CAPITOL MEDICAL CENTER COLLEGES, INC

College of Nursing

PROCESS RECORDING #1
(Orientation Phase)

Name: Villanueva, Ryan Jay

Age: 38 years old
Address: 1136 Avocado St. Bagbagin Valenzuela
Date of Birth: September 13, 1984
Date of Admission:
Educational Attainment: College level
Diagnosis: F31.2 Bipolar affective disorder current episode manic with psychotic symptoms, manageable
Setting: Activity Area in Synergy Nursing Home Care Center, Co.
Date/Time of Interaction: May 15, 2023 / 9:00AM

DESCRIPTION OF THE PATIENT

➔ Patient was seen wearing a colored yellow jersey and gray shorts. He is well groomed, and with an ectomorph body shape
and fair skin complexion, some of his hair is color white. Overall his appearance is neat and clean. Patient was oriented with
the date and time when asked and had eye contact while answering the questions that we asked. He was calm and was able
to answer all of our questions.

DESCRIPTION OF ENVIRONMENT

➔ Nurse-patient interaction was done in the Activity area in Synergy Nursing Home Care Center. The area was clean and
slightly big.

OBJECTIVES
 ➔ To gain rapport and trust from the patient and vise versa
➔ To understand the patient’s problem and demonstrate genuine care and understanding
➔ To manually formulate a contract with the patient and nurse
➔ To gather appropriate date from the client

Nurse Therapeutic Technique Patient Analysis/Interpretation

“Hello, good morning. Ako nga Giving Information “Ryan Jay Villanueva” Responded correctly
pala si Nurse Darlene at ang
aking kasama ay si Nurse
Andrew. Galing kaming Capitol
Medical Center Colleges ang
duty na’min ay Monday to
Wednesday 6AM-2PM sa loob
ng dalawang linggo. Anong
pangalan mo?”

“Anong pangalan ang gusto Seeking Information “Kuya R-Jay” He was able to answer the
mong itawag na’min sa’yo?” question right away

“Ilang taon ka na Kuya R-Jay?” Broad Openings “40 po. Hindi biro lang, 24 na Patient was not able to identify
ako” his age.

“Kailan pala yung birthday Broad Openings “Ano November 13, 1989”
mo?”

“Alam mo ba kung anong araw Exploring “Oo, May 15, 2023” He was oriented to the time
ngayon?” and date

Making Observation “Oo, pag may studyante Patient seems excited to all
“Meron tayong pa exercise ganyan lagi naming ginagawa the activities
mamaya at games, sali ka ha” e, mageexercise tas
magpapalaro sila. Masaya
naman at nakakalibang”

“Kamusta ka ngayong araw?
Ano nararamdaman mo?”
“Alam mo ba bakit ka nandito”
“Nung nasa labas ka pala,
anong trabaho mo o madalas
na ginagawa?”
“Anong natapos mong
course?”
“Bakit pala nagstop ka mag-
aral”
“Patungkol naman sa pamilya
mo, ilan kayong
magkakapatid?”
“Nasan na pala yung Nanay at
Tatay mo?”
Broad Opening “Ok naman masaya ako” Patient facial expression is not
match to her word
Broad Opening “Oo, kasi hindi na ako Patient has flight of idea, this
nakakatulog sa gabe. Mahilig may occur as part of
kasi ko sa softdrinks tsaka Psychosis
kape kaya hindi ako
makatulog. Nagkainsomia
tuloy ako”
Seeking Information “Wala tambay lang sa bahay, Patient doesn’t have any other
kakain manunuod lang. activities aside from playing
Minsan naglalaro ng basketball and watching.
basketball”
Broad Opening “Electronic engineer sa He was still able to recall long
Mapua. Hindi ako term memory
nakagraduate kasi nagstop
ako tas naging tambay lang
ako sa bahay”
General Leads “Feeling ko kasi dun nagsimula Feeling of not sleeping is a
yung hindi na ako makatulog, symptoms in Manic phase of
nung nasa MAPUA ako” Bipolar
Exploring “Tatlo kaming magkakapatid, Patient was able to answer the
ako yung bunso at nag-iisang question
lalaki”
Seeking Information “Si Mama patay na nung 2019 He was not able to recall when
bago magpandemic, si Papa his father died.
matagal na hindi ko na
maalala. Gusto ko na nga
umuwi e.”
“Kung wala na mga magulang General Leads “Ate ko, kasi nga hindi na ako
mo, sino pala nagdala sa’yo makatulog kaya dinala na niya
dito?” ako dito.