Processing Recording 1 (1) .LGreen

NURS. 152 Instructor: M.
Crisler
PSHCHIATRC MENTAL HEALTH NURSNG
PROCESS RECORDING # 1
Students Name: Lynnette Green
Date and Time of Meeting: September 17, 2010 @8:40-9:03 am
Patient's Initials: VJ Gender: Female Age: 57 years Unit: PICP
I. DSM-IV Diagnosis:
Axis I: Bipolar Disorder
Axis II: Deferred
Axis III: Hypertension
Axis IV: Patent lives with her spouse. She is a retired phlebotomist. Patient has a long history of mental illness with last
hospitalization in 2004. She recently stopped taking her medications to return to the unit, per patient. She feels that her family
are too involved in her life, frequently asking her to stop smoking and calling to confirm medication usage. She babysits her
grandchildren frequently as well. She wasn’t sleeping at night, about two hours nightly. She feels she has no control as
everyone tells her what to do.
Axis V: GAF (estimated) 45

NURS. 152 Instructor: M. Crisler
II. Two Nursing Diagnoses:

1. Risk for injury related to poor insight and judgment evident by loud, agitated, and confrontational behaviors with perceived
lack of control and excitability. (Varcarolis page 289)
Nursing Interventions Scientific Rationale Outcome

Evaluation
List assessments, collaborative, Describe the basis for your actions

Indicate if the intervention was
independent and teaching related and reference from your texts or
implemented and the effect toward
actions. Include who, what and articles
reaching the goal written above
when.
1. RN to use a firm and calm Structure and control provide a VJ was placed in a non-demanding VJ was placed in PICP. There were no
approach with patient. patient who is out of control with environment, allowing her to calm demands placed on her. She calmed
feeling of security. w/o due stimulus, as she was told and allow for her medications.
only what was expected of her
2. RN to be consistent with Consistent and clear expectations VJ was non- argumentative with All staff very congruent with
all staff in interactions minimize manipulation of staff. staff and compliant with their interaction with VJ.
with patient. request.
3. RN to encourage the Lack of sleep can lead to Patient was tired and laid herself VJ was allowing rest periods for her
patient to rest throughout exhaustion and death. down to sleep after our interview. to recuperate.
the day. She was further taking medications
to help her to rest.
4. RN to provide patient with Opportunity to vent allows patent VJ vented her concerns and had VJ vented her concerns to SN. She
opportunity to vent and to express her concerns and gain made progress in resolving her was aware of her problem, but was
discuss her problems. assistance with resolutions to her reasons for placement. still not at a point to but an
concerns. appropriate solution into place.
2. Ineffective coping skills related to poor impulse control evident by noncompliance with medications. (Varcarolis page 289).
Nursing Interventions Scientific Rationale Evaluation Outcome

