NCM 117 : CARE FOR CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

PROCESS RECORDING

Name: Ampado Alessandra, Angeles Mikaella, Benitez Bryanne, Sarausa Angelo, Sustituedo Nikka Group: B Date 04-05-2022 DAY: 1 SETTING: Psychiatric Clinic

TIME STARTED: 10:00 AM TIME ENDED: 10:10 AM

PHASE OF NURSE PATIENT INTERACTION: ( / ) Orientation Phase ( ) Working Phase ( ) Termination Phase

OBJECTIVES: To conduct an assessment of the client's condition through the use of primary and secondary sources. This is also the point at which the nurse attempts to establish
rapport with the patient and create a therapeutic environment.

DIAGNOSIS: Disorganized Hebephrenic Schizophrenia

NURSE PATIENT ANALYSIS

REMARKS OF THE CLINICAL
VERBAL NON-VERBAL VERBAL NON-VERBAL INTERPRETATION THERAPEUTIC COMMUNICATION INSTRUCTOR
TECHNIQUES

Tell me why did Sitting in front of To teach (sighs) Patient looks dull The patient mimics the BROAD OPENING
you come to the the patient, both and has no change in psychiatrist's action —
hospital? hands are on the facial expression. head turning.
lap; acts Straight eye contact
approachable to is present. Absence of emotional
the patient. expression

Reduction with ability to

speak, minimal response
present

To teach? What Maintains eye Toilet training 1 Looks straight at the Flat affect, presence of SEEKING CLARIFICATION;
do you teach? contact with the years. Hmm. psychiatrist. Acts disorganized thoughts EXPLORING
client, examines uncomfortably
ideas.
Have you started Same as above For urine test. Uncomfortable in Unorganized thoughts SEEKING INFORMATION
teaching here at sitting position, fixes present
the hospital? hair.

Pardon Same as above Urine test. Sits improperly, Psychiatrist asks the
uncomfortable patient to repeat the SEEKING INFORMATION
movements present answer to clarify what
she heard from the
response .

What were you Maintains eye I was studying Right hand was EXPLORING
Trying to suppress
doing before you contact with biorhythm. placed on the side of
deceitful answers.
came to the hands slightly her face and left
hospital? interlocked. hand rested between
her legs.

Here in Same as above ST. I used opened.., Blunt facial Repetition of words ASKING PERSONAL
Bloomington, or opened the tea bags. expression, places present. No change in QUESTIONS;
were you in hands on the lap facial expression EXPLORING
another city or
another state? Thoughts are
disorganized.

ENCOURAGING
Encouraging the client to
Have you been Same as above I know what the Make eye contact DESCRIPTION OF
describe ideas.
hearing voices? voice box is used for. with the psychiatrist. PERCEPTIONS
Telling you to do
things?

ENCOURAGING
Can you tell me? Same as above Hot and cold Remained on having Same as above DESCRIPTION OF
eye contact. PERCEPTIONS
What does that Tone was slightly The air-conditioning. Same as above but Client’s answer is vague SEEKING INFORMATION
mean? I don’t confused with the made a minimal and needs further
understand. previous response movement of the clarification on the part
and seeks for arms and hands. of the psychiatrist.
clarification

ENCOURAGING
What was… Maintains eye Her vocal cords were Hands on her lap; DESCRIPTION OF
Client's answer was
contact and a calm used straightforward looking straight to PERCEPTIONS
confusing and
voice the psychiatrist.
disorganized.

Do you sometimes Same as above That is a Jehovah's Brushes her hair and Incoherent thought SEEKING INFORMATION
feel as though you Witness. Yes. sits comfortably present
are a robot?

Can you read Same as above Blueprints only . Sighs and answers Encouraging the client to EXPLORING
people’s minds? the question calmly discuss what’s in her
mind.

Where do you get Paused for a while From filling Changed her sitting Validating the client’s
the blueprint while maintaining applications. position and leans answer SEEKING INFORMATION
eye contact slightly forward

Encouraging the client to

Can you tell what Same as above It, I never have done Answers in a calm SEEKING INFORMATION
describe ideas.
people are that. voice
thinking without
them actually
saying it?

Same as above while Thoughts are EXPLORING

Have you ever Tone was slightly Mic. sitting in a straight disorganized
heard your confused with the position
thoughts previous response
broadcast as if and seeks for
they were coming clarification
over a loudspeaker Maintains eye
or television contact and used
 calm voice while
asking

Tell me about that Same as above Mic is 2, Girls 14 Remained on having Expounding client’s EXPLORING DESCRIPTION
(mic) eye contact answer. OF PERCEPTIONS

Do you feel people Used a calm voice. This feeling of thought Sighs and places her Client struggles to SEEKING INFORMATION
put thoughts into Maintains eye process is eliminated… hands over the head. compose her thoughts.
your mind? contact now, was woman’s Answers in a confused (Incoherent thought and
active… political party tone speech present)

Are you a religious Same as above Religious means.., Same as above Seeking more SEEKING INFORMATION
person? wear glasses or information on the
spectacles patient.

False beliefs and

perception present.

Has anyone ever Same as above In a television Sits in an upright SEEKING INFORMATION
Seeking more
put thoughts into position while calmly
information on the
your mind? answering the
patient
question

When? Can you Same as above No Changed the sitting Encouraging the client to EXPLORING DESCRIPTION
tell me about that position. Refused to describe and lower OF PERCEPTIONS
(Television) answer boundaries

How was the Maintains eye They have very Sighing while Same as above SEEKING INFORMATION
television able to contact. Trying to intricate tools. answering the
do that? seek more question and
information from remaining calm while
the client. sitting comfortably
They can put Same as above It’s possible Same as above Flat Affect - absence of VOICING DOUBT, SEEKING
thoughts into your facial expression INFORMATION
mind?