Process Recording Essay

Not met, has never feels that she accomplished anything. No Job or Emily. * Anxiety Continuum Place and “C” on the continuum where your client is currently. Place with an “A” on the continuum where your client was upon admission. Discuss the findings in detail. Mild C Moderate Discuss: Severe A Panic Upon admission, AS exhibited suicidal thoughts and attempted in ending her life. Could not function and did not want to survive. Currently, during this assessment, AS was still at moderate level. Has selective inattention and has a hard time paying attention. Fixates on helping her roommates and involves herself deeply into solving her roommates’ problems and pain.

With guidance and direction, AS was able to answer some questions. * Evaluate the Client in terms of Erosion’s theory Align the client’s behaviors with Erosion’s developmental level. Do the client’s behaviors indicate an appropriate developmental level? If it is appropriate, is the client meeting the tasks at hand positively or negatively. Discuss: At 70 years old, AS should be at the level of integrity vs.. Despair. However, Ass’s behaviors indicate that she did not overcome challenges of Initiative vs.. Guilt. AS has no sense of purpose in life and stated that she knows what she did was wrong but she did it anyway. AS feels guilty for what she did but took no initiative to change.

More over, AS is completely dependent on others and has no courage to be independence even though she has expressed the desire to do so. * Coping Mechanisms – list coping styles and ego defenses. Differentiate Adaptive vs.. Maladaptive Adaptive-Reads a book-Helps her roommate ( altruism) with daily activities-Keeps diary/Journal-Attends groups I Maladaptive * Pain medications abuse * Tobacco (2 packs/day) * Displacement ? deals less with her treatment plan but spends her energy and time making sure her roommates follows with treatment and pain-free. I DOCUMENTATION use ten Narrative Doormat to roller cradles your client Ana want lea up to your client’s admission. Include the client’s mental status and evaluate existing goals. Narrative: AS was admitted on 08/24/13.

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She was found by her cousin who called multiple times to check in but got no answers while Ass’s sister whom has taken care of her was on a vacation. When she came to the house, AS was found unconscious on the floor and the emergency service was called. AS took an unknown amount of Squirrel and other medications in attempt to end her life. AS reported that her trigger was the diagnosis f cancer of her dog and because her sister was out of town. AS was put on 51 50 hold-danger to self-which has ended and now currently on voluntary commitment. This is Ass’s third suicide attempt. AS felt helpless and guilty and stated that she feels like she’s a “burden” to her family.

She has little hope for her depression and she feels that she is completely depends on her pain medications to survive. AS is also dependent on her sister as she doesn’t have a Job or financial meaner. Goals for AS are to keep her safe, to help AS to be medication compliance, to plan for her to be admitted to the inpatient adult program at MALL, which fits for senior. Use the Unit standard documentation (SOAP, API, IIOP etc) and document the 1 interaction you had with the client. Unit Standard – Record of interaction S : no complaints of somatic pain. Stated she feels good and ready to be discharged. She feels hopeful but worried at the same time about the outcome. O: Pat’s vitals are within the normal limits. Fidgeted and will sometimes avoid eye contact.

Anxious about her roommate’s condition and lost focus when she sees her. A: At risk for suicide related to low self-esteem, feeling of isolation, and hopelessness as evidence by multiple history of attempt in suicide. P: Pot will be safe and on suicide precautions. Pot will be discharged once determined stable by the psychiatrist to inpatient adult unit at MALL. NURSING PROCESS #1 Priority Nursing Diagnosis: At risk for suicide related to low self-esteem, feeling of isolation, and hopelessness as evidence by multiple history of attempt in suicide. * Outcome Criteria: * Short term goal (met by end of 1:1) Pot will verbalize by the end of that she will not harm herself.

Long term goal (met Dye Lagrange) By discharge, pot will verbalize two things she can do to prevent the thought of self harm. * List 3 nursing interventions to achieve the Short term goal and 3 nursing interventions to reach the long term goal Interventions Short Term Goal * establish therapeutic relationship with patient * monitor patient behavior for warning signs of suicide I Long Term Goal-Assess support system pot has-administer medications as ordered-help pot identify the trigger and ways to avoid maladaptive behaviors I * #2 Priority Nursing Diagnosis: Alteration in mood related to history of depression ND bipolar disorder as evidence by suicidal thoughts and hopelessness. Pot. Ill exhibit a decrease in anxiety from moderate to mild by the end of 1 :1 * Long term goal (met by discharge) By discharge, Pot will be able to verbalize at least 2 positive coping mechanism. Interventions to reach the long term goal Interventions Short Term Goal * encourage pot. To express her feelings to staff * educate pot with medication management * reinforce decision making as the progresses I Long Term Goal-teach pot. Strategies to help pot cope-encourage pot to do ODL and choose appropriate clothing-encourage pot. O verbalize thoughts and concerns about her goals I * Evaluate: Did the client reach the goals listed in Nursing DXL. #1? * Yes ? * No? Then discuss what you will need to change in the care plan Yes. By the end of 1:1, pot stated that she “regrets” the decision to end her life and has plan to change.

She expressed a clear plan to treat her disorders which is the inpatient program that will also provide safety and will prevent her from self harm * Evaluate: Did the client reach the goals listed in Nursing DXL. #2? Nine Locus want you wall need to change In ten care plan Pot still exhibited behaviors at the level of moderate as her fixation with her roommate could not be redirected. She continued to use that as coping mechanism and care plan will continued until discharged. Write a summary statement regarding your experience with this client: S. S. Was my first elderly patient for my psychiatric rotation and I found her case to be very interesting. S. S. Was polite , kind, and open with her feelings. She consistently gave me praises and had great fixation on her roommate who she felt like she needed to take care of.

