Process Recording NURS 360

Date: September 19, 2015

Clt. Age: 29
Clt. Gender: Male
Date of interaction: September 19, 2015
Diagnoses: MH5, unspecified psychotic disorder; psychosis
Length of Stay (LOS) on the day of the interaction: 3 days

Dialogue column

Good morning. My
name is Charleen. I
am a nursing student
at Kapiolani
Community College.
Is it ok if I sit at the
table with you?
Sure, please sit

Non-verbal
commuication

Techniques/S
kills

SN: Smiling and Introductory

making eye
statement
contact, waiting
for
acknowledgment
.
Patient: Looking
up at me and
smiles.

Student
Feelings

Nervous

Students
Thoughts

Therapeutic
vs Nontherapeutic
(T/N)

Analysis

I hope he
allows me to
talk with him
so I can get
my process
recording
done. Hope
he doesnt
leave before I
can finish
talking with
him.

Maintaining a
friendly and
open
approach.
Appropriate
introduction
to start off.

How are you doing

today?
Im doing great, I am
supposed to be going
home today.

SN: Body facing General lead

patient. At a
question
good distance to
give some
space. Not
crossing arms.

Interested

I hope he
opens up and
doesnt mind
talking with
me.

Attempts to
gain trust.
Allowing
patient to
express self
and open up.

Interested
and sad

I hope he
opens up,
otherwise I
will have to
think of
something
else to ask
him to try and
get him to
open up.

Allowing
patient to
open up and
giving patient
my full
attention.
Able to learn
about his
situation that
led him to
coming to
the hospital.
There was
more that I
learned from
reading his
summary, I
could have
asked him
more details

Patient: Finishing
up breakfast and
facing me when
talking to me.
Can you tell me about SN: Actively
Open-ended
what brought you in to listening and
question
the hospital?
maintaining eye
contact.
Leaning in to
Yes. I came to Hawaii
about two weeks ago to hear him
relax. Hawaii weather is because he talks
very hot for me. I began softly at times.
to feel dehydrated and
started drinking a lot of
Patient: engaged
water. I wasnt sleeping. in conversation
I had felt warm. I was
and actively
throwing up and having
participating.
diarrhea. I kept asking
myself what was wrong
with me. I wasnt feeling
like my self. I was
starting to feel unsafe. I
couldnt think straight
and I was getting

anxious, unable to make

decisions. I am alone
here so no one to ask for
help. So I decided to go
to the hospital.

Please tell me more

about coming here to
relax.
My family is from
Jerusalem, My parents
moved to Boston and
then I moved to
Michigan to go MIT. I
have been going to MIT
for 11 years. I just

about.

SN: Showing
interest in
conversation by
leaning in
toward patient.
Patient: Calm and
collected. Sitting
in his chair with
his blanket around
his back because

Focusing
statement

Interested

I hope he will
continue
talking openly
with me.

Able to get
patient to
further
explain his
reason for
his trip to
Hawaii. Able
to find out a
little about
his

finished my dissertation. he is cold.

So you came here to

celebrate finishing
school?
Yes, I am done with
school! It took me 5
years to complete my
dissertation. In those 5
years I did nothing but
work on my
dissertation.

SN: Full eye

contact,
engaged in
conversation.

Paraphasing

Happy

He just
closed his
eyes, I hope
he is ok and
he is not tired
of talking with
me.

Able to learn
more about
how school
was stressful
for him.
Giving
patient
something
happy to
reflect on.

Reflection of
feeling

Happy

I want to tell
him I hope to
feel that
feeling one
day.

Focusing on
the patient
helped so I
wouldnt get
side tracked.

Patient: Leans
back in his chair,
closes his eyes
and takes a big
deep breath, lets
it all out and has a
smile on his face.

"It sounds like you feel SN: Looking at

very relieved that you
patient not sure
are done with school. if to be
concerned.
Relieved when
Yes, I feel relief
he smiles.
Patient: Relaxed

and making eye

contact.

"You came to Hawaii

by yourself? Did none
of your friends want to
come with you?
I was supposed to
come with my girlfriend,
but at the last minute
she had a family
emergency to attend,
and wasnt able to come
with me
Tell me more about
school.
School was long and
very stressful for me.

SN: Relaxed
and actively
listening.

Open-ended
question

Interested

I wonder why
none of his
friends would
jump at the
chance to
travel to
Hawaii with
him.

Trying to
figure out if
he had any
friends. Able
to get a
glimpse of
his
relationships
with others.

Sympathy

I want to tell
him I know
how he feels,
but this is not
about me.

Giving
patient time
to reminisce
back on
school.

Patient: sitting
back in chair and
continues to make
conversation

SN: continuing
Focus
eye contact,
question
sitting forward in
chair.
Patient: small sigh
and voice getting
softer.

U-Hum
In undergraduate
school everyone helps
everyone else out to
succeed, but in graduate
school everyone is
competing for the same
spot, so everyone only
thinks about themselves.
There is a lot of pressure
and stress. I would be
in meetings where I
would give suggestions
and then someone
would take it. Let me
give an example: I am
sitting around the table
with other people trying
to figure how to make a
cup. I say a cup should
be cylindrical and have a
handle. Someone says
no it should be square.
Then another person will
suggest something else
as this goes on around
the table. At the end
they decide a cup
should be cylindrical
with a handle and they
take my idea.

SN: Maintaining
eye contact and
looking at
patient with
interest.
Patient: shows
facial expression
changes when
talking about how
school was for
him.

Minimal
encourager

Interested
and focused

He has a lot
to talk about,
I hope I will
be able to
remember
our
conversation.

