Process Recording

Personal Data
Name: R.N
Sex: male
Age: 17
Address: Brgy. Calipayan, Mayorga, Leyte
Birthday: March 19, 2002
Religion: Roman Catholic
Occupation: N/A
Living arrangement: In jail

Description of Client
 The client is a 17 year old Grade 10 student of Mayorga National High school active in extra-curricular
activities in school. He is an ordinary student. He is currently convicted in jail with a case of rape but he
is on the sub-jail in abuyog, leyte. He is currently under the custody of DSWD and his case is under
investigation and in due process of law. The client wears clothes appropriately and comfortable in
clothing. Hair is properly groomed, short and clean nails. Client looks calm comfortable while having the
interview. He cooperates actively during the interaction and answers the questions willingly. The client is
attentive and active. He is well oriented in time, place and person. He can talk properly and answers are
related to the topic. He sometimes jokingly answers the questions and laugh and seems happy during the
whole conversation.

Description of the Environment

 The interview was done in Sub-jail. The environment was quiet and comfortable and relaxing since it is
located near in seashore. It was clean and everything was well arranged. It was also safe. Overall the
environment was conducive for a productive conversation.

Objective of the Interaction

 Establish rapport
 Provide the client sufficient information about the interview
 Gather information about the client
 Assess and understand client’s thoughts, feelings and problems

Student Nurse Client’ Analysis

“Good afternoon kuya, mag iinterview “para ngain ito kuya quez?
lang sana ko para sa isang subject
namin”

“yung subject kasi namin ngayon kuya “waray man ako kato” Giving information about the
yung about sa mental health” “Client laughs” interview to gain rapport and trust.

“ay hindi kuya, hindi ibig sabihin may

sakit ka nito, para din to sa mental
health promotion, naghahanap kami ng “aw sige”
mga vulnerable persons like mga
teenage mothers, senior citizens,mga
batang priso mga single tas nag isa na
medyo may edad na”

“sige kuya okay lang ba na ilagay ko “ayaw na gad igbutang an akon

yung name mo dito?” ngaran okay man la diba kay
makarawud?”
“okay kuya, walang problema kasi
para din naman sa privacy mo”

“ilan na edad mo ngayon kuya?” “client laughs” Gathering information

“Bata pa ako tapos na kuya kana”
“client laughs”
“17 palang ako quez bata pa” Accepting by nodding to indicate
“client laughs again” of following and hearing the train
“smiles and nods” “oo nga kuya” of thought
“kelan yung birthday mo kuya?”
“March 19, 2002”
Gathering information
“catholic ka kuya?” “Oo gad”

“single ka ba kuya?” “Mayda ko uyab pero an adi na ak

prisuhan nagbulag kami, pero yana
mayda ko bag o na uyab ha
facebook”
Client’s laugh

Student Nurse Client Analysis

“Taga saan naman jowa mo at ilang “Dulag, mag 18 palang”
taon? “client laughs”

“ano pangalan ng tatay at nanay mo “Carolina Nanos” Gathering information

kuya”? “an akon tatay Jerardo Nanos”

“okay kuya, pang ilan ka sa sa inyong “pito kami at pang anim akong anak nila,” Gathering information
magkapatid?

“Kumusta naman kayong “Ang iba adto manila nagtatrabaho at sila Exploring. To have an idea
magkakapatid?at family mo? nanay at tatay permi busy sa trabaho” and help analyze his
present situation.
“Anung trabaho ng magulang mo?” “Parag-uma”

“may nararamdaman ka ba ngayon, “Mayda ako sipon 3days na, ngan

kahit anong masakit?” nakukurian pagkaturog tungod kay mapaso
ngadi sulod ngan maaringasa”

“nagkaron kaba ng “waray” Gathering information

chickenpox/bulutong dati ?”

“eh yung mumps kuya? Yung bikag?” “nagkamayda gihap ak hito an elementary Gathering information
ako,”

“ahh okay (nods and maintains eye

contact)”
Active listening. Shows
“natandaan mo pa ba ung “oo kumpleto ako” interest and acceptance to
immunization mo? Kumpleto ba yung client
sayo?”

“allergies? “Waray man ako allergies sa pagkaun o bis Gathering information

anu”

“Neozep ng 500 mg para sa sipon ko” Gathering information

“ano man iniinom mong mga gamut
ngayun?”

“Nahospital kana ba?” “Waray simbako” Gathering information

Client’s laugh

“eh injuries? Aksidente sa sasakyan,

nabalian ka or mga ganun na “waray pero nagcrash na ako hin motor pero
injuries?” waray man ako piang,gasgas la”

“Kumusta ang yung pag aaral dati na “Maupay man,asya it akon namingawan tak Exploring. To have an idea
nasa labas kapa?” mga sangkay nga lurong” and help analyze his
Client’s laugh present situation.

