La Consolacion University Philippines

The Catholic university of Bulacan

Valenzuela St. Capitol View Park Subd., Bulihan, City Of Malolos, 300 Bulacan

Process Recording
Name: S.T
Age: 47
Address: Tunuan City, Batangas
Gender: Male
Civil Status: Single
Education: High-school
Religion: Catholic
Occupation: N/A
Diagnosis: Schizophrenia Undifferentiated Type

Objectives : (Client-centered and SMART)

Short term objectives The patient will demonstrate improved social functioning and
self-care abilities as evidenced by engaging in daily activities.
Long term objectives: The patient will actively participate in social activities and
maintain meaningful relationships with family, friends, and peers.

May 1 2024- 5:00 pm:

Nurse and Client Analysis Self Awareness

Interaction
Nurse “ Magandang Active Listening
hapon po.” - Encouraging active listening
and utilizing Cognitive
Client : “ Magandang Behavioral Therapy (CBT)
hapon din po. " techniques, such as educating
__________________ the patient about
Nurse: “ Ako po si schizophrenia symptoms and
Atilla, kayo po ano restructuring cognitive
pangalan ninyo?” patterns, can assist the
patient in comprehending
Client: “ako po si and coping with their
Ronolfo Cabantig” symptoms more effectively.
- Encouraging the patient to
_________________ find joy in celebrating their
Nurse: “ ilang taon na birthday and expressing
po kayo?” gratitude for another year of
life corresponds with CBT's
Client: “ 29 po ako” emphasis on fostering
_________________ positive thinking and
appreciation as means of
Nurse: “kamusta enhancing mental health and
naman po kayo?” wellness.
- patient was well responsive
with answering questions
- He actively participates and
communicate with me
- maintains eye contact for at
least when I am asking
question
- would answer each
question animatedly
- will smile big when I can
relate to what he is talking
- would sometimes bow his
head.
- has a upside smile down
like a “sad look” then he will
smile
- easily distracted with noises

Client: “okay naman po Mindfulness-Based Communication - patient fidgets

ako, pagod lang po - Utilizing mindfulness-based - does hand signal like a sign
mag-laba” communication techniques
language “close enough to
can assist the patient in
interpret one”
coping with anxiety and
 La Consolacion University Philippines
The Catholic university of Bulacan
Valenzuela St. Capitol View Park Subd., Bulihan, City Of Malolos, 300 Bulacan

Nurse: “pwede ninyo enhancing concentration by - patient would lean forward

po ba ikwento paano
po kayo lumaki?”
Client: “lumaki ako sa
San Pedro Laguna,
kasama ko Mama ko at
kapatid ko”
_________________
Nurse: “ano po ang
pangalan ng Nanay
ninyo at kapatid?”
Client: “ang pangalan
ng nanay ko ay Janela, Strengths-Based Approach
kapatid ko nama ay
Francisco” - The strengths-based
_________________
Nurse: “pwede nyo po
ba ikwento yung mga
natatandaan nyong
ginagawa kasama sila”
Client: “Si Mama ko
laging nag titinda ng
samalamig tapos po
kami ni Francisco ay
naglalaro ng holen at
text”
_________________
Nurse: “Maayos po ba
ang relation ninyo sa
nanay nyo at kapatid”
Client: “oo naman
masaya ako nung
kasama ko sila”
encouraging awareness and if he cannot hear what was
acceptance of their present being asked
experiences. Methods like
deep breathing and body - he is calm but he is not in
scans can mitigate observed the present
tremors and nervousness,
- he has this kid expression
enabling the patient to
participate more actively in
discussions about their
birthday. Encouraging
mindfulness practices may
additionally cultivate feelings
of gratitude and enjoyment
for life.
approach emphasizes
identifying and building
upon an individual's
strengths and resources
rather than focusing solely
on deficits or symptoms.
Despite challenges in the
patient's communication
and engagement, his
frequent smiles, nods, and
willingness to participate in
conversations indicate
strengths like resilience
and a desire for
connection. By
acknowledging and
reinforcing these strengths
through positive
affirmations and
celebrating his ability to
express gratitude, such as
through hugs, the patient
can feel empowered

________________ Social Skills Training

Nurse: “Noong bata
po kayo, ano po yung - Social skills training aims to
mga bagay na
natatandaan ninyo?
Client: “Masaya, dati
ako nag trabaho sa
Jollibee, naging actor
din ako sa teatro”
enhance interpersonal
interactions and
communication skills, which
can be especially helpful for
individuals with schizophrenia
facing challenges in social
engagement. Considering the
patient's struggles with eye
contact and occasional
 La Consolacion University Philippines
The Catholic university of Bulacan
Valenzuela St. Capitol View Park Subd., Bulihan, City Of Malolos, 300 Bulacan

_________________ disengagement, instructing

Nurse: “kelan at gaano
po kayo katagal nag
trabaho sa Jollibee at
naging actor sa
teatro?”
Client: “20 years ako
nagtrabaho dun, tapos
naka tatlo akong acting
sa teatro sa shangrila”
him in techniques like active
listening, sustaining eye
contact, and verbally
expressing gratitude can
improve his capacity to
connect with others and
actively participate in social
interactions.

_________________

Nurse: “Noong
nagbinata po kayo,
kamusta naman po
noon”

Client: “mahilig ako

mag mall tumingin ng
TV”
_________________

Nurse: “ nag-karoon
po ba kayo ng
karelasyon noong
binata pa po kayo?”

Client: “ oo kami pa
hanggang ngayon 30
years na kami”

________________

Nurse: “ano po
pangalang niya?”

Client: *was distracted

from the noise from
other students
program*

________________

—end of session—
 La Consolacion University Philippines
The Catholic university of Bulacan
Valenzuela St. Capitol View Park Subd., Bulihan, City Of Malolos, 300 Bulacan
Charting: FDAR ( prioritized problem based on the interaction )
Focus : reducing the frequency and
intensity of delusional beliefs while
promoting engagement in therapy
and improving overall well-being.
Data:
- patient is sitting with his arms across himself
- speaks clearly
- patient is deluded and out of reality
- actively participates
- can hold eye contact but would avoid it if it is
held longer
- will take at least 5-10 sec. before answering
- has a big lump on the right middle finger
- dark like birthmark in the right elbow
Action :
- Build rapport and trust with the patient through
empathetic listening and validation of their
experiences.
- Use motivational interviewing techniques to
explore ambivalence and enhance motivation for
change.
- Provide gentle reminders and reality-based
feedback to help the patient differentiate
between delusional beliefs and objective reality.
- Encourage the patient to seek validation from
trusted individuals when experiencing doubts or
uncertainties about their beliefs.
- Facilitate connections with peer support groups
or community resources for individuals with
schizophrenia.
- Assess and address any safety concerns related
to delusional beliefs, such as risk of self-harm or
harm to others.
- Regularly assess the patient's progress towards
reducing delusional symptoms and increasing
engagement in therapy.
Response:
- the client was able to cooperate during the session,
only slight distraction and problem understanding
the questions.