Process Recording Form - Communication Across the Curriculum ...

Date: 4/22/2013Student's Name: Jesse BishopPROCESS RECORDING FORMDescription of Interaction setting: The conversation took place in the psychiatric nurse’s personal office with the clientand nurse present. The window blinds were open and the door was closed to ensure a private and quiet setting. Lightswere comfortably dim.Environment: Environmental temperature is slightly warm. Client is sitting in an office chair across from me on theopposite side of the wooden desk.Pt. Goal/Purpose: The goal is for the patient to explain progress of treatment since discharge from the inpatientpsychiatric facility and to express concerns related to ongoing psychological issues.Patient's Gender: F Age: 51 Diagnosis: Axis I Schizoaffective Disorder Type II Axis II: Deferred Axis III: None

COLUMN-1 COLUMN-2 COLUMN-3 COLUMN-4 COLUMN-5 COLUMN-6Student’s verbalstatements(exact quotes)Student’s nonverbalbehaviorClient’s verbalstatements(exact quotes)Client’s non-verbalbehavior“Hi, my name isJesse Bishop and Iam a nursingstudent at Lone StarCollege –Montgomery. Howare you feelingtoday?”Relaxed and openposture, legsuncrossed, leaningtowards client.,maintaining eyecontact.“Oh, I guess I’mdoing okay. Justfollowing up since Iwas hospitalized.”Arms crossed atchest, looking at wallto her right, rapidlyand rhythmicallytapping right foot.Communicationtechnique used.DesignateFacilitators (F) OR(B) Barrier and namethe type(F) – “Givinginformation”(Videbeck, 2011, p .103).Evaluation (asdescribed intextbook)and/orRevisionGiving informationbuilds trust with theclient and allows theclient to know whatto expect during acommunicationsession.“Alright. I noticedthat you are tappingyour foot. Are youanxious aboutsomething?”“Okay. Is thereanything inparticular that youfeel you need to talkabout today?”Relaxed and openposture, legsuncrossed, leaningtowards client,maintaining eyecontact.Relaxed and openposture, legsuncrossed, leaningtowards client,maintaining eyecontact.“No, it’s just hard forme to sit still. I’malways on themove.”“Umm, I don’t know.Sometimes I just feellike I’m losingcontrol of myself.”Arms crossed,maintaining eyecontact, rapidly andrhythmically tappingright foot.Arms folded in lap,maintaining eyecontact, rapidly andrhythmically tappingright foot.(F) – “Makingobservations”(Videbeck, 2011, p .103).(F) – “Broadopenings”(Videbeck, 2011, p .102).Allows clients toverbalize feelings or“make themselvesbetter understood”(Videbeck, 2011, p . 103).Also encouragesclients to talkBroad openingsencourage the clientto take the leadwithin theconversation,especially when theclient is hesitant(Videbeck, 2011).

“You feel like youare not always incontrol of yourself?”“What were theevents that led up toyourhospitalization?”Relaxed and openposture, legsuncrossed, leaningtowards client,maintaining eyecontact.Relaxed and openposture, legsuncrossed, leaningtowards client,maintaining eyecontact.“Yeah, I’ve felt thatway since a fewweeks before I wasput in the psychward.”“Well, my boyfriendand I started fightinga lot until I finallytried to kill him.”Arms folded in lap,looking at wall to herright and the ceiling,rapidly andrhythmically tappingright foot.Arms crossed atchest, maintainingeye contact, legscrossed.(F) – “Restating”(Videbeck, 2011, p .103).(F) – “Placing event intime or sequence”(Videbeck, 2011, p .103).Allows client toknow whether or not“they effectivelycommunicated theirideas andencourages them tocontinue” (Videbeck,2011, p . 103).Helps the “nurseand the client seeevents inperspective”(Videbeck, 2011, p . 103).and recognizetrends regardingcause-and-effectbehavior.

“Why did you try tokill your boyfriend?”Tense but openposture, legsuncrossed, leaningtowards client,looking down atdesk.“He just made meso angry and I justhad it in my mindthat that was theright thing to do. Henever seemed likehe wanted mearound and I wasn’tgoing to see himwith anyone else ifwe split up. I had thechainsaw in myhands andeverything until afriend of minestopped me. Ipromise you I wasgoing to kill him. Itwas definitely goingto be a bloodbath.”Arms folded in lap,looking down athands andoccasionallyestablishing eyecontact, legsuncrossed, rapidlyand rhythmicallytapping right foot.(B) – “Requesting anexplanation”(Videbeck, 2011, p .106).Requesting anexplanation with a“why” question maymake the client feellike they need todefend themselves(Videbeck, 2011).Revision:“How do you feelabout your attemptat killing yourboyfriend?”

