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: Mrs. BB Date & Time:04-26-21/ 7:30AM

Age: 38 Civil Status: Married Gender: Female
Diagnosis: Body Dysmorphic Disorder
Background data
Mrs. BB is a 38 years old woman with a history of physical, verbal & emotional abuse from her
ex-husband. Last 3 years ago Mrs. BB and her husband separated due to her abusive husband.
After 3 months of their separation, Mrs. BB was diagnosed with PTSD (Post Traumatic Stress
Disorder) and was treated for 6 months. After her psychiatric treatment, Mrs. BB still
experiencing anxiety and panic attacks. Then, 2 weeks ago she was admitted due to her
anxiety, loss of appetite, panic attacks, and fatigue.
The nurse noticed that the client’s anxiety and panic attacks occur when she is being assessed
physically. In her mental status examination, Mrs. BB expresses feelings of irritability and
anxiousness. She demonstrates perseveration on her physical appearance, particularly in
association with her perceived defect where she experiences a high obsession of undergoing
surgery for her "ugly" body parts.

Objective/s of the interaction

1. Build trust/rapport with the client

2. Establish therapeutic & effective communication with the client
3. Identify patient needs and develop a plan
4. Set goals and limitations for the relationship

Context of the interaction

As the nurse reached the clients room, he can't help but noticed through the window that the
client is appears anxious and irritable while sitting on the bed, the nurse knocked on the door
and entered in the clients’ room. The nurse started the conversation with the greetings and self-
introduction, and followed by asking a question to the client "what seems to be wrong” and the
client responds, this interaction took place on the client’s room which is room 114 Psychiatric
Ward.
THERAPEUTIC
NURSE/Student CLIENT COMMUNICATION INTERPRETATION /
TECHNIQUE USED ANALYSIS

Magandang Umaga Ah ganon ba. Oo Giving recognition The client shows no

po. Ako po Sien okay lang. Magtatagal interest, seems to be
Musngi from kaba iho? (shows no Giving information preoccupied and
University of the interest while keeps looking in the
Assumption. Ako po constantly looking at mirror
ang magiging student the mirror)
nurse niyo ngayong
umaga. (smilling
brightly, speaking
softly, and direct eye
contact.)

College of Nursing +045-961-1482 local 125

Page 1
 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

Bale ako po yung Ganon ba sige The Client still

magiging student (Still looking at the Offering self preoccupied and
nurse hanggang mirror) keeps looking in the
mamayang 1:00 pm Giving information mirror
po.
Maari po bang ako si Mrs. BB Client is responding to
itanong ang iyong ipinanganak noong individual attention
pangalan at ang october 7 1982 (The
petcha ng kaarawan client speaks in a low
niyo?(looking at the voice and stuttering,
patient wrist band) cannot keep the eye
contact)

Napansin ko po lagi Ang pangit pangit ko Making observation The client able to
kayong tumitingin sa kaya lagi akong disclosed information
salamin, Ano po ang sinasabihan ng Giving Broad regarding on what’s
nasaisip niyo ngayon? masamang salita ng Openings on her mind.
asawa ko at
binubugbug ako dahil
sa muka ko. (speaks
in low voice) Using Silence
(Tumatango at hindi ko na talaga
nakikinig) alam kung anong
dapat kong gawin
para mawala ang mga
sugat na to sa muka
ko (Small scar barely
visible) parang
kailangan ko na
talagang mag pa
opera. (speaks in low
voice cannot maintain
eye contact)

Paano po naka sa totoo lang po The client able to

apekto sa iyong napakalaki ng epekto Exploring state the effects of her
buhay ang problema nito sa akin buhay. problem in her life.
niyong ito? Ayoko ng lumabas ng Active Listening
bahay dahil ayokong
makita ako ng mga
tao at pag tawanan
lang nila ang itsura
ko. Hindi ako
makapag trabaho ng
maayos at
hiniwalayan ako ng
asawa ko hindi ko rin
maasikaso ang aking
anak.( Speaks in low
voice, keeps touching
her face)

Nurse: (tumatango at Kasama ko yung anak Exploring The client able to

nakiknig) Ganon po ko siya yung nag- keep the conversation
ba. Sino po ang aalaga sakin.
nagbabantay sainyo Bumibisita siya
ngayon? paminsan-minsan.

College of Nursing +045-961-1482 local 125

Page 2
 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

Kamusta naman po Okay lang na kahit Exploring The clients appears to

sa tuwing andito siya? papaano may be relieved that she
nakakaintindi sa has someone to
sitwasyon ko lagi niya discuss his feelings
akong pinakikingan sa
mga kwento ko.

Mabuti naman po Oo nga eh, medyo Making observation The client becomes
kung ganon kahit gumagaan ang happy and
papaano may pakiramdam ko comfortable in the
nakakausap po kayo tuwing nandito ang conversation
at mukhang masaya anak ko (Smile)
po kayo habang
kinukwento niyo po
ang anak niyo.

Evaluation

Mrs. BB. was able to disclose information regarding her family especially her daughter which
appears to be her legal guardian. She was being hesitant at first and she doesn’t want to be
bothered but along the interaction, the patient is willing to listen and participate in the activity of
the nurse and to identify his past experiences. Therapeutic rapport was established with Mrs.
BB. And the interaction was effective because it showed that Mrs. BB able to respond with the
interaction and displayed an active interest in disclosing her situation and experiences.

Submitted by:
Lising, Mikaella
Bucu, Sophia
Lagazon, Chanel
Musngi, Sien

College of Nursing +045-961-1482 local 125

Page 3
 UNIVERSITY of the ASSUMPTION
Unisite, Del Pilar, City of San Fernando, 2000, Pampanga, Philippines

Flores, Jeric
BSN- 3A4
_____________________________________________
(Name of the student nurse and group)

College of Nursing +045-961-1482 local 125

Page 4