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Process Recording in Psychiatric Nursing, Assessment Example

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In psychiatric nursing, a process recording is an instrument employed in diverse formats to scrutinize nurse-client interaction. The instrument focuses on non-verbal and verbal interaction and is utilized to train communication skills to student nurses in the clinical setting. Student –client role play situations are one technique utilized to familiarize students with the process recording (Bostrom et al., 2007, p. 89).

Client’s Personal Data

Name	J.K.
Age	28
Sex	FEMALE
Civil status	SINGLE
Educational attainment	UNIVERSITY

Patient: J.K. is a 28 year old African immigrant in the U.S. The patient is a Muslim and has recently divorced single. She is currently pursuing a post graduate diploma in Architecture in some university. The patient is being hospitalized for the first time in a Behavioral Health Unit. However, she sees a psychiatrist every day due to strong feelings of depression. She has been hospitalized as a result of the psychiatrist’s advice. The patient is on record as having suicidal intentions. This is from some comments she made in a therapy session. This was the core reason for the psychiatrist’s advice concerning her immediate hospitalization. Several months ago, the patient experienced a rape ordeal, in a college all-night party. This formed the basis of her husband’s grounds to seek divorce. Consequently, the patient has suffered high levels of depression and stress that has made her disoriented even from her job. Her employer has asked her to choose between her job and her troubled private life, the university administration has also asked her to explain her plummeting academic performance. Upon admission to the hospital yesterday, the patient was diagnosed (Axis I) with Major Depression (DSM Code 296.30). J.K has not been diagnosed with any personality disorders (Axis II) and neither any general medical conditions (Axis III). Environmental and psychosocial problems (Axis IV) related to J.K are Post Traumatic Stress Disorder (PTSD) from the rape ordeal on (DSM Code 309.81) along with family-life disruption (DSM Code V61.0) and work-related conflict (V62.2). The patient has been found to have a Global Assessment of Functioning (Axis V) score of 30.

Date of Interaction: July 25, 2011

Process Recording #3

Your thoughts and feelings prior to the interaction: I have not had any interaction with J.K prior to my assignment. I therefore check with her nurse in charge. The nurse in charge has not had much interaction with the patient, but sates that J.K is on the unit for depression, as well as suicide related ideations. The nurse also finds the patient approachable and open-minded. This puts me in a relaxed mood hoping I will be able interact with the patient on a therapeutic level. I desire that J.K will feel comfortable talking to me about her problems. Bearing in mind that the patient and I are in the same age bracket, I am confident that she will be at ease and open in our interaction. I visit the patient’s room, where I find her lying on her bed with the lights out. She is in the company of her roommate, with whom she is having a chat. I call her name, and when she responds I ask her if she would like to come to the day room and with me.

Setting: I choose the day room to talk to the patient because it is a large open room, and would accord us some measure of privacy since there are very few people occupying it at the time. The room is appropriate since distractions would be minimal. The lighting in the room is very bright compared to the room the patient just came out of. I hope this does not make her uncomfortable. I let the patient choose a place to sit, and she picks two chairs which are together, but away from the rest of the group.

Patient: J.K is wearing clean clothes that she brought from home. She is very fresh and put together. The patient appears a lot younger than 28 years old, and comes across as pleasant. She has a smile on her face, and seems ready to talk. J.K keeps eye contact with me throughout the interaction which really shows me she is listening and comprehending what I am saying. While talking to her it feels like I am just chatting with one of my girlfriends. Her ability to socialize is way more developed than many of the other patients on the unit.

Patient Diagnosis (es):

Diagnosis(es)

Goal

Outcomes

Nursing Diagnosis #1:

Managing well, ineffective, related to job, family and social stressors as evidence by making suicidal threats during therapy session.

Manage stressors and depression more effectively.

#1: By the conclusion of the therapeutic interaction the patient will be able to identify four factors which increase her stress levels.

#2: By the conclusion of the therapeutic interaction the patient will be able to identify two ways in which she can effectively deal with stressors.

Patient Medications:

Medication name: generic (Brand)	Reason doctor prescribed medication for this patient	What goal does the patient have that medication will help them achieve	Main side affects of the med, is patient experiencing any of these SE, what can the patient do to avoid or decrease SE
lorazepam, (Ativan) 1 mg PO once a day prn	Ativan is an anti-anxiety medication prescribed for irritability and anxiety in organic or psychiatric disorders.	This medication potentiates the actions of GABA, specifically in reticular formation and the limbic system. In turn it will decrease feelings of anxiety.	ECG changes, tachycardia, apnea, cardiac arrest (Mosby, 2008, p. 639-40).Blood and hepatic studies must be monitored for a patient taking this medication. It is vital that Ativan is taken with milk or food to avert GI disturbances.
alprazolam, (Xanax) 2 mg PO once a day	Xanax is an antianxiety medication used to ease the patient’s anxiety levels.	Xanax depresses sub cortical levels of the CNS, as well as the limbic system. It works in dropping the patient’s anxiety.	ECG changes, tachycardia (Mosby, 2008, p. 107-8). This medication ought to be taken with food and must not be taken with over the counter medications. Slight drowsiness may take place, so patients must avoid driving or related activities that need alertness. Steer clear of alcohol use.
diazepam, (Valium) 10 mg PO once a day	Valium is an antianxiety medication used to ease the patient’s anxiety intensity.	This medication potentiates the actions of GABA especially in the limbic system. This works to decrease anxiety in patients.	ECG changes, tachycardia, neutropenia, respiratory depression (Mosby, 2008, p. 362-63). The patient must take this medication with milk or food for GI symptoms. Hard candy, sugar-free gum, and regular sips of water will assist with dry mouth. Blood and hepatic studies must be evaluated in a patient on this medication.
bupropion, (Wellbutrin) 200 mg twice a day	Wellbutrin is an antidepressant used to decrease depressive feelings in patients.	This medication hinders the reuptake of dopamine, therefore, lessening the depression levels in patients.	Suicidal ideation, seizures, complete AV block. Stevens-Johnson syndrome (Mosby, 2008, p. 208-9). This medication must be administered with foods or mild for GI symptoms, and must not be used at night to avoid insomnia. Avoid alcohol use while on this medication.

