You are on page 1of 11

Please type & print on only one side of paper.

Completed PR must be submitted to


your clinical instructor with a cover sheet and a blank grading sheet in a folder.
Process Recording Template
Follow the PR Directions Sheet Carefully
Date:
Clients Dx: Attention deficit hyperactivity disorder
Age:
LOS: 79 days
Dialogue
Hi, my name is
Hana. I am a
student nurse.
Would it be okay if
I sat and talked
with you for a few
minutes?
I dont mind, Im
just coloring.

Non Verbal Technique


Communicat
ion
Introductory.
Looking at
Offering
patient.
self
Moderate
and shaky
voice tone.
Open
posture.
Standing up.
Hands
uncrossed
and placed
in table.
Appropriate
spatial
boundaries.
Sitting down
coloring.
Looking
down at her
paper.
Legs crossed.
Continued
drawing
while I
spoke.

Student
Feelings

Student
Thoughts

Nervous.
Anxious.
Unsure.
Lacking
confidence.
Hesitant.
Assured.

Am I doing
this right?
What do I
do if she
says no?
She is
coloring the
last thing
she wants is
to answer
my
questions.
You got this
Hana just
walk over
there and
start a
conversation
.

T
Analysis
/
N
T 1. Suggestions for
improvement. I
asked a closed
ended question
which gives them
the option of
saying no. I should
of informed
patient of
approximate time I
will be there and
what I will be
doing. Instead I
should have said,
Hi. My name is
Hana. I am a
student nurse and
will be on the unit
until 3 pm. I will
be talking to you
for the next few
minutes about
your hospital
stay.

How are you


feeling today?
Im doing okay.

Sitting down
across the
table facing
the patient.
Legs
uncrossed.
Open
posture.
Initiated eye
contact.

General
lead open
ended
question

Nervous
Anxious
Optimistic

Minimal
encourager
and open
ended
question

Tense
Nervous
Interested

Reflection
of feelings.

Engaged
Interested

Appropriate
eye contact.
Stopped
coloring.
Leaning over
paper.

I see youre
drawing a picture.
Can you tell me
about it?
It is picture for my
mom when she
comes to visit
later.

Leaning
slightly
toward the
patient.
Maintained
eye contact.
Moderate
voice tone.
Holding
drawing up.
Smiling.
Looking at
her drawing.

I noticed you
wrote Im sorry

Looking at
the drawing.

Im glad she
let me sit
down.

T 3. I was still
feeling nervous at
this point but was
optimistic because
Dont cross
the patient was
your arms
open to talking. I
and legs.
noticed when I sat
down next to the
She is doing
patient with an
okay and
open posture she
stopped
stopped coloring
coloring so
and made eye
maybe she is
contact. This
interested in
contributed to the
talking.
interaction in a
positive way
because there was
no longer a feeling
of authority
between us
because I was
sitting next to the
patient instead of
standing above the
patient.
I wonder
T 4. The patient was
what
no longer making
happened
eye contact.
between her
Instead, her
and her
interest was on her
mom.
drawing. This
showed me that
She stopped
her drawing was
looking at
more important to
me, I hope
her than our
she still
conversation.
wants to
Therefore, I felt it
talk.
would be
appropriate to
She
gather more
probably
information about
would rather
the drawing and
be drawing
its value to the
patient.
Am I
T 2. I asked her a
remaining
clarifying

on the drawing. It
seems you're
apologizing to your
mom. Is that
right?
Yeah.

Pointing to
the word
sorry.
Maintained
eye contact.
Open
posture.
Legs
uncrossed.
Feet on the
ground.

Checkout.

Curious

Is my body
language
open and
appropriate?
Ask more
questions
about what
she is
apologizing
for, maybe
that is the
reason for
being
admitted.

Looking at
the drawing.
Fidgeting
with markers.
Shrugged her
shoulders.
Oh.
I used to fight a lot
with my mom. That
is why I am here.

Nodding my
head.
Leaning
slightly
toward the
patient to
show
interest.
Maintain
eye contact.
Empathetic
tone and
body
language.
Slight eye
contact.
Leans over
table to grab
more
markers.
Looks down
at paper and
periodically
up at me.

calm and in
control.

