Need help with a psych clinical evuation form to fill out, please!

[CrystalClear75, BSN, RN]

Hi,

My current rotation is the psych rotation and I was wondering if you could help. Our assignment is based on a 1:1(one on one) interaction with another patient in the unit, kind of like an interview I guess. I won't say her name of course but this woman was diagnosed with bioploar disorder (as the axis I) and the axis II was "rule out" schizoaffective disorder with dperessive features. I did interview her and she was very delusional and was very distorted in her thoughts(of course). I don't know what to put in the blanks on this paper and are required to fill it out by the end of the clinical day tomorrow. Here's what this 1:1 interaction paper looks like

Description of client: Complete/full asessment data required.

I don't know what to assess except that she was distorted in her thinking and was very random with her stories.

Introduction:(clueless what to say)

Description of environment: I guess I could to that:chuckle

ON THE BACK OF THIS SHEET

Student nurse and client

VERBAL COMMUNICATION:

State the communication verbatim including what the client states and your responses.

Make your statements SN: the clent's statements CL.

NON-VERBAL COMMUNICATION: Include facial expressions, gestures, postition change, changes in eye contact, voice quality, and tone by the client and or yourself.

ANALYSIS: Identify if "T" (therapeutic) or "NT" )Non-therapeutic and also the technique you used. ALSO LIST ANY/ALL defense mechanisms used by your client.

YOUR FEELINGS: List ALL of your feelings/reactions regarding the interaction that is happening. IF THE INTERACTION IS FOR 200 LEVEL COUSES, YOU MUST INCLUDE WHAT YOU SHOULD HAVE SAID ID YOU WERE NT.

I understand the questions but I just need some help on how to "word" it or put the answers in the right perspective. I would tell you the story but I think it's not permitted which would of course violate the Hippa act so if you could give me some examples of how to word a situation that you may have perhaps experienced. BY THE WAY, I hate when we are in a rotation that we never got to learn in the theory part of the class. I'm kinda clueless and never learned this, it's ridiculous. THank you:uhoh21:

[Daytonite, BSN, RN]

This sounds very much like an assignment to complete a process recording. These usually end up being pretty long papers. Did you have a lecture of some sort or a handout from your instructors preparing you on how to do this assignment? If I am right about this being a process recording, I don't know how you could possibly complete it in one night. The assessment data would have to come from the patient's chart. According to what you wrote in your post, your conversation with the patient is supposed to be verbatim (word for word) so you simply write down the patient's statements EXACTLY as they said them, even if their speech was disjointed and made no sense.

[CrystalClear75, BSN, RN]

Thanks again daytonght!:)

I'm getting some of it done except nonverbal communication, like, where could i find examples of HOW to document facial expressions etc related to someone with bipolar disorder that would make it significant.

thanx

[EricJRN, MSN, RN]

For nonverbal, especially in a bipolar pt, it would be important to document those things that would give a clear picture of the pt's activity level. For example, was the pt sitting quietly in a chair? Slouching? Sitting bolt upright? Pacing around the room? Did the pt stare out the window? You could probably even mention whether the pt was neatly dressed, either in nonverbal or in the description of client.

As for facial expression, I would just try not to make it harder than it is. Smile? Frown? Tearful? Were these facial expressions appropriate for the situation? Those are just a few ideas.