CT-CCNP Process Recording

Name Clinical Week -1- Behavioral Health DateCT-CCNPProcess RecordingMEDICAL/SURGICAL/PSYCH DIAGNOSIS:________________________________________________Bipolar NOS; alcohol abuse; obesity; auditoryhallucinations; cut wrist in suicide attemptPERTINENT NURSING DIAGNOSIS/DIAGNOSES____________________________________________________Ineffective copingSituation low self-esteemDisturbed personal identityImpaired social interactionSHORT TERM GOAL(S) interact appropriately with the otherkids on the unitSETTINGVERBAL & NONVERBALCOMMUNICATION:STUDENTVERBAL & NONVERBALCOMMUNICATION:CLIENTSTUDENT’S THOUGHTSAND FEEINGSCONCERNING THEINTERACTIONEVALUATION/ANALYSISOF THE INTERACTIONINCLUDE THERAPEUTICAPPROACH/TECHNIQUESAPPLIEDIt was themorningsessionfor school.The clientwas at theback ofclassroomsittingaloneawayfrom theothers. Iasked tosit next toher.Hello, my name is ___Canyou tell me your name?Client did not speak; her headwas directed downward; herhair was covering her face;very sullen looking.Client seemed sullen and didnot appear interested incommunicating with anyoneor did not know how to getstarted. I was scared andnervous, but felt that thisclient really needed someoneto listen and care andperhaps get her moving inthe direction of recovery.Giving recognition andacknowledging client“Is it okay if I sit with youfor a while?”Client looked up and nodded.She was not participating inthe school work and seemeddisinterested in what wasgoing on in the classroom.She made no attempt to reachout to others on her own.I was hoping that this wouldbreak the ice; she seemedinterested.Offering self“What kind of schoolactivities do you like toparticipate in?”She looked at me again andbriefly smiled before puttingher head back down. “Poetry.”Maybe we are makingprogress towards therapeuticcommunication; I am stillnervous, but becoming morerelaxed.Open-ended question“What kind of poetry doyou like?”No response. She lookedpuzzled by my question.I guess I asked the wrongtype of question. I need toclarify myself. I needed torethink my strategy.Exploring

Name Clinical Week -1- Behavioral Health Date“This says you are lonely.Who do you talk to athome or school?”“Nobody. I have no friends.”She looked sad.I was a bit nervous headinginto a sensitive area,especially since we were in aclass situation. There justwas no real privacyanywhere.Making an observation viaher poetry and exploring“You don’t talk to anyonein class or at home or atany of your activities.”“Your poetry isoutstanding. It reallyexpresses quite a lot.Have you tried sharingyour poetry with others orwriting to people?”At this point, I showed theinstructor her poetry andthe instructor said that itwas good work. Theinstructor then tried toencourage her to do morewriting via writingprompts to be more in linewith school work.“Nobody.” She looked sad“No.” A light seemed to goon in her head. “Can youshow my poem to theteacher?”“Can I submit my poem as myschool work?” She wasdirecting her question to theinstructor.This may not have been thebest opportunity to voicedoubt. It seemed to stunt theconversation again. Ithought perhaps poetry washer way of holding onto herprivacy and retainingcontrol. I struggled to find away to incorporate herpoetry into a means ofreaching out to others andhelping herself.I wasn’t quite sure wherethis was going yet. But Iwanted to encourage her tocommunicate with others onher terms – at least for now.I gave her a moment to thinkafter saying “No.”I considered this progress.She found a way to use herpoetry to express herself andto submit it as school work.This opened up some otheropportunities to speak withme and the instructor.Voicing DoubtI was attempting toencourage formulation ofan action plan (her shortterm goal was to interactappropriately with otherkids on the unit)After this she did speak a bit in class to me and the instructor (not the other students). The class ended shortly thereafter, but wasreconvened later in the afternoon – after the lunch time Staff Assist. I noticed that in the afternoon she sat with her peers andwrote another poem. She shared this poem with the student next to her and then to me. She, also, wrote a poem which she gaveto student X. I hope that she found sharing her words initially through poetry would open up a new world of communication andfriendship.