Allowing
patient to
open up on
his feeling
and talk
about how
school made
him feel by
listening to
him. Not
interrupting
him while he
was talking.
Showing
good
listening
skills.

That must have been SN: Facing

very stressful for you patient with face
of concern and
understanding
It was

Empathic
statement

Sad

That seems
so unfair that
he went to
such a well
known school
and did well
academically
but did not
come out with
a good
experience.

Allowing
patient to
know that I
was listening
and
interested in
what he had
to say.

open-ended
question

Interested

Hoping he
takes time for
himself and
has plans to
get better

Focusing on
treatment to
get better
and focusing
on concerns
of discharge
instead of
just asking
him if he has
any concerns
for being
discharged.

Patient: Looking
around the room
and then making
eye contact back
with me
What are your plans
after you are
discharged?
I will be going back to
my friends house in
Kahala. My friend is not
there, so I will help to
clean the place up and
do some laundry before
I go. I have to look for
someplace to do my
laundry because my
friend does not have a
place to wash his
clothes there.

SN: Facing
patient and
maintaining eye
contact
Patient: Calmly
sitting in chair and
maintaining eye
contact

You talked about

feeling unsafe and
having anxiety. Tell
me your plan to
prevent from feeling
that way again?

SN: Calm voice

and showing
concern

General
leads

Interested
and nervous

Hoping to get
him thinking
of things that
he will enjoy

Showing
concern and
learning if he
needs
additional
education on
ways to cope
with stress or
anxiety.

closed
question and
statement

Interested

His doctor
talked with
him about
being
discharged,
so I guess he
is going home
today.

Making sure
he doesnt
try to get
better on his
own. I think
a follow up
with he
doctor will
just help to
reassure him
that either he
is doing
better or
maybe he
could
suggest
additional
counseling to

Patient: Smiles

My plan is to go sailing,
to the beach, go movies
and hang out with my
good friends. I am also
learning how to
meditate.
Its important to
follow up after you are
discharged to make
sure you are getting
better. Do you have
follow up
appointments?
Yes, I just talked with
my doctor and he said
they will have me follow
up with a doctor after I
am discharged.

SN: Expressing
concern
Patient: nodding
his head

help him.

Its important to have

good support. Is your
family and girlfriend
aware you are in the
hospital?
I havent talked to my
girlfriend since they took
my phone away. I
haven't told my parents
because I dont want
them to worry. My sister
is a doctor and I told her
whats going on

"You seem to be
yawning a lot, are you
feeling okay?

SN: Maintaining Closed

eye contract,
question and
trying not to let
statement
people talking all
around to
distract me

Concerned
and
interested

What else
should I ask
him, before
my instructor
comes back
to get me.

I tried to put
it in a way
where it was
important for
him to not
keep
everything
bottled up
inside where
he might
breakdown
again.
Maybe I
could have at
this point
asked him
about his
relationship
with his
parents.

Concerned
and
interested

I hope he is
feeling okay.

Able to see if
he realized
he seemed
tired, maybe
it was
because he
wasnt
sleeping
well, but he
stated it was
the meds.

Patient: looks a
little down about
not wanting
people to worry
about him

SN: showing
concern

Patient: yawning
The medication I am
and going for a
taking makes me sleepy drink of water

Simple
observation

Seems like you had a

lot of stress build up
when you were in
school. And it sounds
like you know what
your triggers are and
you have a plan and
follow up to prevent
you from feeling
overwhelmed and
anxious again. I hope
you follow up with the
doctor. Thank you for
allowing me to talk
with you. Have a safe
flight back home and
take care.
Thank you, I enjoyed
talking with you also.
Take care.

SN: Facing
patient and
smiling.
Patient: Smiling
and making eye
contact. Facing
me.

Summarizing

Relief and
happiness

I am glad that
he was so
easy to talk
to. I hope I
covered all
the important
points. I
know there is
room for
improvement,
but I think this
went pretty
well.

I wish I could
have thought
of more
questions to
ask. I felt
more of the
talking I did
with him was
not pertinent
to his
diagnosis
and with
more
practice I
think I can
improve on
talking with
my patient.

Transcribe the nurses and the

clients communication
verbatim onto the PR template
form. Clients words are in
regular font. Your words are in
bold. Maintain confidentiality.
Do not use your patients or
others name in the process
recording.

Write a description of
any action or
nonverbal activity that
occurred. Clients is
regular font and yours
in bold font.

1.

2.

3.

Study the
exchanges
and label
your
interventions
by type of
skill used in
the
Techniques/
Skills
column. If
what you
said is not a
skill, then
dont label it.
Note use
of silence in
the nonverbal
communicati
on column
and properly
label in the
Techniques
Column.
If you
make a
communicati
on error,
state
communicati
on error and
type which
one in this
column. (i.e.
communicati
on error
why
questions)

List your
feelings (no
thoughts) as
you experience
them
throughout the
interview in the
Student
Feelings
Column (i.e.,
sad, angry,
helpless, afraid,
frustrated etc.)

Put in writing
your unspoken
thoughts as the
interview is going
on ( i.e., I hope
she opens up,
otherwise it is
going to be really
hard to talk to
her or she is
looking down, I
wonder if she is
upset with me?)

For each
verbal
response you
make to the
client, identify
whether it is
therapeutic (T),
or nontherapeutic
(N). An
alternate
response is
required every
time your initial
response is not
therapeutic.
This alternate
goes in the
analysis
column.

This is where
you can
demonstrate
critical thinking
skills. It
provides you the
practice of
rethinking your
communication
and
demonstrates
that you have
the ability to
correct your
errors.