The Process Recording:

Patient Communication

Nurse Communication

Analysis of Process

Instructor’s Comments

“Hello J.K it’s nice to meet you. Sure, can we have a chat in the day room if you do not mind?”

(The patient looks at me straight in the eyes) “I feel fine, and way better than yesterday. I think I am ready to go home. I surely don’t need to be in this place any longer”

“Well, I feel like I let all my feelings pile up to the brink of despair. I needed time to refresh my mind and think about issues. ”

“My job has been stressing me for the past three months. My boss now disrespects me, and I know I need a new job. But, my brother and I are the providers for the entire family, so I can’t just quit my job. The rape ordeal is another issue that stresses me most. It lead to the divorce, and I just cannot concentrate with my studies anymore ”

“Yeah I let them pile up way too much. I was meeting the psychiatrist, and I got really distressed and felt like to despair. I said to the psychiatrist that I wanted to ‘have an end to all of it’. She recommended immediate hospitalization. I let everything pile up and get me distressed, that I uttered those words sub consciously.”

“My mom and I are very close. I trust her and she is someone that I feel the most comfortable talking to.”

“Yes, my mother is a very good listener, she is my closest friend. That sounds like a good idea to me, and something I could work on immediately.”

(In the hallway after I called the patient out of her room) “Hello J.K, I am Jane and I am a nursing student from The Orthodox University. Would if we had a chat today?” (Establishing rapport, non- therapeutic)

“Yeah, that is great. So how are you feeling today?”(non-therapeutic)

“What was different between your feelings today and yesterday?”

“You said that you wanted to refresh your mind, what kind if issues were worrying you?”

“So you allowed stressors from your and family, college, the rape ordeal, and your job pile up? Then what went on?”

“It seems you comprehend what happens when you allow your stressors to ‘pile up’. Do you have someone such as a member of your family or a friend that you could confide in next time you are feeling this way?”

“Yeah its true, moms are very good listeners. Maybe you could start confiding in your mom more often about your stressors. This way, they will not pile up like previously.”

I am sure that this will turn out to be a positive interaction just from the patient’s first statement to me. J.K seems attentive and well aware of the surroundings. She seems conversational and able to hold an intelligent conversation.

Encouraging comparisons: (Therapeutic) Asking for the resemblance and disparities between behaviors, feelings, and events (Bostrom et al., 2007, p. 93).

This therapeutic technique will assist me in understanding what was going on in J.K.’s life prior to being hospitalized without having to ask her “What brought you here”. In my opinion, that question is intimidating to patients.

Restating: (Therapeutic) Repeating the patient’s precise words with the intention of reminding the patients of their utterances, to assure them that they are being listened to (Bostrom et al., 2007, p. 93).

Questioning: (Therapeutic) Using open-ended inquiry to accomplish relevance and depth in the discussion (Bostrom et al., 2007, p. 93). I am of the opinion that questioning is a good approach which facilitates the patient to tell the nurse more about his or her story.

Encouraging the formulation of a plan (Bostrom et al., 2007, p. 94). (Therapeutic) This is a positive statement, the patient talking about her feelings more when they start to overcome here. By having someone to talk to about life stressors, J.K. can take steps to outlining a plan on what to do in similar circumstances in her emotions.

I believe that the patient really appreciated my proposal, and I am confident that J.K. will benefit from it. Talking to J.K. was very special. This patient was open to conversing about her past with me, and she definitely took some advice from this interaction.

Summary of the Interaction:

J.K. was much easier talking to, unlike other patients I have talked to previously. Usually it gets to a point in the interaction where I am uncertain what to tell the patient. In my interaction with J.K., this did not occur. I am confident that it is because the patient’s responses to my questions were more conversational and interactive. The theme of the verbal interaction was on the stressors in the life of J.K. and the coping mechanisms she could adopt, to deal with the issues. This theme assisted the patient since she was subsequently able to talk about areas of her life which need some intervention. As an example, J.K. appreciates that if she is discontented with her job, then she should now get a new one. The feeling prevalent in the discussion was one of optimism. She recognizes that the manner in which she handled stressors previously was insufficient, and she will henceforth try new methods to deal with the anxiety.

The objectives of this communication were accomplished. The patient was consequently able to talk about four areas of her life which increase her stress level, those being the rape ordeal, her university studies, her family and her job. The other objective was to come up with two ways in which the patient could manage her stressors. Two management techniques discussed during the interaction include not letting her feelings build up as previously and by talking about her feelings more often with someone she trusts such as her mother.

Works Cited

Bostrom, C.E., Keltner, N.L., & Schwecke, L.H. Psychiatric Nursing 5^th Edition. Philadelphia, Elsevier, Inc. 2007.

Skidmore-Roth, Linda. Mosby’s 2009 Nursing Drug Reference. St. Louis: Mosby, 2008