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Process Recording #1 Template

Follow the PR Directions Sheet Carefully
DATE: 01/23/2016
Client Dx: Amphetamine Induced Depressive Disorder with Use, Cannabis Use Disorder, Major Depression Recurrent Severe
Age: 15
Los: 8 days
N: Nurse
Hello, my name is
Rachel and I am a
nursing student.
Whats your name?
Would it be okay if
we talked for about
15 minutes?
Hey. Im _____.
Sure. I like talking.

C: Client
Non Verbal
Smiling. Sitting down,
open posture. Eye
contact with client.
Takes a deep breath.

Closed- Ended


Smiling; Looking down

to eat breakfast.
Minimal eye contact

How do you feel

about being here?
I hate it here. I cant
wait to go home. I
was supposed to go
yesterday with my

Hand gesture toward


You feel frustrated

Eye contact with

General lead;
Open ended


Reflection of


Looks down. Furrowed

eye brows. Minimal eye
contact. Sigh

This girl seems
and nice. I think
I can talk to her
and have a good
Just breathe. You
can do this.
Maybe it will be
easier to figure
out her feelings
for being here.
Try to get
rapport first and
ask how she feels
about being
Wow. She was


3: Because I smiled, introduced
myself, and engaged in eye contact,
the patient acknowledged my presence
and I was able to have a conversation
with her. Also, by doing this, I opened
myself up to her and allowed her to
introduce herself to me without
feeling like I am any threat to her.

3: My thoughts were along the lines of

trying to understand her state of mind
or current emotion at the time. This
resulted in me asking her how she felt
about being in the Family Treatment
Center which is a positive. This
opened up the conversation.

4: I interpreted her non-verbal

about being here
and not being able
to go home
Yes. I hate it here so
Tell me more about
The staff doesnt
listen to us. They
dont give me
therapy like I would
want. I was sitting in
the middle of the
court crying the other
day and no one
wanted to give me
therapy. The other
girl accused me of
stealing her clothes
when thats not even
true. I am a size 0
and shes huge.
That sounds
frustrating. How do
you feel about it
Im okay. I talked it
out with my doctor. I
feel better now. I just
dont like this place.
Also, they take all
my clothes and

patient. Leans toward

patient. Folds hands

feeling; Open
ended statement


so close to going

communications for being here has

negative so I reacted to her nonverbal
communication by acknowledging her
frustration and wanting to go home.

General lead;
Open ended


I wonder why
she didnt get to
go home yet.
What caused her
to stay? She
seems really
upset about
being here. What
if she doesnt like
talking to me?

2: I feel that I should have been more

specific as to what I wanted her to tell
me more about. She understood what I
was trying to ask, but I could have
rephrased my statement by saying,
Tell me more about your feelings of
not wanting to be here. This allows
her to express more about her


and Curious

I cant believe
she went through
that! This poor
girl. What do I
say to her
without sounding
What do I ask
next? I wonder if
she got help after

3: My non-verbal communication was

leaning back and unfolding my hands.
I should not have leaned back because
it made the conversation less intense
and personal. If I had leaned in,
maybe she would have opened up
more about her feelings and not just
responding with a vague answer
regarding her feelings. In this way, my
non-verbal communication had a

Raises voice. Tilts
head to one side.
Shakes heads. Looks
around. Looks down
and at the corner of her
eyes. Readjusts position
in chair. Raises volume
of voice.

Leans back in chair.

Unfolds hands. Places
hands on lap
Shrugs shoulders. Nods
head. Sways head side
to side.

donated it. Whatever.
I dont care. I have a
lot of clothes at
So what you were
saying before is that
the staff here isnt
making themselves
available to you and
listen to you when
you most need it?
Yes! Exactly! I want
someone to talk to. I
love when people
like you come to talk
to us. Talking things
out is one of my
What are your other
Going into the music
room is my therapy. I
love singing and
jamming out with my
close peers.
What do you sing

Repositions in chair.
Looks up and makes
eye contact with
patient. Tilts head up
and to the side.

and Surprised

I dont
understand why
the staff did not
give her attention
when she clearly
needed it. And
donated her
clothes without
her permission.
This is crazy.
Should I believe
what she is

3: Her non-verbal communication

made me think that there was more
that she wanted to say about this topic.
She claimed to not care, but I wanted
to let her know that I was listening by
saying what I said. In this way, she
was able to open up to me more.

General lead;
Open ended


I wonder what
her other means
of therapy is.
Theres got to be
more than one.

2: Instead of saying this, I could have

gotten more into depth about how that
first type of therapy mentioned helped
her so much. I could have said
Talking things out is one of your
therapies? How does it help you?

Closed Ended

Angry, Upset

Oh no! That
was not a
question. Maybe
it is if I am trying
to figure out
what kind of
music she listens

1,5: Communication Error- Closed

Ended Question: Instead of asking her
this non-therapeutic question, I could
have said It seems like music is very
therapeutic for you where you can feel
better about how you are feeling and
also interact with your peers. There
are many songs to sing that have

Points to the music

room. Raises eye
Head tilt. Smiles.
Raises eye brows and
head nods.
Hand gesture. Opens
shoyu packet and pours
it onto food.

negative impact.


