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Psych Nursing Process Recording

In: Philosophy and Psychology

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PROCESS RECORDING

Client’s Initials: _BG__ Student Name:____________________ Date:_10/12/12__

Length of Interaction:___15 minutes_______ Place of Interaction:_____Inpatient Chilrens Unit__________

|Student Says and Does |Student Thinks and Feels |Client Says and Does |Analysis |
|Good morning, how are you today? (Bent down to|I hope she is willing to talk this morning |Good (Pt is smiling and sitting in her chair |Patient is receptive to starting a |
|eye level to talk to patient) | |curled up) |conversation |
| | | | |
|Are you two the only girls here? (Pointing to |They look like friends based on their body | | |
|the other female patient sitting next to her) |language |Yeah, but I’m going home tomorrow so she’ll be| |
| | |the only girl here. (Smiles at other pt) | |
|Oh no, she’ll be the only girl then! | | | |
| | |Yeah (Smiling) | |
|So, how old are you? |I’m smiling at pt, trying to put her at ease | | |
| | | |Hopefully this is a genuine smile. |
| |Trying to redirect pt to pertinent information|Ten | |
| | | |I thought she was older, she is tall and |
|Oh, you’re tall for your age. I was tall when | | |mature looking for a ten year old |
|I was your age too. |Trying to build rapport | | |
| | |Did everyone think you were 12 when you were |She definitely has insight, good sign for her |
| | |10? (Sits up a little straighter, looking |dx’s |
| | |intrigued towards my next answer) | |
|Yeah, they sure did, but you go ahead and make| | | |
|sure they know you are young as long as you | |Yeah, I want to stay little, I don’t want to | |
|can. |Re-enforcing pt that it is ok to be young, she|get big. | |
| |doesn’t have to rush to grow up | |Completely unexpected answer from pt! |
|Well I never hear that response, usually | | | |
|everyone says they are ready to grow up. | | | |
| |Oops, I hope that doesn’t sound insensitive |Well, I want to get big so I can have my | |
|Why is that? | |Quincinera and Sweet Sixteen parties. (Smiling|Hmm, I wonder if she is biracial because she |
| | |big) |stated two different coming out parties |
| | | | |
| |Oh no, I asked a why question. I hope she |Because you get a lot of presents. For |Jumping to Christmas, inconsistency in |
| |answers appropriately none the less. |Christmas, I wish I could see my real brothers|thought? Or just being a child with ADHD? |
| | |and sisters. (Looks off into the distance, | |
| | |possibly remembering the past) | |
|Oh is that right? Where are they right now? | | | |
| | |In El Paso. | |
|That’s pretty far away, where do you live now?|Unsure of her family situation at this time. | | |
| | | | |
| |Trying to find out more about her family/ |With my foster parents in San Antonio. |Ok, so this is why she hasn’t seen her |
|So, how many brothers and sisters do you have?|social situation | |biological siblings recently. |
| | | | |
| | |Five |Are they in foster care as well? Or did |
| |Hoping there aren’t many siblings with her bad| |something happen that she is the only one in |
| |luck. | |her situation? |
|That’s a lot, which one are you? | | | |
| | | | |
| | |I’m the oldest. | |
|Wow, that’s a lot of responsibility being the |Wanting to know what role she plays in her | | |
|oldest. |biological family. | | |
| | | |Possibly confusing role in family by taking on|
|Yeah, but I’m sure you helped out your mom. |Oldest of five siblings, I’m thinking that |Yeah, I didn’t like it because I had to change|parental duties |
| |means they are pretty close together. |a lot of diapers. | |
| | | |Pt seems reassured but bothered by something |
| |Trying to reassure pt that her actions were | |in her past. |
| |needed and she helped the family |Yeah, I helped my mom a lot. | |
| | |(Looking off into the distance again.) | |
| | | | |
| | |(Staff calls over to us, asking me to stop | |
| | |talking with patient because she is expected | |
| | |to be quiet at this time.) | |
| | | | |
| | | | |
| | | | |
| | | | |

Nursing Diagnosis:____Risk for harm to self/others R/T past hx of aggression and physical violence

DSM IV: I ___Bipolar with psychosis, ADHD, PTSD, R/O Oppositional Defiant Disorder, Neglect, Sexual/ Physical Abuse of a child (perpetrator and victim for physical violence)_____________________

II _none_______________________________________________________________________

III _none______________________________________________________________________

IV _Problems with Primary support related to social environment, Housing problems_________

V _GAF score = 15, last year score = 45______________________________________________

Drugs: Seroquel 300mg PO Qhs – mood Concerta 36mg PO Qam – ADHD Tegretol XR 300mg PO Bid – mood Milk of Magnesia 30ml PO Qns PRN - constipation Maalox Plus 30ml Q4 PRN – indigestion Tylenol 325mg PO Q4 PRN – pain/HA Hydroxyzine 25mg PO Q6 - agitation…...

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