Process Recording

Client Diagnosis: Bipolar Disorder, suicidal ideation, suicides attempts

8 suicide attempts, anhedonia, anergia, poor sleep, inability to function,
hopelessness, helplessness, no violent toward others. Hx: HIV(+), COPD.
History RT Diagnosis; Onset,
Duration & Prior Treatment:
Nurse Client Nurse’s Thoughts & Analysis of the
Communication Communication Feelings Related to (Effectiveness,
(Verbal & Non (Verbal & Non the Interaction Technique, Name &
Verbal) Verbal) Rationale)

1. Hello… Hello… I had the feeling that he Greeting the patient:

wanted to talk with It is necessary in
order to have
(Establishing eye (Looking me someone. I
contact directly with an appropriate start
for the
while aproaching a facial
in a expression that conversation.

friendly manner) denotes interest.)

2. My name is Yes, not problem I felt well when he Introducing oneself

Cristina, I’m answered and approved and
Nursing student at establishing a
SCCC, contract:
(The client has a talking with me.
It should be done
flat
when meeting
and I would like to
talk with
emotional but
the client for the first
accepting time in
you for a moment.
Would
expression in his order to have an
face. He
appropriate start
you like to speak
with me?
is calm and has a
for a therapeutic
communication.
soft speech)

(Leaning forward
the

patient, with open

posture)

3. Ok, thank you. My name is J.K Thinking about how to Identifying the
and your name start the conversation patient / Giving
is…? recognition:
Shows to the
(He shows relax and taking him straight
client that the
posture nurse wants to
 ( I took a sit next to and open attitude, to the point without recognizes him as
him at well
being too invasive. an individual, as a
his right side) groomed person.
appearance)

4. How are you I’m ok… Trying to initiate the Broad opening
today? conversation. question:
active Gives the client the
lead in the
(He seems
interaction , and it
(Leaning forward, not very
may stimulate
making
convinced of that)
him to take the
eye contact)
initiative.

5. Would you like to The reason why Satisfied that he Broad opening
tell me a I’m here understood my question question:
little about is because… you Gives the client the
yourself, what know… lead in the
and he was willing to interaction , and it
may stimulate him
brought you here? I had have several
or what open himself to the
him to take the
suicidal attempts
conversation. initiative.
is happening to you in my
if you
life, and last week
want to share it I knew
with me?
I was going to try
it again.

(Using SOLER I wanted to kill

technique of myself,

active listening) but I recognize

the

symptoms and I
came here for
help

before I actually
did it.

I came voluntary
here.

6. Tell me little bit Yes, it is what I I wished not having to Restating:

more… wanted ask that question, it is The restatement
You said you to do. I feel really encourages the
wanted to sad, is
really sad.
client to continue, and
 kill yourself? something in my I knew exactly what he let the
mind,
was talking about, client know that he or
is depression, she
something
(Active listening ) because I was very
communicated the
that I cannot idea
control or closed to a person in my

effectively.
get rid of it, and I life with the same
cannot
problem. I
wish
handle it
anymore. I’m

really tired. It
hurts my

mind, is pain, is
an

uncontrollable
pain that I

feel, and I don’t

know

why I feel this

way.

( His sadness and

powerless

is evident in his
face)

7. How were you Taking my bottle Trying to know more Exploring:

planning to of meds about the situation. Allows the nurse to
kill yourself. at one time. gather more

information regarding
important
(Active listening ) (The sadness
continue) topics mentioned by
the client.

8. You say you tried In November, 2 I was feeling very sorry Placing event in time
it before months for him. He had so much or
to kill yourself? ago. I took 90 sequence:
pills. Putting events in
going on in his life.
proper
When was the
previous time It happen to me
sequence helps both
 that you had also because I have the nurse
tried it? Bipolar
and client to see them
Disorder. I’m also in
HIV(+).
(Active listening ) perspective.
I had being The nurse may gain
suffering information

from Bipolar about recurrent

since 1982 patterns or

and I was themes in the client’s

diagnosed with behaviors.

