UNIVERSITY OF THE CORDILLERAS

NURSE PATIENT INTERACTION

Process Recording

22-24/09/2022

This is a first time experience in a Psychiatric facility and handling a patient with mental disorder. I haven’t had any interaction with De Leon who assigned to me. So, I checked her chart first
before meeting her. I was also able to ask the head nurse what are some of her personality/character and knew that who is just quiet, and calm while doing what she loves to do which is by lying
down on the bed watching the others from the moment she wakes up in the morning until at night before she sleeps. De Leon is in the facility for Psychosis and having mild schizophrenia according
to the head nurse. I hope that De Leon will be comfortable interacting with me. After gathering information about De Leon ., I visited her in the social hall where they the clients usually gather and
found her there lying on bed started greeting her introducing myself and establishing rapport to my client.
 PROCESS RECORDING FORMAT

Name of Student: HASHHASH,BASEMA

Pseudonym of Patient: DE LEON

I. Interaction Number 1-3

II. Date: NOVEMBER 22-24,2022
III. Psychiatric ward
IV. Objectives of Interaction
a) To know and understand the mental disorder of the client.
b) To be able to let the client share her feelings, concern or problem.
c) To observe the action (calm, aggressive, sudden mood changes) of the client while interacting.
d) To let the client open-up about his story.
e) To observe the client if they will be comfortable being around with new people.

V. NPI and analysis

Interaction Nurse’s Verbatim Analysis and Patient’s Verbatim Analysis Recommendations/ Modifications
1ST DAY INTERACTION

H: Hello De Leon good morning nice to meet you by the way I Offered and introduced myself, for the client not to get uncomfortable when Have more time talking to the client, for us
am Hashhash ,Basema a nursing student from University of the I’m talking to her . To establish trust and rapport. to build their trust and rapport. For them to
Cordilleras. be more comfortable in sharing their
Client: (looks at me ) hello. feelings, concerns, and experiences in life.
H:How are you feeling De Leon are you okay? Client may seem curious and uncomfortable at first, but thankfully I am To let them adjust being with student nurse,
Client: Yes, I’m okay able to have a short conversation with her and she was also responsive in to observe if they are pleasant.
H:By the way Tay, I will be the one to help and assist you for 3 answering the questions.
days. We will be staying here until Wednesday and be with you,
is that okay with you?
Client: Yes, it’s okay (looks at me for a bit and back in floor ) It was a challenge to me, for her to express more of herself, hoping she will
H:Okay, that’s good then. So, De Leon just inform if you need in the next days to come.
something, or need my help okay? (gives a smile, even in
wearing our mask)
Client: Uhm. (She just being responsive)
(An attendant was around and I had the chance to ask them
something about De Leon If she’s really like that, not conversant
and is just lying on the bed watching others They responded, yes
that’s what she always does.)
Medication Time
(During giving of medications, the clients fall in line to take in
their medications, for the nurses to check and make sure if they
swallowed the medications, because some patients are not
compliant.)
H: Tay, let’s go there and fall in line. It’s time for you to take-in
your medicine.
Client: (she went to the line and I accompanied her.)
We assisted the nurses in the morning of giving the medications.
H:Okay De Leon here’s your medicine. (Gives a cup of water).
Fluid intake of the client is being controlled as she always
frequently urinates.
Client: (Client took it and swallowed all the medications given.)
NOD: De Leon , open your mouth. Let’s check if you really
swallowed it.
Client: (Opens and showed his mouth. The client was compliant
in taking her medication.)
(After eating their lunch, it was time for medication again and
we were already the one who assisted our client with the
supervision of the instructor and nurses.)
H: she was compliant in taking the meds. There is no problem
with her in taking her medications.)
Shift ends.
H: De Leon we’ll go and rest for now we’re done for today, we
will be back again tomorrow morning okay, see you De Leon
Client: see u tomorrow

2nd Day Interaction

H: (Received the patient on the bed ( Good morning De Leon!

How are you? Are you feeling okay?
Client: Yes…
H:Were you able to sleep well last night?
Client: Yes
H:Okay, then that’s good. What are you doing
Client: Noting just think of my job
H:Oh! You like your job Be careful in handling the patient, avoid
Client: Yes, I like it. Client was comfortable with me having an interaction with her . Not like forcing them to follow your command let
H: what job u was working ? the other day that she was still adjusting. them do the action when they feel like doing
Client : l was working in UC it, as the patient easily get irritated when
H: ohh that’s good ..what was your job there I had more time interacting with her. More time sitting with her while being forced especially by the other clients.
Client: clean worker that was in 2019 showing that you are there for her even though she is just merely watching.
H:how about now ..what is your job?
Client: l don’t have
H:Do u like music ? Patient was able to express more about her self. She was able to answer my
Client: Yes questions without hesitating to answer me or not.
H:That’s great! What kinds of music do you like tay?
Client: I don’t know. I was able to communicate with her more, she was conversant, and was able
H:You don’t know? to share something like loving music without specific genre.
Client: Yes I don’t know.
H:Oh okay, you like listening and watching music but you don’t I have observed that, the patient doesn’t really like someone forcing her or
know what type of music, you just love listening to it? commanding her to do things. Like the incident happened with one of the
Client: Yes (nods). clients. She will just be following your command if she’s comfortable with
(He turns back, and sleep) you and close to you.
H:You want to sleep or rest De Leon ?
Client: (nods and fixed her blanket)
Medication Time
H: let’s go there and fall in line. It’s time for you to take your
medicine.
Client: (She hands her hand waiting for the medicine.)
H: Okay De Leon ,here’s your medicine. (Gives a cup of water).
Client: (Client took it and swallowed all the medications given.)
H:De Leon open your mouth. Can I check it say “ah”.
Client: (Opens and showed her mouth. The client was compliant
in taking her medication.)
H:Okay, very good De Leon
Occupational Therapy
H:Hi De Leon do you like to play table tennis?
Client: No, I don’t like it.
H: You don’t like it? How about drawing, coloring or singing
for karaoke?
Client: No, I don’t like it.
H:Okay so you’ll just watch here, is that what you want to do?
Client: Yes.
H:Okay, De leon. Just tell me if you need anything then.
Client: Okay.
(I didn’t force the client in doing the activities because she might
be irritated and would feel uncomfortable being with the other
clients and student nurses.)
Exercise/Zumba
H: De leon let’s go and exercise, come on let’s go.
Client: No (sways the head no) I don’t want to.
H: Are you sure you’ll just stay here and watch the others
Client: Yes, I will just watch the others
H: Okay De Leon I’ll be back later.
Client: (nods).
H: Do u like me to do make up for u ?
Client: yes sure ( she was enthusiastic)
H: let start… do u like it
Client: yes thank u

