Process Recording Lab PDF

NCM 117 (SKILLS LAB)
MALADAPTIVE PATTERNS OF BEHAVIOR

HANDOUT
PROCESS RECORDING
Documentation and Analysis of NPI or Nurse Patient Interaction
PROCESS RECORDING IS A TOOL used by the Nursing Student, the Clinical Instructor, and the
Faculty Advisor to examine the dynamics of a particular interaction in time.
▪ The process recording is an excellent teaching and learning device for refining therapeutic
techniques of communication and intervention skills.
▪ A verbatim documentation of interaction between the patient and the student nurse (to the
best of the nursing student’s ability)
PURPOSE
(Urbanowski & Dwyer, 1988)
1. To help students conceptualize and organize activities with client systems

2. To have a deeper understanding of the interview process or intervention
3. To develop critical thinking skills by identifying strengths and weaknesses of the
communication process during NPI
4. To put into writing unspoken thoughts and reactions observed during the NPI
5. To improve self-awareness
6. To improve written expression
*Format of Process Recording depends on each institution’s policy. For discussion purposes, below is
a basic format of an NPI or Nurse-Patient Interaction
Process recording is not MSE, but MSE can be a content of a process recording, because during
MSE you are also using therapeutic techniques of communication.
Process recording is not charting or is not progress notes. It cannot be used as document for legal
purposes
BASIC FORMAT
Patient’s Name:
Age:
Diagnosis:
Objective:
Setting of Interaction:
General Appearance:
VERBAL (and Non-Verbal) Therapeutic Rationale / Clinical

Communication Analysis Instructor’s
Nurse Patient Technique/s Used Feelings of Nurse Remarks
____________________________
Name of Student / Signature /
Date of Submission
Prepared by Prof. Amelia Z. Manaois, Prof. Ruhiyyih Barnachia and Prof. Wilma Ymasa for
Arellano University – College of Nursing as Instructional Material only for Maladaptive Patterns of Behavior Skills
Laboratory.
Refrain from reproducing this material without the consent of the preparer and the AU-CN
This study source was downloaded by 100000855992034 from CourseHero.com on 02-10-2024 17:21:12 GMT -06:00
https://www.coursehero.com/file/152592588/4-PROCESS-RECORDING-LABpdf/
PROCESS RECORDING SAMPLE
Patient’s Name: EVB

Age: 54 y.o.
Diagnosis: Schizophrenia, Paranoid Type
Objective:
1. Establish rapport and a trusting relationship with the client
2. To be able to encourage the patient to verbalize her feelings, thoughts and emotions
3. Gather pertinent data related to current confinement
Setting of Interaction:
The first day of my nurse patient interaction happened around 9am. The weather was cloudy and
humid. Our activity was held outside the ward in a quadrangle and we were seated on the bench
under a tree. My patient is in front of me with a space of half a meter. Though it was a bit noisy
because we are all talking at the same time, the patient was generally cooperative and replies in an
audible manner.
General Appearance: The patient is wearing the hospital gown. Well kempt and tidy. She initially has
good eye contact with appropriate affect to her mood. No unusual movements or mannerisms were
observed.
VERBAL (and Non-Verbal) Therapeutic Rationale / Clinical

