Anastacio, Brandi

Process Recording PATIENT-CENTERED COMMUNICATION (PROCESS RECORDING)

PMH, N360

Student: Brandi Anastacio Date: February 8, 2014 PR Date: January 25, 2014 Date of interaction: January 25 & 26, 2014 Clt. Age: 50 Clt. Gender: Male Diagnoses: Paranoid Schizophrenia Length of Stay (LOS) on the day of the interaction: Two days Verbal Speaker Communication Non-verbal communication Communication Technique Student Feelings T/N Analysis Student nurse selfreflection I cant believe I was so nervous, but Im glad that since this exercise, its subsiding. Ive notice that this just hinders the nurse/client relationship. #4 Clients NV: The clients agreement was nice, but because I received no smile back, I still felt very nervous. Which is why I went for a very generic lead for the next question.

Student Thoughts

Client

(Silent)

Sitting quietly at a round table, alone. Looking down at hands.

n/a

Nervous

How will I approach him? I hope he is receptive to me, just be brave and speak with him.

n/a

Nurse

Good Morning, my name is Brandi, I am a nursing student. Is it okay if I sit next to you and speak with you? Yea, thats fine.

Looking at client, smiling and pulling chair out next to client. Turns to look at nurse, affect blunted

Introductory Statement with General Lead Closed

Hopeful

Please say yes.

Client

n/a 1

Nervous

Thank goodness!

n/a

Anastacio, Brandi Nurse How are you doing today? Hands on lap, looking at client

Process Recording General lead Open Curious He looks lonely and sad. T

PMH, N360 #2 SelfImprovement: I should have stated a ROF after his response because his affect did not match his stated mood. Correction: You look sad. #2 Self-Improving: Prior to speaking to a client I should read their history. I walked into this conversation partially blind, so my starter questions were very general. This took me longer to get to the core of the conversation. #5 Non Therapeutic:
I should have stated What happened before your admission? Something more general, because the way that I stated it sounds like I only want to hear what happened on Thursday morning.

Client

Good, not bad today.

Looking down at table

n/a

Even more curious

I wonder how he was doing before this moment

n/a

Nurse

When did you arrive here?

Looking at client

General Lead Open

Unprepared

Wish I got to view his history

Client

Thursday morning, about two days ago

Calm, moving hands from lap to table to lap

n/a

Curious

Ok, not very long ago. We can speak about his admission.

n/a

Nurse

Thursday morning. What happened on Thursday morning?

Facing client and making eye contact

Restatement/Clarifying Open

Curious

Hope he feels he can trust me.

Client

I was hearing voices.

Pulling at right ear and looking down Looking at the

n/a

Anxious

What does he mean by voices

n/a

Nurse

Voices?

Restatement 2

Confused

I think he means

#3 My T/F & NV:

Anastacio, Brandi client, trying to make eye contact Shuffling arms and hands in lap and table, readjusting in seat Sitting with hands on the table, looking at client

Process Recording Open auditory hallucinations but let me clarify

PMH, N360 Im not entirely sure, but my confusion may have been expressed on my face, although I was trying to suppress it, but I think I recovered by asking for clarification in the next question.
#2 Self Improving: I could have asked for more elaboration on the voices, i.e. When did they begin? Have you had an event like this before? Also, I could have been more specific, like, have they told you to harm yourself or others? Or, what do they say? #3 My T/F & NV: I believe that my feeling of fear hindered me from being more specific, do they tell you to harm yourself/others because I was afraid to hear the answer.

Client

Yes, in my head

n/a

Concerned

Now I want to know if they were harmful

n/a

Nurse

Tell me more about the voices.

Open

Anxious and Concerned

I also wonder if this is a normal side effect for him

Client

They were not really saying anything, they were chanting

Makes eye contact

n/a

Confused

Chanting? What does he mean by chanting?

n/a

Anastacio, Brandi The voices in your head were chanting, like a rhythm?

