process recording homework - HOUSTON BAPTIST UNIVERSITY...

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.