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? Opening Statement

I am in a lot of pain and all I want is to go
home. Working Phase
Pt’s body language reflects that she is
in pain. She keeps grimacing.

Do you need something for the pain? No, thank you. I don’t want to take anything
for it. Exploring
Active Listening

May I ask what brought you to the My husband and I were out shopping and I
hospital? 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.
Is there any reason why you didn’t come to
I was hoping that the pain would just go Exploring/Active Listening
the hospital immediately?
away. Attentive Listening

How do you feel now that you are here?

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 Clarifying
bed isn’t like the one I have at home.
You said you miss your husband, how did the Well you know, I was born in Germany and
two of you meet? Active/Attentive Listening
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.
 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 Exploring
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 So you know what it is like to leave home.
Jersey and we came to live here when my
husband came up on orders.

(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 Okay.
done.
(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? Yes, but can you get me to the toilet? I Active Listening
have to urinate.

Of course Mrs. N. Let me go and get Please hurry. I don’t know how long I can
someone to help me move you. 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).
Mrs. N would you prefer that I leave the
room?
Yes please. Exploring

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 Okay. Thank you.
bed.

(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? Exploring
Yes.
Would you like me to get the nurse for you?

I thought you were the nurse.

No Mrs. N, I am the student nurse and I
Clarifying
can go and get the nurse for you so that if
you have medicine for the pain maybe she I do not want anything for the pain. My Termination Phase
can give it to you if it is time. husband will be here in a short while and I
am a bit tired.

Okay Mrs. N, I am will be leaving now so

that you can get some rest.
Is there anything I can get for you or do
for you before I leave?
Yes. Can you please pass me my cup of
water? I am always so thirsty.
Of course I can.

Thank you.
Anything else?

Well, thank you for sharing with me. I will No. Thank you.
return later on after you have rested to
help you with your sponge bath. 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 Safety and Security Psychosocial

She had breakfast before we began our She was ambulated into bed by the CNA She was able to verbalize with me. No
conversation. She was asked if she needed and her nurse and placed in a comfortable speech impairments.
to use the bathroom before we began. position with her side rails up.
However, she was in pain and refused pain
medication.

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 Indicators

Ineffective coping r/t pain AEB facial She kept moaning and grimacing. She
expressions and moaning. was offered pain medication numerous
times but refused them.