Xavier University- Ateneo de Cagayan

College of Nursing
SY 2016-2017
Name of Therapist:
Client: Patient TA
Age: 42 Years Old
Educational Background:high school level
Time: 9:00 am
Religion:Roman Catholic
Sex:Female

I. Pre-orientation
Prior to arrival we texted the husband and asked if we could interview his wife for our
project and he agreed. As we arrived, we noticed the client is asleep in the couch
with the television on. His husband approached us and accommodated us to have a
seat in their living room. He woke the client and assisted her in fixing herself. As the
client is ready her husband introduced her to us and the reason why we are there.
The husband of the client sat beside her as we begin our interview.

II. Background Information

This is a case of a client who is diagnosed with depression for 6 months due to the
death of her only child after being hit by a car. She had a hard time coping up with
the situation since she was her only child and it greatly affected her work and
relationship. 1 month after the incident, she started to stay home and locked the
doors of her room only to come out whenever she wants. Her relationship with her
husband started to fade out since she doesnt communicate to him. She cries a lot
and blames herself regarding the incident that happened to her only child.

III. Setting of Interaction:Puntod, Escobido Street, Cagayan de Oro City

IV. Description of Client during interaction

Appearance: Appears weak and uninterested. She is thin with scars and cuts
noticed on her both arm. Her hair is messy and a slight foul order is
present. She is dressed in an appropriate manner.
Behavior: Client is restless and tends to move from one chair to the other and at
times, stares blankly at the floor. There are times that she doesnt make much
eye contact and needs the question to be repeated twice in order to gain back
her attention. At the end part of the conversation, clients seems to have
realizations and smiles at times when conversing to her.
Affect: Flat at the first part of the conversation but later part, client affect seems
appropriate
Pattern of Communication: intermittent; often answers the questions but tendency of
spacing out is observed; at the end near of the conversation client seems to be
uplifted and determined for change

V. Objectives
A) Objectives of the Nurse
At the end of 3 hours, we will be able to:
1. Build trust and rapport by demonstrating acceptance
2. Encourage patient to participate and answer our questions truthfully
3. Establish a therapeutic environment for the client to be comfortable to also
ensure safety and privacy
4. Apply therapeutic communication to the client
5. Initiate a therapeutic contract by establishing a time, place and duration for
each meeting, as well as the length of time the relationship will be in effect
6. Obtain the accurate data needed
7. Explore clients perception of reality and provide constructive feedback.

B) Objectives of Nurse for the client

At the end of 3 hours of Therapeutic Communication the client will be able to
1. Build a good nurse-patient relationship
2. Verbalize her feelings and concerns comfortably and truthfully
3. Develop positive coping behaviours
4. The client may ask questions to the nurse regarding her condition

PATIENT ANALYSIS
NURSE
Janelle: Maayong buntag Maayong buntag pud maam. Oo Client
maam! Akosi Janelle ug naa
koy kauban si Maam Gian. Mga
student nurses mi sa Xavier
University. Naa mi gamay nga
mga pangutana saimo maam,
okay ra ba?
(smiles and speaking in a soft
tone of voice while looking at
patient)
Janelle: kamusta man ka karon
maam? Ayaw kaulaw ug hisgot
saimong gakabati karon maam
ug ikaw buot as aka gusto mag
sugod
Janelle: Maam? Okay raka?
Gian: Ana akong uban maam
kamusta man ka ug unsa
imong ginabati karon?
Janelle: Unsa man diay imong
ginabati karon maam
hinungdan sa panghitabo
saimoha?
Janelle: Hala mao ba diay na
maam? Dawbe nadala pa siya
sa hospital or patay nagiyod
siya daan?
okay ra maam. recognizes
the
(patient responded but didnt make presence of
an eye contact) the sns and
acknowledg
ed to what
they are
saying.
(patient stared at the student nurses
and didnt respond)
Ay unsa to imong pangutana
maam? SN used
broad
Lain man giyapon maam. Di openings to
gihapon nako madawat ang mga allow client
panghitabo sa akong kinabuhi to take the
initiative in
(speaks in a soft and brittle kind of opening
voice and tears is observed) topic
Namatay man gd akong bata maam
tungod kay naligsan sa usa ka
animal nga driver
Nag dula-dula ra man to akong
anak sa gawas sa among balay
unya pagpauli nako tingala nalang
ko kay nag kagubotgawassa among
balay unya pagkaduol giyod nako,
susmaryosep! Halos ako mamatay
sa akong nakitan
Nadala paman to maam unya kay
pagabot sa hospital gi declare
naman nga patay siya
Student
(patient started to cry out and Nurses
speaks in a brittle voice; husband used
hugged the client and comforted the silence in