Nods head. Voice

raised. Points index
finger in a quick

Hand gesture toward

client. Sits up in chair.

that incident.


Lets talk about

your other means of
Hmm My aunty
helps me cope the
best. I call her
whenever I need to.
Shes not even my
real aunty, but she
helps me with
Where are your
My parents are in
jail. But I dont like
to talk about my
parents. I have my
aunty and shes all I
need. Shes family to
me. I cant wait to go
home with her. I have
so many plans that I
want to do with my

Leans forward and

refolds hands in lap

Focus Statement;
Open ended


General lead;
Close ended


Head tilted up. Looks

up to the ceiling. Makes
eye contact with
student nurse. Shrugs
one shoulder

Furrowed eye brows.

Leans forward. Make
slight eye contact but
looks down.
Shrugs shoulders.
Looks down. Crosses

to and whether
deals with
negative feelings.
I cant believe I
asked this! It
I need to focus
on other
therapies that
she does. This
way she can
realize that she
has other means
of making herself
feel better.
I hope this
question doesnt
make her feel
uncomfortable. I
wonder what
happened to her
parents. This can
determine why
she only depends
on her aunty.
This seems like a
sensitive topic. I
dont know if I
can handle the

many different meanings. What

particular type of music do you listen
to while you are feeling not so

3: I noticed when I learned toward

her, she began to make more eye

1,2,5: Close ended question: I could

have said I hear that you are close
with your aunty. How is your
relationship with your
family/parents? This would change
my technique from closed to an openended question.
3: My thoughts of thinking I was
making her feel uncomfortable
negatively impacted the interaction
because it caused me to change the
topic without going more into depth.
4: Her nonverbal communication


What are your

plans when you get
out and are with
your Aunty?
I want to go to
school. I want to
graduate from high
school. I miss it. Its
been a while since I
went. I want to live a
normal life.
What do you mean
when you say
normal life?
Yeah. Friends who I
can trust and are not
up to no good.
Friends my age. All
my friends now are
way older than me. I
havent had normal
friends and a normal
life before.
So youre saying
you want to turn
your life around by
changing things in

Leaned forward.
Focus statement;
Hands are unfolded.
Engages in eye contact question


made me feel uncomfortable because

she made it seem like the topic at hand
was irritating her.

Wow. I did not

expect that of her
parents. I dont
want to talk
about anything
she refuses to
speak about. I
can explore her
future and
discharge plans.

4: I felt uncomfortable when she

started to look down and look and
sound uncomfortable, so I decided to
explore a different topic.


I dont
understand what
she means by
normal life. I
wonder what
normal life
means to her.

3: I was confused when she mentioned

normal life I wanted know what a
normal life meant to her and that is
why I asked this question. This
contributed to the interaction in a
positive manner because it shows my
interest and care for her future and
what she wants for herself.


This girl is very


3: Because I was engaged in the

conversation and I actively listened to
what she had to say to me, I was able
to take what she said and put them in


Uncrosses arms. Puts

hands on table. Smiles
and looks up. Makes
eye contact. Takes a
bite of her breakfast
Straightens posture.
Makes eye contact

Open ended

Continues to smiles.
Crosses her legs in her
chair. Continues to
make eye contact and
looks away for a second

Continue to make eye Paraphrase; Open

contact with the client. Ended Question

2: I could have asked You said you

dont like talking about your parents.
What is that you dont like?

your life that you
hadnt had before?
I dont want to turn
to drugs anymore. I
am done with that. I
can deal with my
problems on my own
and with my aunty.

Continues to be
leaned forward.
Repositions in chair.


Silence and

I wonder if she
will elaborate
more. I want to
know more about
her thoughts
about this.



Approval; Closed
ended statement


She seems to
know what she
wants and does
not want. She
seems to know
who her support
system is now
and how to
depend on
herself. By what
she is saying, she
has big goals for
Oh no! Whyd I
say that?! That
was not
therapeutic at
all! I am just so
surprised by her

Slight frown. Legs are

still crossed. Moves
hair out of her face.
Nods her head. Frown
turns into a grin.

My goal is to stay
positive and I really
want to go to Kahuku
High School,
graduate, go to
Chaminade College,
and become a nurse
with the babies.

Nods. Sits up in chair.

Wow! Thats
awesome that you
have goals such as
Yeah. I dont want to
live that life

Raises eye brows.

Repositions in the
chair. Smiles. Voice
Nods and continues to

Smiles. Looks to the

side at the others.

my own words as a way of showing

that I was listening. I knew having an
active listener was important to her, so
I made sure I did this.
3: Showing that I was interested in
what she was going to say by being
silent, allowing her to talk, and
leaning forward had a positive impact
because she was able to elaborate
more and add more to the topic. This
allowed me to understand her current
state of wanting to keep her life
aligned and clean.