“Bakit lurong?” “Kay magkaupod ha tanan na

kalurungan,pag cutting ha

Student Nurse
“yung mga kapatid mo kuya? Buhay
pa lahat yung sa tatay mo?”
“Kuya sa pag inom, umiinom kaba?”
“kelan ka nagstop ng sigarilyo?
“drugs kuya, nagtry ka ba dati?”
“nods and maintains eye contact”
“nagtravel kaba nitong past year?
Kahit labas lng ng jail, o leyte, o kahit
sa ibang bansa?”
“ano man usually ginagawa mo, o
pampalipas oras?”
“anong nagpapastress sayo ngayon ?”
“anong year kana?
“para sayo kuya healthy kaba
ngayon?”
“para sayo ano bang healthy na tao?”
“smiles”
“ano man mga ginagawa mo para
maging healthy ka?”
“ano man usually mga kinakain mo
ngayon ?”
“yung tubig ? Malakas kaba uminom
ng tubig? Nakakaabot ka ng 8 na
baso?”
“kamusta naman yung pag ihi mo?
Okay naman? wlang problema?”
“ano man yung color ng ihi mo ?
Student Nurse
“yung pag tae mo kamusta naman?
May masakit ba? O nahihirapan?”
klase,panigarilyo,pag inum except la ha
pagdrugs.”
Client’s laugh
Client Analysis
“oo, buhay pa lahat, ou pero lahat sila adto Gathering information
na sa manila kami nala 3 ngada ha balay na
magburugto.an iba may asawa na”
“ou nainum ako tikang an naghighschool
ako, pati an sigarilyo”
“5 years na ada” Exploring. To have an idea
and help analyze his
“client smiles” “waray gad” present situation.
Gathering information
“Nakagawas la kami kun sugo nan jail
guard”
“nanonood ng TV, danay liwat bantay
tindahan kay duty man anmon ito ngadi”
“it akon kabutangan yana na bata pa ako Neutral response. Showing
napriso na ako,ngan it pagkita han mga tao interest and acceptance
ha akon” “client laughs” and being nonjudgmental.
Grade 9 Gathering information
“Di ko alam, bagat okay man la ako pero Gathering information
mayda ko sipon”
“syempre malakas yung katawan, waray gin
aabat,kumauon hin masustansya na pagkaun” Gathering information
“laughs”
“waray na ako nag inom ngan sigarilyo, Gathering information
syempre makaon hin healthy nga mga
pagkaon, jogging, nasaka hin bukid”
“kun anu it rasyon ngadi sulod asya la it Gathering information
akon nakakaun”
“oo nasobra pa ngani sa 8 nga baso okay Exploring. To have an idea
kelangan nasiring hi doc” and help analyze his
present situation.
“okay man, sige man tak ihi ihi kay damo
man tak gin iinom na tubig. Nkakadamo ak
pag ihi siguro mga 5 ka beses sa adlaw tapos
mga tulo kun gab e, mga alas dose, ala una,
ngan alas dos depende. Clear man tak ihi,
pero kung diri gud ak makainom hin damo
na tubig, madarag, pero an sakto la nga
darag”
Client Analysis
“nakakauro ko yana duha or tulo kada adlaw,
waray man ko nafeel nga masakit”
“yung pagtulog mo kamusta naman
?nahihirapan kaba matulog?”
“yung pagtingin mo naman kumusta?
Malabo ba o okay naman?”
“okay, yung sa hearing mo ? may
problem ba?”
“kumusta naman te yung pagtingin
mo sa self mo? Confident kaba sa self
mo?”
“aw oo” “smiles”
“May time ba na nafeel mo na
nawalan ka ng pag asa?”
“ano man ginagawa mo para
mabawasan yung lungkot mo na mag
isa?”
“minsan ba pumasok yung suicide sa
isip mo?”
“kelan?”
“ano man yung ginawa mo para
mawala yun or maging okay ka?”
“May mga nagbago ba sayo,simula
nung nandyan ka?”
Student Nurse
“if ever dumating ka ulit sa point na
ganun ano yung pwede mong gawin
para maging okay ka o mawala yung
pag isip ng ganun?”
“nitong past year nagkaroon kaba ng
malaking problema?
“Diri gud ako nangangaturog hin tuhay,Kay
tungod mapaso ngan maaringasa ngan
minsan kun duty pagbantay asya piraw ak
yana”
“okay pa man.”
Exploring. To have an idea
and help analyze his
present situation.
“waray man gehap”
“ oo minsan, pero yana na akon sitwasyon
nawawarayan gad ako hin pag – asa saypa na Exploring. To have an idea
it pagkita it kadam an ha akon” and help analyze his
present situation.
“Danay kay namimingaw man tak pamilya
na panagsa ko la nakikita hira nanay ngan
tatay”
“videocall,pero tinagu-tago la liwat kay
bawal ngadi sakob” (laughs)
“kinausap din ako nung mga kasama ko
ngadi sakob”
“Ou an oras na nasugad ak hini pero kay ada
man hira nanay ngan tatay na nayakan kaya Exploring. To have an idea
ko ini ngan ada la hira ha akon” and help analyze his
present situation.
“Ginoo nala it bahala ha akon ngan hiya it
labi na maaram” Accepting to show interest
and listening.
“Ou, usa na an pakikisama ngan pagrespeto
ma bata man o nakakamagurang haak ngan Self-Disclosure and sharing
dako an ak paghinayang ngan pagbasol nga personal information to