Minimal
encourager

Curious
Uncertain
Concerned
Informed

I hope she
can tell Im
interested.

question; I should
have phrased the
statement as an
open-ended
questions that
allowed her to
express her
feelings. An open
ended question
such as, tell me
more about why
you're
apologizing?
would have been
more appropriate.

T 3. I used a
minimal
encourager hoping
the patient would
Am I
open up about her
making her
relationship with
nervous,
her mom. I didnt
maybe that
want the patient to
is why she
feel as though she
wont
was getting
maintain eye
bombarded with
contact?
questions so I
wanted to give her
She leaned
a chance to open
over to grab
up without being
her markers,
asked. I noticed
is she going
when I leaned
to start
toward the patient
coloring
and nodded my
again and
head she began to
not want to
talk a bit more.
talk.
Did I lean
too close to
her and
thats why

she reached
away to grab
markers?
It seems you are
saying you're in the
hospital because
you used to fight a
lot with your mom.
Is that right?
Yeah, we use to
argue all the time.
She was always
yelling at me about
school, my attitude,
just everything. And
I would get so mad
and yell back and
then the last time I
got so angry I hit
her.
How long ago was
this argument?
Almost two months
ago.

Maintaining
eye contact.
Open
posture.
Curious
facial
expression.

Validation/
Paraphrasi
ng with
checkout

Hopeful,
Motivated,
Calm,
Comfortabl
e

She is really
starting to
open up.

Open
ended
focused
question.

Calm
Interested
Optimistic
Engaged

Why has she


been here so
long?

Open
ended
focused
question

Uncertain
Uncomfort
able
Calm

Stopped
fidgeting
with markers.
Maintained
eye contact.
Open
posture.

Eye contact,
Open
posture.
Hands on
the table.
Paused
before
answering.
Concentrated
facial
expression.
Looked up
while
thinking

Tell me more
about how you
were feeling and
the thoughts you

Am I being
objective?

Used gentle
hand
gestures to
encourage

T 4. I felt a lot more


comfortable when
the patient
maintained eye
contact and
stopped fidgeting
with the markers. I
felt she was less
nervous and more
willing to talk
about her past.

T 2. This would
have been a good
opportunity to
explore her
That was a
feelings during the
long pause.
argument and
Thought she
further explore
wasnt going
what triggers her
to answer.
anger. Instead of
just asking when
Keep it up
this argument
you're
occurred, I could
getting
have added, tell
somewhere.
me more about
how you were
feeling and the
thoughts you were
experiencing
during this
argument.
She seems
T 4. The patient was
like she is
getting sad when
sad and
talking about the
genuinely
argument she had

were having during


this argument?
I dont know, I was
just so upset and lost
control and I didnt
want to hurt her but
I was so mad.

You sound sad


when you talk
about this fight you
had with you
mom.
Yeah I feel bad for
hitting her.

How has your


relationship with

patient to
elaborate
more on her
feelings.
Nodding
head.
Interested
facial
expression.
Maintaining
eye contact.
Fidgeting
with her
markers
while
speaking.
Looking
down at
drawing.
Sad facial
expression
Concerned
facial
expression,
readjusted
myself in
chair

feels
bad for
hitting her
mom.
I hope I did
not upset her
talking
about this
argument.
Remain
calm.
Find out
how she
controls her
feelings and
thoughts
today.
Reflection
of feelings

Nervous
Tense
Uncomfort
able

Remained
looking down
at her paper.
Sad facial
expression.
Arms down
by her side

Leaning
slightly

with her mother.


She did not
verbally say she
was sad, therefore
I responded by
using ROF with
the unspoken
emotion I
observed.

You got her


to express
her feelings
but now she
seems really
sad.
You made
her sad.
I want to
make her
feel better.
Dont show
you feel
tense

Open
ended

Calm
Focused

She appears
to not be as

T 3. I noticed my
behavior changed
when the patient
became sad, my
voice changed and
I became nervous
and
uncomfortable, my
non verbal cues
contributed to the
interaction in a
negative way
because the patient
responded by
looking down and
putting her arms
down by her side.
I felt
uncomfortable so I
changed the
subject from the
past to the present
3. My tone of
voice changed

your mother been


lately, has it
changed since
admission?
It is a lot better, she
visits every day and
we talk about what I
did today and stuff
like that, and we
dont really fight
anymore. I think
because I am
learning ways to
control my feelings
when I get upset.
Tell me more
about how you do
that?
I have always liked
to color, so when I
get mad or anxiety it
helps to draw or I
walk around by
myself.

