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MENTAL HEALTH NURSING Process Recording Guide

This document provides guidance for nurses on how to complete a process recording of an interaction with a patient. It describes including descriptions of the patient's nonverbal and verbal behaviors, the nurse's responses, the therapeutic techniques used, and an evaluation/interpretation. Key elements to observe and document about the patient include appearance, body language, affect, tone of voice, appropriateness of conversation. For the nurse, it recommends reflecting on one's own verbal and nonverbal responses, the techniques used, and an honest evaluation of what went well and could be improved.

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Vijaya Rani
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
1K views

MENTAL HEALTH NURSING Process Recording Guide

This document provides guidance for nurses on how to complete a process recording of an interaction with a patient. It describes including descriptions of the patient's nonverbal and verbal behaviors, the nurse's responses, the therapeutic techniques used, and an evaluation/interpretation. Key elements to observe and document about the patient include appearance, body language, affect, tone of voice, appropriateness of conversation. For the nurse, it recommends reflecting on one's own verbal and nonverbal responses, the techniques used, and an honest evaluation of what went well and could be improved.

Uploaded by

Vijaya Rani
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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MENTALHEALTHNURSING

PROCESSRECORDINGGUIDE

Theinteractionbetweenthenurseandthepatient,asyourecall,isrecordedandexaminedinthe
processrecordingCthatis,arecordoftheongoinginteraction,the processoftwopeoplerelatingwith
eachother.Therecordingincludesadescriptionofthepatient'snonverbalandverbalbehaviors,the
nurse'sresponse,identificationofthetherapeutictechniqueusedbythenurse,andanexplanationofthe
nurse'sevaluationandinterpretationoftheinteraction.
Themajorelementsoftheprocessrecordingarereviewedhere:

Patient'sNonverbalBehavior:
First,noticethepatient'snonverbalbehavior,becauseitoftenspeakssomuchmoreloudlythanthe
patient'sactualwords.Lookatthepatient'sappearanceCisclothingappropriatetotheweather,the
activity,theplace?Arejewelryandmakeuplikewiseappropriate?Isthepatientneat,clean,freeof
odors,etc?
Next,lookatthepatient'sbodylanguageCishesmiling,laughing,crying,maintainingatensefacial
expression?Ishispostureerect,stooped,slouched?Doeshewalkrapidly,shuffling,notmoveatall?
Arehisbodymovementsslow,fast,jerky?Whatarehismotoractivities(kickinghisfootagainstachair,
fallingasleepduringaconversation,etc.)?Isthepatientabletoestablisheyecontactwithyou?Does
talkingaboutcertaintopicscausetheeyecontacttoincreaseordecrease?Aretheresignsofanxiety
(moistpalms,restlessness)?
Basedontheseobservations,youmayassessthepatient'saffect(orfeelingtoneCareflectionof
mood).Ishehappy,sad,lonely,apathetic,cheerful,angry,etc.?Ishisfeelingtoneappropriatetothe
situationandrecentevents?
Youmaymakemanymoreobservationsofnonverbalbehaviorandincludetheminyourprocess
recording.Thebehaviorsmentionedhereareonlytoserveasaguide,abriefoutlinetohelpyougather
ideastogether.

Patient'sVerbalBehavior:
Now,considerthepatient'sactualconversationwithyou.Whileyouaretalkingwiththepatient,
thinkaboutthefollowingpointsandincludetheminyourassessment:
1. Noticethepatient'stoneofvoiceCisitsoft,harsh,commanding,frightened?

