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Jason Barber N360 2/5/14 Patient-Centered Communication Process Recording Date of interaction: 1/22/14 Client age: 26 Client gender:

female Diagnosis: Psychotic Disorder LOS: 12 days

Dialogue (M=Me, P=Patient) M: Hello, my name is Jason. I am a Kapiolani community college nursing student. May I sit and talk with you for a while?

Patients Nonverbal Communication CommunicationTechnique Behaviors Patient is smiling and pacing around Introductory community room, Statement looks disheveled, and under weight.

Student Feelings

Student Thoughts

T/N Psychodynamics. Therapeutic or nontherapeutic

Analysis, student nurse reflection

nervous

I'm wanting to do this PR properly

My confident T - general mannerisms need opening statement improvement

P: Yeah, thats fine, whatever.

Patient sits down with legs crossed in chair facing me

relieved

I'm glad she agreed to talk to me.

Depersonalization loss of appetite, and worsened hygiene are symptoms of psychotic disorder T - Knowing how the patient is feeling will determine where the conversation goes, based on what concerns they are having at that moment and why

M: Okay, thank you. Tell me how are you feeling today.

I sit down next to her, turn towards her, and cross my legs

Open-Ended, general lead

curious

Let's see where this question takes her

2. I might have asked how she was feeling today compared to previous days in the hospital.

P: Im like super nervous because Im getting out today.

Patient is constantly tucking hair behind ears and looking around

intrigued

Is she nervous about relapsing or what else?

A symptom of psychotic disorder is being very anxious

4. I felt uncomfortable and distracted with her constant fidgeting and moving 2. "You are saying that you are nervous, explain that to me."

M: nervous?

I lean forward towards her

Restatement, Clarification Statement

T - This allows for further explanation and self evaluation

P: Yeah, Im getting discharged today and Im kind of like happy but scared, you know?

changes to sit with feet on floor, not crossed

confused

Did she find safety in the hospital?

Inability to sit still could be a side effect of antipsychotic meds- akathisia, or high level of anxiety T-I clarified my understanding of her statement and then added an open question to help us both identify what she was scared of.

I could have asked if she was scared of somebody or something in the hospital setting.

M: You say you are scared. What are you scared of?"

I readjust my posture and cross my arms

Restatement, Open-Ended

1. I could have used just a restatement here such as, "Scared?"

P: Im afraid I might fuck up again and use drugs again. M: Im hearing you say that you are nervous about relapsing. What stressors or triggers might cause you to relapse?

Patient quickly throws up her arms

sad

I feel sad for her struggle

3. Having a daughter, I felt closer and more concerned than with other (male) patients I feel this was an appropriate question at this point of the interview.

I uncross my arms and gesture to her

Clarifying, Open, Focused Question

curious

T - This will help identify stressors Why does she in order to avoid relapse? or manage them in the future

P: My friends and boyfriend use drugs, I'm homeless, anxious, my mind is all fucked up. Im sorry. It says I'm gonna to use again."

Patient is staring out the window

confused

Is that considered loose thought process

Disorganized thoughts are symptoms of psychotic disorders (tangentiality)

M: "Which of those concerns you the most?"

I lean forward to get her to look at me again and talk in a quieter voice

Open-Ended

confident

I feel sure this will lead to identifying the most important stressor

T - Question to identify the patient's most troubling stressor

3. Patient seemed to open up more when I leaned toward her and talked in a lower, concerned voice.

P: My brain, I'm weak, it tells me that Im no good and will use cocaine and meth again.

Patient taps head with palms

Is this just low selfconcerned esteem or something deeper I hope she better explains that comment

3. I was trying to Patient is blaming not be her actions on her judgmental. I brain as if it were was raised with a separate part of the belive that her. drug users chose to be such.

M: Uh-huh. Go on.

I have a concerned yet intrigued look on my face

Minimal Encourager

hopeful

P: I sometimes have to just tell it to shut the fuck up or go walk up and down the hall, that makes the voices be quiet. M: So you've found a way to manage the voices when you have them? P: Yes, that works for me. M: "Do you have any thoughts of harming yourself or anyone else?"

Patient gets up and walks a few steps, returns, then sits back down

intrigued

Patient's auditory Wow, she hallucinations are really has indicative of auditory psychotic hallucinations disorders

3. I had to fight my old stereotyped beliefs of those suffering from mental illnesses from interfearing with my compassion 2. I could have delved deeper into the voices she hears but time was limited.

tucking hair behind ear again

Clarification

intrigued

Can she really make the voices stop?

T - This allowed for confirmation that the patient manages her auditory hallucinations

Patient nods and smiles T - Although it's a closed question, it is therapeutic and needed to be asked for safety reasons I realize that this needs to be asked to every patient. Safety is a top priority.

Closed Question

P: "I sometimes get real angry with others and fight them but I dont want to do suicide or nothing like that. I know I'm supposed to tell somebody if I feel like suicidal or angry, right?" M: "Yes, please tell a staff member if you feel that way. As far as having a discharge plan, how do you plan on dealing with stressful triggers that may lead to drug relapse once you are out of the hospital?" P: "I'm going to a rehab place to get clean."

