Aurelio, Lyca Mae M.

BSN IV-A

PROCESS RECORDING

Patient Name: Jerlyn

Age: 34

Sex: Female

Civil Status: Single

Religion: Pentecost

Educational Attainment: College Graduate

Date and Time of Interaction: February 22, 2023, 10 am

Milieu of Interaction:

The assessment took place in the home care’s lounge. The environment is conducive for
interview in which the student nurse elicited the needed information. The client was seen
sitting on chair. The client’s body build is ectomorph and the general skin tone is light brown.
Her apparent age is younger that her actual age. She is seen wearing t-shirt and short that is
appropriate to the hot weather. The client was not a threat and kept calm voice. She shared her
thoughts but was not able to share ideas consistently.

Objectives:

The interaction aims the following:

 To critically analyze communication and its effect on client’s behavior.

 To gain the patients confidence and get cooperation’
 To establish rapport with the patient
 To study the patients psychological social and emotional behavior.
 It helps to increase the ability to identify problems and develop skills in solving them.
  It gives students an opportunity to gain the ease and function in written expression that
are important for professional development.
Nurse
Goodmorning Ma’am Jerlyn,
ciak ni Lyca from MMSU nga
student nurse.
Nagpintas pinag lipstick yun
Ma’am.
Am ammum diay Ma’am mi
didiay?
Nagbasaam idi college ka idi
Ma’am?
Nagwork’m met ma’am after
ka maka graduate?
Paano naman po nagging
work niyo don?
Was it something like
nakakaburn out po yung
trabaho niyo?
Kamusta naman po nagging
buhay niyo sa Saudi?
Ilang years po ba kayo dun?
Ah, 3 years, medyo matagal
rin
Patient Communication Technique
Hello… Giving Recognition
Giving Information
Smiled Giving recognition
Wen ma’a, instructor ko siya Broad Openings
noong college
Sa Northwesthern, I took Exploring
nursing rin noon.
First, I volunteered sa Exploring
hospital samin, sa marcos.
After that I decided to work
as a private nurse sa Manila.
Actually, I quit the job kase Exploring
mahirap, tapos na home sick
pa ako ng sobra.
Siguro, kaya after that I Encouraging Comparison
decided to go to Saudi para
mas maka earn ng pera.
Okay naman, kaya lang Exploring
nagging LDR kami ng
boyfriend ko
Mga 3 years Exploring
Pero pagkatapos nun nag Restating
decide na akong uwuwi tsaka