List assessments, collaborative, Describe the basis for your actions

Indicate if the intervention was
independent and teaching related and reference from your texts or
implemented and the effect toward
actions. Include who, what and articles.
reaching the goal written above.
when.
1.SN to administer prescribed Medications to stabilize mood state VJ is taking medication without Prior level of functioning was being
medications per MD orders. and restore patient to prior level of refusal. restored to patient with medication
functioning. compliance and therapeutic
intervention.
2.RN to encourage patient to relax. Fatigue can increase restlessness, VJ was in a stress free location. Stress level was decreasing and VJ
and slow thinking process. was more in control.
3. RN will listen to messages and Relief is gained through VJ wanted to talk. She wanted to VJ was already expressing self to
ask patent to express her plans for communication; allowing venting ease her mind and seek resolutions all who would listen; she was more
success. and response is caring expressed to to her concerns. stable and eager to resolve her
patient. concerns.
4.RN to help patient to question Counseling services allow for VJ was expressing her concerns, During interview, VJ wanted to
underlying beliefs and consider exchange of appropriate ideas and and knew what she wanted to do to have her family involved n her
alternative to problems. cause direction in inappropriate of resolve her issues; however she did plans for discharge. Her spouse was
healthy thought plans. not know how. notified and request to come to
family visit. VJ wanted to express
her concerns and resolve her issues
as a family.
III. Context and Mental Status Exam:
My patient and I met in the common area of PICP; I was assigned to her on this date, as my other patient was discharged. She sat
across from me. She is a Black female; she is alert and oriented times three. She was well groomed and in non-skid socks. She is very vocal
and is interested in knowing who I am, in particularly “my people” are. I ignore these statements and direct the conversation to her. VJ
appeared a little drowsy, but aware of her surroundings and what was happening to her. She had a liable mood. She was a bit defensive, and
excited. VJ appeared irritated or upset as well. I asked her, who she was, the day, the date, our location, our city, our state, and our current
president. She answered all questions appropriately. She further completed a math problem for me mentally. The problem was (10+31)-3-3-
3=32. She answered the problem correctly. My patient is alert and oriented times three. She told me that she was here because her family
would not “let her be”; they stayed in her business. This was the recurrent theme of our later conversation. Her delusion was that people in her
business or trying to dictate her life. In fact, it appears that her family was trying to be supportive. My patient, VJ, saw it as too much and
overbearing. She displayed no other impaired thought processes. However, her judgment was impaired and her insight towards her family was
lacking. Her beliefs were negative towards them. She perceived them as a burden and bothersome.
I asked VJ, if I could interview her privately, as I needed to asker her a few personal questions. She suggested her room, for her
interview. Per patient, she was tired, but willing to talk. She insisted, as she had not recently had any company. She gestured and invited me
to sit down on her bed with her, as no chairs were present in the room. The patient sat first and later laid- down dorsally, with her hands
coupling her face, later during the interview. My goals for this interview was to find out why she had a negative perception of her family;
impact that perception if it was incorrect and assist my patient in changing that thought. MY goal for my patient was to assist her in finding a
proper outlet to address her problems versus admissions to St. Mary’s hospital.
IV. Processing Recording :

Verbatim Recording of Interaction: (SN= student nurse; PT=patient)
Verbatim Recording of Client's Verbatim Recording of Student's

Analysis of Client's Behavior Critique of Interaction (and Process)
verbal/nonverbal interaction Verbal/Nonverbal Interaction
Patient and SN sitting on side of bed at Patient appears calm. Manic stage of For therapeutic conversation, we sat at
25 degree angle. illness has decrease considerably, since 25 degree angle; we sat very close. This
hospitalization. She was receptive to may have been intrusive to her personal
SN: Hi. My name is Lynnette. I am a conversation and relaxed with SN. space. There was no environmental
student nurse at RCC. How are you noise; the door was open.
today?
PT: I am fine now that I got my head Patient was attentive and calm. Sitting in close proximity was not
on my shoulders. negative for patient as she was
interested in talking. She had no
concerns with our relationship, as I
identified myself as a student.
SN: What do you mean by that? Clarification of abstract statement was

(Brows raised, facing patent) requested to be sure we had the same
understanding. Body communication
showed misunderstanding.
PT: Girl, I need to lie down (She Patient addressed me as girl. She My patient was relaxed. She positioned
repositioned herself on the bed on her placed both of us on the same level; I herself on her bed as though she knew
stomach.). did not appear as authority to her. writer “forever”. She laid down with no
regard to defense. She was calm. She
may be not interest in the interview.
Processing Recording
SN: Okay, go ahead and I’ll come back Writer conveyed understanding of need
in a bit. to rest.
PT: Naul (no)! Go ahead I wanna talk. Mixed signals. Writer assumed that she Again, writer assumed patient was not
My feet hurt. I need to lie down. was tired and wanted to rest. She just interested. Her posture showed me that
laid down with no regard of my she was ignoring my presence, but
presence. She just wanted to talk. spoke otherwise.
SN: (Student nurse stood and leaned Writer leaned over table to have better
over bedside table and lowered to eye contact with patient. Again we
patient’s face height) What brought you were in close proximity, however
to the hospital today? Are you sure you patient had her eye closed most of the
do not want me to come back? time talking. Position showed interest
in the conversation.
PT: I want to talk to you. My feet hurt. Patent put her feet up to get Patient showed interest in the
You see. I need to put them up. comfortable. This was her home or conversation. She was looking at writer
environment. She was at ease. and gesture I stay.
SN: (Looked at patient’s feet and Writer observed patient’s feet for care
observed open callus like areas on both needs. Action showed concern in her
feet) Are you diabetic? well-being.
PT: (Eyes opening) Nobody told me I Patient concerned about her feet. Physical characteristics of observable
was. autonomic response to self-
preservation. She was concerned about
her feet.
SN: Okay. Just asking. I‘ll tell the Verbal expression of the situation being
nurse about your feet’s condition, when in control and managed, presents
we are done. comfort to patient. Her need will be
met. There is no need to worry.
PT: Okay. Might as well get the **** Verbal expression of agreement and
done since I’m here (Patient rose up receipt of message.
and sat on the bed with her lips poked
out)!
SN: Sounds like a plan. (Smiling at May have projected disgust in delaying
patient) Can we talk now? (unsure).
PT: Go ahead (laid back on bed). Relaxed Normal tone; open to conversation. Her
behavior allowed SN to lead.
SN :( Leaning over the table) Why are Posture again showed concern and eye
you here? contact showed interest.
PT: Cause everybody is n my business. PT displayed that she was upset. Patient’s behavior showed that she was
I can’t do damn thing cause everybody upset. She had facial grimaces and
is trying to tell me what to do (facial rigidity of her posture.