Process Recording I hope I am understanding correctly

PMH, N360 #5 NonTherapeutic: I believe this was non-therapeutic because I could have said Tell me what chanting means to you or restated chanting? to clarify. Instead, I replaced it with another word, which could still carry different meanings for each of us. #4 Clients N/V: Because the client seemed to respond non-verbally as if I asked something that I should already know the answer to, I did not explore his auditory hallucinations further. I feared looking even more unintelligent.

Nurse

Keeping eye contact

Check Out Closed

Yearning for insight

Client

Yes, kind of like a song.

Sitting forward, then back

n/a

Validated

Ok, I understand slightly. But how did he know they were a hallucination?

n/a

Nurse

How did you know they were in your head?

Looking at client, facing client in the chair, with hands on the table Both hands on the table and staring at hands, then turns to look at nurse, appears confused

Clarification Open

Curious

What if he thought it was just music playing around him or something.

Client

Because no one else could hear them

n/a

Dumbfounded

Of course, very logical

n/a

Anastacio, Brandi So, a few days ago you began hearing voices chanting that no one else could hear, what happened after that? I called my doctor

Process Recording

PMH, N360 #2 Self Improving: Thinking back, there is so much more that Id like to help him to explore, like possible triggers and what changed in his life, since this was the first episode for him. #4 Clients NV: The clients shuffling made me think that I was adding to his anxiety, so I tried to remain still and calm to help emulate what I wanted him to feel. #3 My T/F & NV: I wanted to help him remember what he was feeling at that moment and what made it emergent enough to call 911.

Nurse

Looking at client, watching his hand move from table to right ear, back to table Looking at nurse and then back to table Looking at client and nodding

Paraphrasing Clarification Open

Overwhelmed

Okay a lot of info coming fast, let me clarify so that I remember the details. I wonder what happened after and what lead up to his admission I wonder if the doctor referred him here He must have been feeling really terrible to come in emergent. Hope I am appearing concerned and not judgmental It must have really been terrible for him to want to hurt himself

Client

n/a

Curious

n/a

Nurse

Go on. I got his message it said if its an emergency, call 911. So, I called 911. Tell me about how you were feeling then. I was worried I was going to hurt myself

Minimal Encourager Open

Anxious

Client

Shuffling in chair

n/a

Concerned

n/a

Nurse

Sitting still, with hands on table

Clarification Open

Engrossed

Client

Staring at hands

n/a

Empathetic

n/a

Anastacio, Brandi Looking at client, with a slight turn of the head

Process Recording I wonder if the voices were telling him to.

PMH, N360 #4 Clients NV: The clients mood changed when talking about hurting himself. He looked very sad. I wasnt sure if I should point it out, but I went for it and as you can see by his next response and NV, that he seemed to be surprised by the acknowledgment and it appeared that it also helped him to notice the feeling. #1 Communication Error: I should have allowed him time to respond before making the empathetic statement. Correction: Silence

Nurse

Hurt yourself?

Restatement Open

Concerned

Client

I wanted the voices to go away so badly, I just wanted die

Still looking at hands, eyes appear glazed over, mood appears slightly depressed

n/a

Sorrowful

I hope this feeling has decreased or gone away.

n/a

Nurse

You look sad. It must have been frustrating.

Looking at client, trying to make eye contact

Reflection of Feeling Empathetic Statement Closed

Sympathetic

This must have been very difficult for him How can I help him

Client

Yeah I was, I Client looked up was really scared from hands too. toward nurse

n/a

Concerned

n/a

Anastacio, Brandi How are you feeling now? Better, the voices have quieted down and Ive been able to participate Looking at client

Process Recording Clarification Open I hope he feels he can answer truthfully

PMH, N360 #4 Clients NV: Because of the prior NV response, I changed focus from the feelings he was getting regarding hurting himself and focused on how hes coped since being admitted. #2 Self Improvement: I should have asked for clarification on what quieted down means by restating Quieted down? Now I wonder, did he mean the voices went away or are they simply turned down like the volume on a radio? #5 NonTherapeutic-I should have stated What else has helped you cope? Has anything, seems to state that nothing has helped so far.

