process recording homework - HOUSTON BAPTIST UNIVERSITY School of Nursing and Allied Health NURS 4414 Psychiatric and Mental Health Nursing Process

process recording homework - HOUSTON BAPTIST UNIVERSITY...

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HOUSTON BAPTIST UNIVERSITY School of Nursing and Allied Health NURS 4414 Psychiatric and Mental Health Nursing Process Recording Form Process recording #: 1 Include Goals for this Process Recording: -Establish a communication/contact with the patient -Help patient with effective coping skills -Observe verbal/non-verbal communication Topic Focus: Establish a trusting relationship with the patient. Multi Axis Diagnosis: Axis I: Bipolar Axis II: Denied previous diagnosis of developmental disorder. Deferred due to acute psychiatric symptoms. Axis III: None Axis IV: Negative life events Axis V: 20-unable to function in all areas (B) Nurse’s Verbal/ Non-verbal Communication (C) Patient Verbal Communication (D) Patient Non-verbal Communication (E) Analysis /Interpretation Evaluation/ (F) Restatement Corrective Response (if appropriate) 1) I’m a nursing student at Houston Baptist University. It is 10:30 am and I would like to ask you a few questions. This conversation will take about 10-15 minutes. Ok. Patient stood up and went somewhere to sit to talk. Facial expression showed interest. Introducing myself to the pt., set boundaries with the patient. Conveyed the length of the interview. Patient was calm and relaxed. 2) Thank you for your time. What is on your mind? How are you feeling today? None 3) I understand. What did they tell you that your diagnosis was for your condition? Validation, was used to hear from the patient the reason for admission and if it matched the diagnosis in the chart. Pt. was disappointed.
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  • Spring '14
  • LucindraCampbell-Law
  • Nursing, eye contact, pt.

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