NURS323 Mental Health Nursing

Written Assignment - Process Recording

Student Name_Adam King_________________________________________________________________________________Date______3/6/18__________

Patient Information and History __42yo male. Visiting the CC to get away from abusive and drug using girlfriend______

Purpose of Conversation_To get to know the patient and let them know that I care (build rapport). Also, to seek for any way that I can help them._____

Interviewer Patient Responses Nonverbal Response Communication Technique Analysis (Patient Nursing Interventions
Statement/Questions by Patient Feelings/Affect, Needed
Effectiveness)
Hi, is your name <stated name> Slumped, reserved Introductory Reluctant but willing to
<name>? My name is posture, patient at least recognize
Adam. Nice to meet looking ahead and not introduction and
you. at me answered question.
I’m a student nurse “okay” Slumped, reserved Stating purpose of conversation Recognized statement
here today, and I was posture, patient but seemed
hoping I could get to looking ahead and not uninterested.
know you. at me
You seem depressed. <Silence> Slumped, reserved Making observation Brief glance showed
posture, patient me he heard me but
glanced at me for a may not want to
brief second. respond.
How are you feeling <pause> “Sad, angry, Slumped, reserved Asking question directly to get Answered Need to assess for
right now? depressed, worthless, posture, patient information. straightforward. suicidal ideation, or
powerless” looking ahead and not Multiple words used, potential harm to
at me so he seems in tune others.
with how he feels.
Tell me about what’s <pause> My girlfriend Slumped, reserved Open ended statement, to After pause, he
making you feel this has been using drugs posture, patient allow patient to tell me what answered openly and
way. and alcohol, been looking ahead and not he wants. told me about his
aggressive, been at me situation.
abusing me, and
hasn’t been the same
for the past several
months. I just want my
old girlfriend back. I
feel depressed about
his whole situation, I...
NURS323 Mental Health Nursing

...was hoping she’d

change by now, but
it’s only gotten worse.
I’m here not because I
just needed to escape
for a little.

That sounds very <pause> No, I don’t Slumped, reserved Assessing for suicidal ideation Answered with Need to look deeper
difficult. Does this think so, I just want posture, patient or want to harm others. hesitation, and gave into suicidal ideation or
make you want to my old life back before looking ahead and not answer with valid want to harm others.
hurt yourself or she started the drugs at me reasoning.
anyone else? and became an
alcoholic.
When you said ‘I <pause> No. I just feel Slumped, reserved Clarifying Answered
don’t think so’, does down and want my old posture, patient straightforward
that mean you are life back. looking ahead and not
considering hurting at me
yourself or others?
Okay, if you ever feel “Ok.” Slumped, reserved Informing patient Brief acknowledgment
that you would like posture, glanced in my that I spoke. He may or
to harm yourself or direction. may not have heard
others, please let me entirely, but he
one of the staff sounded sincere.
know. We are here
to help, and if you let
us know what is
going on inside your
head we will be
much more equipped
to assist you.
When you said She hits me and says Slumped, reserved Clarification Made clear he doesn’t
earlier that your extremely rude things posture, patient have intentions of
girlfriend abuses you, when she’s at her looking ahead and not hurting her.
what did you mean peak of drug use. I at me
by that? don’t dare hit back
though because I
don’t want to harm
her because I know
NURS323 Mental Health Nursing

she isn’t being herself.

I don’t know how to
fix this, I don’t know if
I can.
Thank you for telling Not really, but I’m Slumped, reserved Offering self Patient seems to know
me about your fairly hungry. I’d like posture, patient what he wants, but
situation. That lunch soon if possible. looking ahead and not may have a hard time
sounds really at me getting it outside of the
difficult. Is there CC. He showed he is
anything that I can aware of his feelings.
do to help you feel at
least a little better
right now?
Okay, I’ll go see how “okay, thank you” Slumped, reserved Informing patient about my He showed
soon we can get you posture, looks in my future actions gratefulness with his
lunch. Thank you general direction. words. May have just
again for talking to been polite as he is
me about your pleasant to converse
situation. If there is with, but it may have
anything else that we been sincere.
can do for you while
you’re here please
don’t hesitate to tell
us.

