MSSU Nursing
Concepts of Mental Health Nursing N328
Process Recording
Student Name: Noah Carpenter Client gender/age: M/20 Date: 3/10/2023
Introduction (Patient background that led to this admission):
Self admit after having an argument with father that led to pt threatening to self-harm
Behavioral Health Diagnosis (DSM-5): Bipolar 1 disorder, manic, moderate; cannabis induced
anxiety disorder
Medical Diagnosis (if applicable): N/A
NOTICE: (What do you observe about your patient?)
I noticed that he was very talkative but at a reasonable level, was kind and friendly, approached us to
talk when we first arrived, was friendly with the other patients, and looked clean and tidy. Patient was
with another patient away from the others talking because they were “being too loud” according to the
other patients. Patient was well mannered during cards and spoke in conversation well.
Mental Status ABCT Assessment:
Appearance: (posture, movement, dress, hygiene)
Straight posture, expected movement, tidy clothing (scrubs), good hair and teeth hygiene
Behavior: (LOC, mood, affect, speech)
AOx4, “good” mood, animated and congruent affect, rapid pressured speech
Cognitive Functions: (Orientation, attention span, memory)
Well oriented, moderate attention span, good memory aside from night of admission, was able to play
cards and read and have a conversation
Thought Process: (thought process, content and perception)
History of grandiose ideas, risky activities, flight of ideas; currently grandiose ideas but tame content
and perception
Screen for suicidal thoughts: (SAD PERSONS scale Fosbre text Pg 379 Box 23.1)
S-Male (1)
A-20 (0)
D- none (0)
P- previous attempt (1)
E- excessive THC/weed use (1)
R- rational thinking loss-grandiose ideas-bipolar 1 (1)
S- single (1)
O- no plan (0)
N- has social support (0)
S- no future attempt (0)
0-5 (5) May be safe to discharge (depending on circumstances). If sent home, have follow-up
appointment arranged and discharge patient with family or friend.
INTERPRET (Interpret what you’ve noticed):
I think the patient is a lot calmer and his symptoms look a lot more managed because of his behaviors
but I was still wary of his behaviors as being manipulative. He did seem to want to talk a lot and
wanted to always be at the center of the conversation which makes me concerned about how easily a
manic episode may happen or if that is just baseline behavior. During card games he was competitive
but was humorous and didn’t seem to become upset when he lost and went into a long story about his
past history and his life that led to him being here after we talked about how we were nursing students-
wanted to help us by telling his story. He did seem to compete with the other patient for control of the
conversation.
Problem (most relevant): management of bipolar 1 symptoms-risky ideas, grandiose ideas, etc.
Patient Goal related to their Problem (measurable with a timeframe):
Family will report zero risk taking behaviors at first outpatient visit
RESPOND (interventions to help client achieve goal)
& Rationale (why you are doing it):
1. Educating family to withhold materials
Educate the family to withhold money/car keys/other high risk behavior tools when pt is in a manic
state to prevent risky behaviors from happening
2. Reorient to reality
When patient is in a manic state or is experiencing grandiose ideas, reorient patient back as to reduce
the amount of time the ideas are ruminating and help to reduce the other effects of the bipolar disorder
3. Adherence to medication
Educate patient to create a drug regimen and stick to it, educate family to assist to ensure the bipolar is
managed or the drug prescribed can be altered if necessary to protect patient safety
Interactions:
I Techniques
What the
What I said and did I felt thought used
What the client client did
(Verbal & Non- (Your (Your (Therapeutic
said (Verbal) (Non-
verbal responses) feelings) thoughts and Non-
verbal)
) therapeutic)
I felt I thought
I played cards and The client talked comforta that he
conversed with the about how he ble but seemed
patient alongside was struggling The client still very put
Non-therapeutic
another nurse and with manic was calm slightly together
while playing
patient. We talked bipolar 1 and and was on edge for being
the games and
about pt’s history how he got into playing because in this
therapeutic
and how/why he an argument with cards with of how situation
when asking
was admitted and his father and a relaxed manipulat but was
about his life
his life. I asked was afraid of his demeanor ive some cognisant
general questions. own strength and patients that it
self admitted. may be could all
be an act
Patient was talking
to the nurse and I
was observing, the I thought
I felt
nurse didn’t initiate that it
awkward Non-theraputic
or really respond to was
that the since it was a
the conversation but The client said strange
The conversat patient
was non-verbally that he was the
patient ion was communicating
responsive and was leaving patient
stood happenin but the nurse
nodding her head tomorrow or the was
confidentl g but was used semi-
and encouraging the next day because telling
y and content in therapuic since
pt to continue while his mom was the nurse
spoke the fact she was
administering coming what was
with his the nodding and
medications to tomorrow and his going to
hands and patient encouraging but
another patient mom and dad happen
was acted wasn’t giving
were coming the like he
energetic calmly the full
day after was in
attention
control,
required
very
cluster B
REFLECT: (Were patient goal(s) met? Why or why not?):
The patient's goal of redirecting back to reality was met when the patient was talking about
his past but the nurse made sure to remind him that it wasn’t an accurate recollection. This
helped to ground the patient. The patient also has had his phone and keys taken away during
his stay to help him refrain from risky behavior as well as his medication adherence being
almost mandatory since they are being administered to him.
Summary of your experiences on the unit today:
I was also pretty surprised at how not scary it was. From the beginning when we saw all the
safety measures outside in the halls and inside the rooms was very reassuring. When we first
entered the open area with the patients it was very shocking to see how young a lot of them
were but it was nice to hear them talk and, whether real or not, they sounded like they were
having a good or at least decent time and that they enjoyed the others company. Playing
cards and talking with the patients was cool just to hear their stories and chat with them. I
think I enjoyed it a lot more than I expected but I do think I enjoyed it slightly more than the
Ozark rotation, just barely.
Medications: (Skidmore-Roth, 2022)
Generic
Trade Name Medication Class Reason
name
short-term relief of anxiety symptoms
lorazepam ativan benzodiazepines related to anxiety disorders, in this case
cannabis induced
Acute and long term treatment of manic or
olanzapine Zyprexa zydis Atypical antipsychotic
mixed episodes of bipolar disorder
References
Skidmore-Roth, L. (2022). Mosby's Drug Guide for Nursing Students with 2022 Update (14th
ed.). Elsevier Health Sciences (US). https://online.vitalsource.com/books/9780323876575
