KIELA EVANGELINE A.

ARTIZADA
BSN-III
July 13, 2023
Working Phase
Objective:
 Identify the problems
 The focus is on assessment; the relationship of the client’s behavior and the focus of interaction.
 To establish the client’s security is to develop by being consistent at all times.
 To Identify the defense mechanism.
NURSE INFERENCE CLIENT RESPONSE ANALYSIS/INTERPRETATION
“Magandang Umaga, Greetings “Magandang umaga, po” *nodded while sitting*
Marlon.”
“Kumusta ang tulog Focusing “Ok namn po, naka 8 hrs naman po” *maintained an eye contact*
mo?”
“Maari mo bang Exploring “Ito po kasi, sa Lemery batangas po *points out drawing* The patient
maikwento, bakit ito ang yan, dyan po yan sa mga tita ko, was able to provide the place of the
napili mong iguhit noong nakapunta nako dyan nung bata pa drawing
oras na mabagal ung ako tapos maganda po dyan, may
tugtog?” *maintained an dagat, may bundok, tapos puno po.”
eye contact and firm sit*
“Maari mo bang I Exploring “Mangga po yan, Ma’am” *points out drawing while
kwento kung anong Active listening nodding*
klaseng puno ito?”
“Maari ko bang Exploring “Paborito ko po kasi ung manggang *nodded while smiling*
malaman bakit manga?” hinog”
“hmm, masarap nga yun, Acknowledging “Ano po yan, sa batangas po yan *points out drawing, while
ay yung bundok kaya, at Exploring taal po yan at dagat, naalala ko po gesturing hand through
dagat? kasi ung bahay ng tita ko don pati elaboration* The patient was able

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 po tyaka po sa pinsan ko.” to provide details of his drawing as
well as elaborating well.
“Ah, ganoon ba, *nods* Exploring “Yung ulap kasi po, maaliwalas *points out drawing*
ay yong ulap naman ba at yung paligid kaya po ulap, yung
araw?” araw naman po kasi po maaraw non,
tapos ibon po yan.””
“*nods* ganoon ba, Encouraging description of “ano po kasi, maganda po doon *gestures of hand through
maari ko bang malaman perception probinsya po kasi, tahimik po tapos elaboration, while nodding* The
bakit sa malungkot mo nakakaaliwalas po gawa ng tanawin, patient is communicating
nailagay ang drawing na pag dito po kasi maynila, puro usok efficiently while maintaining an eye
ito?” ganon tapos makalat po.” contact.
“Ah, ganon po ba Restating “Sa ano po yan ma’am, Valenzuela *points out drawing, while
makalat po sa maynila, at Exploring din po sa kababata ko naman po na smiling* The patient was able to
medyo maaliwalas po sa si AJ, kalaro ko po yun dati saka provide details such as place and
probinsya *nods*, maari pinsan nya, Ma’am, naglalaro po names of his childhood friend.
ko po bang malaman pag kami dun may abandonado po
naman po mabilis yan po kasing billiaran sa kanila sa Malolos
ang iginuhit po ninyo? po, sa bulacan po. Ung talon naman
po may bangin po kasi dun e parang
falls po.”
“Ah ganon po pala Encouraging description of “Oo, kasi kasama ko sila e tyaka *nodded*
mukang maganda nga po perception maganda yung tanawin, Opo.”
pala dun ano, masaya po
kayo pag andoon po
kayo?”
“Ah ganoon po ba?, Encouraging evaluation “Malolos po andun din po ung ate *nods* The patient was able to give
maari ko po bang itanong Exploring ko si ate mae, binibigyan po ako a name of his cousin and the
kung saan ang gusto nyo nun ng pang yosi, tyaka details*
po uli gusting bisitahin pangmeryenda.”
ung lemery po or dun po
sa malolos?”
“Pede nyo po bang I Exploring “Ate ko po sya pinsan ko po *nodded
Kwento si Mae?” Ma’am, mabait po yun.”