Analysis
1. Identify presenting issues. Include the client’s cognitions (basic beliefs about self, others, and the world) and the impact those had on you.
Patient states he feels he is worthless and powerless. He loves his girlfriend, but she appears to enjoy her drugs more than she loves him. “I feel
depressed about his whole situation, I was hoping she’d change by now but it’s only gotten worse”
2. Identify any recurring themes and patterns, if applicable.
This is the patient’s first time visiting the CC, and he states his problem has be occurring for “the past several months”. He said “okay” several times,
and didn’t seem to respond more than just a simple “ok” when provided information.
3. What cultural factors were you aware of during the interaction? How did these factors influence the session?
His ethnicity is Native American. His culture may have been a factor in him not looking directly at me except briefly.
4. What specific observations should the nurse make with regard to mental status? Thought processes?
Assess for fidgeting, poverty of words, posture, logical sentences, confusion, self esteem, judgement, reliability, mood, affect, attitude, speech,
behavior, coping skills, stressors.
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5. How did the patient’s behavior/affect fit with what you know about their past behavior/affect?
He talked very, very quietly. The way he spoke expressed he was feeling depressed. His eyes were bloodshot, and appeared to be on the verge of tears,
or had just finished crying before I talked to him. His past behavior of depression was shown during our conversation with his posture and statements.
6. What are two issues that emerged?
He wanted things to go back to the way before. He stated he doesn’t know how to fix it and is unsure how he can fix the situation. He was ineffectively
coping, he was not doing anything about it. He stated he came to CC just to “escape for a little”. Escaping isn’t a solution to the problem, it is simply
post-pones the future. It can provide rest and safety, but besides that he is unsure of how to fix the problem.
7. What were your thoughts and feeling about the interaction?
I felt bad for him. He is in a difficult situation because of the choices a loved one is making. I know of the difficulties that can come with drug abuse by a
loved one, and it is not easy to cope. I thought the interaction went very well. He was pleasant to talk to, and recognized the current conversation. I
feel that my responses and questions were sufficient, as it offered support, showed caring, and gave the patient a chance to say what they would like
to.
8. What are the goals and functions of the therapeutic nurse-patient relationship? Explain if you feel you were able to establish a therapeutic relationship?
The goals and functions of a therapeutic nurse-patient relationship are to establish rapport, and let the patient feel cared for. Yes I think I was able to
establish a therapeutic relationship. I showed the patient I cared about them, listened attentively, and offered myself to help.
9. What were the boundaries and roles in this relationship?
The boundaries should be professional, confidential, and the patient should be allowed autonomy and dignity. These types of boundaries keep
conversations civil, allow for plans of care to take place, and let the patient know who is there to help. The roles of the relationship is for the nurse to
care for the patient, and the patient to have someone to talk to about problems openly without criticism or judgment.

Reflection:
1. What behaviors did you exhibit that you would want to change, based on the experience?
During the conversation, my voice was more monotone that I would have liked it to be. I felt that I said many of the right things at the right time, but
without the correct intonation, it can be less effective. I also think that I should have let the patient talk more. Allowing a bit more silence after their
statements would likely be beneficial to the patient, in case they had not completed their thought and had something else to say.
2. What are your feelings about the interview process?
I felt that the interview process is a well-designed method to allow the patient to speak and say what they need to. It is a great platform for the nurse
to learn about the patient, establish a therapeutic relationship, and build rapport. When I implemented the interview process, I felt that it allowed the
patient to be asked the right questions to promote open-ended responses. This is hugely beneficial, as sometimes it is difficult to get patients to
adequately answer our questions.