And then?
Kamusta naman po ang
nagging desisyon niyo, okay
naman?
Are you suggesting na nagsisi
po kayo sa desisyon ninyo?
Ibig sabihin nandiyan siya
para sayo sa hirap at
ginhawa?
nag live in na po kami ng
boyfriend ko.
Nagkaroon po kami ng General leads
dalawang anak. Si Bea 6 yrs
old tsaka ni Angel 3 years old.
Actually sana pinag-isipan Exploring
naming mabuti bago naming
yun ginawa kase ambata pa
naming noon eh.
Siguro po at some point. Pero Translating into feelings
mahal ko po sya eh, we’ve
been together for almost 13
years na. We always have
each other through ups and
downs.
Before kase we usually share Consensual Validation
our problems to each other
and try to solve it but ngayon
I felt alone. Diko naman siya
masisisi kase dapat
maprovide’n ko ang asawa ko
at mga anak ko ng mga
kanilang basic needs, as well
as give love, attention,
understanding, acceptance,
time, and support to them.
But right now I can’t be
completely be there for
them.
What are the specific
difficulties you encountered
sa asawa niyo po o pag
mamanage po sa pamilya
ninyo.
Silence
I notice you are like talking to
someone on your side.
Okay let’s continue Ma’am
May iba po pa kayong
support system?
Tell me about it.
Okay lang naman sa inyo yun
noon, to seek professional
help pag nahihirapan na
kayo?
Ahh I see. Di pa po natin
nagpag-uusapan yung mga
parents mo, support system
niyo rin po ba sila?
Tell me about it more po
Okay po, to continue po,
saan po pala kayo nag
Kuha mo na ako ng tubig ko Focusing
kase uyaw na ako.
Looks like speaking to
someone on her side but not
uttering a sound.
Nodd Making Observation
I think yung mga kapatid ko, Exploring
lalo na si Jenelyn.
Kase lagi kong sinasabi General Lead
sakanya yung problems ko in
life and mga realizations ko.
Actually siya nagpunta sakin
dito noon.
Oo kase nakakaapekto na Exploring
siya sa lahat ng bagay na
ginagawa mo.
Okay naman pero noon pera Exploring
lang tingin nila sakin noong
may trabaho pa ako.
Ahy wag na. General Lead
Don samen, Pentecost ako. Exploring
chechurch?
Lagi naman po kayong nag-
aatend?
Do you think illness is a test
of faith?
Do you think this can be an
inspiration for others?
Para sa inyo anong mabuting
or acceptable na behavior?
Okay lang po na proceed na
tayo sa iba kase magsisimula
na yata activities natin.
Magbibigay po ako ng tatlong Eyeglasses, cellphone,
words tapos I recite niyo po
magkatapos ah?
Ang mga words po ay
Eyeglasses, cellphone,
Oo noong wala pa ako dito.
Yes, yes kase the more you Exploring
hold on to God during
difficult times, the more you
are closer to him and faith in
a higher being is often a
strong source of strength and
support. Having a strong
faith will enable me to
overcome whatever
obstacles I may face and will
protect me and my family
from harm.
Yes.. Exploring
I think the ones which will
bring goodness to other
people, not pain or suffering.
Sige
ballpen
ballpen
Ahh galing Smile Giving Recognition
Pano naman po kayo nag Nagcelebrate ako kasama
celebrate last Christmas? ang pamilya ko. Kumain kami
ng mga masasarap na
pagkain. Kumanta pa ako ng
Christmas song ah.
Mahilig pala kayong kumanta smile Giving recognition
Can you spell beautiful b-e-a-u-t-i-f-u-l
Oo tama
Next po, 100-7 Uhmmm. 93
93-7 86?
86-7 70…..diko na alam (Laugh)
Diba po sa isang week mag Ano yun…uhmm Saturday…
start ng Sunday, Monday, Friday… ahy ewan ko na
Tuesday, Wednesday,
Thursday, Friday, Saturday.
Can recite it backward po.
Meron po kayong bottle dyan (Do the task correctly)
po sa tabi niyo. Can you
shake it, open it and close it
again
Next po is meron po akong Sige
sasabihin tapos explain niyo
po kung anong ibig sabihin
non.
What you plant now, you will I think what you lay down
harvest later. Kung anong now, you will have to deal
tinanim ay siya ring aanihin. with later. By that I mean, if

How about, time is gold.
Tapos na po tayo sa ating
interview. Ang galling niyo
pong sumagot.
Proceed na po tayo sa ating
activity. Join po kayo ahh
Aurelio, Lyca Mae M. BSN IV-A
you make a bad choice, do a
bad thing, you will have to
pay for it later. On the other
way around, if you make a
good choice, do a good thing,
you will get a reward later.
I think time is very important.
If you waste time you will not
have it back. Make the most
out of life, opportunities pass
by, and we should grab it
unless we might end up
regretting not doing the
things we should have.
smiled Giving recognition
smiled
PSYCHOSOCIAL ASSESSMENT
 A. HISTORY

1. Age: 34

2. Developmental Stage

The patient is 34 years old. She is still in early adulthood which is between 18 years old

to 40 years old. The area of resolution or conflict at this stage is ego intimacy vs. isolation.

Positive resolution is intimacy and the developmental hazard is isolation. The patient is

currently possessing ego isolation. It’s easy for someone with depression to become isolated.

Major depression is a mental illness that causes symptoms like loss of interest in activities,

feelings of hopelessness, guilt and shame, fatigue, difficulty focusing or thinking, and changes in

sleeping and eating patterns. The symptoms persist and are severe enough to cause

dysfunction and impairment in several areas of your life, including social relationships. She used

isolation as a self-induced coping mechanism to deal with excessive worry and avoid human

interaction.

3. Client’s History

The patient once works as a private nurse in an elite family in Manila. However,

according to her it did not go well so she quit her job. The student nurse tried to further explore

it but the patient was not able to respond. She also verbalizes that starting a family with her

boyfriend was hard and life-changing. She regretted it because of a young age she engaged

herself. The student nurse again tried to further explore it but the patient was not able to

respond clearly. She also expressed her relationship with her parents in which she described it
as awful since when she was still working all what they want from her is money. The student

nurse again tried to further explore it but the patient was not able to respond clearly.

Furthermore, in accordance to her chart, her depressive symptoms started in 2017

when she was 5 months pregnant. It even became worst when her boyfriend brings her to his

house

There is no specific history of hospitalizations obtained however she verbalized that

when she was confined in a hospital, her days and nights felt long. Every minute she is hoping

that it can felt little bit better since she can’t do the things she used to do.

There are no family members of her who had been diagnosed with alcoholism, bipolar

disorder, suicide, or other conditions as seen in her chart.