Nurse

Intrigued

Client

Sitting still and looks at nurse

n/a

Inquisitive

I wonder what we can do to help him

n/a

Nurse

Participate?

Makes eye contact

Restatement Open

Concerned

Maybe I can help him improve in this if its helping

Client

We have group therapy and I participate because it helps to quiet the voices

Holds eye contact for brief moments looking back and forth to hands and readjusting hair

n/a

Elated

Participation is something I can help him build on if it helps.

n/a

Nurse

Has anything else helped you since youve been here? Medication and finding quiet places

Looking at client, hands on table Adjusting hair, then placing hands on table

Focusing Open

Earnest

I wonder what else he believes can help him cope Finding quiet places is another thing I can assist with

NT

Client

n/a

Hopeful

n/a

Anastacio, Brandi What are your goals before you leave here? Goals? To just be as normal as I was before. They are setting me up with a social worker. What does normal mean for you? Makes eye contact

Process Recording General lead Open I wonder what other goals we can assist with Everyones normal is different, I wonder what his is. Normal, so many versions of normal

PMH, N360 #2 Self Improvement: I could have better stated it like, What are your goals? This would leave it open to in and out of the hospital. #4 Clients N/V: The clients confusion prompted me to ask the next question. I could have possibly asked him to describe who he was prior to the auditory hallucinations.

Nurse

Enthusiastic

Client

Confused look. Looks at nurse, then answers.

n/a

Concerned

n/a

Nurse

Looking at client

Clarification Open

Absorbed

Client

Just to be who I was before the voices started.

Looks confused. Adjust in seat.

n/a

Confused

Wish I knew who he was before this admission

n/a

Nurse

Tell me what a normal day is like for you at home. I live by myself and I dont do much, I used to go to school at HCC, but I havent for a while. What family do

Looking at client, hands on the table, readjust in seat

Clarification Open

Determined

Maybe if I could hear a day in the life schedule for him, I can understand his version of normal Okay, so it sounds like he was pretty functional, but I wonder about his support system. Hope he has

Client

Sits forward, then back, then forward

n/a

Excited

n/a

#3 My T/F & NV: I believe that my excitement of finally getting to know his belief of what normal is kept me from expanding on it.

Nurse

Looking at

Open 8

Inquisitive

#1 Communication

Anastacio, Brandi you have nearby? client

Process Recording someone he can call on for support.

PMH, N360 Error: I changed the subject too early. I should have asked him more about how or if his illness effected his daily life prior to this event. To better assess for needs after discharge. Correction: Were there any challenges that you faced prior to this admission besides the voices or What has kept you from going to school?

Client

My mom and sister live in Chicago. Im thinking about going there. My sister wants me to go, but I dont have an ID card to get on the plane. I want to try to do that.

Smiles, then appears frustrated when speaking about ID

n/a

Sympathetic

We should speak to the social worker about this, maybe there is a way that we can assist.

n/a

Anastacio, Brandi Ok, so let me clarify. You came here because the voices that were chanting in your head were getting so scary for you that you wanted to hurt yourself and now they are quieting down with medication and group therapy. Now your goal is to be as normal as you were before and possibly going to Chicago if you can get an ID card, to live with your sister. Is that right?
Thats right, I am worried about returning home, but I am glad they are getting me a social worker to help me out and possibly going to

Process Recording

PMH, N360

Nurse

Keeping eye contact, but client looks up, then down to table frequently. Nurse hands gesturing slightly.

Summarizing Check Out Closed

Enthusiastic

I got a lot of info, let me repeat what I heard to him and see if he can confirm my assessment.

#3 My T/F & NV: Because I was so worried about writing down my PR, I didnt elaborate on his worries about returning home. My personal thought definitely got in the way of this opportunity. Correction: What concerns do you have about returning home?