HIV 8 years ago.

(Very cooperative
and

providing detailed

information about
himself)

9. I imagine how hard Yes it is, and I I’m feeling sad, and Emphaty:
should cannot thinking how can I help When empathetic, the
be for you to have explain myself
this two why I have
him to alleviate his pain. nurse is
nonjudgmental,
diseases. this depression sensitive, open, and
I believe it is too much
and this
capable of imagining
pain. suffering for an another
(Active listening )
I can not tolerate individual having this person’s experience.
it any
two diseases.
more. I live with
my

partner and I
cannot talk

with him about

this.

(Confused,
frustrated, sad)
10. Can you explain it He is very I’m realizing his support Seeking
little it supportive system is failing. Is hard clarification:
bit more. with me, and I It helps the nurse to
don’t want avoid
to understand the
What it’s the
reason why to talk with him making assumptions
refusing of seeking help
because I that
you cannot speak
with him? don’t want to hurt in his close family and understanding has
him. It occurred when
(Active listening ) keeping all to
himself. I’m
is enough with it has not.
my pain. I

don’t want to pass

him my

problems.

(Confused and
depressed)

11. But what do you But the thing is. His depressive disease Presenting reality:
think he What you makes him disoriented Clarifying
would prefer? Help would do if you misconceptions that
you if have to
about the potential
client may be
you open to decide between expressing.
consequences of
him, or see you hurt
Intents to indicate an
self-injury could
that you took your yourself and hurt alternate
the
life. produce to his significant line of thought for the
person you love? client to
(Active listening others.
techniques ) consider.

(Poor judgement)

12. It is a difficult Yes I know but is He is having poor Non therapeutic:

answer but … something very judgment about the It could be non
Don’t you think
 that hurting difficult significance of hurting therapeutic

yourself and taking to explain, the other person or himself. because

your life, pain inside I’m Rejectingand
refusing to consider or
is a way of hurt my brain, the
him too? depression, showing contempt for
the
the loneliness has
such client’s ideas or
behaviors.
(Small frown)
dimension that is
very I’m also Probing or
persistent questioning
the client.
difficult to think
clear.

(Frustrated, sad)

13. Do your partner Yes, he has. We Feeling sorry for both Non therapeutic:
has HIV both now. I’m Introducing an
too? contracted it but unrelated
we never topic or changing the
subject.
knew how we got
it.
(Non judgmental
The topic could be a
little related
expression)
but I’m loosing the
(The depression focus about
seems to be

my patient. The fact

bothering him
of knowing
much more

if his partner has or

than the HIV
not HIV it
disease)

doesn’t contribute to
identify the

patient’s feelings or
problems.

14. Are you taking Yes, I’m taking I think 44 pills at day is Exploring:
medicines to 22 pills something that even Allows the nurse to
control the HIV twice at day. gather more
and the
myself I wouldn’t even
But other problem information regarding
 Bipolar Disorder? is that tolerate. Thinking about important

the pills are good what are the positives topics mentioned by
for the client.
( Light surprised things in his life and
expression certain time and
after a
ways to help him to find
after the client’s
answer) period they are
not the support he needs.

effective
anymore.

(Continues
willing to give

information about
him)

15. I know. It happens Yes he does. I believed he has Giving information:

because I would like also loneliness and I am Increases the client’s
your body and here knowledge
metabolism
maybe helping him in
at the hospital let about a topic, let the
get use to them and us talk client
some way to escape from
the
in groups, to have know what to expect,
it.
meds turn not a way and builds
being as much
to share each trust with the client.
effective than they other our
were
problems. It is
before. necessary

It is something that to have therapy

your groups,

doctor needs to that can help for

address our

periodically to situation.
ensure you

get the best option

available.
( Showing
hopeful interest

on being
(Trying to be
 explicative) accomplished his

desire)

16. Have you ever Yes, I was I realize that that the Encouraging
participated member of a patient is willing to talk comparison:
in therapy groups therapy group for The client benefits
in the many from
and he trusts me.

past and that has years, but now making this

helped you here we comparisons because
he or
with your need someone
depression? that listen he might recall past
coping
to us. It is why we
are strategies that were
effective
(Active listening )
here. If nobody
talk or or remember that he
has
listen to us is the
same survived a similar
situation.
that being at
home.

