Laryngeal spasm Ω Ω Ω Ω Ω
Akathisia
1. Restlessness Ω Ω Ω Ω Ω
2. Tenseness Ω Ω Ω Ω Ω
3. Inability to sit still Ω Ω Ω Ω Ω
4. Rocking back and forth Ω Ω Ω Ω
on feet
5. Crossing leg frequently Ω Ω Ω Ω Ω
6. Inability to relax Ω Ω Ω Ω Ω
Tardive Dyskinesia
1. Involuntary Ω Ω Ω Ω Ω
movements of mouth,
tongue, face, may extend
to fingers, arms and trunk

Analysis and Interpretation:

Day 4: Mr. A.G. was observed negative to all items listed above.

Day 5: Mr. A.G. was observed negative to all items listed above.

Day 6: Mr. A.G. was observed negative to all items listed above.

Day 7: Mr. A.G. was observed negative to all items listed above.

Day 8: Mr. A.G. was observed negative to all items listed above.
Thinking and Communication:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Looseness of
Association
a. Neologism Ω Ω Ω Ω Ω
b. Word salad Ω Ω Ω Ω Ω
c. Echolalia Ω Ω Ω Ω Ω
d. Echopraxia Ω Ω Ω Ω Ω
e. Clang Association Ω Ω Ω Ω Ω
f. Illogical thinking Ω Ω Δ Ω Ω
Alogia Ω Ω Ω Ω Ω
Concrete thinking Δ Δ Δ Δ Δ
Lack of insight Δ Δ Δ Δ Δ
Aphasia Ω Ω Ω Ω Ω
Apraxia Ω Ω Ω Ω Ω
Agnosia Ω Ω Ω Ω Ω
Flight of Ideas Ω Ω Ω Ω Ω

Analysis and Interpretation:

Day 4: Mr. A. was observed having lack of insight and having a concrete thinking.
These things was evident during our conversation when he answered all my questions
illogically and cannot give me an abstract reason to our topic, instead, he answered
me in a concrete thinking.

Day 5: Mr. A. was observed having lack of insight and having a concrete thinking.
These things was evident during our conversation when he answered all my questions
illogically and cannot give me an abstract reason to our topic, instead, he answered
me in a concrete thinking.

Day 6: Mr. A. was observed having illogical thinking, lack of insight and having a
concrete thinking. These things was evident during our conversation when he
answered all my questions illogically and cannot give me an abstract reason to our
topic, instead, he answered me in a concrete thinking.

Day 7: Mr. A. was observed having lack of insight and having a concrete thinking.
These things was evident during our conversation when he answered all my questions
illogically and cannot give me an abstract reason to our topic, instead, he answered
me in a concrete thinking.

Day 8: Mr. A. was observed having illogical thinking, lack of insight and having a
concrete thinking. These things was evident during our conversation when he
answered all my questions illogically and cannot give me an abstract reason to our
topic, instead, he answered me in a concrete thinking.
Theories:

-Based on Jean Piaget’s Cognitive theory, by the age of 12-15 years old, an individual
should developed his abstract reasoning, logical thinking and achieve cognitive
maturity. In this case, Mr. A. didn’t achieve his maturity which is caused by different
factors of his past life.

- It is also stated in the neurochemicals theory that if a person is under the substance
abuse state, in will affect different neurotransmitter that can cause brain cells death
that may affect thinking.

-According to Psychosocial theory of Eric Erickson, if an individual didn’t attain or

achieve his important task in each stage, there will be a fixation affecting his thinking
ability
Perceiving and Interpreting:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Delusions
1. Reference Ω Ω Ω Ω Ω
2. Persecution Ω Ω Ω Ω Ω
3. External influence Ω Ω Ω Ω Ω
4. Somatic Ω Ω Ω Ω Ω
5. Grandiose Ω Ω Ω Ω Ω
Hallucinations Ω Ω Ω Ω Ω
Illusions Ω Ω Ω Ω Ω
Depersonalization Ω Ω Ω Ω Ω
Attending to irrelevant Ω Ω Ω Ω Ω
stimuli
Poor reality testing Ω Ω Ω Ω Ω
Attending to relevant Ω Ω Ω Ω Ω
stimuli
Poor reality testing Ω Ω Ω Ω Ω

Analysis and Interpretation:

Day 4: Mr. A.G. was observed negative to all items listed above.

Day 5: Mr. A.G. was observed negative to all items listed above.

Day 6: Mr. A.G. was observed negative to all items listed above.

Day 7: Mr. A.G. was observed negative to all items listed above.

Day 8: Mr. A.G. was observed negative to all items listed above.
Feelings and Affect:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Flat Ω Ω Ω Ω Ω
Blunted Ω Ω Ω Ω Ω
Inappropriate Ω Ω Ω Ω Ω
Lability Ω Ω Ω Ω Ω

Analysis and Interpretation:

Day 4: Mr. A.G. was observed negative to all items listed above.

