UNIVERSITY of the ASSUMPTION

Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

PROCESS RECORDING

__________________ORIENTATION PHASE_________________
(Indicate the phase of nurse-client relationship)

Name of Client:______PATIENT X_______________Date & Time: 05/10/21, 2021 7:00 AM__

Age:___60 Y/O___ Civil Status: WIDOWED Gender: FEMALE
Diagnosis: POST-TRAUMATIC STRESS DISORDER
Background data: (brief history and mental status exam):
Patient X reported experiencing nightmares, auditory hallucinations, and flashbacks about her
husband abusive behavior towards her when he was still alive, as well as uncontrollable
thoughts about the event. She decided to go to the psychiatrist to be checked. She was
diagnosed having Post-Traumatic Stress Disorder. Based on the result of her psychological
evaluation that includes a discussion of the patient’s signs and symptoms and events that may
possibly led up to them. The patient is also having trouble sleeping, because she is scared to
have a nightmare again.

Objective/s of the interaction (Should be congruent to the objectives of the nurse client
relationship phases):
After the 6 hours of nursing patient interaction, the patient will be able to:
1. Establish nurse-client therapeutic rapport.
2. Be aware and oriented of the activities that will be performed by both nurse and patient
like verbalization of concerns.
3. Show understanding of the set priority and limits prepared by the student nurse.

Context of the interaction (description of the environment where the interaction took place
which includes the following information may include: location, activities involving the client that
occurred before the interaction, how the interaction began, or a brief summary of the nurse’s
previous contacts with the client):
The nurse met the patient in his hospital room, sitting on a chair while looking pale and
lethargic. Upon entering the room, the patient was easily frightened and always being on guard
for danger.
THERAPEUTIC
COMMUNICATION
NURSE/Student CLIENT TECHNIQUE USED INTERPRETATION /
ANALYSIS

ORIENTATION

“Good morning “I don’t really feel well, Giving information Client is scared.
ma’am. I am the one because I don’t have
who is assigned to enough proper sleep
assist you for today. because of my Offering self Client is restless.
My name is Ronniella nightmares.’’ (stand
Diane Cruz from the up and look around
University of the with fear in his eyes;
Assumption and I will speaks in a low Giving Broad
be your student nurse voice.) openings
until 1 o’clock in the
afternoon. I would like
to ask you how are

College of Nursing +045-961-1482 local 125

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

you feeling today?

( Smiling; speaking
softly; gazing directly
at patient X while
approaching the client
who is sitting on a
chair looking around.)

“Yes, Ma’am go on,

you can tell me more
about it.’’

(Shows willingness to
listen through nodding
as a sign of
encouragement.) ‘’I feel like he was
going to hurt me,
especially if I sleep,
because he will surely
appear in my dreams.
‘’ When did this start I don’t want that to Offering general leads Client is responding to
to happen?’’ happen.’’ the nurse

(Maintaining eye
contact while sitting in
chair beside his bed.)
‘’ I think my nightmare
started to happen
when my husband
died, I always hear his
voices whenever I go
into my room every
night I attempted to
‘’As soon as I enter sleep.’’
your room a while
Client is manifesting
ago, I observed that Placing the event in auditory hallucinations
you seemed really time or sequence
‘’ When my husband based on what she
scared and tense, is is alive, he always said.
there anything that punches me for no
you would like to reasons and most
share about your late
husband?’’ especially when he is
drunk, I’m really
(fully focused on the scared of my husband
patient) but I can’t leave him.’’

(appears anxious)

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

‘’ What are the Client is starting to

reasons why you can’t disclose her feelings
leave him despite of
what he is doing to Making observations
you?’’ ‘’Maybe because I
(taking notice of a love him, and he is
my husband whom I Encouraging
single gesture of the
promised to be with descriptions of
patient that indicates
him through sickness perceptions
she is hiding
something.) and in health, and if I
am not there for him,
who will be the one to
take care of him?

(removed her eye

contact with the
student nurse while
talking, She was
looking outside the
window.) Client appears not
telling everything.

Exploring

‘’I find that hard to

believe is there any (The client started to
other reason? Don’t cry.) Focusing
worry I am here to
help you.”

(Sincerely looking at
the eyes of the
patient.)

(The student nurse

gives the client the
opportunity to collect
and

organize thoughts, ‘’Actually, the real

and space until the reason why I can’t
client is ready to talk leave him because
again) every time I will
attempt to

leave, he always says

that if I leave him, he The client expresses
will always find her feelings.
wherever I am and kill

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

me.’’ Voicing Doubt

(Crying; observed fear

in her eyes)
Offering self

‘’I see you are really

scared of your
husband.’’
‘’ Everytime I
attempted to sleep, I
can hear his voices
and I am feeling like I
am running out of air,
I can’t breathe
properly, and I am Client is beginning to
really sweating a lot, I trust the nurse
can feel my whole through saying the
body shaking. real reason.
Using Silence
Actually, I can hear
his voice now!’’

‘’He is telling me that

he will going to kill us
both!.’’

‘’Is he telling you (Trembling with fear)

something?’’

(Focused on what the

client will about to
say)
‘’ What do you think I
should do to have a
peaceful sleep and to
‘’I understand that you stop having
are afraid of your nightmares, Client is manifesting
husband, but I do not flashbacks, and auditory hallucinations
hear anyone who hearing his voices
suddenly?.’’
is with us right now.’’
Eagerness to know
the solution) Making Observations

(The patient looked at

the nurse, convinced)

‘’I understand that you

are afraid of the

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

people around you,

because of your past
but I think you need to
look forward on
something that will
encourage you, and Client is so agitated
of course take your
medicine regularly
prescribe by the
doctor.’’

(stating while flashing

a warm smile) Encouraging
description of
perceptions
Clients appears to be
looking for a solution
‘’I see that you are
through asking
trying your best, I’ll
questions to her
stay with you awhile ‘’Yes, I think I should
student
do what you told me.’’
(Offering self) So, if Presenting Reality
there is anything that (Smiling)
you need or any
concerns you can
approach me

anytime.’’

Client becoming
comfortable with the
conversation and
accepting reality

Presenting Reality

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

Client accepting
reality and showing
trust to the nurse

Giving recognition

Offering Self

Evaluation (is a reflection of the nurse to the nurse-client interaction, it also contains a
description of the goals that have been met, how therapeutic the interaction was for the client,
how the nurse felt during the interaction and when she was reviewing it):
The patient is willing to listen and participate in the activity of the nurse and to identify her past
experiences towards her abusive husband even if at first, she was scared and hesitant.
Therapeutic rapport was established between the nurse and client, that is why effective
communication was possible.

Submitted by:
Cruz, Ronniella Diane S.
BSN – 3A3

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 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

(Name of the student nurse and group)

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