2: Drug Addiction was a problem for

her. I feel that it would have been
therapeutic for me to go more into
depth about this. I could have said,
How did the drugs make you feel?

1,5: Communication error: Expressing

Approval: I could have rephrased this
error by saying that I noticed she has a
number of goals for her future and
then proceeded to ask how she would
accomplish them. This way I could

anymore. I want to
get better.


I dont like the
feelings I had before.

Nods. Looks at the

client. Lowers volume
of voice.
Shakes head. Smile
turns into a frown.

I used to have
feelings of killing
myself before, but I
dont anymore. My
life, any life, is too
precious to give up
so easily. I value my
life and I am ready to
You say that you
dont have feelings
of killing yourself. I
have to ask. Have

Closed Ended


Think about
something more
Rachel. Listen to
what she is

Furrowed eye brows.

Turns head to the side. Open Ended
Voice trails up at the
end of the question.
Leans forward.
Looks down and away.
Sits up in her chair.
Uncrosses her legs.


I am not too
sure what she
means by

Makes eye contact

with patient. Folds
hands on table.
Continues to lean

Anxious and

I have never
actually asked
someone this
question before. I

Clarification and
Close Ended

acknowledge her efforts to create a

brighter future for herself as well as
explore how she would accomplish
2: I feel as though we were jumping
topics. I should have gone more into
depth about her drug problems and
slowed the conversation down. It
would have been therapeutic for me to
ask how she felt about drug use now,
and later in the conversation brought
up her goals again.
4: Her smiles affected my response
because I wanted her to continue and
tell me more about why she did not
like that life anymore. I wanted her to
proceed without changing the topic or
4: Her frowning and shaking of her
head made me feel like she was really
disappointment in her past choices
and I wanted to have a better
understanding of those feelings that
made her react in such a way.

3: I was very afraid of asking this

question and I am sure it was
noticeable in my tone of voice. I feel
that this had a negative impact to the

you been having
thoughts of suicide?
Nope! I dont have
those anymore.

If you had any

feelings or thoughts
of hurting yourself
or others, can we
trust that you would
let the staff know?
Yes. I like it when
they ask these
questions. It makes
me feel like they care
about me.
Based on what you
told me, you have
been in many
experiences that
caused you to make
the wrong decisions.
However, you were
able to find
positivity in all of it.
It must have been
hard to get to where
you are now.
Yeah. I am working
on it every day. I just
want to be positive.

forward. Slow and

serious speech.
Shakes head. Raises
voice. Smiles and
makes eye contact
Continues to make eye Close Ended
contact with patient.
Hands are still folded
and leaned forward.

dont know if I
am asking the
right thing. I
dont want her to
get offended.

This isnt so
bad. Asking
about this stuff is
scary though.
She must think I
ask a lot of
questions. I hope
this is helping

3: I was still scared of asking this

question. I should have practiced
saying it before, because my
apprehension could have affected her
actual response which is a negative
impact to the interaction.

Nervous, and

I hope I can
summarize this
well and show
that I have been
listening to her. I
want to show
empathy and
active listening.

2: I should have been more specific

with the many experiences
statement. Instead I could have said
We have talked about many things
which included your frustrations with
the staff, your different therapies, your
goals after discharge, and changing
your life for a normal life. Through
all of this, you were able to stay
optimistic. It must have been hard to
get to where you are now. This could
have been a better help to her because
she can hear her positive thoughts and
experiences she had explained and
also help her understand her progress

Nods. Looks down at

food. Takes a bite of
food. Looks back up
and smiles.
Adjusts position in
chair. Hand gesture
toward patient.

Nods. Smiles and

continues to eat.

Empathy; Open
Ended Statement

interaction because it slowed down

the conversation and made me seem


Well it seems like

we are regrouping
with the rest of the
group. Thank you
for talking to me.
Would you like to
talk about anything
I am okay. Thank
you. Would you like
to come into the
music room with me?

Looks toward the

other patients and the
nurses. Smiles.

Smiles. Looks over to

the music room and
stands up.
Stands up.

Conclusion and
Close ended


Looks like they T

are regrouping. I
have to sum this
up before she
takes her
breakfast and
leaves me. I like
listening to what
this girl has to
say. I hope this
conversation was
helpful to her. I
feel a little
relieved because
she accepted and
chose to open up
to me. And I am
glad she asked
me to join her in
the music room. I
feel like I

since and prior to admission.

2: I did not want to end the
conversation so abruptly such as this
because I feel like there was so much
more that could have been said and
talked about, but it was hard when the
group was on a schedule. I would
have rephrased this by saying, I
noticed that the rest of the group is
regrouping and going into the other
room. Before ending this, I wanted to
ask if there was anything you would
like to talk about before joining the
rest of the group. We can still continue
talking if youd like. This way, I am
not forcing her to stop talking and it
seems like she has more of choice to
continue talking to me.