PROCESS RECORDING
INTRODUCTION
As a part of Psychiatric Nursing Clinical Posting we were posted at Mental hosital
indore from 01-04-2024 to 31-04-2024. As a part of Clinical rotation I was posted in Female
general ward and selected the patient name Ms. Rani Malviya for my Process Recording .
that was diagnosed as Eating Disorder .
PATIENT PROFILE
Name of patient : Ms. Rani Malviya
Age : 45 years
Date of Admission : 20/06/2024
Marital Status : Married
Ward : female ward
I P no :
Education : 5th
Occupation : Nill
Income : Rs.3000/-
Address : Bhopal
Religion : Hindu
Socio Economic Status : Low Income Group
Diagnosis : Eating disorder ( Bullimia Nervosa)
Languages know : Hindi, English
Date of Verbatim : 5/05/2023
Objectives
1. To establish good rapport.
2. To identify signs and symptoms of illness.
3. To get identification data of Patient .
4. To maintain activities of Patient .
Patient’s response
Nurse’s response Verbal Nonverbal Inference
Duration 15 mints
Client setting on chair Eye contact
Hello, good morning Mrs. Rani Good morning Smiling developed.
How are you? Fine. Verbal
Why are you setting in this setting Oh, I will go later. Setting on chair. communication
constantly? Just go to out side of Smiling adequate
this ward.
Are you happy here? I like this place. Face became Eye contact.
happy happy
Oh, you just leave that. Did you Yes. i eat Smiling happy
taken your breakfast? poha,chai,biscuit,pulav immediate and
How was your sleep? , Smiling recent memory
Ok. When did you slept yesterday? It was nice. Smiling intact.
Yes it was ok. Smiling Happy.
Who all are your family members? 8 ‘o clock and waken . Smiling Happy.
Not answers .
In which person you have more Smiling Happy.
preference? Not answers
Doctor came for rounds and he Smiling
went by saying bye. Bye……..
Summary –
I was trying to maintain good IPR with the patient and some time Respond to
my question and some time not . Told my patient to do exercise daily and do
prayers. listen song I reduce his insomnia by the conduct of psychological
therapy my patient co operate with me and he was happy & feeling well
comfort .