4. Cultural and Spiritual Beliefs

The patient lived through hard times and she believes that this can be a source of

inspiration for others. For her, acceptable social or personal behaviors were the ones which will

bring goodness to other people, not pain or suffering. The patient also verbalize that eye

contact is good to establish the interaction however she considers prolonged eye contact as

intrusive or inappropriate. Lastly, the patient believes that illness is a test of faith because the

more you hold on to God during difficult times, the more you are closer to him and faith in a

higher being is often a strong source of strength and support. She also believes that despite the

declined physical and mental capacity, she has strong faith in God, she will always have peace

of mind and just leave everything in God’s hands.

 5. Beliefs and Practices about Mental Health and Illness

According to the patient, even when things are difficult, her spiritual viewpoint keeps her

going. She feels that having a strong faith will enable her to overcome whatever obstacles she

may face and will protect her family from harm. The support persons are her siblings. She

usually confides in her sister about her problems and realizations in life. The patient believes

that when you have thoughts, emotions or behaviors that are out of control, especially when

they are affecting your relationships, your work or your sense of well-being. It’s okay to seek

outside or professional help. Management like talking about your feelings, being active, eating

and drinking well, and keeping in touch with important people in her life can somehow help her

to resolve some of her problems. She also takes her prescribed medication regularly even

though she is not feeling sick.

B. General Appearance and Motor Behavior

1. Hygiene and Grooming

The client appears neat and her hair is properly groomed.

2. Appropriateness of Dressing

She is seen wearing t-shirt and short that is appropriate to the hot weather.

3. Posture

The patient has forward head posture where the head is positioned with the ears in

front of the body’s vertical midline.

 4. Eye contact and Facial Expressions

The patient does not maintain eye contact and she tend to look on the other sides. She

does not maintain congruence of facial expressions with the speech content.

5. Unusual movements or mannerisms

The patient is frequently looking at her nails and moving her mouth without uttering a

sound.

6. Speech

The client does not seem to perseverate. Some responses are also elaborated and the

content of the client’s speech is relevant to the question being asked. The rate of speech is fast

and the tone is often not audible. The patient also often stutter when speaking.

C. Mood and Affect

1. Expressed Emotions

The client seems to be happy and calm while answering some questions at the same time

sad and dismayed on other moments. The client is expressing a full range of emotions

according to the some current or specific situation however sometimes the patient expressed

labile affect in which she shows inappropriate emotions in specific situations. She was not able

to answer and rate her degree of depression.

2. Facial expression, Gestures, and Tone of Voice

The patient’s facial expression is mostly neutral but also seems to be happy and sad. She

also shakes her head up and down indicating agreement and shake her head from side to side,
indicating disagreement. The tone of voice of the patient is almost not audible. Above all, the

patient sometimes demonstrates appropriate facial expressions, gestures and tone of voice

with the affect and sometimes, inappropriate.

D. Thought Process and Content

1. Content and Process

The patient’s verbalization makes sense when heard but it is often not audible. Her

ideas also flow logically from one to the next however at first, the patient seems to be stuck on

one topic and unable to move to another idea. She is preoccupied sometimes since she is

paying attention to other things like looking at the TV. The patient demonstrated thought

blocking since she begins discussing on certain topics and then stop speaking midway through

the sentence.

2. Self-harm and Suicide Urges

The patient doesn’t have any suicidal thoughts or any self-harm urges. She was not also

planning on hurting someone else.

E. Sensorium and Intellectual Processes

1. Orientation

The patient recognizes the place and time she was currently in. She also acknowledges

the people around her, who she is, where she lives but the patient forget what was the day or
date. She also told me that that the situation she’s currently having is having an interview with

me as student nurse and she is not feeling threatened at all.

2. Confusion

The patient was able to make sense on her surroundings or figure things out.

3. Memory

I gave the patient three unrelated words to remember and I ask her to recite them right

after telling her. The patient was able to consistently remember the words when I asked her to

recite.

I asked about how the patient celebrated Christmas recently. She told me that she

celebrated it with her family and they ate many delicious foods. She was also able to sing

Christmas songs.

I asked her how was her long distance relationship with her boyfriend work 10 years

ago. She told me that it lasted 3 years and they always openly communicate to resolve such

problems and stay patient and kind to each other. To end the long distance relationship, they

decided to start family but she admit that she regretted it since they were too young that time

and mostly, they did not know anything about managing a household.