grimaces, eyes closed).
SN: Okay. Why do you think that? Accepting displayed and giving a broad
opening for more information.
PT: You can’t smoke; you can’t do this Patient was expressing feelings. Patent was giving information about
or that! (In a loud voice) her family life and why she was here.
Raising her voice showed her anger
with her issues.
SN: But why do you think they are in Exploring the cause of their concerns
your business? that lead to her frustrations.
PT: Because they love me. Processing her family’s reason for their Processes family action, but was not
actions. ready to accept it.
SN: You’re probably right. SN should not have showed agreement.
This is giving approval. This can lead
to pleasing behaviors.
PT: They want what’s right for me, but Continued to show frustration and Agreeing with patient increased her
I get a right to live like I want to. My express her rights to do so. intensity of speech about it. She
own life, no matter if I’m crazy or not. continued to talk about her life and
doing as she pleases.
SN: (Puzzled look) That’s true, but Writer attempted to redirect the
how did that get you here? Living your conversation to the cause of admission.
own life? Attempted time line of admission.
PT: I stopped taking my medications. I Patient was very much aware of her Patent was accepting of her behavior.
knew that not taking them would get reason of placement and her diagnosis. She was giving information.
me here. You see, I’m Bipolar. Been so
all my life; since I can remember.
SN: So have you always taken Focusing on medication concerns.
medication for your bipolar disorder?
PT: Yes and it’s pretty good. Hell, I Patient redirected conversation back to Client was focusing on a single
was smoking all my life. But if I wanna her venting concerns about her family. pertinent concern of hers.
go out and get ****-up on the streets, I
can. They worry “the sh*t” out of me.
Don’t smoke. I can’t figure it out. They
do what they want, but not me.
SN: When did you start smoking? Focusing on one subject.
PT: I started smoking as a kid. Rolled Reminiscing to direct conversation to a
up cotton in paper and smoked it. It period where we can discuss her family
burned my throat, but I liked it. w/o loud profanity.
SN: What does smoking do for you? Exploring the patient’s need for
smoking.
PT: Smoking calms me, myself. I love Patient continued to express what was Patient was scattered in her
me some Newport’s. My daughter says happening to her related to her illness conversation, but summarizing events
that I love Newport’s more than my and smoking. of her home life. She was giving
husband. She doesn’t know. information.
SN: How does your husband feel about SN attempted to explore the
you being here? relationship of PT and spouse.
PT: He thinks I’m faking (lips Patient continued to express what was Patient continued to show that she was
puckered). He doesn’t believe in mental happening to her related to her illness upset. Patient continued was scattered
illness. He tells me to quit it. Quit and smoking. in her conversation, jumping subjects.
faking. Stop doing this.
SN: How do you feel about this? Attempting to get patient to express her
feelings. Broad statement.
PT: Makes me mad. He don’t do PT continues to be upset, while taking Patient continued to argue about her
nothing, but sit in the bed wiggling his about spouse. spouse and look at him negatively.
feet. Writer listened attentively, allowing her
to lead the conversation.
SN: Does he work? Unnecessary question; probing