Day 5: Mr. A.G. was observed negative to all items listed above.

Day 6: Mr. A.G. was observed negative to all items listed above.

Day 7: Mr. A.G. was observed negative to all items listed above.

Day 8: Mr. A.G. was observed negative to all items listed above.
Behaving and Interacting:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Withdrawal Ω Ω Ω Ω Ω
Motor Hyperactivity Ω Ω Ω Ω Ω
Motor Hypoactivity Ω Ω Ω Ω Ω
Ambivalence Ω Ω Ω Ω Ω
Anhedonia Ω Ω Ω Ω Ω
Avolition Ω Ω Ω Ω Ω
Poor Personal Ω Ω Ω Ω Ω
Hygiene
Impulsive Ω Ω Ω Ω Ω
Paranoia Ω Ω Ω Ω Ω

Analysis and Interpretation:

Day 4: Mr. A.G. was observed negative to all items listed above.

Day 5: Mr. A.G. was observed negative to all items listed above.

Day 6: Mr. A.G. was observed negative to all items listed above.

Day 7: Mr. A.G. was observed negative to all items listed above.

Day 8: Mr. A.G. was observed negative to all items listed above.
Negative Cognition:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Overgeneralization Ω Ω Ω Ω Ω
All or nothing thinking Ω Ω Ω Ω Ω
Should statements Ω Ω Ω Ω Ω
Labeling Ω Ω Ω Ω Ω
Mind reading Ω Ω Ω Ω Ω
Fortune telling Ω Ω Ω Ω Ω

Analysis and interpretation:

Day 4: Mr. A.G. was observed negative to all items listed above.

Day 5: Mr. A.G. was observed negative to all items listed above.

Day 6: Mr. A.G. was observed negative to all items listed above.

Day 7: Mr. A.G. was observed negative to all items listed above.

Day 8: Mr. A.G. was observed negative to all items listed above.
Others:
Day Day Day Day Day Day Day Day Day
1 2 3 4 5 6 7 8 9
Amnesia Δ Δ Δ Δ Δ
Fugue Ω Ω Ω Ω Ω
Depersonalization Ω Ω Ω Ω Ω
Phobias Ω Ω Ω Ω Ω
Memory Ω
1. remote(long Δ Δ Δ Δ Δ
term)
2.recent(early am) Δ Δ Δ Δ Δ
3.recent part(current Δ Δ Δ Δ Δ
events
4.immediate Δ Δ Δ Δ Δ
memory(short term)
5.immediate recall Δ Δ Δ Δ Δ

Analysis and Interpretation:

Day 4: Mr. A. was observed having amnesia but then some of his memory was intact
to his mind. He can remember his past life especially when he was 5 years old, and he
can enumerate all events that happen from his past days. But then there are some
memories that he can’t remember especially when he was in adolescene stage either
intentionall or not, just to forget some bad memories.

Day 5: Mr. A. was observed having amnesia but then some of his memory was intact
to his mind. He can remember his past life especially when he was 5 years old, and he
can enumerate all events that happen from his past days. But then there are some
memories that he can’t remember especially when he was in adolescene stage either
intentionall or not, just to forget some bad memories.

Day 6: Mr. A. was observed having amnesia but then some of his memory was intact
to his mind. He can remember his past life especially when he was 5 years old, and he
can enumerate all events that happen from his past days. But then there are some
memories that he can’t remember especially when he was in adolescene stage either
intentionall or not, just to forget some bad memories.

Day 7: Mr. A. was observed having amnesia but then some of his memory was intact
to his mind. He can remember his past life especially when he was 5 years old, and he
can enumerate all events that happen from his past days. But then there are some
memories that he can’t remember especially when he was in adolescene stage either
intentionall or not, just to forget some bad memories.

Day 8: Mr. A. was observed having amnesia but then some of his memory was intact
to his mind. He can remember his past life especially when he was 5 years old, and he
can enumerate all events that happen from his past days. But then there are some
memories that he can’t remember especially when he was in adolescene stage either
intentionall or not, just to forget some bad memories.

Theories

-According to Sigmund Freud, forgetting something intentionally or not, it is under

the defense mechanism that was used to decrease their anxiety.

-According to biological theory, there are some factors that can affect the memory of
a person, either accident, disease or affected by some chemicals. Based on the his tory
of Mr. A., he is inhaling rugby, taking alcohol in his past life affecting his brain cells
responsible for memory.

-According to Han Seyle’s stress theory, there are two effects of stress, the eustress
and distress; recovery and exhaustion. Under the exhaustion, it can result from
prolonged exposure to stress and adaptive mechanisms can no longer persist, which
can affect a lot of things including memory as a result of over use of defense
mechanism.