(Increased
interest in

talking about it)

17. I understand what Ok thanks. Trying to explain that Accepting:

you mean. people in this hospital is An accepting
We do have response indicates
meetings groups
(Showing doubt willing to help him when
of the the nurse has heard
here, and you will and follow
he needs it.
have the
possibility of
being the train of thought. It
I believe that he really
opportunity to talk does not
and
helped in the
feels lonely and
hospital) indicate
express your agreement but is
feelings. But desperate for communi- nonjudgmental.

Giving information:
always remember cating with someone Increases the client’s
you have
knowledge
willing to listen him.
the right to call the
about a topic, let the
nurse client

anytime you need know what to expect,

 it and ask and builds

help or something trust with the client.

else you

need.

(Trying to be
explicative)

18 Do you believe that I don’t know if it Thinking in orienting the Encouraging

maybe would client to find a support expression:
participating in relieves Asking the client to
therapy 100% from consider
system that help him to
people and events in
light of his
groups can help my depression but
you to deal it resolve his emotional
own values , the nurse
with your may help problem.
problems, something. encourages the client
to make his
as it was in the
past? own appraisal of the
situation.
(Slightly hopeful,
but not

(Active listening ) convinced)

19. Tell me what No I don’t work, I Thinking also that Exploring:

activities you have having a passive life Allows the nurse to
normally do? Do disability. gather more
you work?
style doesn’t help to his
information regarding
important
disease.
(Flat expression)
(Active listening ) topics mentioned by
the client.

20. I see… and the fact Well, life is very Trying to find more Non therapeutic:
that you difficult reasons that may This question could
don’t work, can today but that is be done
that not
influence in his
instead a like: Does
situation also be affecting me so this situation
depression.
much contribute to your
distress? ,
contributing with because some people
economic with my
don’t like
depression.
problems you may
to speak about their
 have? economic

Since life is very (Sadness and flat problems, and they

difficult actually can
expression)
today for deny a fact that is
everybody. It is real, without

that situation also giving more

affecting information.

you in your
depression?

(Trying not being

too invasive)

21. And, what about Yes, it could help Feeling that he wanted Encouraging
doing for to find help in a expression:
activities to help moments but the Asking the client to
you consider
therapeutic group as
people and events in
depression always
light of his
distract come
he did in the past.
yourself from your
own values , the nurse
back.
depression?
encourages the client
to make his

(The sadness
own appraisal of the
(Active listening ) expression
situation.

continues)

22. I believe that the Yes, I know. I wanted to remark Making observation:
fact that the positives aspects It verbalizes what the
you nurse
recognized your
(Hopeless) about himself, and his
perceives when the
suicidal thinking client cannot
accomplishments to
and decide

increase his self-esteem. I

to come to the
wanted to remark
hospital
verbalize or make
themselves
seeking help it is a
good
understood.

point, and a
positive

alternative you Formulating a plan

chose instead of action:
It may be helpful for
the client
of harming to plan in advance
 yourself. It is what he or she might

something that you do in future similar

would situations.

have to implement
in the

future if it ever
happen

again.

( Showing a
positive attitude)

23. You are doing a Thank you for I think that it is necessary Summarizing:
big progress in have help him to visualize the Brings out the
seeking help, and listened to me. important points
coming
positive side of his
(Grateful of the discussion,
here voluntary to expression) increase
situation in order to give
the
awareness and
him some hope and
hospital. I wish provides a sense
you a soon
I think I have to
take my encouragement. of closure at the
relief of your completion of
medical
medicines now…
each discussion for
problems, and the both client
ability to
and nurse.
continue increasing ( He sudden
strength in remembers

something…)
dealing with them.

(Trying to give
some hope)

24. Thanks to you for

share
with me your
concerns.

(Smiling, standing
up)