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


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

List assessments, collaborative, independent and teaching related actions. Include who, what and when.

Scientific Rationale

Describe the basis for your actions and reference from your texts or articles

Evaluation

Indicate if the intervention was implemented and the effect toward reaching the goal written above

Outcome

1. RN to use a firm and calm approach with patient.

Structure and control provide a patient who is out of control with feeling of security.

VJ was placed in a non-demanding environment, allowing her to calm w/o due stimulus, as she was told only what was expected of her

VJ was placed in PICP. There were no demands placed on her. She calmed and allow for her medications.

2. RN to be consistent with all staff in interactions with patient.

Consistent and clear expectations minimize manipulation of staff.

VJ was non- argumentative with staff and compliant with their request.

All staff very congruent with interaction with VJ.

3. RN to encourage the patient to rest throughout the day.

Lack of sleep can lead to exhaustion and death.

Patient was tired and laid herself down to sleep after our interview. She was further taking medications to help her to rest.

VJ was allowing rest periods for her to recuperate.

4. RN to provide patient with opportunity to vent and discuss her problems.

Opportunity to vent allows patent to express her concerns and gain assistance with resolutions to her concerns.

VJ vented her concerns and had made progress in resolving her reasons for placement.

VJ vented her concerns to SN. She was aware of her problem, but was still not at a point to but an appropriate solution into place.


2. Ineffective coping skills related to poor impulse control evident by noncompliance with medications. (Varcarolis page 289).

Nursing Interventions

List assessments, collaborative, independent and teaching related actions. Include who, what and when.

Scientific Rationale

Describe the basis for your actions and reference from your texts or articles.

Evaluation

Indicate if the intervention was implemented and the effect toward reaching the goal written above.

Outcome

1.SN to administer prescribed medications per MD orders.

Medications to stabilize mood state and restore patient to prior level of functioning.

VJ is taking medication without refusal.

Prior level of functioning was being restored to patient with medication compliance and therapeutic intervention.

2.RN to encourage patient to relax.

Fatigue can increase restlessness, and slow thinking process.

VJ was in a stress free location.

Stress level was decreasing and VJ was more in control.

3. RN will listen to messages and ask patent to express her plans for success.

Relief is gained through communication; allowing venting and response is caring expressed to patient.

VJ wanted to talk. She wanted to ease her mind and seek resolutions to her concerns.

VJ was already expressing self to all who would listen; she was more stable and eager to resolve her concerns.

4.RN to help patient to Counseling services allow VJ was expressing her During interview, VJ wanted


question underlying beliefs and consider alternative to problems.

for exchange of appropriate ideas and cause direction in inappropriate of healthy thought plans.

concerns, and knew what she wanted to do to resolve her issues; however she did not know how.

to have her family involved n her plans for discharge. Her spouse was 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 verbal/nonverbal

interaction

Verbatim Recording of Student's Verbal/Nonverbal

Interaction

Analysis of Client's Behavior

Critique of Interaction (and Process)

Patient and SN sitting on side of bed at 25 degree angle.

SN: Hi. My name is Lynnette. I am a student nurse at RCC. How are you today?

Patient appears calm. Manic stage of illness has decrease considerably, since hospitalization. She was receptive to conversation and relaxed with SN.

For therapeutic conversation, we sat at 25 degree angle; we sat very close. This may have been intrusive to her personal space. There was no environmental noise; the door was open.

PT: I am fine now that I got my head on my shoulders.

Patient was attentive and calm. Sitting in close proximity was not 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? (Brows raised, facing patent)

Clarification of abstract statement was requested to be sure we had the same understanding. Body communication showed misunderstanding.


PT: Girl, I need to lie down (She repositioned herself on the bed on her stomach.).

Patient addressed me as girl. She placed both of us on the same level; I did not appear as authority to her.

My patient was relaxed. She positioned herself on her bed as though she knew writer “forever”. She laid down with no regard to defense. She was calm. She may be not interest in the interview.

Processing Recording


interaction


Interaction



SN: Okay, go ahead and I’ll come back in a bit.

Writer conveyed understanding of need to rest.

PT: Naul (no)! Go ahead I wanna talk. My feet hurt. I need to lie down.

Mixed signals. Writer assumed that she was tired and wanted to rest. She just laid down with no regard of my presence. She just wanted to talk.

Again, writer assumed patient was not interested. Her posture showed me that she was ignoring my presence, but spoke otherwise.

