Example of nursing process recording

Therapeutic Communication

Student’s Name: Client’s Initials: M.P.

Date of Interaction: 27 October 2015 Therapeutic Communication #3

ASSESSMENT:

· Background Information: M.P. is a 54yo separated Caucasian woman who was encouraged to go to ABH after sharing with her day group that she possibly overdosed the day before on one of her home medications. She has a history of major depressive disorder which has left her out of work for several years and recently she has developed suicidal ideations in the past several months.

· Medications

1. Aripiprazole (Abilify), 15mg tab PO nightly—for psychosis

Side effects: dizziness, weakness, nausea, vomiting, fatigue, excess saliva, choking or trouble swallowing, blurred vision, headache, anxiety, weight gain, sleep problems, constipation

2. Diphenhydramine (Benadryl), 50mg cap PO nightly—for insomnia

Side effects: sedation, fatigue, dizziness, disturbed coordination, constipation, dry mucus membranes, blurred vision, tremor, anorexia, nausea

3. Fluoxetine (Prozac), 5mg tab PO nightly—for depression

Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness, dizziness, heart palpitations, weight changes, cold symptoms, dry mouth, impotence

4. Lithium, 300mg cap PO QID—for mood stability

Side effects: tremors, increased thirst, increased urination, diarrhea, vomiting, weight gain, impaired memory, poor concentration, drowsiness, weakness

5. Oxybutynin (Ditropan), 5mg tab PO BID—for bladder spasm

Side effects: dry mouth, blurred vision, constipation, diarrhea, nausea, dizziness, weakness, headache, insomnia

6. Propanolol (Inderal), 10mg tab PO BID—for tremors

Side effects: dizziness, fatigue, nausea, vomiting, stomach pain, vision changes, insomnia

· Assess myself: While I had prepared to present my teaching project that day, I was eager to help the nurses and spend time with patients. It was my last week on Montgomery unit, so between my teaching project and interacting with patients on the unit, I was eager to have a productive day.

· Assess milieu : There were 12 patients on the unit that day. Many of the patients were spending time with each other in the day room, laughing and chatting as they painted each other’s nails. Because of MP’s fluctuating SI and recent attempts to hide plastic utensils in her room, the nurse asked if I would sit with MP while she ate dinner.

DIAGNOSIS:

Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety, hopelessness, social isolation

PLANNING:

· Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on the positives in her life, like her family and her possibilities.

· By completion of the TC, the patient will:

1. Discuss her desire to die.

2. Recognize possible stressors leading to SI.

3. Focus on the positives and motivations in her life.

IMPLEMENTATION:

Nurse Communication

Patient Communication

Analysis of Process

Therapeutic Technique

“How are you doing today?”

“Okay. Depressed, I guess, but that’s normal.”

Although I’ve talked with this client before, I was a bit surprised at her openness.

Using broad openings

“How long have you been feeling depressed?”

“I guess about one year with major depression, but about five years depressed.”

From her chart I knew she had a history of depression, but I was curious what her perception was.

Exploring, seeking clarification

“How have you been feeling lately?”

“It’s been… well, bad enough to be hospitalized. I was having suicidal thoughts so they thought it best that I come in.”

Her feelings have been fluctuating, so I wanted to understand why they are fluctuating.

General leads (nodding my head), exploring

“Do you still have suicidal thoughts?”

“Yeah”

I ask this not just to gauge her fluctuating feelings but also to check her safety and risk of danger to her safety.

Seeking clarification, exploring

“Do you have the desire to kill yourself?”

“Sometimes.”

After talking with another client about his lack of desire to kill himself but the presence of suicidal thoughts, I was curious if she actively desired to end her life. I am not surprised by her answer, but I want to understand her further.

Summarizing, encouraging description of perceptions

“Tell me more about that. What do you think brings on those thoughts?”

“Well a long time ago I was abused, and I blamed my mom for the abuse but I also blamed myself.”

I hadn’t known about the abuse, so it is an interesting piece of her case. Because we are alone and it doesn’t sound like she wants to go into details with the abuse, I decide not to press for more details.

Exploring, focusing, using broad openings, seeking clarification

“That’s interesting. Why do you think you blame your mom?”

“She was passive. She was the kind of person who put on a smile even if things were going bad. I respect and admire her in a lot of ways. She visited me last week and talked about the abuse.”

She has a lot to say about her mom, so I guess she has thought a lot about her and their relationship. Looking back, I should have asked the client why she felt guilty for the abuse.

Restating, encouraging description of perceptions, seeking clarification

“You sound glad that she talked about it with you.”

“Yeah, she’s never done that before, I was very surprised. She also talked about my sister’s abuse. My sister and I only talked about it recently, and I felt like I should have known.”

I feel sad that she endured abuse within her family, and that her whole family was affected by it. Thankfully, by talking with her mom about this, it seems like she has begun to heal from it. I wonder how she would have grown up if her family recognized and dealt with the abuse sooner.

Attempting to translate into feelings

“You have a lot of siblings, right?”

“Yeah, 6 sisters and 3 brothers. Big Catholic family.”

She chuckled as she said the last part. I had remembered her having a big family from a previous conversation.

Exploring

“Do you get support from your family?”

“No, not really. Some live nearby but I lost touch with them. I tend to isolate myself because of the depression, which I know I need to fix.”

I found this insight interesting because she seems to want to get better and fight her depression, even though she sometimes has the desire to kill herself.

Focusing, exploring,

“So you want to spend more time with people.”

“Yea, I think I should try to spend more time with my family.”

She sounds interested in improving her health with this feasible fix.

Restating

“I think I have to go now, but it was great talking with you and I hope you get better soon. I’ll see you later.”

“Thanks, see you later”

It was time for me to leave for dinner, but I wanted to assure her that I listened and sincerely wanted her to find healing.

Encouraging formulation of a plan of action, offering self

EVALUATION:

· Strengths and weaknesses of the interaction: She seemed honest with me about her risk for suicide, although I think I could have asked her more about that. She had good insight of her social isolation and how that contributes to her depression. Despite her openness, I am unsure if she found meaning in our conversation or if she was merely going through the motions.

· Outcomes of the session: She shared her history of depression and abuse, which shows that she recognizes the negative things in her life. It was difficult to explore the problems weighing on her mind and give adequate time to redirect to the positive parts of her life. All in all, I believe that after our conversation, this client has reinforcement to build healthy relationships and fight her depression.