Process Recording Form

PROCESS RECORDING FORM (Refer to Process Recording Guide to Complete) Student's Name:

Patient's Initials: I. N.

Date of Interaction: 21 October 2009

Length of Interaction:

Interaction with this patient: A. Background Information: Mrs. I. is an 80 y/o white female who was admitted into the hospital yesterday, 20 October, due to re-fracture of her right hip bone. She speaks fluent English and though she is in pain she is very much aware of her surroundings.

B. Goals of this interaction. My goal for this interaction is to have a therapeutic conversation with Mrs. I. about how she feels about the re-fracture and any other stressors she may be experiencing. C. Your thoughts and feelings immediately before the interaction: I am looking forward to getting to know this patient. D. Describe the setting in which this interaction occurred: The room is dimly lit with semi comfortable chairs. The patient is laying in bed as she was uncomfortable sitting in her wheel chair. It is fairly quite.

PROCESS RECORDING

Nurse or Patient

Nurse or Patient

Evaluation (The introductory phase took place earlier that morning in the dining room while pt was eating breakfast).

How are you feeling this morning?

Do you need something for the pain?

I am in a lot of pain and all I want is to go home.

No, thank you. I don’t want to take anything for it.

May I ask what brought you to the hospital?

My husband and I were out shopping and I broke my hip. You know, this is the sixth time this has happened to me.

Did you fall Mrs. N

No. I was just standing there and the next thing I hear is a crack and then the pain. I went home but eventually I had to come here to the hospital because the pain was unbearable.

Opening Statement Working Phase Pt’s body language reflects that she is in pain. She keeps grimacing. Exploring Active Listening

Is there any reason why you didn’t come to the hospital immediately?

How do you feel now that you are here?

I was hoping that the pain would just go away.

Exploring/Active Listening Attentive Listening

I miss my husband very much and I am hoping that he will do the dusting while I am here. I can imagine a pile of dust this thick. (She shows me with her fingers how much dust is too much dust). I have a hard time sleeping when I am in the hospital.

You can’t sleep?

I can but they keep waking me up and this bed isn’t like the one I have at home.

You said you miss your husband, how did the two of you meet?

Well you know, I was born in Germany and he was an American G.I. who was stationed near my home. One night I went out with the girls to have a drink and that’s how I met him. He looked so handsome in his uniform. He is still a handsome man and he is such a gentleman.

Clarifying Active/Attentive Listening

Back then you couldn’t be in the Army if you married a foreigner so he left the Army so that we could be together. It took a year for my paperwork to come through and then I came to be with him here in the United States.

How long have you lived here in Missouri?

A very long time. We use to go to Germany to visit my sister but now she comes to see us instead. Are you from here?

No I am not Mrs. N. I was born in New Jersey and we came to live here when my husband came up on orders.

So you know what it is like to leave home.

(At this time the physical therapist arrived and I excused myself so that they could do her P.T.). Mrs. N, I will leave you to do your Physical Therapy but I will return after you are done.

Okay.

Exploring

(I came back to the room about 15 minutes later to see if Mrs. N was done). Hello again Mrs. N. Can we continue our conversation?

Of course Mrs. N. Let me go and get someone to help me move you.

Yes, but can you get me to the toilet? I have to urinate. Please hurry. I don’t know how long I can hold it.

Okay Mrs. N. (I went and got the CAN and we ambulated her onto the pot. I went and stood behind the curtain and a few minutes passed).

Excuse me. Miss? Yes, Mrs. N? Could you run the faucet for me? I am having difficulty going. Of course I can. (I turn on the faucet and stay by the sink away from the curtain. I can hear her struggling like she is trying to push).

Active Listening

Mrs. N would you prefer that I leave the room? Okay, let me give you your call light and you can press this button once you are done and we will get you freshened up and back into bed.

Yes please.

Exploring

Okay. Thank you.

(Patient hit the call light when she was done and the CAN and I got her back into bed). Mrs. N, I see you are making funny faces. Are you in pain? Would you like me to get the nurse for you? No Mrs. N, I am the student nurse and I can go and get the nurse for you so that if you have medicine for the pain maybe she can give it to you if it is time. Okay Mrs. N, I am will be leaving now so that you can get some rest.

Exploring Yes. I thought you were the nurse. Clarifying I do not want anything for the pain. My husband will be here in a short while and I am a bit tired.

Termination Phase

Is there anything I can get for you or do for you before I leave? Of course I can. Anything else? Well, thank you for sharing with me. I will return later on after you have rested to help you with your sponge bath.

Yes. Can you please pass me my cup of water? I am always so thirsty. Thank you. No. Thank you. Okay dear.

PROCESS RECORDING E. Your thoughts and feelings immediately following interaction: I enjoyed my conversation with Mrs. N and I could not believe how at ease she made me feel with her.

F. Evaluation of total interaction. Was the overall interaction therapeutic? Did you accomplish your goals? I believe that this conversation was indeed therapeutically good because it gave Mrs. N the opportunity to not only express her feelings about how she was feeling pertaining to her pain and hospital stay but it also afforded her the opportunity to personal memories with me. I believe that the goals for this interaction were indeed met.

G. Goals for your next interaction and your reason for choosing these goals. Goal #1: I will again listen closely to what Mrs. N has to say about her feelings about her hospital stay. Goal #2: I will ask more questions about why she doesn’t want to take pain medication.

PROCESS RECORDING H. List all needs identified in this written interaction. See Basic Human Needs. Needs:

Physiological

She had breakfast before we began our conversation. She was asked if she needed to use the bathroom before we began. However, she was in pain and refused pain medication.

Safety and Security She was ambulated into bed by the CNA and her nurse and placed in a comfortable position with her side rails up.

Psychosocial She was able to verbalize with me. No speech impairments.

Choose one unmet need from those identified above. Indicate its corresponding nursing diagnosis with a R/T statement and the appropriate indicators. (Label Subjective or Objective). Need

Nursing Diagnosis Ineffective coping r/t pain AEB facial expressions and moaning.

Indicators She kept moaning and grimacing. She was offered pain medication numerous times but refused them.