Mental Health Nursing
Process Recording
Student Name:
Date & Location:
Client Diagnosis:
History RT Diagnosis; Onset,
Duration & Prior Treatment:
Nurse Communication
(Verbal & Non Verbal)
1. Hello…
(Establishing eye contact
while aproaching in a
friendly manner)
2. My name is Susan, I'm
Nursing student at……,
and I would like to talk with
you for a moment. Would
you like to speak with me?
(Leaning forward the
patient, with open posture)
3. Ok, thank you.
and your name is…?
( I took a sit next to him at
his right side)
4. How are you today?
active
(Leaning forward, making
eye contact)
5. Would you like to tell me a
little about yourself, what
brought you here? or what
is happening to you if you
want to share it with me?
(Using SOLER technique of
active listening)
6. Tell me little bit more…
You said you wanted to
 
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.
Client Communication Nurse’s Thoughts & Analysis of the (Effectiveness,
(Verbal & Non Verbal) Feelings Related to Technique, Name & Rationale)
the Interaction
Hello… I had the feeling that he Greeting the patient:
wanted to talk with It is necessary in order to have
(Looking me directly with someone. an appropriate start
I for the
a facial expression that conversation.
denotes interest.)
Yes, not problem I felt well when he Introducing oneself and
answered and approved establishing a contract:
(The client has a flat talking with me. It should be done when meeting
emotional but accepting the client for the first time in
expression in his face. He order to have an appropriate start
is calm and has a for a therapeutic communication.
soft speech)
My name is J.K Thinking about how to Identifying the patient / Giving
start the conversation recognition:
(He shows relax posture and taking him straight Shows to the client that the
and open attitude, well to the point without nurse wants to recognizes him as
groomed appearance) being too invasive. an individual, as a person.
I’m ok… Trying to initiate the Broad opening question:
conversation. Gives the client the lead in the
(He seems not very interaction , and it may stimulate
convinced of that) him to take the initiative.
The reason why I'm here Satisfied that he Broad opening question:
is because… you know… understood my question Gives the client the lead in the
I had have several and he was willing to interaction , and it may stimulate him
suicidal attempts in my open himself to the him to take the initiative.
life, and last week I knew conversation.
I was going to try it again.
I wanted to kill myself,
but I recognize the
symptoms and I came here for help
before I actually did it.
I came voluntary here.
Yes, it is what I wanted I wished not having to Restating:
to do. I feel really sad, is ask that question, it is The restatement encourages the
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 kill yourself?
(Active listening )
something in my mind,
is depression, something
that I cannot control or
get rid of it, and I cannot
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.
really sad. client to continue, and let the
I knew exactly what he client know that he or she
was talking about, communicated the idea
because I was very effectively.
closed to a person in my
life with the same
problem. I wish

( His sadness and powerless

is evident in his face)

7. How were you planning to
kill yourself.
(Active listening )
8. You say you tried it before
to kill yourself?
When was the previous time
that you had also tried it?
(Active listening )
Taking my bottle of meds Trying to know more Exploring:
at one time. about the situation. Allows the nurse to gather more
information regarding important
(The sadness continue) topics mentioned by the client.
In November, 2 months I was feeling very sorry Placing event in time or
ago. I took 90 pills. for him. He had so much sequence:
It happen to me going on in his life. Putting events in proper
because I have Bipolar sequence helps both the nurse
Disorder. I'm also HIV(+). and client to see them in
I had being suffering perspective.
from Bipolar since 1982 The nurse may gain information
and I was diagnosed with about recurrent patterns or
HIV 8 years ago. themes in the client’s behaviors.

(Very cooperative and

providing detailed
information about himself)

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

(Confused, frustrated, sad)

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

(Confused and depressed)

11. But what do you think he But the thing is. What you His depressive disease Presenting reality:
would prefer? Help you if would do if you have to makes him disoriented Clarifying misconceptions that

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 you open to him, or see you decide between hurt
that you took your yourself and hurt the
life. person you love?
(Active listening techniques )
(Poor judgement)
12. It is a difficult answer but … Yes I know but is
Don’t you think that hurting something very difficult
yourself and taking your life, to explain, the pain inside
is a way of hurt him too? my brain, the depression,
the loneliness has such
(Small frown) dimension that is very
difficult to think clear.
(Frustrated, sad)
13. Do your partner has HIV Yes, he has. We both Feeling sorry for both
too? contracted it but we never now.
knew how we got it.
(Non judgmental
expression) (The depression seems to be
bothering him much more
than the HIV disease)
14. Are you taking medicines to Yes, I'm taking 22 pills
control the HIV and the twice at day.
Bipolar Disorder? But other problem is that
the pills are good for
( Light surprised expression certain time and after a
after the client’s answer) period they are not
effective anymore.
(Continues willing to give
information about him)
15. I know. It happens because Yes he does.
your body and metabolism I would like also here
get use to them and the at the hospital let us talk
meds turn not being as much in groups, to have a way
effective than they were to share each other our
before. problems. It is necessary
It is something that your to have therapy groups,
doctor needs to address that can help for our
periodically to ensure you situation.
get the best option available.
( Showing hopeful interest
(Trying to be explicative) on being accomplished his
desire)
16. Have you ever participated Yes, I was member of a
in therapy groups in the therapy group for many
 