PT: Yeah! ADM and Aramark. I don’t Anger was displayed when talked about Resident was very negative about her
get enough money to support myself. I spouse. She was angry with him as he spouse even though he sustained them
retired a few years ago from here. I’ll was involved in her getting better and financially.
tell you if he ever put his hands on me ,
sustaining from further psych visits.
I’d kill him (eyes closed).
Verbatim Recording of Client's Verbatim Recording of Student's Critique of Interaction (and
Analysis of Client's Behavior
verbal/nonverbal interaction Verbal/Nonverbal Interaction Process)
SN: Is violence a problem for you? Probing for additional concerns.
PT: Not anymore. MY ex-husband Clarification of additional concerns.

did hit me.
SN: Would you like to see your Writer attempted to probe patient
husband come in to family meeting more. Attempted to seek what she
(Looking at patient who is desired of him.
scratching skin very hard)?
PT: Yes, but he will not. I got this Patient is able to express her needs. Patient was aware of her medical
eczema and I am itching all over. problems and her medication
I’ve had it all my life. My smoking reaction to patch.
patch irritated my skin too. I can
use it to stop smoking.
SN: (Looked at dry area) If he is Encourage patient to invite spouse in an

invited to a meeting will he come; effort for him to be supportive and
invited by hospital staff? resolve their issues.
PT: Yes I know they love me. But they Patient acknowledges her family’s
have got to let me do what I can concern, but wants to be independent. I
whether right or wrong. felt sorry that she had to admit herself
to a psych unit to get this satisfaction.
SN: This is something you can discuss Actively listening, but avoided the
with him in a group family session. So subject. Attempted to pulling out the
are you going to ask your family to idea that this is what she desires as
come? well.
PT: I will, but he probably won’t come. Firm on here decision that smoking is This needs to be shared with her family
I am not gonna smoke till I’m ready to not an option as she enjoys this. as she feels strong about it and is not
quit (laughing). willing to stop.
SN: Well, what have you learned from Summarizing our conversation and
this hospitalization experience? clarifying resolution.
PT: I had 33 years at this hospital. (Up Patient again clarified herself and gave
in bed) Five years Vista volunteer and insight that she is not ignorant. But a
worked for job corps. I’ve learned that I mature adult.
do not want anybody n my business.
And if you do not, then do not tell
anyone your problems. I told people
my problems and they are in my
business.
SN: This sounds like a plan. Sounds Judgment of patient’s action was not
awesome that you got a plan. What appropriate, but I gave positive
would you do without family help for feedback, as she is progressing.
problems?
PT: Call my doctor (eyes opened)! Summarizing our conversation and
clarifying resolution.
Verbatim Recording of Student's
Verbatim Recording of Client's Verbal/Nonverbal Interaction Analysis of Client's Behavior Critique of Interaction (and Process)
verbal/nonverbal interaction
SN: For marriage issues? Re
PT: Call a marriage counselor! Patient is pleased wither decision. She Patient had appropriate resolution to
is looking forward to resolving her
problems with the demand of others on her issue.

her.
SN: (Smiling at her) Sounds like a plan, Acknowledging her progress and
and for your mental health concern? showing support. This s therapeutic.
PT: My counselor. She seems confident in her decision. Patient had appropriate resolution to
her issue.
V. Medication Grid of VT:

Name/Dose/ Classification Expected Therapeutic List: Teaching points
Route Effects Nursing Implications
Adverse Effects
Trazadone HCL Antidepressant; Increases total sleep time. Teaching points: Inform patient that relief may
(Desyrel) Psychotherapeutic Sleeping inducing agent or take up to 1 week, do not alter dosages, limit
50 ml PO HS sedation. alcohol, no OTC drugs, and notify all DM of
medication prior to services.
Nursing Implication: Penile erectile sues,

changes in alertness, monitor BP and pulse rate,
and
Adverse effects: Drowsiness, light-headedness,
impaired memory, chest pain, HTN, nasal
congestion, dry mouth, weight gain, and sexual
dysfunctions
Clonidine Antihypertensive; Decreases BP by and heart Teaching point: Nurse to teach patient to change
(Catepres ) 0.2 Analgesic rate by inhibiting A- positions slowly, do not stop medication w/o MD
mg PO HS adrenergic receptors in CNS. order, do not use drugs other than prescribed, and
no OTC drug.
Nursing implication: Monitor BP, monitor
I&Os, weigh daily, may lead to further depressive
states; monitor for depression.
Adverse effects: Hypostatic BP, peripheral
edema, dry mouth, sedation, drowsiness, agitation
and skin irritation.
Risperidone Atypical; Effective in controlling the Teaching points: Teach patient to monitor blood
(Risperdal) Psychotherapeutic S/S of schizophrenia by glucose levels, wear sunscreen and learns adverse
4 mg PO binding to dopamine effects and notify MD immediately if they occur.
2000Clonidine receptors. Nursing Implications: Monitor for glycemic
(Catepres ) 0.2 control in diabetics, monitor for confusion or
mg PO HS changes in cognitive status, and monitor labs of
CBC, electrolytes, and blood glucose levels.
Adverse Effects: Photosensitivity, V&D, dry
mouth, abdominal pain, DM, hyperglycemia,
UTI, retention of urine, and sexual dysfunction
for males.
Lithium Mood Stabilizer; Inhibits neurotransmitters Teaching Point: Teach patient that medication
Carbonate Psychotherapeutic; causing changes in facial makes contraceptives ineffective, monitor activity
450 mg PO BID and Antidepressant effects, improved posture, with usage, monitor sodium intake, drink plenty
improved ability to of water, and monitor for excessive output.
concentrate, and improved Nursing implication: 1-2 weeks before
sleep pattern. therapeutic, monitor for toxicity, monitor I&Os,

hypothyroidism, EPS symptoms, and monitor
thyroid function.
Adverse effects: Dizziness, lethargy, restlessness,
peripheral circulatory collapse, N/A, tremors,
edema, and flu-like symptoms.
VI. Genogram
Attach a drawing of the patient's genogram that includes information on parents, grandparents, siblings, children,
brothers, and sisters-look for multigenerational transmission patterns. The genogram should include ages,
diseases (medical and especially psychiatric), habits, jobs, sibling order, and deceased relatives.
VII. Evaluation of Interaction