SN: (Student nurse stood and leaned over bedside table and lowered to patient’s face height) What brought you to the hospital today? Are you sure you do not want me to come back?

Writer leaned over table to have better eye contact with patient. Again we were in close proximity, however patient had her eye closed most of the time talking. Position showed interest in the conversation.

PT: I want to talk to you. My feet hurt. You see. I need to put them up.

Patent put her feet up to get comfortable. This was her home or environment. She was

Patient showed interest in the conversation. She was looking at writer and gesture I stay.


at ease.



interaction


Interaction



SN: (Looked at patient’s feet and observed open callus like areas on both feet) Are you diabetic?

Writer observed patient’s feet for care needs. Action showed concern in her well-being.

PT: (Eyes opening) Nobody told me I was.

Patient concerned about her feet.

Physical characteristics of observable autonomic response to self-preservation. She was concerned about her feet.

SN: Okay. Just asking. I‘ll tell the nurse about your feet’s condition, when we are done.

Verbal expression of the situation being in control and managed, presents comfort to patient. Her need will be met. There is no need to worry.

PT: Okay. Might as well get the **** done since I’m here (Patient rose up and sat on the bed with her lips poked out)!

Verbal expression of agreement and receipt of message.




interaction


Interaction



SN: Sounds like a plan. (Smiling at patient) Can we talk now?

May have projected disgust in delaying (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 you here?

Posture again showed concern and eye contact showed interest.

PT: Cause everybody is n my business. I can’t do damn thing cause everybody is trying to tell me what to do (facial grimaces, eyes closed).

PT displayed that she was upset.

Patient’s behavior showed that she was upset. She had facial grimaces and rigidity of her posture.




interaction


Interaction



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 or that! (In a loud voice)

Patient was expressing feelings.

Patent was giving information about 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 your business?

Exploring the cause of their concerns that lead to her frustrations.


PT: Because they love me. Processing her family’s reason for their actions.

Processes family action, but was not ready to accept it.



interaction


Interaction



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 I get a right to live like I want to. My own life, no matter if I’m crazy or not.

Continued to show frustration and express her rights to do so.

Agreeing with patient increased her intensity of speech about it. She continued to talk about her life and doing as she pleases.

SN: (Puzzled look) That’s true, but how did that get you here? Living your own life?

Writer attempted to redirect the conversation to the cause of admission. Attempted time line of admission.

PT: I stopped taking my medications. I knew that not

Patient was very much aware of her reason of placement and

Patent was accepting of her behavior. She was giving


taking them would get me here. You see, I’m Bipolar. Been so all my life; since I can remember.

her diagnosis. information.



interaction


Interaction



SN: So have you always taken medication for your bipolar disorder?

Focusing on medication concerns.

PT: Yes and it’s pretty good. Hell, I was smoking all my life. But if I wanna 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.

Patient redirected conversation back to her venting concerns about her family.

Client was focusing on a single pertinent concern of hers.

SN: When did you start smoking?

Focusing on one subject.

PT: I started smoking as a kid. Rolled up cotton in paper and

Reminiscing to direct conversation to a period where


smoked it. It burned my throat, but I liked it.

we can discuss her family w/o loud profanity.



interaction


Interaction



SN: What does smoking do for you?

Exploring the patient’s need for smoking.

PT: Smoking calms me, myself. I love me some Newport’s. My daughter says that I love Newport’s more than my husband. She doesn’t know.

Patient continued to express what was happening to her related to her illness and smoking.

Patient was scattered in her conversation, but summarizing events of her home life. She was giving information.

SN: How does your husband feel about you being here?

SN attempted to explore the relationship of PT and spouse.

PT: He thinks I’m faking (lips Patient continued to express Patient continued to show that


puckered). He doesn’t believe in mental illness. He tells me to quit it. Quit faking. Stop doing this.

what was happening to her related to her illness and smoking.

she was upset. Patient continued was scattered in her conversation, jumping subjects.



interaction


Interaction



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 nothing, but sit in the bed wiggling his feet.

PT continues to be upset, while taking about spouse.

Patient continued to argue about her spouse and look at him negatively. Writer listened attentively, allowing her to lead the conversation.