Can you tell me


how you would
handle a similar
situation now?
I would try not to
yell and just talk to
my mom and
explain to her what I
am doing. But if Im
still really mad, Ill
probably just walk
away so I dont get

toward
patient.
Concentrated facial
expression.
Moderate
tone

focused
question

Concerned

Am I being
supportive?
I hope she
doesnt feel
uncomfortable

Looked up
made eye
contact.
Used small
hand gestures
when talking.
Smiled after
talking
Eye contact,
open posture,
moderate
tone, sitting
up

Open
ended
clarifying
question

Engaged
Calm
Optimistic

Maintain eye
contact.
Leaning back
on chair.
Open
posture.

The
conversation
is flowing
better.
I wonder
how much
longer she
will want to
talk to me.

Maintains
eye contact,
hunched
posture,
Hands on
table next to
drawing
Chin resting
on one hand.
Maintain
eye contact.
Sitting up
right.

sad
anymore.

Open
ended
focused
Question

Interested
Pleased
Happy
Comfortable

Good job on
getting a
good insight
of how she
will act
when she
gets upset.
I hope she
really feels
this way and
can walk
away when

from shaky and


nervous to clean
and confident at
this time. The
patient responded
by maintaining
eye contact and
began to open up a
bit more.
2. This statement
is very wordy.
Instead I should
have said, How
has your
relationship with
your mother
changed since
admission?T I was able to use
and open ended
question to assess
how the patient
handles her
outburst

T 2. I start a lot of
questions with
tell me, Instead
of continuing to
say, can you tell
me, I should have
stated, how
would you handle
a similar situation
now? or what
are some ways you
would handle a
similar situation

more mad.

Thats great you


recognize coping
strategies to
manage your
feelings. Can you
tell me about any
medications that
you take to help
manage your
feelings?
Yeah, I am on a
medication for my
ADHD, depression,
and one that helps
control my outburst,
and I want to start
birth control for my
skin.
How do your
medications make
you feel? Will you
continue to take
them after you are
discharged?
They make me feel
tired but I will take
them because they
help me focus and I
kind of feel better.

Hands on
table.
Moderate
clear tone of
voice.
Smiling.
Open
posture.
Eye contact.
Legs and
arms
uncrossed.

she is upset.

Closed
statement.
Open
ended
focused
question,

Relaxed
Comfortable
Optimistic
Calm

I wonder if
she is good
about taking
them.

Holding
marker in one
hand tapping
it gently on
the desk.
Relaxed
posture.
Focused
facial
expression

Repositioned
in chair.
Sitting up
straight.
Concerned
and engaged
facial
expression.
Hands
placed on
table free of
any objects
and not
crossed.
Pause before
answering.
Deep facial
expression.

Thats good
she knows
her
medication.

She seems
relaxed,
thats good?
I feel
comfortable
and relaxed?
Dont look
to relaxed sit
up straight!
Open
ended
clarifying
question.

Interested
Hopeful
Comfortable

Dont
reposition
too much
she might
think you're
nervous.
Find out her
discharge
plans or
goals
Thats good
you brought
up her
medication
Her answer
seems
honest

now?

T 2. I started off this


statement using a
closed ended
question stating
my opinion of how
I feel about her
being able to
recognize her
coping strategies.
Instead of
expressing my
opinion I should
have said, can
you tell me about
any medications
that you take to
help manage your
feelings?

T 3. At this point I
was starting to feel
a lot more
comfortable and
my body language
was relaxed. My
tone of voice was
moderate and
clear. These nonverbal
communications
techniques
contributed to the
interaction in a
positive way. I
noticed that when
I relaxed in my
chair the patient
relaxed and
stopped fidgeting

Hands placed
on the table
free of any
objects.
Tell me your
Nodding
about your plans
head.
and goals you want Focused
to reach to get
facial
discharged.
expression.
Leaning
I want to be able to
forward in
go home soon so Im chair.
working on
controlling my
Focused
feelings and
facial
focusing in group. I contact.
have to stay at level Maintained
3 if I want to go
eye contact.
home.
Sitting up in
chair on the
edge of her
seat

Level 3?
When I got here I
started at level 1 but
if I follow directions
and go to class I get
points and go up a
level. But if I dont
follow directions or
dont go to class, I
go back to level 1.

