Process sample for mental health

please follow the sample ” process recording example ” and use the information on the 2nd paper” process lolo ” background information , you can reformulate and add some medications if needed and come out with the remaining part but follow the standard of the process recording example.

Therapeutic Communication
Student’s Name:
Date of Interaction: 27 October 2015
Client’s Initials: M.P.
Therapeutic Communication #3
ASSESSMENT:
• Background Information: M.P. is a 54yo separated Caucasian woman who was
encouraged to go to ABH after sharing with her day group that she possibly overdosed
the day before on one of her home medications. She has a history of major depressive
disorder which has left her out of work for several years and recently she has developed
suicidal ideations in the past several months.
•
Medications
1. Aripiprazole (Abilify), 15mg tab PO nightly—for psychosis
Side effects: dizziness, weakness, nausea, vomiting, fatigue, excess saliva,
choking or trouble swallowing, blurred vision, headache, anxiety, weight gain,
sleep problems, constipation
2. Diphenhydramine (Benadryl), 50mg cap PO nightly—for insomnia
Side effects: sedation, fatigue, dizziness, disturbed coordination, constipation, dry
mucus membranes, blurred vision, tremor, anorexia, nausea
3. Fluoxetine (Prozac), 5mg tab PO nightly—for depression
Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness,
dizziness, heart palpitations, weight changes, cold symptoms, dry mouth,
impotence
4. Lithium, 300mg cap PO QID—for mood stability
Side effects: tremors, increased thirst, increased urination, diarrhea, vomiting,
weight gain, impaired memory, poor concentration, drowsiness, weakness
5. Oxybutynin (Ditropan), 5mg tab PO BID—for bladder spasm
Side effects: dry mouth, blurred vision, constipation, diarrhea, nausea, dizziness,
weakness, headache, insomnia
6. Propanolol (Inderal), 10mg tab PO BID—for tremors
Side effects: dizziness, fatigue, nausea, vomiting, stomach pain, vision changes,
insomnia
• Assess myself: While I had prepared to present my teaching project that day, I was eager
to help the nurses and spend time with patients. It was my last week on Montgomery
unit, so between my teaching project and interacting with patients on the unit, I was eager
to have a productive day.
• Assess milieu: There were 12 patients on the unit that day. Many of the patients were
spending time with each other in the day room, laughing and chatting as they painted
each other’s nails. Because of MP’s fluctuating SI and recent attempts to hide plastic
utensils in her room, the nurse asked if I would sit with MP while she ate dinner.
DIAGNOSIS:
Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety,
hopelessness, social isolation
PLANNING:
•
•
Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent
suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on
the positives in her life, like her family and her possibilities.
By completion of the TC, the patient will:
1. Discuss her desire to die.
2. Recognize possible stressors leading to SI.
3. Focus on the positives and motivations in her life.
IMPLEMENTATION:
Nurse
Patient Communication
Communicati
on
“How are you “Okay. Depressed, I
doing today?” guess, but that’s normal.”
Analysis of Process
Although I’ve talked with this
client before, I was a bit
surprised at her openness.
Therapeutic
Technique
Using broad
openings
“How long
have you been
feeling
depressed?”
“I guess about one year
with major depression,
but about five years
depressed.”
From her chart I knew she had Exploring,
a history of depression, but I
seeking
was curious what her
clarification
perception was.
“How have
you been
feeling
lately?”
“It’s been… well, bad
enough to be hospitalized.
I was having suicidal
thoughts so they thought
it best that I come in.”
“Yeah”
Her feelings have been
fluctuating, so I wanted to
understand why they are
fluctuating.
“Do you still
have suicidal
thoughts?”
“Do you have
the desire to
kill yourself?”
“Tell me more
about that.
What do you
think brings
on those
thoughts?”
“Sometimes.”
General leads
(nodding my
head), exploring
I ask this not just to gauge her Seeking
fluctuating feelings but also to clarification,
check her safety and risk of
exploring
danger to her safety.
After talking with another
client about his lack of desire
to kill himself but the
presence of suicidal thoughts,
I was curious if she actively
desired to end her life. I am
not surprised by her answer,
but I want to understand her
further.
