Process Recording- Example (1)

 

PROCESS RECORDING Circumstances (Description of environmental setting and major reason for interaction, significant data prior to interaction suc as, ave !ou tal"ed to tis client #efore$% &is is te first time I've encountered te client at te itteral )ouse* Since te client loo"s fairl! !oung, and !ounger tan oter residents at te facilit!, I've figured e +ould tal" to me if I approaced im* &e client +as in te "itcen at te time  (+as e doing someting at tat time$%, time$% , and e agreed to tal" to me so +e +ent outside to cat* a cat* ass tere oter people around$ Do ou ave enoug privac!$ -ccording to te client, e is ne+ to te ouse and tr!ing to fit in +it te residents tat are alread! tere*

.eeling tone  Nurse/s0 I +as feeling a little little an1ious as it +as m! first time tal"ing to a client one2on2one at te itteral )ouse* )o+ever, I +as a+are of m! emotions and I "ne+ I needed to calm m!self do+n #ecause as an1iet! increases, m! a#ilit! to focus narro+s, and it +ouldn't #enefit me nor te client* &us, I +as a#le to calm m!self do+n "no+ing tat I needed to get m! assessment done torougl!, and made tis interaction as terapeutic as possi#le, and I reall! felt comforta#le tal"ing to te client +en +e started interacting +it eac oter* Great* Self2 a+areness is important #efore approacing te client*

Client/s0 &e client +as ver! cooperative and +illing to open imself up during te interaction* )e +as also ver! engaging* During te assessment, e stated feeling out of place at te itteral )ouse #ecause a lot of te residents +ere older tan im and e +asn't familiar +it San 3ose* In addition, e +as feeling +orried #ecause e got "ic"ed out of is parents ouse, and e doesn't "no+ +ere to go once e gets out of ere* Indeed, uncertainl! leads to a iger level of an1iet!* an1iet!* It gave te SN a cance to elp elp out* 4nit milieu0 &e interaction +it te client too" place outside te itteral )ouse, and +e sat on te #enc* &ere +ere minimal to no noise levels, and it provided te privac! te client needed  #ecause tere +ere a lotsection, of people te ouse* paragrap circumstances%* In tis !ouinside ma! +ant to sa!(&is someting a#outcan temoved itteraltoouse suc as it is a #oarding facilit! for te mentall! ill +o just step out from te ospital* &e average sta! for te client is 5 +ee"s* &e main purpose of teir sort sta! is 66 P!sical description of client0 &e client is a 57 !ear old 8ietnamese and Caucasian male* )e's a#out 9' 9: or 9' ;,: and e is +earing a +ite &2sirt, &2sirt, #lac" #as"et#all sorts, and slippers* I noticed some mar"s on is forearms +en I soo" is ands* It +ould #e #etter if !ou can include te client level of self2care and ealt condition in general suc as does e ave pro#lem +it mo#ilit! and<or perceptions* Goals  Nurse2centered0

 

-% &e nurse +ill activel! listen to te client to identif! issues of concerns, and to e1plore is tougts and feelings* =% &e nurse +ill gain an in2dept understanding of te client's perception of te issue, and foster empat! in nurse2client relationsip* Client2centered0 It +ould #e nice if tis section is focusing on te current interaction +it Client2centered0 It te client* -% &e client +ill sare and discuss is pro#lems +it addiction during is sta! at te iteral )ouse* =% &e client +ill remain safe trougout is sta! at te iteral )ouse, +itout arming self*

S4>>-R? &emes perceived in interaction0 During te interaction, te client e1pressed is concerns regarding +ere e +ould #e going once e g gets ets out of iteral )ouse* -t times, e seemed an1ious a#out it, and I suggested sugg ested tat it +ould #e #est for im to tal" to te staff at iteral )ouse as to +ere e +ants to go* go * -lso, anoter teme tat I notice from te interaction +as te client's reali@ation of is mista"es* Client +as a#le to admit is +rongs, and o+ is coices in life ave led im to attempt suicide* >oreover, e so+s tat e's read! to move for+ard, and fi1 is  pro#lems*

Evaluation in terms of goals  Nurse2centered goals -% &e nurse +as a#le to identif! te client's concerns and issues tat are #otering im #! listening attentivel! and using appropriate terapeutic communication tecniAues* =% &e nurse +as a#le to give emotional support and positive attitudes to te client to increase is sense of self2+ort* Good