Communication Analysis Instructor’s
Nurse Patient Technique/s Used Feelings of Remarks
Nurse
ORIENTATION PHASE (13 November 2020, 9:00am)
“Magandang “Hello, Giving Recognition It shows that the
umaga Ms. E” magandang nurse recognizes
umaga rin sa iyo” the client as a
Non-verbal – person, an
• Waves Non-verbal – individual that
hands • Waves gives the client
• Smiles back fulfillment of his
• Maintains • Smiles worthiness and
moderate back existence.
eye • Shows
contact moderate Making a pause
• Open eye after the greeting
posture contact will give the client
• In face to • Open a time to greet
face posture back and gauge
position • In face to the client’s
with the face openness to
client position receive the
• Made a with the presence of a
short nurse nurse
pause
after the
greeting
“Kamusta po “Ok naman ako, Giving information This is
kayo? Ako po si EVB ang buong the Orientation
James, 3rd year pangalan ko, Phase so it is
nursing student po pang-apat na important that
ng Arellano rapport and
Laboratory.
Universit. Ako po student nurse na a trusting
ang magiging kita ha” relationship
student nurse mo, with the client is
simula po ngayon Non-verbal – established by
hanggang • Nods giving basic
December 14, head information about
tuwing Lunes, • Smiles my self
Martes at while
Miyerkules” gazing at Seeking information Client’s response
“Kayo po, anong me proves that he
buong pangalan • Open knows her own
nyo?” posture name, oriented
Non-verbal – • In face- with what’s
• Maintains to-face happening at the
moderate position moment and even
eye with the without asking,
contact nurse she openly
• Open shares
posture information about
• Smiling having previous
In face-to-face student nurses
position with the assigned to her. I
client feel that at this
point my patient
may be ready to
express self more
“Ikaw, ilang taon At this point the
ka na, taga saan client is the one
ka”, may asawa asking questions
ka na ba? probably she also
wants to gain my
Non-verbal – trust and gain
• Smiles connection or
while may want to take
gazing at in control with the
me interaction. The
• Open client already
posture have 3 previous
• Leans nursing students
forward and may already
as she have learned the
asks pattern of Q&A in
questions an NPI
“Ah, ako po ay “Batang-bata ka Giving information Making facts
19y.o. na, taga pa, ako hulaan available to the
QC ako at wala pa mo kung ilang patient according
naman po akong taon na ako to her inquiries
asawa” dali…dali”
Non-verbal –
• Maintains Non-verbal –
moderate • Smiles
eye while
contact gazing at
• Open me
posture • Appears
• Smiles playful
Laboratory.
• With • Open
minimal posture
hand • Leans
movement forward
• In face-to- as she
face asks
position questions
with the
client
“Naku hindi po “Ganun ba? Sige Rejecting – a Non- At this point I
ako manghuhula hindi na lang Therapeutic thought the
e, sabihin mo na bale” response of the patient is trying to
lang kung ilang nurse at a given manipulate the
taon ka na baka Non-verbal – situation by refusing conversation by
kasi ako • Leans to consider patient’s asking questions
magkamali ng back to behavior one after another.
sagot” her seat Hence, I threw
• Eye back the
contact questions on her,
were only to realize
gone thru her non
• Gazes at verbal reactions
other that I have used a
nurses non-therapeutic
and response to her
patient behavior which
having rejected her
NPI from attempt to
a far connect with me
“Napansin ko na No response Making observations Verbalizing what
nalungkot ka nung is perceived
hindi ko hinulaan Non-verbal –
ang iyong age?” • Still no At this point I am
eye trying to validate if
contact my observation is
• Hands correct. She may
are not verbally
fidgeting replied but her
non-verbal
gestures are
enough to
communicate with
me regarding her
inner thought and
feelings
“Tingin ko hilig mo No response Reflecting Directing back to
ang maglaro ng the patient’s
hulahulaan?” Non-verbal – feelings and ideas
• Still no
eye I made an attempt
contact here to make her
• Hands feel I knew how
are she felt and the
fidgeting message she tries
to convey at this
point
Laboratory.
“Sige ganito, “Sige, sige gusto Offering self At this point I
huhulaan ko ang ko yan” realized that
tatlong bagay sometimes, we
tungkol sa iyo, Non-verbal – have to play
una na yung • Eye along with the
edad, kaya isip ka contact client’s behavior
pa ng 2 bagay na regained to gain her
tungkol sa iyo • Fidgeting cooperation but
ok?” hands making sure still
stopped that limits are set
• Appears to avoid
interested manipulation of
again to the situation as
interact evidenced by
“listing of 3 things
to guess”
Evaluation of Objectives:
1. Rapport may have been established at this point by knowing the likes and dislikes of the client
in order to gain her cooperation every time we interact for our NPI. However further trust and
confidence must be gained in order to make our NPR a therapeutic one through the use of
therapeutic techniques of communication
2. The patient is yet to verbalize her feelings, thoughts and emotions during the first day of NPI.
But was able to appreciate the importance of non-verbal behaviors that conveys her
emotions, feelings and thoughts even without the “talk part”. Hence further use of therapeutic
communication skills and techniques will be observed on our coming NPI
3. Gather pertinent data related to current confinement – Since this is our first day NPI, the
interaction was focused more on establishing rapport and trust with each other. On our
second NPI, the objective of data gathering related to her confinement is still standing
____________________________
Name of Student / Signature /
Date Submitted
References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th

edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 6th edition 2011.
Laboratory.
Powered by TCPDF (www.tcpdf.org)

Process Recording Lab PDF

Uploaded by

Copyright:

Available Formats

Process Recording Lab PDF

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Process Recording Lab PDF

Uploaded by

Copyright:

Available Formats

NCM 117 (SKILLS LAB)

MALADAPTIVE PATTERNS OF BEHAVIOR

1. To help students conceptualize and organize activities with client systems

VERBAL (and Non-Verbal) Therapeutic Rationale / Clinical

Patient’s Name: EVB

VERBAL (and Non-Verbal) Therapeutic Rationale / Clinical

• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing, 8th

You might also like