“Well a long time ago I
I hadn’t known about the
was abused, and I blamed abuse, so it is an interesting
my mom for the abuse but piece of her case. Because we
I also blamed myself.”
are alone and it doesn’t sound
like she wants to go into
details with the abuse, I
Summarizing,
encouraging
description of
perceptions
Exploring,
focusing, using
broad openings,
seeking
clarification
decide not to press for more
details.
“That’s
interesting.
Why do you
think you
blame your
mom?”
“You sound
glad that she
talked about it
with you.”
“She was passive. She
was the kind of person
who put on a smile even
if things were going bad. I
respect and admire her in
a lot of ways. She visited
me last week and talked
about the abuse.”
“Yeah, she’s never done
that before, I was very
surprised. She also talked
about my sister’s abuse.
My sister and I only
talked about it recently,
and I felt like I should
have known.”
“You have a
lot of siblings,
right?”
“Yeah, 6 sisters and 3
brothers. Big Catholic
family.”
“Do you get
support from
your family?”
“No, not really. Some
live nearby but I lost
touch with them. I tend to
isolate myself because of
the depression, which I
know I need to fix.”
“Yea, I think I should try
to spend more time with
my family.”
“So you want
to spend more
time with
people.”
“I think I have “Thanks, see you later”
to go now, but
it was great
talking with
you and I hope
you get better
soon. I’ll see
She has a lot to say about her
mom, so I guess she has
thought a lot about her and
their relationship. Looking
back, I should have asked the
client why she felt guilty for
the abuse.
Restating,
encouraging
description of
perceptions,
seeking
clarification
I feel sad that she endured
abuse within her family, and
that her whole family was
affected by it. Thankfully, by
talking with her mom about
this, it seems like she has
begun to heal from it. I
wonder how she would have
grown up if her family
recognized and dealt with the
abuse sooner.
She chuckled as she said the
last part. I had remembered
her having a big family from a
previous conversation.
Attempting to
translate into
feelings
I found this insight interesting
because she seems to want to
get better and fight her
depression, even though she
sometimes has the desire to
kill herself.
She sounds interested in
improving her health with this
feasible fix.
Focusing,
exploring,
It was time for me to leave for
dinner, but I wanted to assure
her that I listened and
sincerely wanted her to find
healing.
Encouraging
formulation of a
plan of action,
offering self
Exploring
Restating
you later.”
EVALUATION:
• Strengths and weaknesses of the interaction: She seemed honest with me about her risk
for suicide, although I think I could have asked her more about that. She had good
insight of her social isolation and how that contributes to her depression. Despite her
openness, I am unsure if she found meaning in our conversation or if she was merely
going through the motions.
• Outcomes of the session: She shared her history of depression and abuse, which shows
that she recognizes the negative things in her life. It was difficult to explore the problems
weighing on her mind and give adequate time to redirect to the positive parts of her life.
All in all, I believe that after our conversation, this client has reinforcement to build
healthy relationships and fight her depression.
Therapeutic Communication
Student’s Name: Laurence Ngonla Lonla
Date of Interaction: 27 October 2015
Client’s Initials: Mrs.T.S
Therapeutic Communication
ASSESSMENT:
• Background: A 49-year-old patient comes to the clinic with a history of depression and
UTI. She tells the nurse that she was treated for it by a doctor in another county, but he
ran out of pills a week ago and did not know how to get a refill. She could remember the
name of the medication but said ‘‘it was for depression’. She also has been having trouble
sleeping since her husband cheated on her and asked for a divorce. She lost 34pounds in
1 month. A family member called 911 because she was feeling uncontrollable with
suicidal ideation, thoughts of overdose on medications, current denied HI. After a
psychiatric evaluation, she was given a 2-week prescription for fluoxetine (Prozac) and
melatonin for sleep at night, Lexapro 10 mg.
•
•
Medications
1. melatonin, 5mg PO nightly—for sleep
Side effects: dizziness, drowsiness, headaches, nausea, irritability, hormonal
effects for long term use.
2. escitalopram (Lexapro), 10mg cap once PO nightly—for depression and anxiety
disorders.
Side effects: Nausea, fatigue, dizziness, insomnia, constipation or diarrhea, dry
mouth, sweating. Sexual side effects such as decrease libido, difficult achieving
orgasm.
3. Fluoxetine (Prozac), 5mg tab PO nightly—for depression
Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness,
dizziness, heart palpitations, weight changes, cold symptoms, dry mouth,
impotence
Assess myself: I have been assigned bto work with the nurses in magnolia unit and I
found this case interesting and decided to know more about this particular patient. It was
a pleasure for me to note her 5 priorities values un life as love, family, honesty, respect
and success.
