Harrison

Kristin Miura
Process Recording #1 Template
Follow the PR Directions Sheet Carefully
DATE: Week 3
Client Dx: Major Depression
Age: 17
Los: 2 months 2 days
Dialogue
Hello, My name
is Kristin. Im a
student nurse.
Hi, Im ____. I
talk to student
nurses all the
time. What do you
want to want to
know?

Tell me what
brought you here
to Kahi Mohala?

Non Verbal
Communication
Eye contact,
friendly facial
expression
(smiling), sitting
down

Eye contact,
smiling, sitting
down with feet in
water.
Sitting facing
toward pt., open
posture. Affect
friendly

Technique

Student
Thoughts
She is letting me
talk to her. Oh she
is the podiatry
patient I heard
about from earlier
in report.

T/N

Introductory
statement

Student
Feelings
Feeling
eager

Open ended
Question

Feeling
anxious

This is a good
start. She mustve
felt alone. It must
be hard living in a
foster family.

Analysis
4. Non-verbal interpretation.
Pt. is sitting down with feet in
water for nursing care and is still
open to talking to me on top of
that. She is comfortable sharing
her story with me because of her
non-verbal communication (eye
contact and smiling).

Harrison
I live in a foster
home. I tried
talking to my
foster parents but
no one was
listening to me.
This was
happening for a
few weeks. So, I
had to do
something. Thats
why I came here.
Had to do
something?

Pt. is making
occasional eye
contact. Looking
down at feet.
Sitting, leaning
forward. Affect
sad.

Restatement

Feeling
concerned,
shocked

Let me try
focusing.

Reflection of
feelings

Feeling sad

She seems like she T

felt like she had
no other choice.

I had to cut myself

because no one
was listening to
Pt. affect sad and
me. My foster
gloomy.
parents were just
arguing with me.
You felt like no
one was listening
to you and
cutting was the
only way to get
help?
I know it sounds
bad, but there was

Leaning forward
(45 degree
angle). Affect
concerned.

3. Thinking of focusing allowed

me to catch that she had to do
something. I was able to learn
about cutting through this
observation. (Positive
contribution)

3. Feeling sad allowed me to

focus on the patient and gain a
better understanding of where
the pt. was coming from.
(Positive contribution)

Harrison
no other way. Im
not manipulative.
I have been
admitted for
cutting before so
thats how I know
Ill get what I
needed.

Youre saying
that you were
here before for
cutting?
Ive cut myself
before and this is
my third time. I
was here in
August and once
before that.
Could you tell
me about the
cuts on your
arm?
This one needed 6
stiches a couple of
months ago. And

Pt. leaning
forward, looking
down. Affect
defensive.

Paraphrasing

Feeling
interested

Has she been here

before? I wonder
what for.

1. Discussing pt. history related

to current admission of cutting,
recognizing patterns allows the
pt. and I to analyze the
relationship between
hospitalizations and discover
ways to prevent another
admittance related to cutting.

Open ended
question

Feeling
worried

6 stiches!

2. Self improvement. Shouldve

been more descriptive because
pt. talked about cuts from
previous admittance. Couldve
said tell me about the cuts that
brought you here into Kahi
Moahla this time. It wouldve
allowed for a more focused

Leaning forward
(45 degree
angle). Eye
contact.
Pt. using hands to
explain/gesture
time of
admittance. Pt.
affect appropriate.
Pointing to my
arm as a gesture.
Leaning in
towards pt.
looking at pt.
arm.

Harrison
the superficial
ones are from this
time. Its painful
but I dont feel
much anymore.
Could you
explain what you
get from cutting
yourself?
Its really not a
good coping skill
because it doesnt
work. Its just a
bad habit. I dont
get what I want.
What do you
mean when you
say that you
dont get what
you want?
I know cutting
myself is wrong. I
probably wont do
it again. I just
used it as a way to
come here.

How would you

get what you

Pt. pointing to
cuts on arm.
Affect is relaxed.
Leaning towards
pt. Speech is
thoughtful.
Slightly slower
rate of speech.

Pt. has a calm

affect. Speech is
articulate.
Eye contact.
Leaning in.

dialog which she couldve then

possibly went into the history of
her cutting.
Open ended
question

Feeling
nervous

Im trying to say
this
therapeutically.
She is realizing
her thoughts on
cutting herself.

Clarification
Question

She acknowledges
that she doesnt
believe cutting is
right for her.

Clarification
Question

Better
communication
I wonder if she is

Looking down.