It was interesting to see that she took the role of the care Akers while hospitalized. Her roommate’s pain and suffering were her main concern. I believe because she has history of being completely dependence and helpless, she’s coping with that by attaching herself with someone who is more in need. She tends to like to talk about her roommate’s situation and ways to fix them more than about her personal goals. Even though this is her 3rd suicide attempt, I have hope that because she have chosen the senior inpatient program at MALL, her chance of developing into a “whole” person will be greater as her old environment cannot provide the same opportunity.

Record of Actual Patient/Nurse 1:1 Interaction 3 PAGE MINIMUM Nurse’s dialogue: Record verbal and nonverbal communication. Place the nonverbal in parenthesis I Client’s dialogue: Record verbal and nonverbal communication. Place the nonverbal in parenthesis I Evaluate the verbal and nonverbal of the NURSE. Identify the communication technique in parenthesis. Use ALTERNATIVE statement if the communication technique was inappropriate I Evaluate and interpret the verbal and nonverbal communication of the CLIENT. Place the communication technique/ego defense in parenthesis I “Hello, Ms. S. My name is Tania and I’m a student nurse. I would love to talk to you if you have about 10 to 15 minutes to spare. Friendly tone but intimidated to ask)”Alright, I’ll wait right here and I will walk with you to the darkroom” -waited 5 minutes- (walked side by side to the day room with AS)”How are you feeling today’ (sit 90 degrees angle from client and using direct eye contact seem concerned about L a lot. ” “Uh-huh. (nodding head) Let’s talk about your discharge. Tell me about how you feel about going to MALL” “From what you said, I suspect you seem to have some doubts about this treatment hospice. “(with doubting voice tone)”What seemed to lead up to your drug use¦l see. WSDL you tell me more about your depressed feelings? What do you think is causing you to feel depressed¦Go on… Tell me more about what you loved about working at the coffee shop! (my eyes widen as I wanted to show interest in her positive experience)”That sounds wonderful. It sounds like you enjoy being around people and talking to people. “Well, Mrs.. S, it’s almost your dinner time. Thank you for allowing me to talk with you. It was great. I will be here until 8 pm and if you feel like liking more, don’t hesitate to come get me. I’d be happy to chat with you more. I hope you have a good dinner! I Sure, let me make sure my roommate feels K and we can talk. (with eye contact but reluctant as she rather stays by her roommate’s 10 ) “on, I Tell okay. But L. , seen NAS problem going ten Donation. I’m worrier auto her. ” “Well, I’m being discharged this Friday and L will be without me.

I tried to tell her that she should also choose MALL but I don’t know if her husband would agree” “Oh, I went to visit the facility yesterday. It’s really nice. I feel like it would be a good lace for me. I hope it works this time”(stopped fidgeting and started looking at me)Well, I have a mixed feeling. This is my third time being here. I have tried to kill myself before. I’m very depressed and I don’t know if anything will change that. I know why I have this problem. It’s because of drugs! “l have a bad knee so I couldn’t work. The only thing that helped was those pain medications. I took too much of it and then I couldn’t stop taking them.

It was the only thing that helped with my depression toњl feel like I’m a burden to my family. I can’t do anything to help myself. I always cause them problem and now I Just did it again. I really regret what I did. I wish I can do more. You know? I loved working at the coffee shop back home. I miss it. ” (She cut this short as she looked away from me to see L. At the nursing station)”oh! I loved talking to people and making different drinks for them. It was so fun. There would be people in there all day and I would remember their drinks” “Oh yes. It was nice. “(with a big smile ! ) I (Providing information ; Offering self. )Should also use broad opening and paraphrasing my contract .

Also, I can use better eye contact. Alternative: ” Hello, Mrs.. S. My name is Tania and I’m a student nurse. Could we sit 1 on 1 to talk for about 10 minutes in the darkroom? (Broad opening. ) I also positioned myself for active listening (SOLES) (Restating) I restated her statement. I did not want to ignore her concern but need to find a way to redirect this conversation(Accepting &Focusing) I tried to redirect to focus on AS instead. (Attempting to translate into feelings) I want her to clarify what she said about, this time, she hopes it will work. ” (Placing the event in time or sequence) I suspect that there is more to the story than drug use.

I want her to go back before the drug use to assess her trigger for this coping. (Accepting ; Exploring ; Seeking clarification. ) I think I asked too many questions at once. AS might feel overwhelm as she feels like she has to answer many questions. (She’s at moderate level of anxiety and would benefit from short and clear direction) (Using General Lead & Exploring) I successfully redirected her attention back to the conversation by mention her positive experience and her interest. (Restating & Summarizing)(Terminating & offering self terminated the 1:1 but makes sure to offer myself to further immunization to maintain therapeutic relationship with S. S. I Incongruent verbal/ non verbal.

I think she thinks she has to talk to me but really wishes to monitor her roommate instead. Displacement. S. S. Seems to fixate on her roommate’s problem to avoid dealing with her own anxiety. Displacement and Denial: AS continued to displace her own anxiety on L’s situation and deny that this she’s actually the one who’s afraid to be alone. (Congruence verbal/non verbal)Ass’s attention is finally on the conversation. Rationalization: AS is trying to reasons her depression and her disorder on drugs. Also, AS uses drug as a way to cope with her anxiety. Rationalization. AS again is reasoning that her drug use was for a good reason. AS is not using any defense mechanism. Her anxiety came down.

Again, because of the environment, there were a lot of distractions that inhibited this therapeutic communication. S. S. ‘s statement shows that she likes to be surrounded by people and have fear of Isolation. (l nee triggers were ten Tear AT losing near go Ana near Slater Delve away)Congruence. AS seems to enjoy talking about her interaction at the coffee shop.


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