Gian: sorry sa pagkawala
saimong bata maam.
Janelle: Cgemaam, karon unsa
may ginabuhat nimo aron ma
ibis-ibisan ug di nimo ma
dumduman tong mga
panghitaboa?
Janelle: (nodding)
Janelle: Maam, nabantayan
lage nako naa kay mga samad
sa imong kamot dapit ug sa
braso
Gian: diba maam dili mana
mayo na pasakitan ang
kaugalingon?
Janelle: Ah sigimaam, so
karonmaamunsa may
planonimobuhaton? Mag pa
dayonbagihaponkanga mag
client) order for
client to
(continued crying and was handed continue in
tissue to wipe out tears and a glass conversing
of water) her
experience
Ga sigi lang jud kog higda sa akong
kwarto pero dili ko katulog ug wakoy
gana mo kaon man, gaimbitaron ko
sakong bana molakaw pero dili man
ko gusto mag suroy
gusto man komaka move-on na ani
sa panghitabo pero galisod man jud
ko maam; gaka apektohan naman
gd halos akong pamilya ug trabaho,
ug di nako gasulod sakong trabaho
ambot ug dawaton pa bako balik
didto
(looks at both arms and tries to hide Used
it from us) Formulating
ay kini maam, ako may nakabuhat a plan of
ana sa akong kaugalingon action to
ask the
client to
ako raman na nabuhat tungod kay consider
ginabasol nako ang pagkamatay sa kinds of
akong anak kay wala ko diha para behavior
niya sigira kog trabaho likely to be
appropriate
(stares at the floor blankly and in future
avoided to make eye contact) situations.
Suwayan nako maam nga mag balik
saakong normal nga routine,
hunahunaon lang nako nga bisag
wala na akong anak physically pero
naa japon siya diha pirmi ug
malipayon na siya sa langit
Lain man sad gud kay
dilinamanjudmabalikakonganakugga
kahuna-hunaannakonga ma
lukonglangsaimohangkwarto? guolsiyaugapil kung Used
makitakoniyangagainanirapirmi acceptance
indicating
suwayan nako ug balik sa akong the student
ginatrabahoan ug tanawon nako ma nurse
Janelle: Nabantayan nako dawat pa ba ko, dili pa sad unta follows
maam nga naa nakay gusto ulahi ang tanan ug ibalik nako akong what the
buhaton aron di naka mag sigi pagkaon kay nabantayan pud nako client is
lukong saimong kwarto, unsa nag niwang jud ko trying to
paman imong buhaton pa convey.
maam aron padayon nana? (smirks and drink a glass of water)
wala naman maam, tungod pud
siguro ani nga pagstorya nato Used
nabantayan nako nga dili nako inani making
dapat, dili man mounding ang observation
kalibutan para sa akong anak pero verbalizing
pirmi siya saakong kasing-kasing ug what the
di na mag bago student
Gian: Naa pakay gusto ipasinati Salamat sainyoha maam nurse
sa amoa maam, naa mi diri perceives
aron maminaw pa saimong
ginabati
Used
oo siguro kay wala may gusto voicing
makakita sailing inahan maguol, ako doubt to
man gali inahan dili gusto Makita express
akong anak nga guol, pati pud uncertainty
siguro ang anak about the
reality of
clients
perception

(nodding at us and offering us some

biscuits to eat)
Gian: saimong gibuhat karon
maam ug saimong mga na Used
realize, nalipay kaha ug tanaw formulating
imong anak saimoha nga gusto a plan of
naka mag bago para sa action
kaayohan? again to
consider
kinds of
Janelle: Sa atong pagstorya behavior to
karon maam, atong nahisgutan kung mahimo ug magiyod siguro be
nga galisod ka ug lihok tungod aron mapasinati nako sa akong appropriate
kay guol kayo ka sa panghitabo gitrabahoan sa panghitabo aron in future
sa pagkamatay saimong anak makasabot sila ug modawat pa sila situations
pero gusto naka ma undang ni nako
kay gakadaot na imong trabaho
ug relasyon saimong pamilya kana sa siguro para kung madawat
ug ready nakamo move on aron man galiko, dili na kayo ko inanaka
malipay ug tanaw imong anak pabigat saakong bana kay basin Used giving
saimoha gikapoy nani siya saakoa sigi ug pa recognition
ariglar and
(smiles at husband and holds his focusing
hand) towards the
Janelle: so kanusa mani nimo lage maam, salamat pud kayo ani clients
sugdan maam ang pagbago? maam kay naa koy mga nasinati nga action
dapat dili nako mag inani, salamat regarding
kayo maam! how to
lessen
Janelle: unsa paman diay (stands up and leads us to the door) episodes of
imong buhaton maam? depression
and
focusing on
the
(smiles at us and waves back) possible
actions
Gian: Nalipay kami aning towards it.
paghinigstoryaha nato maam
ug unta mabuhat nimo ang mga
butang nga imong gipanghisgot Used
saamoa offering self
to assure
(stands up with a smiling face client that
looking at patient) SNs are
there to
Gian and Janelle: Sigi maam listen
ma unanami. Salamat kayo furthermore
saimong oras! regarding
her feelings
(waves at patient)

Used
reflecting
directing
client
actions,
thoughts,
and
feelings
back to
client
Used
summarizin
g to sum up
everything
that has
been talked
about

Used
general
leads to
give the
client more
possible
actions
towards
future
doings.