Client2centered goals -% &e client ac"no+ledged is addiction and participating in te treatment plan* =% &e client reported no suicidal tougts and demonstrated logical, realit!2#ased tougt Good  processes*

References to teor! 2 Buote a paragrap from !our te1t#oo" tat descri#es o+ a client +it tis diagnosis +ould usuall! communicate* communicate* Include autor and page num#er*  Nurses #egin to elp clients relinAuis denial first first #! esta#lising relationsips #uilt on trust* trust* &reating clients respectfull!, respectfull!, maintaining a nonjudgmental attitude, and e1amining personal attitudes to+ard su#stance use are critical components of care* &o elp clients confront denial, nurses respectfull! #ut firml! present evidence of te severe d!sfunction tat as resulted from su#stance a#use* E1amples migt #e jo# losses, financial pro#lems, estrangement from famil! and friends, and legal difficulties* .or e1ample, te client ma! state tat su#stance a#use +as a +a! to deal +it pressures at +or"* Instead of s!mpati@ing +it tis rationali@ation, te nurse

 

can point out tat su#stance a#use pro#a#l! compromised te client's jo# performance (>or, p* ;%* Content of te interaction0 ver#atim during te interaction including ver#al and non2ver#al interactions IN&ER-C&ION  N4RSE2CEN&ERED CIEN&2CEN&ERED (8ER=- -ND NON8ER=-% -N-?SIS -N-?SIS SN0 )ello, o+ are !ou doing$ -re !ou ne+ ere$

Esta#lis rapport =road opening*

>0 )e!, !up* Came in ere !esterda!* SN0 >! name is in, and I am a student nurse from San 3ose State 4niversit!* e are doing a ps!ciatric<mental2ealt clinical rotation at tis ouse, and is tat o"a! +it !ou if +e go outside and cat for a little #it$

Spontaneous response* Introuduced self< Introu suggested a Auite environment and private  place #ecause tere +ere a lot of people in te ouse** 8er! good ouse

>0 O !ea, sure man, let me just gra# m!  jac"et* I am >att #! te +a!*

-ppeared friendl! and +illing to tal"*

(soo" ands, and noticed some mar"s on client's arms% So tell me o+'ve !ou #een doing, >$ -nd +ould !ou li"e me to address !ou as >att$

Giving #road openings< So+ing respect to client as to o+ e +ants to #e  8er! good addressed 8er! addressed

?ea, !ou can call me >* ell, I am doing o"a!* I am just tr!ing to fit in +it all

Cue tat someting is  #otering im and e

tese people in tis ouse*

rolled is e!es*

I see, can !ou tell me o+ are !ou feeling tat +a!$

Offering general leads< Getting clarification 8er! good* E1pressed +at's  #otering im and appeared to #e an1ious* It is a good start* &e client is +illing to sare is pro#lem*

It's just tat people tat live ere are older tan me, and I don't "no+ tis neig#orood* Plus, I just came in !esterda! so I am still tr!ing to adjust, !ou "no+$ 42u* )ave !ou tal" to an!one in te ouse$ I ave tal"ed to some residents

Empatetic response<Encouraging

ere and te! seemed reall! friendl!*

client to interact +it

 

I ave onl! tal"ed to a couple of people,  #ut I just came ere !esterda! so I +ill tr! to get to "no+ tem* ?ea, I follo+ +at !ou said, and I tin" ?ea, !ou +ould feel more and more comforta#le eac da! living ere* Reassurance I ope so*

oters* See"ing oters* information

-ccepting<Empatetic response Rea Reass ssurance urance

(9 seconds pause% So !ou said !ou came ere !esterda!* Do !ou mind telling me o+ did !ou end up ere$

=rea"ing te silence* .ocusing on client's  pro#lem to gater more data* .ocusing on ere and no+* 8er! good*

I +as a 9597 #ecause I attempted suicide and I failed* &en, te! too" me to aiser Santa Clara* No+ tat I loo" #ac" at it toug, it +as stupid of me to tr! to ta"e m! o+n life* I see* &ell me more a#out it as to +! are !ou feeling tat +a!$

i"e o+ I felt stupid for doing it$

E1pressed is reali@ation of te mista"e and loo"ing a+a! at te street and not ma"ing e!e contact* E1ploring anted a nted to find out more a#out +! e attempted suicide, #ut I felt li"e I need to reflect is emotion and conve! empat! for no+*