Patient had a smile on her face when talking about fighting others

relieved

At least she knows to tell a staff member if she feels SI/HI

Social withdrawal (observed by me in her social settings) and agitation are symptoms of psychotic disorder

I change my sitting posture to face her and put Open-Ended one arm up on the chair

pressured

I need to ask about her discharge plans now because she's getting out

T - Focusing on triggers and how to prepare to deal with them once she is out of the hospital setting

Patient has a confident smile on her face, readjusts her seating

glad

I'm glad she seems to be motivated to go to rehab

M: "What is your plan when faced with the urge to use drugs again?" P: "I talked with the counselor about that and they gave me a list of people I could call. I also have a sponsor, my psychiatrist, psychologist and can catch a bus to the hospital if I need to." M: "I noticed that you were in a drug rehab facility before and you left before completing treatment. Tell me about that."

Open-Ended

concerned

I'm not sure she's ready

T - This allows for self analysis of what to do if faced with the urge to use

Patient looks confident, and still constantly tucking hair behind ears

3. Her ability to list several This answer resources gave I'm impressed could be related me a good that she to the patient's feeling that she Impressed knows all of own agenda to get was taking this the resources out of the next chance at she can use hospital. rehab seriously, whether I was right or wrong.

Open-Ended

confused

I'm wondering why she left

T - This was intended to help understand how she will do once discharged to a rehab facility

P: "Yeah, my boyfriend didn't want me in there so I ran out. He just wanted to get high with me. That's when I went crazy for a few days before coming here." M: "It sounds like your boyfriend may not be the best person to be around when trying to stop using drugs. What do you plan on doing if your boyfriend does this again?" P: "He said he stopped using and will help me stop. He only uses cocaine and pot on occasion. I can't stop once I start until I get locked up."

Patient waves arms in the air, shakes her head, and smiles

Her boyfriend concerned seems to be bad for her

Delusions are a part of psychotic disorder. She thinks her boyfriend is helping her.

3. Having a mother, sister, wife, and daughter, I tend to want to defend females against abusive or corrupt men. This can lead me to jump to conclusions.

I noticed that I had tilted my head towards the patient (like my father used to do to me when correcting me)

Open-Ended

N - judgmental

5. Tell my how your boyfriend is a positive influence in your life when it comes to drugs.

Patient stands up and sits back down quickly

sad, helpless

She just doesn't get that her boyfriend is not helping her

M: "Would you consider him a negative influence on your goal of handling your drug addictions?"

Patient is staring out the window

Closed Question

P: "Well, I mean, Patient continues he loves me and to stare out the doesn't want me to window do drugs but."

sad

He doesn't love you if he's helping you destroy your life with drugs T-This allowed the patient to spend more time thinking about the question and come to the realization that her boyfriend may not be helpful in her recovery Disorganized thoughts are symptoms of psychotic disorders

2. I think I should have ask the patient about why she thinks her boyfriend loves her and yet causes her to use drugs.

M: "...But?"

Minimal encourager

afraid

I hope she realizes that he's a serious problem in her life

P: "Yeah, I guess maybe we might Patient's eyes are need some time beginning to tear off or something. I up need to get better first."

relief

Um, Yes. You need to get rid of him.

M: "It sounds like you know what you need to do in order to be Patient is wiping successful. Tell away tears but me what you smiling would tell him if he were to ask you to leave the rehab place again."

Open-Ended

4. The patient looking out the window and tearing up lead me to believe she was finally understanding that her boyfriend is not conducive to a positive outcome I'm glad she is starting to see the people and things she needs to be able to handle to get better

P: "I'd tell him to fuck off, oh shoot, sorry again. I'd tell We laugh at the him to leave me same time alone so I can get better."

relieved

M: "So in summarizing, it sounds like you know your strengths and weaknesses, along with specific triggers that lead to a path of drug use. Knowing this, how do you

I turn to face her directly with a more relieved expression on my face

Paraphrasing, Open-Ended

hopeful

I really hope this girl takes this recovery seriously

T - This allowed for a refresher on what we were talking about and to assess her feelings of anxiety compared to the start of the interview

feel about getting out of the hospital now?"

P: "Wow, I mean, I feel better. I'm still nervous as hell but I'm really going to try this time.

Patient quickly pulls up both legs to sit crosslegged facing me, smiling

sad

(I pictured my daughter) I pray that this is not my daughter's future.

4. The patient seemed to get excited about starting rehab again and seemed confident in her abilities to have a successful outcome with the resources she had 5. Tell me what resource you would reach out to first if one of the stressors we discussed should present itself to you.

M: "Just take it one day at a time. If you feel overwhelmed or weak, use your support resources that you told me about earlier. They are there for you... Right?"

Paraphrasing

N-I'm not there to give advice or interject my thoughts

P: "Yes, I guess. I'll try my best. I have to pray for help."

Patient looks up when talking about prayer.

surprised

I'm glad she has prayer to help her T - We were able to identify a similarity between us, giving her hope 4. My follow up response was going to be longer but the patient just quickly walked away.

M: "Okay. Well, I'll pray for you to find strength when Patient seemed you need it. Good relieved and less luck to you and nervous use your resources when needed. Patient stands up and shakes my hand with a smile and then quickly walks away

Self disclosure

hopeful

I hope and pray this girl can get her life straight

P:"Okay. Thank you. Bye."

M: "Thank you for your time. Goodbye."

sad, hopeful, weak

I wish I could personally help this person be successful. She will leave here today and I will probably never see her again. I'll always wonder if she made it.