KINGSBOROUGH COMMUNITY COLLEGE
Of
The City University of New York
NURSING 20 PROCESS RECORDING
Planned Goals/Nursing Actions For Interaction:
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Interaction
Student Verbal/Nonverbal
Technique/ Rationale
Patient response/ Analysis
2
Student Verbal/Nonverbal
Technique/ Rationale
Patient response/ Analysis
3
Student Verbal/Nonverbal
Technique/ Rationale
Patient response/ Analysis
4
Student Verbal/Nonverbal
Technique/Rationale
Patient response/ Analysis
5
Student Verbal/Nonverbal
Technique/ Rationale
Patient response/ Analysis
6
Assessment
STRENGTHS
WEAKNESSES
Appearance
Affect/Mood/ Attitude
Behavior/ Activity
Communication
Thought Process
Thought Content
Perception
Insight
7
Defense Mechanisms
Support system
Occupation/ skills
Stressors/ Coping
Skills
8
Student _____________________________________________
Date(s) Experience _____________________
NURSING CARE PLAN
Nursing Diagnosis
Expected Outcome &
Criteria for Measuring
Nursing Actions
Rationale
Evaluation of Outcome
Problem:
Etiology (related to)
Signs & Symptoms
(as evidence by)
9
Student _____________________________________________
Date(s) Experience _____________________
NURSING CARE PLAN
Nursing Diagnosis
Expected Outcome &
Criteria for Measuring
Nursing Actions
Rationale
Evaluation of Outcome
Problem:
Etiology (related to)
Signs & Symptoms
(as evidence by)
10
Student _____________________________________________
Date(s) Experience _____________________
NURSING CARE PLAN
Nursing Diagnosis
Expected Outcome &
Criteria for Measuring
Nursing Actions
Rationale
Evaluation of Outcome
Problem:
Etiology (related to)
Signs & Symptoms
(as evidence by)
11
Student _____________________________________________
Date(s) Experience _____________________
NURSING CARE PLAN
Nursing Diagnosis
Expected Outcome &
Criteria for Measuring
Nursing Actions
Rationale
Evaluation of Outcome
Problem:
Etiology (related to)
Signs & Symptoms
(as evidence by)
12
Nursing 20
PROCESS RECORDING GRADING SHEET
Name_________________________________________________________________Section________
NOTE WELL: STUDENTS MUST SUBMIT A MINIMUM OF 5 PROCESS RECORDINGS: ONLY ONE IS TO FOCUS ON THE
CONTRACT(INITIAL PHASE); THREE--FOUR ARE TO FOCUS ON THE WORKING PHASE AND ONLY ONE IS TO FOCUS
ON TERMINATION PHASE.
*PLEASE REFER TO SYLLABUS REGARDING PENALTY FOR LATE SUBMISSION
Objectives
Possible
1
2
3
4
5
points
1. Identify goals/ planned actions appropriate for client
0- 20
2. Describe verbal/ nonverbal interaction verbatim (Word For Word)
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3. Identify techniques used- indicate if therapeutic/ non-therapeutic; describe your
purpose for using this technique
0-20
4. Evaluate interaction( How/ why you interacted; how/why you might have
interacted differently; what future techniques/ approaches you will use
0-20
5. Assess client’s strengths/ weaknesses for each assessment area
0-10
6. Develop psychosocial nursing care plans (a minimum of four) based on
assessment data.
0-30
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COMMENTS:
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Signatures: Students______________________________________________________________
Faculty_______________________________________________________________
Revised spring 2007
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