nasulod ak hinin na sitwasyon kay nakarag convey understanding
an ak panahon”
Exploring. To have an idea
about her problem and help
her analyze and solve the
problem.
Client Analysis
“Amu la gihapon siguro, ada man la pirme Formulating a plan of
hira nanay ngan tatay ngan ada akon mga action to increase
patod na pwede ko kaistoryahon” likelihood that the client
will cope more effectively
next time in similar
situation
“asya man la ini aa akon dako na problema” Exploring. To have an idea
and help analyze his
present situation.
“ano man ginagawa mo para mawala
ung stress mo about jan sa problema
?”
“aw kaya mo yan lahat kuya, andyan
man lagi parents mo yung ibang
barkada mo din, andito din kami,
kung kelangan mo ng may makausap
or makasama”
“Sige , yun lang muna lahat. Salamat
sa time”
“nawawara man la ito na mga problema
parehas kung nagppray ako o kun nabusy,
pero nabalik liwat kun nag uusahan la ako”
“sige kuya quez salamat”
(smiles)
“salamat gihap kuya”
Exploring. To have an idea
and help analyze his
present situation.
Offering Hope. To keep her
in a more positive state of
mind
Offering self. Offeing to
time and attention to show
we value the patient
Recognition. Noting the
efforts the client has made.
 NURSING CARE PLAN
Nursing Rationale to Goals and Rationale to Nursing
Cues Nursing Interventions Expected outcome
Diagnosis Nursing Diagnosis Objectives Interventions
Subjective Cues: Risk for Separation from After the nursing Establish therapeutic Client may feel free to talk about After one week of nursing
Client states of loneliness loved one interventions, the relationship and spend feelings in context of an interventions, the client reported
feeling hopeless related to client will report time with the patient empathetic relationship decreased feelings of loneliness
when problems separation decreased feelings by:
arise. from Affectional of loneliness by: Discuss individual Motivation can impede or 1. Identifying reasons for his or
significant deprivation Identifying reasons concerns about feelings facilitate achieving desired her feelings of loneliness
Client states other for his or her of loneliness and outcomes such as:
feeling lonely feelings of relationship.  Living alone in her house
sometimes since loneliness  Her spouse left her
his alone in her Risk for loneliness Explore ways to increase Satisfaction with support  She has no child
house. Discuss ways to the client’s support networks and personal
increase meaningful system and participation involvement in groups 2. Discussing ways to increase
Client states that relationships in groups and demonstrated significantly lower meaningful relationships
he had suicide in organizations scores of loneliness such as:
mind when he  Attending zumba
accussed of rape Encourage client to to be It is important to recognize that sessions in the barangay
case involved in meaningful the positive relevance of social  Jogging or walking with
relationship that have relationships is related to the friends
characteristics of both content and quality of the  Attending community
giving and receiving relationship activities such as
support pinatakasi
 Increasing time for
Identify individual This will provide opportunities socialization instead of
strengths, areas of for involvement with others just staying at the house
interests alone during free time
 Attending community
Provide opportunities for Helps reduce stress, provides
events such as the day
interactions in a reinforcement, and facilitates
care center graduation,
supportive environment successful outcome
barangay meetings,
programs of the barangay
Let the client know that It is up to the individual to build
 Always being positive
loneliness can be self-esteem and learn to feel
that loneliness can be
overcome good about self
overcome
Encourage involvement
in special-interest groups,
charitable services,
attending community
events with friends and
family
It will be easier for the client to  Talking to close friends if
interact with others if there are there are problems
close families and friends
present.
 University of the Philippines Manila
School of Health Sciences
Main Campus
Palo, Leyte

CLINICAL REQUIREMENTS

Nursing Care Plan Evaluation

Submitted by:

Quezon D. Lerog Jr.

BSN 37th – Group C

Submitted to:

Oscar B. De Paz, RN MAN

Clinical Instructor, UPM-SHS