about the potential client may be expressing.
consequences of Intents to indicate an alternate
self-injury could line of thought for the client to
produce to his significant consider.
others.
He is having poor Non therapeutic:
judgment about the It could be non therapeutic
significance of hurting because I’m Rejecting and
other person or himself. refusing to consider or
showing contempt for the
client’s ideas or behaviors.
I’m also Probing or
persistent questioning the client.
Non therapeutic:
I’m Introducing an unrelated
topic or changing the subject.
The topic could be a little related
but I’m loosing the focus about
my patient. The fact of knowing
if his partner has or not HIV it
doesn’t contribute to identify the
patient’s feelings or problems.
I think 44 pills at day is Exploring:
something that even Allows the nurse to gather more
myself I wouldn’t even information regarding important
tolerate. Thinking about topics mentioned by the client.
what are the positives
things in his life and
ways to help him to find
the support he needs.
I believed he has Giving information:
loneliness and I am Increases the client’s knowledge
maybe helping him in about a topic, let the client
some way to escape from know what to expect, and builds
it. trust with the client.
I realize that that the Encouraging comparison:
patient is willing to talk The client benefits from
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 past and that has helped you years, but now here we
with your depression? need someone that listen
to us. It is why we are
(Active listening ) here. If nobody talk or
listen to us is the same
that being at home.
and he trusts me. making this comparisons because he or
he might recall past coping
strategies that were effective
or remember that he has
survived a similar situation.

(Increased interest in
talking about it)

17. I understand what you mean.
We do have meetings groups
here, and you will have the
opportunity to talk and
express your feelings. But
always remember you have
the right to call the nurse
anytime you need it and ask
help or something else you
need.
(Trying to be explicative)
Ok thanks.
(Showing doubt of the
possibility of being
helped in the hospital)
Trying to explain that Accepting:
people in this hospital is An accepting response indicates
willing to help him when the nurse has heard and follow
he needs it. the train of thought. It does not
I believe that he really indicate agreement but is
feels lonely and nonjudgmental.
desperate for communi-
cating with someone Giving information:
willing to listen him. Increases the client’s knowledge
about a topic, let the client
know what to expect, and builds
trust with the client.

18 Do you believe that maybe
participating in therapy
groups can help you to deal
with your problems,
as it was in the past?
(Active listening )
I don’t know if it would
relieves 100% from
my depression but it
may help something.
(Slightly hopeful, but not
convinced)
Thinking in orienting the Encouraging expression:
client to find a support Asking the client to consider
system that help him to people and events in light of his
resolve his emotional own values , the nurse
problem. encourages the client to make his
own appraisal of the situation.

19. Tell me what activities you No I don’t work, I have Thinking also that Exploring:
normally do? Do you work? disability. having a passive life Allows the nurse to gather more
style doesn’t help to his information regarding important
(Active listening ) (Flat expression) disease. topics mentioned by the client.

20. I see… and the fact that you
don’t work, can that
situation also be
contributing with economic
problems you may have?
Since life is very difficult
today for everybody. It is
that situation also affecting
you in your depression?
(Trying not being too invasive)
Well, life is very difficult
today but that is not
affecting me so much
with my depression.
(Sadness and flat
expression)
Trying to find more Non therapeutic:
reasons that may This question could be done
influence in his instead a like: Does this situation
depression. contribute to your distress? ,
because some people don’t like
to speak about their economic
problems, and they actually can
deny a fact that is real, without
giving more information.

21. And, what about doing
activities to help you
distract yourself from your
depression?
(Active listening )
22. I believe that the fact that
you recognized your
Yes, it could help for Feeling that he wanted Encouraging expression:
moments but the to find help in a Asking the client to consider
depression always come therapeutic group as people and events in light of his
back. he did in the past. own values , the nurse
encourages the client to make his
(The sadness expression own appraisal of the situation.
continues)
Yes, I know. I wanted to remark Making observation:
the positives aspects It verbalizes what the nurse

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 suicidal thinking and decide (Hopeless) about himself, and his perceives when the client cannot
to come to the hospital accomplishments to
seeking help it is a good increase his self-esteem. verbalize Iorwanted
make themselves
to remark
point, and a positive understood.
alternative you chose instead
of harming yourself. It is Formulating a plan of action:
something that you would It may be helpful for the client
have to implement in the to plan in advance what he or she might
future if it ever happen do in future similar situations.
again.

( Showing a positive attitude)

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

24. Thanks to you for share I’m going to get my It was a good conversa- Closing of the interview
with me your concerns. medicines. tion. I feel he wanted to
talk and it may helped
(Smiling, standing up) (Standing up) him.

 
 

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