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*Times up* Giving recognition “Sige po ma’am, salamat din po.” *The patient nodded*
Putulin ko na muna
Maraming Salamat,
Marlon, bukas nalang uli,
pede kana magpahinga.”

EVALUATION:
The working phase is ongoing, the service user is expressive as well as communicative, he was able to tell his details and his
past experiences. During the music and art therapy he was able to draw well and explain the meaning of his interpretation and was
actively participating on all the activities given.

pg. 3
KIELA EVANGELINE A. ARTIZADA
BSN- III
JULY 14, 2023
Working Phase
Objective:
 Identify the problems
 The focus is on assessment; the relationship of the client’s behavior and the focus of interaction.
 To establish the client’s security is to develop by being consistent at all times.
 To Identify the defense mechanism.
NURSE INFERENCE CLIENT RESPONSE ANALYSIS/INTERPRETATION
“Magandang Umaga, Greetings “Magandang umaga, po” “Nodded while sitting”
Marlon.”
“Kumusta ang tulog Focusing “Ok namn po naka 10 hrs po ako “Maintained an eye contact”
mo?” masarap po tulog ko.”
“Magkwentuhan na uli Focusing “Ah mahilig po kasi ako maligo, “Gestures on his skin pointing out
tayo ha, napansin ko kasi tinuruan po ako magayos nung ex that he loves to bath and clean
mahilig ka magbasa ng ko si Vilma, mahilig din po ako himself*
ulo mo, habang nag maglinis pati ng katawan simula po Patient is using Regression since he
hihilamos ka, maari ko bata pa ako Gawain ko na po” is been doing it since he was little
bang itanong kung ano as well as he has Identification
ang dahilan?” upon knowing that his ex-also help
him to always have a proper
hygiene, He is also showing signs
of Obsessive compulsive behavior
since he also mentioned that he
often took a bath for about 10
times, and when we did our

pg. 4
 hygiene I asked him if he already
brushed his teeth, and he said yes,
but then brushed his teeth again to
feel satisfied.
“Ah kaya namn pala, Giving Recognition “Opo, Ma’am” *Smiles while nodding*
malinis ka lagi at maayos
ang gayak, mahilig pala
ikaw maligo.”
“Maari ko bang itanong Encouraging description of “Maaliwalas po kasi sa balat, tyaka *shows arm while gesturing his
ang nararamdaman mo perception malamig yung ulan.” arms*
pag naliligo, lalo na sa
ulan na pansin ko din kasi
mahilig kang maligo sa
ulan, nasabi mo din nung
last na meeting natin na
tumatakbo ka sa
ulanan.?”
“ah ganoon pala, maari Focusing “Mahilig po talaga ako sa tubig, *nodded* As mentioned above
ko bang itanong kung mga 8 glasses a day po naiinom ko patient is showing signs of OCD
bakit mahilig ka sa tubig, tas pagnaliligo po ako nakaka 10 na
kasi madalas kang beses po ako.”
maihi?”
“ah ganoon pala kaya Exploring “ah opo ma’am, mahilig po ako *Nodded while also giving
madalas ka maihi, doon dun, mga crossfire, counter strike insights*
naman sa kahapon ganon po.”
itatanong ko din sana
sayo mahilig ka sa video
games ano, kagaya ng
counter strike?”
*Time stops* Giving Recognition “Salamat din po, Ma’am sige po.” *The patient nodded*
“Ah putulin ko muna
usapan natin ha, may
mask kasi kayo kaya

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hanggang ditto nalang
muna sa lunes nalang uli,
salamat pede kana
pumunta para sa misa.”
EVALUATION:
The working, phase is ongoing, the service user is able to express his defense mechanisms as well as his problem since the
priority is safety as the service user mentioned that he loves to bath in rain especially in the road before, but he can have detailed his
bizarre behavior and expresses signs of willingness to improve himself as the service user is going home by August. The service user
is also actively participating in different activities, and is raising hands in questions given, lastly can communicate effectively.

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