2. Arethepatient'sconversationsappropriatetothepersonshe'swithandthesituationhe'sinCfor
example,inthemidstofabaseballgame,doeshebegintocryandtalkabouthisrejectionbyhis
mother?
3. ArehismoodsexpressedappropriatelyCthatis,doeshelaughorcryinresponsetohearingavery
sadstory?
4. Arehisthoughtsandideasconnectedandfollowingalogicalorder,ordisconnected,hardto
follow,etc.?
5. Doeshisconversationdemonstratethatheisrealityoriented(thatis,intouchwithreality)and,
therefore,awareofwhoheis,whereheis,whootherpeopleare,andwhatmonthandyearitis?
Whatdoesthepatientactuallysay?
Onceagain,considertheseverbalbehaviorshereassessedtobeamereguideforyou.Pleasedonot
berestrictedbytheguide,foryoumayhavemanymoreverbalbehaviorsofyourpatientthatyouwishto
record.Butremember,themoreaccuratelyyourecordthe patient'sactualwords,theeasieryouwillfind
ittounderstandthecommunication.

Nurse'sResponse:
Aninteraction,asyourecallfromyourexperiencewiththerapeuticcommunication,byitsnature,isa
twosidedevent.Forexample,thepatientmayseemtoexhibitcertainnonverbalandverbalbehaviors
whenalone. However,thesebehaviorsare,inactuality,aresponsetononverbal(and/orverbal)stimuliin
theenvironment!Theseinfluencescanincludesuchthingsasrulesandregulations,punishmentsor
rewardsforbehavior,andveryimportantly,theverbalandnonverbalbehaviorofyou,thenurse.
Asyourselfawarenessincreases(anditwill!):
1. Youwillprobablyfindyourselfreflectingonyourownbehaviorinspecificsituationsand
wonderingwhyyourespondedtoyourpatientinthiswayorthat.Also,whyyourpatient
respondedtoyouinthiswayorthat.
2. Youmaywanttorememberwhatyousaidinresponse toyourpatient'sverbalizations.
3. YoumayalsowanttoknowwhatnonverbalcuesyouhavetothepatientCwhileyoutoldthe
patientthatyouweregladtoseehim,didyourvoicesoundstrainedordidyoubegintowring
yourhandsanxiously?TheseverbalandnonverbalresponsesCobjectivelydescribedandwhether
theyactually Amatch@oragreewitheachotherCwillgiveyouandyourinstructorimportant
informationtoassessyourprogressioninusingtherapeuticcommunicationtechniques.

TherapeuticTechnique:
Throughoutyournursingprogram,youhavebeenlearninghowtointeracttherapeutically
withyourpatient.Learningbetterandmorehelpfulwaystocommunicateis(andwillbe)a
neverendingprocessinyournursingcareer.
Youstartedstudyingaboutcommunication,includingthosetechniqueswhicharetherapeutic
andthosewhichblockcommunicationinyourfirstnursingcourse.Atthispoint,youmaywant
toreviewthosetechniquesandblocks.
Forexample,yourpatientmayspeaktoyouinawaythatisillogicalandconfusing.You
wouldwanttostophisflowofconversationtoaskhimtoexplainandclarifyingreaterdetail.
Thetherapeutictechniqueusedinthisinteractionwouldbe Aaskingforclarification.@
Inanothersituation,yourpatientmaybegintorevealsomeofhisdeepestfeelings.Ifyou
becameanxiousandcouldn'ttoleratewhathewassaying,youmightinterruptbychangingthe
subject.Changingthesubjectinthisparticularsituationwouldprobablyloweryourownanxiety
butmostlikely Ablock@furthercommunicationwithyourpatient.
Remember,theProcessRecordingisalearningexperienceforyou.Itwouldbemosthelpful
toyouifyouhonestlyrecordthetherapeutictechniquesandthosetechniquesyouusedwhich
blockedcommunication.

EvaluationandInterpretation:
Asyouwriteyourprocessrecording,certainthoughtsmaycometoyourmind.Youmay
wanttostatewhyyoudidorsaidaparticularthingorwhyyouneglectedtodoorsaysomething.
Youmaywishtocommentonwhataparticularflowofbehaviormeans,asyouinterpretit.You
maywanttosuggestanothertherapeuticactionthatmighthavebeenmorehelpfulthantheone
youchose.Bypracticinginmakinginterpretationsofyoursandthepatient'sbehavior,youwill
developnewwaysoflookingateventsandnewinsightsintobehavior.

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