Client’s Initials: R.G. Date: December 13, 2011 Student Nurse: Guintu,Cristiane S.

Setting: Mental Institution Time started: Time ended:

GOALS For the nurse
a. To build trust and security by: a.1 Establishing a contract a.2 Convey honesty


a.3 Show caring and interest a.4 Setting limits on undesirable behavior b. To be able to establish rapport with the client c. To describe the purposes of the interaction d. Identify own thoughts, feelings, and behavior as Ms. T.S talks about stressful situations e. Utilize the therapeutic communication techniques in the nurse-client interaction.

a. To trust and feel secure in interacting with the nurse.

For the client

b. To collaborate with the nurse in the

plan of interaction

c. To be able to engage in communication effectively d. To be enthusiastically involve in the nurse-client interaction


I looked if she is oriented to time.siya mahilig.babae. Okay po.. It’s good that she knew who brought her in that…sex” “inubos…niya…lahat….. both… my… parents… are Chinese” “wala… na…” “patay….am. Balik po tayo ditto sa pinaguusapan natin. metropsyche” “okay . She looked….. “ahh. Ganun po ba... place and person. It feels like she wants to talk about the things that happen to her past.. My husband…is Filipino” “yes. Alam niyo po ba kung sino nagdala sa . I also look if she is oriented to time.” “may babae siya....pera…” “my son” Inference Thoughts and insight Patient is in the good mood and she is always smiling. in……. Caloocan” “yes. naman” “yes.niya ako.kasi. na” “iniwan.babaeng…yon… mahilig…. yung…..pera…ko” “matakaw sila ….morning” “okay” “tin” *smiles “I am Remedios…Gochuico” “no” *looking at her sides *nods head and smiles “I. When she is talking about her husband she look a little bit mad I think that one of the reason why she is admitted is because of her experience in her past about his husband.. I kept reminding her of my name so she wont be able to forget me.84” “sa. I will be your student nurse” “so ma’am sino po ulit ako?” “so ma’am may I know what’s your full name?” “Do you know ma’am what date today is?” “ma’am today po is December 13” “so ma’am R.. place and her name I feel pity for her because of her age she is in this kind of facility. how old are you na p o?” “saan po kayo nakatira?” “alam niyo po ba ma’am kung asaan po kayo?” “So ma’am how are you feeling today?” “Are you married ma’am?” “do you have a Chinese blood?” “oh okay ma’am nasaan po yung asawa ninyo?” “eh asaan po siya?” Patient “good.Student Nurse “goodmorning ma’am” “I’am Tin po.

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