Confused
facial
expression.
Leaning
forward to
show
interest.
Reaching for
a marker.
Slight eye
contact.
Rate of
speech
increased.

with markers.

Open
ended
focused
question

Interested
Calm

Restatement

Unsure
Calm
Curious

I wonder if
she wants to
be
discharged.

T 4. The patient had


a very focused
facial expression
as she spoke about
her discharge
Will this
plans. She
topic make
maintained eye
her upset
contact
throughout. My
Stay positive
response to her
non verbal
Am I being
communication
supportive?
was to be very
engaged,
interested, and
supportive of her
thoughts and
feelings. She
opened up about
her discharge
plans so I
responded by
asking a
restatement to
gather more
information about
her goals.
She is
T 3. I tried to change
talking
the way I ask
faster.
questions and take
a break from open
Maybe she
ended questions.
wants this
Therefore, I asked
conversation
her a question by
to end soon.
restating
something she said
Is she
previously. I also
getting
used body
bored?
language such as a
confused facial
expression and
leaning in to show

How do you think


going home will
affect your
relationship with
your mom?
I think it will be
good for us. We
would be able to
spend more time
together and work
on getting along and
not fighting.
Silence
I think it's time for
group.

Thats great! Im
glad to hear you
will be able to
spend more time
together.
Silence

Hands
crossed.
Sitting
upright but
on edge of
the seat.
Slight eye
contact

Open
ended
focused
question.

Anxious
Rushed

She folded
up her
drawing she
is ready to
go.

Slight eye
contact, put
her markers
away and
folded up her
drawing

Eye contact
Smile
Open posture
Looking at
peers going
into group.
Holding
drawing,
sitting on

She is being
very
cooperative
but I think
she wants to
go to group.

Your hands
are crossed!
Stop being
so anxious,
stay calm
and thank
her and let
her go join
her group.

Closed
ended
statement,
opinion

Anxious
Uncertain
Rushed

This is
uncomfortable she
didnt say
anything.
She is ready
to go, say
thank you
and let her

I am engaged,
curious, and
interested in what
she had to say. I
was surprised how
effective
restatement and
body language can
be and allow the
patient to open up.
T 3.I started to feel
rushed because it
was getting close
to the time we get
off the unit, also
by the patients
body language I
was able to tell she
was get anxious to
join her peers
because group was
about to start. I
started to look
around and didnt
realize I had my
hands crossed and
I noticed these non
verbal cues made
the conversation
feel rushed and did
not flow as easily.
The patient also
stared around the
room and put her
coloring things
away.
N 1. I made a
communication
error, by observing
her body language
I could tell she
was getting
anxious and
wanted to join
group so I just
stated an opinion

edge of seat.

go.
That was a
good
conversation
while it
lasted.
I shouldnt
have said
my opinion.

Ill let you get to


group. Thank you
for talking with me

Eye contact
Closing
Stood up
statement
slowly after
she stood up.

Positive
Pleased
Happy

That went
well.
Take a deep

that did contribute


to the situation and
her response was
to say nothing
because I wasnt
asking her a
question or saying
bye. Instead I
should have
noticed she was
getting anxious
and summarized
what we talked
about and thanked
her for taking the
time to speak with
me.
5. Instead of
expressing my
opinion I should
have instead
summarized what
our conversation
was about and
thanked her and let
her go to group. I
should have said.
It sounds like
your relationship
with your mom
has improved
since you have
been here and you
are learning
strategies to
handle your
feelings and
thoughts. Today
you're at level 3
and working hard
to reach your
discharge goal.
T 4.By observing the
patients nonverbal
cues such as
looking at her

Thank you. I have to


go to group

Smiling

breath

Held her
drawing.
Stood up.
Smiling,
Waved bye.
Left in a
friendly
manner

Think of
ways to
improve for
next time.

peers go to group
and starting to
stand up, I felt
rushed to end the
conversation. My
response to her
non verbal cues
was to thank her
for speaking with
me and show her
by smiling and
saying goodbye in
a friendly manner.
I wanted her to
know that I
enjoyed our
conversation.

You might also like