Process Recording

Initials of the Client: Mr. L.T.

Age/Sex: 34 yrs. old Male
Admission date: 2011
Previous Hospitalizations: None
Job: Security guard
Religion: Roman Catholic
Educational Background: College Graduate
Marital Status: Single
Chief Complaint:
Tentative Diagnosis: Undifferentiated Schizophrenia
Objectives of the Interaction:
At the end of the communication or interaction, I would/patient would be able to
established rapport and gain trust to each other to test the effectiveness of nurse-patient
interaction. To interact comfortably and communicate therapeutically to avoid conflict.
General description of Client:
Mr. L.T, a 34 yr. old male, admitted on 2011 was diagnosed of Undifferentiated
Schizophrenia. Mr. L.T. is well-groomed before the onset of interaction and already ate
his breakfast. He is actively participates during the interaction.
Description of Setting:
The interaction was conducted around 11 o clock in the morning outside the Pavillion.
The place is quite clean and well ventilated because it surrounded by trees and flowers
that is conducive for the patients learning and recovering of their illness.
Feelings and thoughts of the Nurse before the interaction:
Before the interaction, I feel nervous because it is my first time to communicate to person
having mental disorders. I thought they were going to hurt you because of their behavior
but I was wrong, instead they make you happy and flattered to their peculiar skills and
talent.

Evaluation of the Nurse-Patient Interaction: (goal met/partially or not met, changes to be

made after evaluating the interaction)
After the interaction or communication, the goal was met as evidenced by Mr. L.T. shared
information about his life that the student must want to know. The patient trusted the
student nurse and treated nicely.