A Process Recording Final
Student Name: Christina Hitchcock
Date: 02-12-2015
Patient initials: RS
Patient age: 15
Agency/Hospital: Shadow Mountain
Erikson’s Development Stage: Identity versus Role confusion
This client is in the confusion stage as she has doubt and confusion about her role in life and her family. She has gone from basically being the care giver to her mother which was her identity to the role of actually being a daughter with her dad. She is not used to having the role of just being the daughter and fewer responsibilities. She has gone from been rejected by one parent to having consequences with the other.
Setting
The setting is in the day room unit on one west with no windows the radio on and good lighting. There are many distractions as there were sixteen clients on this unit twelve of them being girls. The boys were in school but the girls were in the day room as well with the techs and they had group.
Goals
My goal was to be more relaxed and use better active listening techniques and to formulate questions to help the client relax and build trust.
My patient goal was to get the client to explain the reason why she was here and what her plans were for discharge.
Nursing Diagnosis
Low self-esteem related to depression as evidenced by withdrawal from school and other activities.
DSM IV Diagnosis
Axis I: Anxiety
Axis II: Deferred
Axis III: Asthma
Axis IV: Deferred
Axis V: Deferred
Therapeutic Communication Skills
Student: Hello (Establishing eye contact while approaching in a friendly manner & SOLER). Client: Hello (Looking me directly with a facial expression that denotes interest.)
Therapeutic: Giving Recognition (Townsend, p. 132 2009)
Ongoing analysis and evaluation of student nurse communication skills:
Student - Greeting the patient: (Giving recognition)
It is necessary in order to have an appropriate start for the conversation.
Ongoing analysis and evaluation of student nurse communication skills:
Client - I had the feeling she wanted to talk with someone
Date: 02-12-2015
Patient initials: RS
Patient age: 15
Agency/Hospital: Shadow Mountain
Erikson’s Development Stage: Identity versus Role confusion
This client is in the confusion stage as she has doubt and confusion about her role in life and her family. She has gone from basically being the care giver to her mother which was her identity to the role of actually being a daughter with her dad. She is not used to having the role of just being the daughter and fewer responsibilities. She has gone from been rejected by one parent to having consequences with the other.
Setting
The setting is in the day room unit on one west with no windows the radio on and good lighting. There are many distractions as there were sixteen clients on this unit twelve of them being girls. The boys were in school but the girls were in the day room as well with the techs and they had group.
Goals
My goal was to be more relaxed and use better active listening techniques and to formulate questions to help the client relax and build trust.
My patient goal was to get the client to explain the reason why she was here and what her plans were for discharge.
Nursing Diagnosis
Low self-esteem related to depression as evidenced by withdrawal from school and other activities.
DSM IV Diagnosis
Axis I: Anxiety
Axis II: Deferred
Axis III: Asthma
Axis IV: Deferred
Axis V: Deferred
Therapeutic Communication Skills
Student: Hello (Establishing eye contact while approaching in a friendly manner & SOLER). Client: Hello (Looking me directly with a facial expression that denotes interest.)
Therapeutic: Giving Recognition (Townsend, p. 132 2009)
Ongoing analysis and evaluation of student nurse communication skills:
Student - Greeting the patient: (Giving recognition)
It is necessary in order to have an appropriate start for the conversation.
Ongoing analysis and evaluation of student nurse communication skills:
Client - I had the feeling she wanted to talk with someone