• Assess milieu: There were 12 patients on the unit that day. Many of the patients were
spending time with each other in the day room, laughing and discussing. Base on the
background history,
DIAGNOSIS:
Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety,
hopelessness, social isolation
PLANNING:
• Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent
suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on
the positives in her life, like her family and her possibilities.
• By completion of the TC, the patient will:
1. Discuss her desire to die.
2. Recognize possible stressors leading to SI.
3. Focus on the positives and motivations in her life.
IMPLEMENTATION:
Nurse
Patient Communication
Communicati
on
“How are you “Okay. Depressed, I
doing today?” guess, but that’s normal.”
Analysis of Process
Although I’ve talked with this
client before, I was a bit
surprised at her openness.
Therapeutic
Technique
Using broad
openings
“How long
have you been
feeling
depressed?”
“I guess about one year
with major depression,
but about five years
depressed.”
From her chart I knew she had Exploring,
a history of depression, but I
seeking
was curious what her
clarification
perception was.
“How have
you been
feeling
lately?”
“It’s been… well, bad
enough to be hospitalized.
I was having suicidal
thoughts so they thought
it best that I come in.”
“Yeah”
Her feelings have been
fluctuating, so I wanted to
understand why they are
fluctuating.
“Do you still
have suicidal
thoughts?”
“Do you have
the desire to
kill yourself?”
“Tell me more
about that.
What do you
think brings
on those
thoughts?”
“Sometimes.”
General leads
(nodding my
head), exploring
I ask this not just to gauge her Seeking
fluctuating feelings but also to clarification,
check her safety and risk of
exploring
danger to her safety.
After talking with another
client about his lack of desire
to kill himself but the
presence of suicidal thoughts,
I was curious if she actively
desired to end her life. I am
not surprised by her answer,
but I want to understand her
further.
“Well a long time ago I
I hadn’t known about the
was abused, and I blamed abuse, so it is an interesting
my mom for the abuse but piece of her case. Because we
I also blamed myself.”
are alone and it doesn’t sound
like she wants to go into
details with the abuse, I
decide not to press for more
details.
Summarizing,
encouraging
description of
perceptions
Exploring,
focusing, using
broad openings,
seeking
clarification
“That’s
interesting.
Why do you
think you
blame your
mom?”
“You sound
glad that she
talked about it
with you.”
“She was passive. She
was the kind of person
who put on a smile even
if things were going bad. I
respect and admire her in
a lot of ways. She visited
me last week and talked
about the abuse.”
“Yeah, she’s never done
that before, I was very
surprised. She also talked
about my sister’s abuse.
My sister and I only
talked about it recently,
and I felt like I should
have known.”
“You have a
lot of siblings,
right?”
“Yeah, 6 sisters and 3
brothers. Big Catholic
family.”
“Do you get
support from
your family?”
“No, not really. Some
live nearby but I lost
touch with them. I tend to
isolate myself because of
the depression, which I
know I need to fix.”
“Yea, I think I should try
to spend more time with
my family.”
“So you want
to spend more
time with
people.”
“I think I have “Thanks, see you later”
to go now, but
it was great
talking with
you and I hope
you get better
soon. I’ll see
you later.”
E
She has a lot to say about her
mom, so I guess she has
thought a lot about her and
their relationship. Looking
back, I should have asked the
client why she felt guilty for
the abuse.
Restating,
encouraging
description of
perceptions,
seeking
clarification
I feel sad that she endured
abuse within her family, and
that her whole family was
affected by it. Thankfully, by
talking with her mom about
this, it seems like she has
begun to heal from it. I
wonder how she would have
grown up if her family
recognized and dealt with the
abuse sooner.
She chuckled as she said the
last part. I had remembered
her having a big family from a
previous conversation.
Attempting to
translate into
feelings
I found this insight interesting
because she seems to want to
get better and fight her
depression, even though she
sometimes has the desire to
kill herself.
She sounds interested in
improving her health with this
feasible fix.
Focusing,
exploring,
It was time for me to leave for
dinner, but I wanted to assure
her that I listened and
sincerely wanted her to find
healing.
Encouraging
formulation of a
plan of action,
offering self
Exploring
Restating