College of Nursing and Allied Health Sciences

Lucena City

Name of Student: Date: 03-12-2022

Year Level/Group: BSN III - GROUP#2 Clinical Instructor: Raleen R. Cortez, PhD, RN
PROCESS RECORDING
Phase of the Relationship: Orientation Phase
Code name of the Patient: Ms. Gracia Alad-iw
Diagnosis: Schizoaffective Disorder
Description of the Place: The environment is depressing
Date and Time: February 12, 1:00pm
Objectives: 1. To identify boundaries of relationship
2. To clarify expectations
3. To establish rapport

NURSE INFERENCE PATIENT ANALYSIS

(Verbal and Nonverbal) (Verbal and Nonverbal)
Good afternoon, Ms. Gracia Alad- Giving recognition- Greetings the client No verbalization (looking at the The patient looks uninterested.
iw(smiling while walking to get a seat) by name, indicating awareness of change, surrounding area while smiling
noting efforts the client has made all show inappropriately)
that the nurse recognizes the client as a
person, as an individual.
I am Warren Reyes from MSEUF, and I Giving information- Informing the client I want to leave here (repeating the same The patient showed unusual behavior and
will be your student nurse for three weeks of facts increases his or her knowledge statement while crying) still looked uninterested.
every Saturday in the afternoon, starting at about a topic or lets the client know what
1:00 pm to 8:00 pm. Is that okay with to expect. The nurse is functioning as a
you? (smiling and eye contact) resource person. Giving information also
builds trust with the client.
(making eye contact) Silence- Silence often encourages the (silence and making a little eye contact) The patient looks interested, and I think
client to verbalize, provided that it is that she is trying to have a conversation
interested and expectant. with me.
Does that mean that you are ready to have Seeking information- The nurse should Yes, I am ready (smiling and nodding) The patient became calm suddenly, and I
a conversation with me? If not, I will stay seek clarification throughout interactions was trying to make her realize that I was
with you because I am interested in what to avoid assumptions. willing to listen.
you think. (eye contact) Offering self- The nurse offering itself to
show interest, and desire to understand. It
 is important that this offer is
unconditional, that is, the client dos not
have to respond verbally to get the nurse’s
attention.
I am happy to hear that. Before we start, Seeking information- The nurse should I am Gracia Alad-iw, 58 years old. I was The patient was cooperating well with my
can you tell me your name, age, date of seek clarification throughout interactions born on February 29, 1964, and I live in questions in a calm voice.
birth, and address? (smiling and eye with the client. La Trinidad, Benguet. (smiling and eye
contact) contact)
Okay, thank you. Is there something Broad opening- it makes explicit that the Why am I here? I do not want to stay here The patient was insisting that she did not
you’d like to talk about? (eye contact with client has the lead in the interaction. because I do not have a disorder. (eye have any disorders but was still
gentle voice) contact and slight shouting) cooperating and I was trying to make a
gentle conversation with her.
How are you feeling about being here? Encouraging expression- To encourage Because of my sister, I feel disappointed The patient sounds tired and frustrated.
(making eye contact and relaxing) the client to release the emotions. and sad because I cannot breast feed my
son. (Nodding)
I am sorry for how you are feeling right Suggesting collaboration- The nurse Oh… thank you nurse (smiling) The patient is feeling excited and looking
now. I am here to help you feel better if it seeks to offer a relationship to help the happy.
is okay with you. (smiling) client.
Okay, Ms. Gracia, can you tell me more Exploring- When clients deals with topics My sister brought me here by mistake The patient looked irritated when I was
about your sister? (smiling) superficially, exploring can help them (nodding) trying to ask about her sister.
examine the issue more fully.
Focusing- Is is a useful technique when a
client jumps from one to another topic.
Okay, go on. I follow what you are Accepting- an accepting response Because she said that I stole a shirt and a She was uncomfortable upon saying the
saying. And then? (eye contact, nodding, indicates the nurse is following. pair of pants at the SM, but they were statement, and she was nervous.
and relaxation). General leads- To encourage the client to given to me. Do you think I should tell the
continue if he or she is hesitant or doctor? (not making eye contact and
uncomfortable about the topic. having frisky hands)
Do you think you should? (eye contact Reflecting- the nurse indicates that the I am not sure because the other people The patient has experienced a
and open posture) client’s point of view has value. here might laugh at me. (nodding and hallucination suddenly.
looking around the corners of the room)
Are you sure? That is hard to believe Voicing doubt- the nurse neither agreed I am sure and I am scared. (trembling and The patient became afraid after knowing
because I see no one else in the room nor disagreed, however, he or she has not not making eye contact) that she was hallucinating.
aside from you and me. (eye contact and let the misperceptions and distortions pass
calm) without comment.
Presenting reality- When it is obvious
that the client is misinterpreting reality.
 Have you had similar experiences? (eye Encouraging comparison- The client Yes (nodding and no eye contact) The patient was anxious after asking
contact and gentle voice) benefits from making these comparisons about her past experience.
because he or she might recall past coping
strategies.
I understand how you are feeling right Formulating a plan of action- Making Walking, eating, and sleeping (making The patient looked relieved after asking in
now, and I am here to help you. Is there definite plans increases the likelihood that eye contact and nodding) regards to her therapy while I was trying
any activity that helps you relax when you the patient will cope more effectively in a to show empathy.
are experiencing hallucinations? (eye similar situation.
contact and relaxation)
I am happy to hear that you have coping Giving recognition- To inform the client Thank you, nurse. (smiling) The patient was feeling happy after
strategies to feel better. I think that is all that he or she has done well and to receiving compliments.
for today’s session, Ms. Gracia. And maintain the good conversations for the
thanks for your cooperation. (smiling) following sessions.

Conclusion:

-After 8 hours of nursing intervention, the objectives were met. First, I was still able to make her understand the boundaries of our relationship by giving her information even
though she did not cooperate well at first. Second, I was also able to clarify her expectations by providing her with sufficient information about what we are doing. Third, I
managed to establish rapport as I gained her trust during the conversation as she opened up or answered the therapeutic questions.