Gatpandan Diagnosis:
Date: September 30, 2011 Time started: 2:00pm Place conducted: CCMH
Perception to the client: The patient sits calmly. He has a good eye contact and he had a hand tremor which is obviously observed in my two hours nursing interventions. Perception to the environment: The environment was calm and therapeutic. The breeze of the wind makes the patient feel comfortable and relaxing.
Sige po Tay, magtoothbrush at maghilamos na po tayo para maging maganda ang inyong pakiramdam.
The patient walks through the faucet and started his ADLs for the day without assistant.
Analysis Showing respect is an important factor in effective communication. Greeting a client by name shows that the nurse recognizes the client as a person, as an individual. It does not carry the notion of value, of being good or bad. The patient is following task given. This indicates that the patient knows and aware of his daily routine, therefore the patient was able to perform self-care. Dorothea Orems selfcare theory states that self-care is where an individual performs independently throughout of life to promote and maintain personal well being. Silence or long pause in communication may indicate different things. The client may
ng mga activity at inaasahn po naming ang inyong kooperasyon sa loob ng dalawang oras.
therapeutic
Dito po tayo umupo Tay. (pointing to the left side of the hall) Giving Information therapeutic Offering Selftherapeutic Setting limitstherapeutic
Ako po si Nikka, ang inyong student nurse sa araw na ito, makakasama mo po ako mula alas dos ng hapon hanggang alas quarto ng hapon simula ngayon biyernes hanggang sabado. Ano naman po ang pangalan mo?
Questioning therapeutic
Tay maari ko po ba kayo kunan ng BP, Temperatura ng inyong katawan, pulso at RR nio po? Para malaman po natin
The patient nodded and gets the thermometer on the nurse hand and place on his underarm.
be depressed and struggling to find the energy to talk. Sometimes pauses indicate the client is thoughtfully considering the question before responding. At times. The client may seem to be lost in his or her own thoughts and not paying attention to the nurse. It is important to allow client sufficient time to respond even of it seems like a long time. (Vedebeck 2nd Edition) The patient follows instruction and show interest by maintaining eye to eye contact with the nurse. Informing the client about facts increase his awareness. Giving information builds tryst. This is very important during orientation phase of nurse patient relationship. It allows the client to open up to the nurse. The patient is responsive thou he added some nickname on his real name such Bruno Brosyo. Cooperative and knows what to do in the VS apparatus as well in the BP app.
kung normal po ang inyong VS? Normal naman po ang inyong Bp = 120/80 po.
Giving informationtherapeutic
Ahh..ano ang aking temperature? (while pointing at the thermometer) The patient stares at me and nodded again. Ok naman, nakatulog naman ako ng ayos. No response. The patient is just starring outside.
Cooperative
Tay, 36.8 po, wala naman po kayo lagnat. Ok naman po lahat ng VS nio. Kamusta po kayo? Encourages Ang tulog niyo po? verbalization of feelings May gusto po ba kayo Broad Openings pag usapan ngayon? (Leaning forward)
Ano po tumatakbo sa isip nio ngayon? (Looking at the client and making observation) Ilang taon na po kayo? Ilang taon na po kayo dito?
Broad Openings
Wala naman.
Questioning Exploring
Asking Direct Question Asking Direct Question Asking Direct Question Exploring
Encourage client to verbalize what he feels today. Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak. Broad openings let the client lead the interaction. It may stimulate the client to take an initiative speak. Ill try to know more about the patient. The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution. Patient remembers his birthday but not the exact year. Patient is responsive. The patient somehow recalls the past events that took place un his life and the reason that he comes and go in the institution. Helps the nurse
inyo dito?
nanay ko.
identifies the individual involve in the client life and the relationship to his family.
Asking direct question Asking direct question Identifying participants and relationship Restating Exploring
Ahh. 60 po kayo lahat? Kilala mo po lahat ng iyong kapatid? Ganun po ba? May asawat anak po ba kayo? Ano naman po ginagawa nio sa loob kapag walang student nurse?
Exploring
Exploring
Oo, may dalawa kami anak, babae at lalaki. Nanunuod ng TV, natutulog
Obtaining data regarding clients personal life. Allows client to verbalize other activities and obtaining information of what occupies their time when there is no students around.
Ano naman po ang pinapanood mo lagi? E di alam mo po laruin ang Pinoy Henyo?
Eat Bulaga
Mabuti naman po at alam nio po laruin, mamaya po tayo ay may activity, magkukulay po kau. Gusto nio po ba un? ART THERAPY Ano po ang nasa drawing nio?
Asking question
The patient understands the mechanics of Pinoy henyo game because he always sees it at the TV. The patient understands the instructions given by the student nurse and he shows willingness to join the activity. Exploring the clients ideas and thoughts. Encouraging verbalization of feeling and expressing
Seeking information
Wow, ang galing naman po, kuhang kuha po ang kotse. Bakit po yan ang napili mo kulay?
Giving Recognition
Questioning exploring
Ah, nagagandahan po kayo sa kulay gray, tapos na po tayo sa ating activity, kakain naman po kayo ng merienda, dito po muna kayo umupo haba kinukuha ko yun pagkain. After eating, Kamusta naman po ang lasa ng pagkain ngayon? masarap po ba? Tay, pabalik na po tayo ngayon sa ward, babalik po kami ulit bukas ng hapon. At magkakaron ulit tayo ng activity.
Restating
The patient sits in the chair and waits for his food.
of his thoughts. To acknowledge the patient effort in doing the activity. Exploring the clients ideas and thoughts. Encouraging verbalization of feeling and expressing of his thoughts. The patient follows instruction and understands the student nurse is saying. The patient is always behaved and quiet.
Seeking Information
Opo, masarap naman. He is happy on the food that the nurse gives to him and he was satisfied. Nodded The patient is looking forward for the activity.
Giving information
Introduction ORIENTATION PHASE Problem defining phase Starts when clients meets nurse as stranger Defining problem and deciding type of service needed Client seek assistance, conveys needs, asks question, shares preconceptions and expectations of past experiences
General Objectives: To distinguish the sickness of the client thru the observation done To reduce the anxiety felt by the client towards the nurse To discuss the contract to my patient To explore patients thoughts, feelings and actions
Specific Objective as a student To be able to introduce myself to my patient and getting to know each other To show interest and sincerity to my patient To gain trust from my patient To observe and assess my patients personality
Specific Objective for patient: Encouraging verbalization of feeling and expressing of his thoughts and ideas
Summary: On the first day of handling Mr. L.M, theres a lot of uncontrolled behavior that was observed. First, his hand tremors that sometimes distracted me in our conversation. Second, sometimes he doesnt response and just starring at me. And lastly, he whispers something I cant clearly understand. At first interaction with Mr. L.M. he seemed to have low self-esteem but when the nurse=patient interaction lasts he can now established eye to eye contact. Though he has manifested these behaviors he is still aware of his own basic needs and his ADL. To wrap it up, the objectives was partially met, the patients data was gathered, and he was able to remember the name of the student nurse assigned to him. He had also maintained eye to eye contact within the conversation. He was been participating in the activities and therapies done.
Evaluation: After 2 hours of my nursing interaction the goal was partially met. When dealing with this kind of client who is mentally ill I need to familiarized my self in different therapeutic techniques in order to meet my desired goals and objectives. Because my client is not totally active and had flight of ideas when giving information though sometimes he made eye contact and pay attention in my question. I was able to explain the purpose, duration and termination phase of our meeting.