Client

Nods and shuffles in seat

n/a

Hopeful

I can share this with the primary nurse so that they can share it with the rest of the health care team.

n/a

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Anastacio, Brandi
Chicago.

Process Recording

PMH, N360

Nurse

(Silent)

Quietly sitting.

Silence

Relieved and Concerned

Client

My doctor is here.

Stands up and points to doctor

n/a

Optimistic

It seems like I made progress in addressing this clients thoughts on his admission, treatment and discharge goals. I just hope they are addressed and met before he leaves. Hopefully, since we just discussed his goals, he will have an easier time bringing them up to his doctor. I really hope he trusts me enough to return, Id like to help him communicate his thoughts and feelings even more.

n/a

#1 Communication Error: I should have stated the above instead of being silent and beginning to close the conversation. Correction: Tell me more about what concerns you about returning home.

Nurse

I will be here until this afternoon at 3pm, Im here to listen if you would like to talk more later.

Wave and smile

Closing

Genuine

By the end of the day, this client and I held several conversations that I believe were therapeutic for the client and helped to build rapport and a trusting nurse/client relationship.

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Anastacio, Brandi

Process Recording

PMH, N360

NURS 360 Psychiatric /Mental Health PROCESS RECORDING GRADING RUBRIC

STUDENT NAME: Brandi Anastacio ___Assignment is complete ___PR format utilized correctly ___ Returned to student for corrections above ___ Late penalty ___ Penalty for improper grammar and spelling errors (max. 2 pts)

DATE: February 8, 2014

NSTRUCTOR: Prof Chat Agustin

EVALUATION CRITERIA: Communication Errors (Use Communication Error Handout): max 3 pts ____ (3.0 pts) No communication errors

.5 pt lost for each different communication error identified and corrected 1 pt lost for each different communication error not identified up to 3 pts

(Correction includes: identifying the error by name and writing an appropriate alternative i.e., 2 parts. Each part must also include a rationale. Corrections go in analysis column.)

Communication Skills: max 8 pts ____ (2 pts) Skills labeled correctly

All Skills per the (NURS 210) therapeutic communication skills handout.

1 pt lost for each skill labeled incorrectly up to 2 pts

____ (2 pts) Use of open questions rather than closed > 70% (label all open questions: including open focused, open clarifying. ____ (1 pt) Use of focusing and/or clarification questions 2 or more times _____(1pt) Use of reflection of feeling at least once _____ (1 pt) Use of restatement at least once

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Anastacio, Brandi
____ (1pt) Use of a paraphrase at least once

Process Recording

PMH, N360

Awareness of Self during the Interview: max 6 pts ____ (2 pts) Feelings identified in the feelings column with no thoughts

1 pt if < 5 feelings identified or one thought in feeling column

____ (2 pts) Thoughts identified in the thoughts column with no feelings

1 pt if < 3 thoughts identified or one feeling in thoughts column

____ (1 pts) Identifies own non verbal communication in non verbal column

Analysis (See Process Recording Instructions) max 13 pts ____ (4 pt) Demonstrates use of the Cognitive Behavioral Model as a guide for interview. Connecting the clients thoughts feelings and behaviors. ____(4) Focus of therapeutic conversation is on clients illness, mental status examination, hospitalization, triggers, medication and compliance, discharge plan- follow up care. ____ (1 pts) Suggestions for improvement of self. Minimum of three. Must be marked in analysis column as self improvement. ____ (1 pt) How your feelings/thoughts/nonverbal communication contributed to the interview positively or negatively. Minimum of two. ____ (1 pt) How you interpreted the clients nonverbal communication. Minimum of t wo. ____ (2 pts) Complete and thoughtful analysis reflected in the analysis column.

TOTAL POINTS __________/30 possible points The student MUST meet a minimum score of 70 =C to Pass (21 points out of 30 points). COMMENTS:

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