1. What were major nonverbal and verbal themes? In other words, what was the patient telling you non-verbally, as well as verbally?
The patient was lying on the bed for most of the interview. She had her eyes closed and did respond to all of my questions. My first
interpretation was that she was not interested, but she said she wanted to talk. As we discussed her situation, she rose-up and would
change posture. Her facial grimaces and expression told me, how irritated and upset she was with the situation. She opened and closed her
eyes and showed her frustrations. I believe that her verbal and non-verbal cues were congruent, but she was tired as she expressed initially.
2. How would you describe the interaction in terms of the phase of therapeutic relationship and the characteristics of this phase?
Our communication session did have an opening phase (orientation), middle phase (working), and termination phase. We began with an
explanation of my reasons to talk with her, prior to the process recording. I tried to direct the conversation, to focus only on her. Prior to
the process recording, she desired to ask me questions; I believe it may have been important to her to know, who I was, as well as my
purpose. I believe our roles were clearly defined; she was to be interviewed and not be the interviewer.
3. Did you use a variety of the therapeutic communications skills? What skills did you use the most/the least? Why? What suggestions for
improvement do you have for yourself?
During our conversation, I used broad openings to encourage her to talk. I gave her information, as to the purpose of the conversation.
Getting her to open up was difficult, as she desired to sleep and was tired. To encourage her to talk, I also tried to lead her through
reflection, exploring, focusing, and restating. I desired for her to look at her situation and reflect back on it to see where her loss of control
was coming from. I believe she had identified this , with her family being to involved, that it was in a sense “choking” her; this lead her to
stop her medication and be placed in the hospital. Getting her to explore her problems was the challenge. She could not see a better way to
help herself, than to stop her medication; this was disheartening. I felt that she still did not find a constructive solution to feeling
overwhelmed by her family, and hence would return. She did identify her smoking and medication compliances were their concerns; this
is probably an ongoing issue with her and her family. She frequently jumped subjects. Wow! Keeping her focused was a challenge. I think
our conversation was all over the place. She wanted to vent and complain; I wanted to identify the problem and seek a resolution. Our
focuses were not congruent. I did allow her to vent to settle; this seemed important to the patient. So, I tried to allow her to lead with me
passively controlling the direction and flow of the conversation. Prior to terminating the conversation, we restated her possible solutions.
This was in an effort to clarify this understanding between her and me. I hope she had somewhat of an understand of this part of her
possible resolution.
4. Were your goals met: For the patient? For you, the SN?
My goals for the patient were the following:
1. Help my patient to identify one of her problems: Reason for admission.
2. Assist my patient to see any underling issues related to that problem.
3. Assist my patient in developing an appropriate resolution to the problem.
My goals for myself were the following:
1. Be mindful and of assistance to my patient in resolving an issue: Reason for admission.
2. Do no harm to the patient
3. Finish process recording
5. What goals do you have (for the patient and for you) for your next interaction (if you could meet again)?
My only follow-up with this patient would be that she utilized her plans. Even if the plan is flawed or wrong, she did at least
attempt to utilize it. I believe as health care professional, we all want what is best for our patient. But, it they cannot or will not put their
plans for success in action, they cannot progress. Only through action can they see that their “plans of resolution” will work or need to be
scraped. I believe that we get a chronic visitor to the psychiatric unit, because no action happens once patient leave the hospital. People
(patients) go back to their environments and resume, where they left off; the plan does not happen.
My goal for myself would be to seek a better resolution for her. I tend to tie my success into outcome. This can be unhealthy and
cause loss of reward and job satisfaction. My goal would be a health care sponsor for her. This does not exist. Perhaps this is a starting
point. Perhaps sponsors would be good for those experiencing mental health issues as with substance abuse. The one on one individual
attention may be what some need to get them over and through difficult continuation and maintenance phases. In this patient’s case, this
could have been a big help, as she sees no bond with her family, particularly her spouse. An outside support would have been idea.

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NURS. 152 Instructor: M.

PSHCHIATRC MENTAL HEALTH NURSNG

Students Name: Lynnette Green

Date and Time of Meeting: September 17, 2010 @8:40-9:03 am

Patient's Initials: VJ Gender: Female Age: 57 years Unit: PICP

Axis I: Bipolar Disorder

Axis II: Deferred

Axis III: Hypertension

everyone tells her what to do.

Axis V: GAF (estimated) 45

II. Two Nursing Diagnoses:

Nursing Interventions Scientific Rationale Outcome

List assessments, collaborative, Describe the basis for your actions

Nursing Interventions Scientific Rationale Evaluation Outcome

List assessments, collaborative, Describe the basis for your actions

III. Context and Mental Status Exam:

IV. Processing Recording :

Verbatim Recording of Client's Verbatim Recording of Student's

SN: What do you mean by that? Clarification of abstract statement was

met. There is no need to worry.

is trying to tell me what to do (facial rigidity of her posture.

SN: Does he work? Unnecessary question; probing

PT: Not anymore. MY ex-husband Clarification of additional concerns.

SN: (Looked at dry area) If he is Encourage patient to invite spouse in an

SN: For marriage issues? Re

problems with the demand of others on her issue.

V. Medication Grid of VT:

Nursing Implication: Penile erectile sues,

sleep pattern. therapeutic, monitor for toxicity, monitor I&Os,

VII. Evaluation of Interaction

improvement do you have for yourself?

My goals for the patient were the following:

1. Help my patient to identify one of her problems: Reason for admission.

2. Assist my patient to see any underling issues related to that problem.

3. Assist my patient in developing an appropriate resolution to the problem.

My goals for myself were the following:

1. Be mindful and of assistance to my patient in resolving an issue: Reason for admission.

2. Do no harm to the patient

3. Finish process recording

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