Process Recording Student Name: Client Initials: Interview Date: Instructor: I. Purpose of Contact and Goal of Session II. Basic Client Description, brief medical and psychiatric history, and medications: Patient is a 21 year old female who was admitted into the Voluntary psychiatric unit at Jersey City Medical Center due to aggressive behavior and delusions. The boyfriend reports that she was very aggressive towards him while he was carrying their one year old son, showing no care for the safety of others and her child. She has a diagnosis of schizoaffective disorder- bipolar type. The patient had 1 prior admission before this one so this is now the patient’s second hospitalization psychiatrically. The patient has a boyfriend and a 1 year old child named kendrick. While being admitted into the hospital after lab exams it was found that she is pregnant. She is currently taking Haloperidol, Prenatal vitamins, and melatonin. She has been in the treatment center for a week and seems to be doing better and on her medication regime and attending groups. III. Pre-engagement: Describe how you found the client: Who, What, Where, and How (ex. Client sitting in a chair near alcove, slouched over, appeared sleepy and tired….). Patient was was in the day room in the psych unit at the hospital sloughed watching TV. Drinking a cup of coffee.As all the nursing students and I walked in she repositioned her body to look at us while we were introducing ourselves. Expand and make a hypothetical scenario. TIPS: – Ask about how she is doing – Ask about if she would like to talk about why she is here – Ask about her child – Ask about her Plans Conversation Log Nurse Verbal (Nonverbal) Client Verbal (Nonverbal) ““Hi, My name is…I’m a student nurse at …. And I am on my clinical rotation for behavioral health. Do you mind if I sit here and talk with you for a bit? “ Hi, I’m A.G. That’s fine, I don’t mind. Nonverbal: Nonverbal: “Do you remember me from the Emergency room last week? Nurse’s Thoughts and Feelings Concerning the Interaction Analysis of the Interaction Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: ““Yes I do, I wasn’t sure you would remember. Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “How are you feeling today? “CONTINUE ON Self Analysis: Nonverbal: Nonverbal: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Self Analysis: Nonverbal: Nonverbal: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: “ “ Nonverbal: Nonverbal: Self Analysis: Nonverbal: Patient Analysis: Mood/Affect → Speech: Defense Mechanisms: Nonverbal: Plan for future interactions: IV. Interview Assessment V. Briefly present your impression of the client situation VI. Plans for future action VII. What developmental theory is applicable to this client? Discuss USE ONE OF ERIK ERIKSON PSYCHOSOCIAL THEORY THAT IS APPLICABLE TO CLIENT!!!! References
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