Nursing Process Recording

I. Personal Data
 Name:
 Age:
 Sex:
 Civil Status:
 Educational Attainment:
 Order/Position in the family:
II. Assessment prior to Introduction (Observation)
The family lives in under privileged area. Their establishment is composed of light materials.
The house is not well ventilated and there is inadequate lighting. Breeding sites for mosquitoes,
flies, cockroaches and rodents are unavoided due to open drainage and poor environmental
sanitation. Their toilet facility is located inside their house which they share with all the family
members. The general surroundings of the family is unhygienic and drainage system is open and
near to the houses. Only wooden walls separate them from their neighbours and electrical
connections are tangled and dangerous. However, the client’s house is clean and free from
clutters compared to what is seen outside their place.

III. Objectives
a. Short-term Objectives
To establish rapport with the family and be able to identify and discuss possible
interventions regarding their health concerns.
b. Long Term Objectives
To be able to instil knowledge to the family regarding disease prevention and health
promotion through health education.

IV. Date, Place, Time and Duration of Nurse Patient Interaction

The interview took place dated August 7, 2017 inside Mrs G’s house. At around 10 in the
morning it lasted for about 15 minutes and I was very glad that Mrs G’s were very
accommodating. She was always smiling when asked and she is very participative to the
conversation. She was cooking at the time when we arrived but still she allowed us to step inside
their house and ask questions.

V. Brief description of the setting

I was able to visit Mrs G’s house twice and she always welcomed us in. As I was asking
questions, I was also observing their area. Their establishment is composed of light materials.
The floor is almost 6 sq. meters. They are resting together peacefully in a wooden bed foam
located near the entrance door which is also their receiving area. They live in a house which is
composed of bamboo, not cemented floors and a galvanized roofs. Their kitchen where they cooked their
 foods is easy for the children to climb of, and when they wash their dishes the floor becomes wet which
makes it slippery.

VI. Nurse-Patient Interaction

Nurse Client Non-verbal Implication
Gestures
“Hello! Good morning “Hello, maayong Cooking The mother was
ma’am” aga man”. preparing their
lunch during our
visit, she did not
hesitate to greet us.
“Ako gali si Erl “Huo, sulod lang Smiling The mother was
Canete student nurse day” welcoming us into
ako halin Colegio San their house.
Agustin-Bacolod
ma’am, may ara lang
ko tani gamay nga
pamangkot para sa
amun requirements if
okay lang sa inyo?”
“Thank you ma’am, “Sige lang, pwede Smiling She did not make us
mahulat lang ko tapos man lang ka wait for her to finish
mo luto ah” kapamagkot sa cooking.
akon”.
“Sige ma’am ah, ma “Sige ah” Mrs G looked She is ready to
mangkot lang ko sang calm answer the
mga basic information questions.
niyo”.
“Ano imo pangalan “Jinky A. Garcia, Looks straight She looks calm and
ma’am?” day” while answering comfortable with
question then the questions.
smile.
“Pila imo edad ya “26 day” Looks straight She looks calm and
ma’am?” while answering comfortable with
the question. the questions.
“Ah, Ano imo “Wala ko naka Looks away She looks
natapusan ma’am?” graduate elementary then starts doing uncomfortable in
day asta lang ko things. the question and
grade 4” changed tone of
voice.
“Ah, Pila ka bilog imo “Tatlo lang sila” Looks straight She looks calm and
bata ya ma’am?” while answering comfortable with
the questions.
“Diin sila subong “Ang duwa ara to sa Looks straight She looks calm and
ma’am?” sagwa ga hampang while answering comfortable with
ang magulang nag questions then the question.
skwela”. points out her
children
outside.
“Pila na kamo di “Mga 5 years na Looks straight She looks calm and
katuig ga istar day”. while answering comfortable with
ma’am?” the questions.
“Ano di nga masami “Ah, kis a hilanat Looks straight She looked like they
nga mga masakit ang ukon ubo kung tig while answering do not have major
kalabanan nga makuha ululan”. concerns regarding
ninyo?” their health.
“Ano ginahimu niyo “Ga bakal lang Smiling He looked confident
ma’am kung gina kami bulong while answering the
masakit kamo?” parehos sa mga questions
Paracetamol kung
indi madala sa
bulong gina pahilot
ko ukon gina paluy-
ahan, kung indi pa
gid amo pag lakat
namon sa health
center”
“Ga inom man kamo “Huo mga oregano Looks straight She was open to
herbal ma’am?” kag iban pa”. while answering answering the
questions
“Kabalo ka ma’am na “Wala man gid, ga Looked curious She was not aware
pwede ma apektuhan mayu man amon of the dangers in
inyo nga kindey pamatyag tapos drinking herbal
tungod sang pag inom inom sina”. medicines.
sang mga herbal?
“Kamusta man di pag “Maayu man ah, ok Smiling She looked happy
istar niyo ma’am?” man lang kami di”. and contented with
their living
condition
 Happy man kamo di “Huo ah, sadya man Smiles then She was smiling
ma’am? lang, kapin pa gid laughs while answering the
may mga bata ka question
nga mga
salawayon”
“May mga problema “May ara di isa sa He showed
man kamo di sa inyo tupad balay lang unlikeness to the
mga tupad balay namun, wala kami family living next to
ma’am?” ga intsindihanay their house
tungod sa ila mga
basura naga lapta sa
gwa balay, kag wala
gina tinluan ila
palibot”.
“Nakulbaan man Wala man, maayo Smiling He looked confident
kamo di sir sa inyo lang man mga tawo answering the
lugar?” di sa amun”. question.
“Anu gid inyo main “Baha lang man. Explaining He is aware of the
problem di sir sa inyo Kis-a ga sulod na sa main problem of
lugar?” balay. Amo man their area but he
lang na”. does not looked
burden or stressed
by it.
“Anu gina ubra niyo “Nagpahimu kami Explaining He has found a
sir regarding sa sina kalog kag baral para solution to their
na problema?” indi kami ma baha- problem and he
an”. looked like it does
not bother him that
much anymore.
“Sige sir, Thank you “Sige, halong Smiling He looked happy
gd sa inyo time gn kamo”. talking to us and
hatag para sa amun answering our
interview, malakat na questions.
kami”.

VII. Evaluation
Based on my interview, the family has inadequate information regarding their
health beliefs. They still believe that by drinking herbal drinks, it would help them
 feel better. They should be more aware of the effects of it to their health.
Nonetheless, all their 4 children has completed their prenatal and immunizations
and they have their own family physician where they always consult with,
regarding their health issues. Overall, the family is prioritizing their health and has
enough knowledge to improve their wellness.

VIII. Future Plans or Objectives for the next interaction

Identification of health hazards and development of awareness to the side effects of
drug/herbal medications would be my next objective to promote health wellness
within the family.