SN: Does he work? Unnecessary question; probingPT: Yeah! ADM and Aramark. I Anger was displayed when Resident was very negative


don’t get enough money to support myself. I retired a few years ago from here. I’ll tell you if he ever put his hands on me , I’d kill him (eyes closed).

talked about spouse. She was angry with him as he was involved in her getting better and sustaining from further psych visits.

about her spouse even though he sustained them financially.



interaction

Verbatim Recording of Student's

Verbal/Nonverbal Interaction



SN: Is violence a problem for you?

Probing for additional concerns.

PT: Not anymore. MY ex-husband did hit me.

Clarification of additional concerns.


SN: Would you like to see your husband come in to family meeting (Looking at patient who is scratching skin very hard)?

Writer attempted to probe patient more. Attempted to seek what she desired of him.

PT: Yes, but he will not. I got this eczema and I am itching all over. I’ve had it all my life. My smoking patch irritated my skin too. I can use it to stop smoking.

Patient is able to express her needs.

Patient was aware of her medical problems and her medication reaction to patch.



interaction


Interaction



SN: (Looked at dry area) If he is invited to a meeting will he come; invited by hospital staff?

Encourage patient to invite spouse in an effort for him to be supportive and resolve their issues.

PT: Yes I know they love me. But they have got to let me do what I can whether right or wrong.

Patient acknowledges her family’s concern, but wants to be independent. I felt sorry that she had to admit herself to a psych unit to get this


satisfaction.

SN: This is something you can discuss with him in a group family session. So are you going to ask your family to come?

Actively listening, but avoided the subject. Attempted to pulling out the idea that this is what she desires as well.

PT: I will, but he probably won’t come. I am not gonna smoke till I’m ready to quit (laughing).

Firm on here decision that smoking is not an option as she enjoys this.

This needs to be shared with her family as she feels strong about it and is not willing to stop.



interaction


Interaction



SN: Well, what have you learned from this hospitalization experience?

Summarizing our conversation and clarifying resolution.

PT: I had 33 years at this hospital. (Up in bed) Five years

Patient again clarified herself and gave insight that she is not


Vista volunteer and worked for job corps. I’ve learned that I 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.

ignorant. But a mature adult.

SN: This sounds like a plan. Sounds awesome that you got a plan. What would you do without family help for problems?

Judgment of patient’s action was not appropriate, but I gave

positive feedback, as she is progressing.

PT: Call my doctor (eyes opened)!

Summarizing our conversation and clarifying resolution.



interaction


InteractionAnalysis of Client's

BehaviorCritique of Interaction (and

Process)

SN: For marriage issues? Re

PT: Call a marriage counselor! Patient is pleased wither Patient had appropriate


decision. She is looking forward to resolving her problems with the demand of others on her.

resolution to her issue.

SN: (Smiling at her) Sounds like a plan, and for your mental health concern?

Acknowledging her progress and 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/Route

Classification Expected Therapeutic Effects

List: Teaching points Nursing Implications Adverse Effects

Trazadone HCL(Desyrel)

Antidepressant; Psychotherapeutic

Increases total sleep time. Sleeping inducing agent or

Teaching points: Inform patient that relief may 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, andAdverse effects: Drowsiness, light-headedness, impaired memory, chest pain, HTN, nasal congestion, dry mouth, weight gain, and sexual dysfunctions

Clonidine(Catepres ) 0.2 mg PO HS

Antihypertensive; Analgesic

Decreases BP by and heart rate by inhibiting A-adrenergic receptors in CNS.

Teaching point: Nurse to teach patient to change positions slowly, do not stop medication w/o MD 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(Risperdal) 4 mg PO 2000Clonidine(Catepres ) 0.2 mg PO HS

Atypical; Psychotherapeutic

Effective in controlling the S/S of schizophrenia by binding to dopamine receptors.

Teaching points: Teach patient to monitor blood glucose levels, wear sunscreen and learns adverse effects and notify MD immediately if they occur. Nursing Implications: Monitor for glycemic control in diabetics, monitor for confusion or 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 Carbonate450 mg PO BID

Mood Stabilizer; Psychotherapeutic; and Antidepressant

Inhibits neurotransmitters causing changes in facial effects, improved posture,

Teaching Point: Teach patient that medication makes contraceptives ineffective, monitor activity with usage, monitor sodium intake, drink plenty


improved ability to concentrate, and improved sleep pattern.

of water, and monitor for excessive output.Nursing implication: 1-2 weeks before 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.

Processing Recording 1[1].LGreen

Documents

Transcript of Processing Recording 1[1].LGreen