Eye contact.
Nodding in
listening.

1. Pt. is able to communicate

with the nurse and reflect on
reasons, triggers, and feelings
about cutting herself. Pt. is able
to express herself without being
stereotyped by myself. She is
able to express herself freely in a
therapeutic manner.

Harrison
want?
Better
communication. I
probably wont
cut myself again
because Im going
to be turning 18
years old so I
dont want this to
be on my record.
Your record?
Once I turn 18, it
becomes
permanent. So I
need to make sure
that I dont come
back here again.
Tell me about the
tools you have
learned while at
Kahi Mohala?
Theyve taught
me some coping
mechanisms like
journaling.

being sincere.

Posture is slightly
slumped.

Eye contact.
Affect
appropriate.

Restatement

Shes concerned.

This is her third

time being
admitted for the
same issue. What
has she learned so
far in this
hospitalization
that will prevent
her from being
admitted again.

Eye contact.
Eye contact.
Nodding with
response.

Open ended
question

Feeling
Surprised

2. Self improvement. Shouldve

asked pt. how she felt about
being readmitted. I couldve
asked her what she would do
this time to avoid being
readmitted. This is more direct
and would help the patient to
understand my intentions.

Harrison

How do you feel

about journaling
as a coping
mechanism?

Sitting straight
yet leaning in.
Affect is
comfortable.

Open ended
question

Feeling
pleased

Wow, she knows a

coping
mechanism.

Paraphrasing

Im going to tell
her other coping
mechanisms that
she can try. She
seems ready to
end this
conversation.

1. Discharge focused.
Recognizing coping mechanisms
that can be utilized to prevent
admittance related to poor
coping mechanisms. Pt. feels
that journaling is a positive
coping mechanism for her. She
also mentioned previously that
cutting herself wasnt a positive
coping mechanism.

Informative
statement

Hopefully she can

use these to not
come back. I think
Im going to end
the conversation.

4. Non-verbal interpretation.
Pt. is touching towel in her hand.
Slightly preoccupied with towel,
while appearing to be listening
and engaged in the conversation.

I like it. Its good.

So youre saying
it is therapeutic
for you?
Ya. It helps.

There are also

other coping
mechanisms such
as deep
breathing,
listening to
music, and
exercising.

Pt. nodding head,

affect is relaxed.
Eye contact.
Leaning towards
pt. Affect is
comfortable.
Nodding.

Pt. has towel in

hands, sitting. Pt.
affect anxious.
Eye contact.
Affect is calm
and content.
Sitting straight.

Pt. nodding head

and squeezing her
towel that was
Oh. I like listening used for her foot,
to music, but I
together in her
dont like to
hand.

Harrison
exercise. I will try
music.

Great. Before I
Eye contact.
end our
Sitting upright.
conversation, is
Pleased affect.
there anything
else you would
like to talk about,
any questions or
concerns?
No. Im going to
put this towel
away.
Okay. Thank you
for letting me
talk with you. I
appreciate it.
Youre welcome.
Good luck in your
nursing career.

Stopped playing
with towel. Stood
up first.
Standing up, eye
contact.
Pt. walking to put
her towel away

Closed
question

Feeling
concerned

Let me see if she

needs anything
else. I dont want
to just leave her
hanging. I think
its okay to end
the conversation
here.

Closing
statement

Feeling
content

Aw, that was nice

of her.

2. Self Improvement.
Shouldve summarized to show
pt. that I understood her
perspective. I couldve said you
mentioned that you had to cut
yourself because no one was
listening, and that you feel
cutting isnt a good coping
mechanism. We talked about
several coping mechanisms, and
you recognize that journaling is
helpful.

Harrison
Synopsis: Pt. feels that no one (foster family) was listening to her. Pt. thought that if she cut herself, she would get out of her
situation at home and get the help that she felt she needed. Pt. cut herself because she felt that thats how she can get out of her foster
home situation that she was unhappy with. The pt. actions of cutting herself were attributed to her feelings that no one was listening to
her which lead to her thinking cutting would get them to listen. Pt. was able to recognize that cutting herself hasnt given her what she
wanted. She also was able to state that she could work on her communication and coping skills. Pt. stated that she probably wouldnt
cut herself again. We were able to discuss positive aspects of her life such as her skills (ability to read fast and writing books). We
discussed her plans to avoid coming back to Kahi Mohala through focusing on what she has learned (journaling as a coping
mechanism) and focusing on herself.