COLUMN-1 COLUMN-2 COLUMN-3 COLUMN-4 COLUMN-5 COLUMN-6Student’s verbalstatements(exact quotes)Student’s nonverbalbehaviorClient’s verbalstatements(exact quote)Client’s non-verbalbehaviorCommunicationtechnique used.Designate Facilitators(F) OR (B) Barrier andInterpretationAnd/orRevision“Before thisincident, had youever felt this kind ofanger before?”“So, what do youthink you could doin the future to avoidtrying to kill him if hemakes you thatangry again?”Relaxed and openposture, maintainingeye contact, legsuncrossed, leaningtowards client.Relaxed and openposture, maintainingeye contact, legsuncrossed, leaningtowards client.“Actually, he’s mademe that angry plentyof times before but Ijust never acted on ituntil then.”“Oh, I’m not sure. Ireally don’t plan onever seeing himagain, but I guess I’dprobably go to afriend’s house until Iwas able to calmdown and think alittle more clearly.That’s what I used todo before.”Arms folded in lap,head down andlooking at hands,feet and legs still.Arms folded in lap,maintaining eyecontact, feet andlegs still.name the type(F) –“Encouragingcomparison” (Videbeck,2011, p . 102)(F) –“Formulating a planof action” (Videbeck,2011, p . 102)Comparisons of pastideas and experiencesencourage clients tothink about effectivecoping mechanismsutilized in similarsituations.Formulating a plan ofaction increases thelikeliness of the clienteffectively coping withsimilar situations inthe future (Videbeck,2011).

“I think that might bea good plan.”Relaxed and openposture, maintainingeye contact, legsuncrossed, leaningtowards client.“Yeah, it might keepme out of trouble.”Arms crossed atchest, maintainingeye contact, rapidlyand rhythmicallytapping right foot.(B) – “Agreeing”(Videbeck, 2011, p .105).Agreeing with theclient prevents themfrom being able tochange their mindabout their decisionwithout feeling likethey are wrong(Videbeck, 2011).“Can you think ofany other ways thatmight help you copewith youremotions?”Open and relaxedposture, maintainingeye contact, legsuncrossed, leaningtowards client.“Well, the doctorchanged mymedicine around, soI’m hoping that’llhelp me deal withmy problems. Otherthan that, I don’tthink so.”Arms folded in lap,maintaining eyecontact, feet flat onthe floor and legsare still.(F) –“Formulating a planof action” (Videbeck,2011, p .102).Revision:“Has that worked foryou in the past?”Formulating a plan ofaction increases thelikeliness of the clienteffectively coping withsimilar situations inthe future (Videbeck,2011).

“Okay. So, in thepast few minutes wehave talked aboutalternative ways todeal with yourchanging moods,including takingyour medication asprescribed andstaying away fromyour boyfriend whenyou become angry.Is there anythingyou would like toadd?”“You’re welcome.Remember to callthis clinic or thecrisis hotline if youfeel like youremotions arebecoming toooverwhelming. Thecrisis hotline isavailable 24/7. Havea good day!”Open and relaxedposture, maintainingeye contact, sittingup straight.Standing,maintaining eyecontact, armsrelaxed at sides.“No, I think that’s it. Iactually feel a littlebetter now that I’vebeen able to vent toyou. Thanks.”“Thank you somuch! I alwaysforget about thecrisis hotline.”Arms at sides,maintaining eyecontact, smiling, feetflat on the floor andlegs are still.Standing,maintaining eyecontact, armsrelaxed at sides.(F) – “Summarizing”(Videbeck, 2011, p . 104).(F) – “Givinginformation” (Videbeck,2011, p . 103).Summarizinghighlights theimportant pieces ofthe conversation andeliminates theirrelevant informationdiscussed.Summarizing alsohelps organize thediscussion as well asprovide a closure tothe conversation(Videbeck, 2011).“The nurse functionsas a resource person”(Videbeck, 2011, p . 103).Giving informationbuilds trust with theclient.ReferenceVidebeck, S. L. (2011). Psychiatric-Mental Health Nursing (5th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams& Wilkins.

Overall Self Evaluation:The process recording performed during the psychiatric rotation was startling, yet pleasantly different in context aswell as content. I feel like I have greatly improved my communication skills and strengthened my therapeuticcommunication since the completion of my last process recording. Although some of the client’s comments took me bysurprise, I believe I reacted well and adapted fairly quickly to the situation. I believe my strengths involve understandingthe client’s condition and how it may affect their thinking and behavior. I believe my weaknesses involve trying to relate tothe client on a more casual level as well as visibly reacting to somewhat shocking statements made by the client. Duringmy psychiatric rotation, I learned great information about fairly common mental disorders. In completing my processrecording, I realized how easily emotions, and even mental disorders, can be overlooked and confused with behavioralissues. As a society, we must recognize these types of disorders within our community and be able to accommodate thementally ill accordingly. Overall, I believe this experience has enlightened me and allowed me to think more deeply aboutthe causes of people’s behaviors instead of solely focusing on the behaviors themselves.