Name
Clinical Week -1- Behavioral Health
Date
CT-CCNP
Process Recording
MEDICAL/SURGICAL/PSYCH DIAGNOSIS:
________________________________________________
Bipolar NOS; alcohol abuse; obesity; auditory
hallucinations; cut wrist in suicide attempt
PERTINENT NURSING DIAGNOSIS/DIAGNOSES
____________________________________________________
Ineffective coping
Situation low self-esteem
Disturbed personal identity
Impaired social interaction
SHORT TERM GOAL(S) interact appropriately with the other
kids on the unit
SETTING
It was the
morning
session
for school.
The client
was at the
back of
classroom
sitting
alone
away
from the
others. I
asked to
sit next to
her.
VERBAL & NONVERBAL
COMMUNICATION:
STUDENT
VERBAL & NONVERBAL
COMMUNICATION:
CLIENT
STUDENT’S THOUGHTS
AND FEEINGS
CONCERNING THE
INTERACTION
Hello, my name is ___Can
you tell me your name?
Client did not speak; her head
was directed downward; her
hair was covering her face;
very sullen looking.
Client seemed sullen and did
not appear interested in
communicating with anyone
or did not know how to get
started. I was scared and
nervous, but felt that this
client really needed someone
to listen and care and
perhaps get her moving in
the direction of recovery.
Giving recognition and
acknowledging client
“Is it okay if I sit with you
for a while?”
Client looked up and nodded.
She was not participating in
the school work and seemed
disinterested in what was
going on in the classroom.
She made no attempt to reach
out to others on her own.
I was hoping that this would
break the ice; she seemed
interested.
Offering self
“What kind of school
activities do you like to
participate in?”
She looked at me again and
briefly smiled before putting
her head back down. “Poetry.”
Maybe we are making
progress towards therapeutic
communication; I am still
nervous, but becoming more
relaxed.
Open-ended question
“What kind of poetry do
you like?”
No response. She looked
puzzled by my question.
I guess I asked the wrong
type of question. I need to
clarify myself. I needed to
rethink my strategy.
Exploring
EVALUATION/ANALYSIS
OF THE INTERACTION
INCLUDE THERAPEUTIC
APPROACH/TECHNIQUES
APPLIED
Name
Clinical Week -1- Behavioral Health
Date
“Do you like writing
poetry or reading it or
both?”
She lit up. Her face and body
became more relaxed. “I love
writing poetry.”
Success. I am wondering
how I can turn this into
something more therapeutic
and client-directed. I
remembered something in
the text that said – focus on
feelings.
Exploring
“How does it make you
feel when you write?”
She looked more engaged and
willing to talk – more relaxed.
“I feel better when I write.”
I was trying to see if I could
find a safe means of
exploring inner thoughts and
feeling and help her find a
way out of her shell so that
she could interact with others
on her grounds; she seemed
to need to feel safe and in
control in her interactions
with others.
Attempting to translate into
feelings
“Do you mean that writing
helps you cope and relieve
anxiety?”
She is still looking at me and
seems engaged in the
conversation. “Yes.”
I was attempting to clarify
her use of poetry; but I
should have used a different
question. This was too
closed-ended. I struggled to
turn this around.
Closed-ended; I used this to
clarify
“Would you like to write
some poetry now?”
She looked eager to write and
began to write in silence.
I was attempting to get her to
focus on her feelings and
perhaps express them
through writing as this
seemed to be her safety net.
I thought writing would open
up a plan of action.
Encouraging formulation of
a plan of action
Nothing said for a few
minutes.
She was eagerly writing and
erasing.
Using silence, but sitting
with her provided her the
opportunity to express
herself in her own time and
means. This was very
effective.
Giving silence
“You seem to be done
writing. May I read what
you wrote?”
She said nothing, but moved
her paper towards me and
nodded her head.
This was a very different
way of communicating with
a client, but it worked for
her. Her poetry expressed
her inner thoughts and
feelings – she is very sad and
lonely. Her words were dark
and insightful and gave us
some things to talk about.
She seemed to relish in the
fact that I asked to read her
poetry. I was trying to give
her control and express
respect of her privacy.
(privacy seems hard to come
by and much needed)
Making an observation and
providing a general opening
Name
Clinical Week -1- Behavioral Health
Date
“This says you are lonely.
Who do you talk to at
home or school?”
“Nobody. I have no friends.”
She looked sad.
I was a bit nervous heading
into a sensitive area,
especially since we were in a
class situation. There just
was no real privacy
anywhere.
Making an observation via
her poetry and exploring
“You don’t talk to anyone
in class or at home or at
any of your activities.”
“Nobody.” She looked sad
Voicing Doubt
“Your poetry is
outstanding. It really
expresses quite a lot.
Have you tried sharing
your poetry with others or
writing to people?”
“No.” A light seemed to go
on in her head. “Can you
show my poem to the
teacher?”
This may not have been the
best opportunity to voice
doubt. It seemed to stunt the
conversation again. I
thought perhaps poetry was
her way of holding onto her
privacy and retaining
control. I struggled to find a
way to incorporate her
poetry into a means of
reaching out to others and
helping herself.
I wasn’t quite sure where
this was going yet. But I
wanted to encourage her to
communicate with others on
her terms – at least for now.
I gave her a moment to think
after saying “No.”
At this point, I showed the
instructor her poetry and
the instructor said that it
was good work. The
instructor then tried to
encourage her to do more
writing via writing
prompts to be more in line
with school work.
“Can I submit my poem as my
school work?” She was
directing her question to the
instructor.
I was attempting to
encourage formulation of
an action plan (her short
term goal was to interact
appropriately with other
kids on the unit)
I considered this progress.
She found a way to use her
poetry to express herself and
to submit it as school work.
This opened up some other
opportunities to speak with
me and the instructor.
After this she did speak a bit in class to me and the instructor (not the other students). The class ended shortly thereafter, but was
reconvened later in the afternoon – after the lunch time Staff Assist. I noticed that in the afternoon she sat with her peers and
wrote another poem. She shared this poem with the student next to her and then to me. She, also, wrote a poem which she gave
to student X. I hope that she found sharing her words initially through poetry would open up a new world of communication and
friendship.