Medication Time (After Lunch)

H: De leon it’s time for your medicine again. Let’s go.
Client: (She sit and wait for the medication .)
H: Okay De Leon , here’s your medicine. (Gave the medicines
and a cup of water).
Client: (Client took it and swallowed all the medications given.)
H: De Leon open your mouth. Can I check it say “ah”.
Client: (Opens and showed her mouth. The client was
compliant in taking her medication.)
H: Okay, very good De Leon . Let’s listen to the music
Vital signs taking
H: De Leon , we will be taking your vital signs. Is that okay for
you?
Client: (nods and offers her hand)
L: (Took the v/s) OkayDe Leon , thank you. I’ll be back again
later.
Client: Okay.
Shift ends.
H: Hi De Leon we’ll go and rest again we’re done for today, we
will be back again tomorrow morning okay, see you De Leon
Sleep well
Client: (nods).

3rd Day Interaction

H: Received the patient on the bed lying ) Hi, good morning De

Leon !Are you good?
Client: Yes
H: Were you able to sleep well last night? And are you okay?
Client: Yes (nods).
H: : Are you feeling any pain or is something bothering you?
Client: None.
H: Okay, then that’s good De Leon
By the way De Leon today is our last stay here at Roseville. It’s
our last day, will you be missing me, us?
Client: Yes, I will. (nods)
H: You will discharge today
Client: yes l’m okay now
H: Take care for your self and health . Eat your meals De Leon
and take good care of yourself okay?
Client: okay thank you

H: it’s the time to get your V/S

Client: okay
H: everything it’s normal De Leon
Client: Okay (nods).
H: Tay, just inform or call me if you need something okay?
Client: Okay.
H: By the way De Leon , did you eat your breakfast already?
Client: Yes done
H: You’re done eating your breakfast that’s good
Client: Yes.
H: Okay The patient just needs time for her to adjust before expressing more of her Continuous treatment in the rehabilitation.
Medication Time self. She needs more time but we lack time for 3 days. Be observant to the patient especially when
H: De leon it’s time for you to take your medicine. sudden mood of changes occur or
H: Okay De leon, here’s your medicine. (Gave the medication Let the patient do it when she feels doing it. She doesn’t want to be force something unusual is being seen. Continue
and a cup of water). because he doesn’t like it. Be gentle when talking to him. giving the ordered medications on time, and
Client: (Client took it and swallowed all the medications given.) always monitor the patient.
H: De leon , open your mouth. Can I check it say “ah”. Establishing rapport from the very start was one of the important actions. I
Client: (Opens and showed his mouth. The client was compliant was able to build that to my client that’s why I was able to communicate Be with the patient always, the patient needs
in taking his medication.) with her and she was comfortable with me. someone just to be with her showing care,
H: Okay, De leon that’s nice. that you are concerned for her.
Occupational Therapy The patient was the one who initiates to do actions for her .. Like her
H: HelloDe leon , come let’s join the exercise. We don’t need to telling you to take his vital signs.
go outside we’ll just do it here.
Client: I don’t want to join. Patient participates in the activities, just tell her she can and she will. She
H: Are you sure? Come on, we will just do it here, see the others was able to participate in performing the exercise, even just for a short
are joining. while, it was still a positive action for us.
Client: (no response)
H:You’ll just stay here?
Client: l’m shy
H: don’t be shy it’s okay enjoy
Medication Time (After Lunch)
H:De leon it’s time for your medicine again. Let’s go.
Client: (She sit and wait .)
H: Okay De leon here’s your medicine.
Client: (Client took it and swallowed all the medications given.)
H: , open your mouth, for me to check it.
Client: (Opens and showed his mouth. The client was compliant
in taking her medications.)
Vital signs taking
H: De leon we will be taking your vital signs again. Is that
okay?
Client: (nods and offers her hand)
H: (Took the v/s) Okay De leon , thank you. I’ll be back again
later.
Client: Okay.
At the lunch: l saw my patient leave the ward l meet her and l
tell her to take care for her self and get her medication in time.