42u* I mean I am still !oung and I reali@e tat it's not +ort it for me to ta"e m! o+n life  #ecause I ave time to fi1 all m!  pro#lems* .irst of all, I need to fi1 te relationsips +it m! famil! #ecause I am noting, #ut trou#le for m! parents and loo" +ere I am at no+ #ecause of m! drug addiction* I ain't got no place to go  #eside ere, and te! don't +ant me #ac"*

ting$ ting$   Did im$ te SN agree +it -llo+ing te client to tal" +itout interrupting*

I see* &e people tat +or" ere at te iteral )ouse can elp !ou +it +ere

Does te client reall! tin" e did a stupid

Empatetic

-gain, not ma"ing e!e contacts +it me and loo"ing at te street* Client started to open imself up more* ?ou ma! move te nonver#al part to te first colume*

 

!ou are going +en !ou leave* )ave !ou tr! tal"ing to tem !et$ If not, +e can go inside and tal" to tem*

response<Offering information tat ma! elp client* client* 8er! good* Information saring*

I ave* &e! mentioned to me a#out a group ome or some "ind of selter* e e +ill see, I am going to tal" to tem a#out

Does te client feel guilt! a#out is  #eavior$

it* Of course, I'd rater live at m! o+n ouse, !ou "no+* =ut I ave alread! given so muc trou#le to m! parents* &an"s toug*  No pro#lem, >* It's m! pleasure, So earlier, !ou said !ou ave drug addiction* )o+ did it start$ refocusing

?ea* Started in ig ?ea*  ig scool +en I #ro"e m! collar#one* I +as a#out F #ac" ten and te doctor prescri#ed me a #ottle of 8icodin* 8icodin* I reall! enjo!ed te ig I get from it, and tat's o+ it all started* Overtime, I started injecting m!self +it te needles* 42u* I see* at appened ne1t$

Didn't +ant to come off as pro#ing, #ut at te same time, I +anted to gater more data and it so+ed m! interest to te client*

Client revealed a#out is past and is speec  #ecame slo+er tan Offering general leads<  placing te events in time earlier* Does te SN ave an! assumptions seAuence and elps me a#out tis$ follo+ and understand +at's going on Good*

I got "ic"ed out of te ouse (client cuc"led%* &en, I +as outup onliving te street +it no mone! and ended +it te eroin drug dealer* >! addiction got +orse +ile living +it im #ecause e +ould so+ me +ere and o+ to get te drugs* )o+ did e feel a#out tis$ O I see* -re !ou still getting6(client interrupted% =ut I did >etodone deto1 for a#out a mont and it +eaned me off of narcotic addiction* It +as a turning point for me and it +as curing m! addiction* I ave

&r!ing to "eep te conversation going +it general leads

Client cuc"led in a sarcastic +a! +en e said e +as "ic"ed out of te ouse* iving +it te drug dealer furter deteriorates is addiction*

 

 #een on te maintenance for almost a !ear and a alf no+*

o+* &at's reall! good, >* Good jo#H So +ere !ou still living +it te eroin dealer   prior to !our attempted suicide$  No, I +as #ac" living +it m! parents tan"s to tat Deto1 program* &e! +ere nice enoug to let me #ac" in, #ut ten I came to reali@e o+ muc of a mess I am and I +anted to end m! life* O I see* )o+ +ould !ou descri#e !our relationsip +it !our parents #efore !our addiction$ e +ere fine* e +ere one app! famil!,  #ut I tre+ a+a! all tat #ecause I +anted to get ig* It sounds stupid, and it +asn't +ort it* I just +is I made #etter coices* -re !ou planning to tal" to !our parents again in te future$ at do tin" !ou sould do$

Positive reinforcement<Encourage

Client +as smiling and appeared e1cited and

ment< Refocusing* Refocusing* e1cellent

 proud*

-n! triggers to is tougt a#out ending is life$

&r!ing to find out is relationsip +it is  parents #efore te addiction** E1ploring is addiction supportt s!stem* 8e suppor 8er! r! good*

Client +as sa"ing is ead and loo"ing a+a!*

Encouraging formulation of a plan< )elping te client pro#lem2solve* ver! good*

I am* I +ill tal" to tem eventuall! even tuall!,, just not rigt no+* i"e I said, I still ave time to fi1 tings and ma"e tings rigt* et's go #ac" inside* I am going to go #ac" upstairs to get m! soes*

Cange su#jects* Is it too ard for im to tal" a#out is famil!$

Sure* &an"s for letting me tal" to !ou and an d ta"ing te time to cat +it me*

Client reali@es is addiction +as te cause of is damaged famil!  process*

?our +elcome*