4. Ability to Concentrate

The patient was able to spell “beautiful” correctly. Within the serial sevens (beginning

with the number 100, subtract 7, subtract 7 again and so on), the patient only gets it twice. The
patient wasn’t able to correctly repeat the days of the week backward. I also ask her to perform

three-part task. I told her to shake the bottle on her side, open it and close it again, and she

correctly did it.

5. Abstract Thinking and Intellectual Abilities

Proverb: What you plant now, you will harvest later.

The patient thinks that the meaning of the proverbs is what you lay down now, you will

have to deal with later. By that I mean, if you make a bad choice, do a bad thing, you will have

to pay for it later. On the other way around, if you make a good choice, do a good thing, you

will get a reward later.

Proverb: Time is gold

The patient thinks that the meaning of the proverbs is that time is important, time is

expensive, if you waste time you will not have it back. She also added that make the most out

of life, opportunities pass by, and we should grab it unless we might end up regretting not doing

the things we should have.

The patient has an intact abstract thinking abilities as the he explained the proverbs

deeply and did not give any literal meanings to it.

F. Sensory-Perceptual Alterations

1. Hallucinations
 The patient doesn’t experience any hallucinations at all as per verbalize however it was

observed that she was murmuring on the other side as if she is talking to someone.

G. Judgment and Insight

The patient interpreted his environment and situation correctly. Sometimes she ignores her

daughter request because she is too tired to get up and she think that a lack of reasonable care

for others. Risky behaviors like shouting, saying bad words, slamming the door and throwing

something is a reflective of her poor judgment as she described it.

To assess judgment, I asked the patient if she found the refrigerator opened, what would

she do. She told me that he would close the refrigerator. I also asked her again that if he found

a broken pieces of glass on the floor, what would she do. He told me that he would pick up the

broken glass with a dusk pan and broom and put it on the trash can. With all this, the patient

understood the true nature of the situation and accept some responsibility for it without

putting blame on others.

H. Self-Concept

The patient describes herself as beautiful but not already young and carefree. Her being

hopeful despite some difficulties is the personal characteristic that she like the most. She got

angry easily and that’s the personal characteristic she wanted to change. She frequently

experiences sadness or lack of energy. When she has a problem she usually talks it out to
someone and keep himself busy on other things. She also deals her anger issues with closing

her eyes to calm all her thoughts or she just walk away sometimes.

I. Roles and Relationships

1. Current Roles

Despite being in her condition right now, she want to provide her partner and children

their basic needs, as well as give love, attention, understanding, acceptance, time, and support

to them.

2. Satisfaction with Roles

She is not satisfied with these roles since she can’t completely be there for her partner

and her children because her lack of capabilities to help them out. She wished he could do

more.

3. Success at Roles

She is not fulfilled if she is taking those roles adequately because of her current

condition, the things she can do are very limited because she got tired easily.

4. Significant Relationships and Support Systems

The patient is close to her family. The patient and her partner were already together for

almost 13 years. As per verbalize by the patient, they always have each other through ups and

downs. Before, her and her partner was meeting the needs for companionship since they

usually share their problem to each other and try to solve it but since she was challenged and
wasn’t able to talk clearly, the patient felt alone. The student nurse asks about the specific

difficulties she encountered while being in a relationship with her partner but she diverted the

topic.

J. Physiologic and Self-Care Considerations

1. Eating Habits

The patient ate 3 meals a day and 2 snacks. She usually had his breakfast at 7:30 am,

morning snack at 10am, lunch at 12pm, afternoon snack at 4pm and dinner at 7pm. Her meals

mostly contain rice, fish or meat and vegetables while her snacks are pastries.

2. Sleep Patterns

The patient sleeps 12 hours a day. She spends 1 hour sleeping after having her morning

snack, 2 hours in the afternoon and 9 hours at night.

3. Health Problems

The patient was prescribed Olanzapine 5mg once a day at bedtime and Sertraline once a

day for her mental health problem. Ensure gold was included in her diet to help resolve her

malnutrition. She does not drink alcohol. The patient is also taking paracetamol when he has

headache or fever and Solmox or Lagundi capsules when he has cough or colds.

4. Compliance with Prescribed Medications

 The patient is compliant with her prescribed medication because she does not want to

experience too much discomforts from her condition. She also claims that her drugs do not

have any undesirable effect to her, they produce the desired effect. She doesn’t have difficulty

in obtaining her medications since it is already provided in the home care.

5. Ability to perform ADL

The patient can still bath herself completely and get clothes from drawers and puts on

clothes. She also goes to toilet, gets on and off, arranges clothes, cleans genital area without

help and have self-control over urination and defecation. She moves in and out of bed or chair

unassisted. Lastly, she can get food from plate into mouth without help.