Ok - So I’m just slightly watchful of the time, we seem to be coming to the end of today’s session for the

appointment, - Oh right, OK. - but what I wonder is whether we should meet again, perhaps next week,
and look again more carefully at some of the treatment options, and think together about which might
suit you best. How would that sound, Julie? - Oh that’s fine, that’s fine. - Any other questions before we
finish? - No, I’ll make an appointment to see you next week. - That’s fine, and I’ll see you next week. -
Ok, thank you Doctor. - It’s a pleasure, bye. - Bye.

PROCESS RECORDING SHEET

Client’s Initials:  Diagnosis: 

Age: Sex:  NPR Phase: 
Date of Interaction: Student’s Name:

Nurse (Student)  Client Communication  Analysis of the  

Communication Interaction/Technique Used

First of all, what would you like - Oh, Julie’s fine, yeah
me to call you?

Ok. Right Julie, so what is it Well, it’s the same thing that
that’s brought you to see me I see Dr Jones about, it’s my
today? heart.

Yeah, yeah, I understand that No, not at all, it’s just I keep
you’ve been in to see him a few getting these situations
times over the last few months. where my heart starts to
Would you mind if I ask you to really, really race like boom
go over again what the boom boom boom boom
problem is, perhaps in your boom. I get chest pains,
own words so that I get an
understanding of it?

Aha – I can’t catch my breath. It’s

making me feel funny talking
to you about it! And, um, so
my heart starts to race, I
can’t get my breath and
 then I get chest pains and I
get very afraid that I’m going
to have a heart attack.

Right, right and you’re feeling a I am.

little bit anxious just here with
me?
yeah, just talking about it. I
- Ok can feel it starting to come
up.

Right, take your time, take your - Ok, thank you.

time

So, your heart starts to race, it Yeah, that’s exactly it, yes
really beats really fast and you yeah.
feel like you can’t catch your
breath, is that right?

- How long’s all this been going I think it’s probably about
on for Julie? six months, basically, yeah.

Right Ok. And can you Er, well, I think, urm, we

remember what happened to have had some problems at
start it all off? work erm and erm I’ve felt
more stressed about work
than I normally do, and
basically I was just trying to
get into town one day on a
day off and it was very hot,
one of those funny hot days,
and it just happened; my
heart started to race and
race and race and I couldn’t
get my breath. I was just,
like, gasping for breath, then
I started to get chest pains
and it was just awful. And I
managed to sit down and
call my husband and he
came out, he actually left
work to come and get me.

Right, so that sounds like quite It was awful, it was really,

an unpleasant experience for really frightening, yeah.
you, at the time.
And when that was happening - I thought I was having a
to you, Julie, when you were in heart attack
the middle of town, what was it
that you thought was going on?

You thought you were having a I really did, yeah, and each
heart attack? time it happens I’m so afraid
that that is what’s
happening.

Right, ok. So, you know, I started to try

and avoid situations where I
might get like that, basically.

Right, so what kind of things I can’t get into town now

are you finding yourself without my husband taking
avoiding? me because my husband has
to take me to and from
Right work. And I also thought I
shouldn’t do anything to put
any strain on my heart at all,
so I don’t do much exercise
Right or anything at the moment
and other things as well.

And other things, what sort of Well, just some personal

other things are you not doing? things.

Personal things, ok. I guess I’m Yeah

wondering if you’re talking
about your sex life there.

Right I just feel that I shouldn’t,

you know, do anything like
that because it just might
put too much strain on me.

Right so you’re avoiding sex in Yeah, yeah.

case that puts you’re heart rate
up?

Ok, ok. How’s that affecting It’s not, I mean, yeah, my

things between you and your husband’s getting really fed
husband? up with it, to be honest
Right, aha. doctor.

He’s been really, really kind

 and really supportive but I
think it’s starting to affect
Right his life quite a lot now.
He wanted me to go to the
pub last week, and I
absolutely promised that I
would, because I’d begun to
stop wanting to go out
because I’m so afraid it’s
going to happen. And I
promised and promised him
I’d go to the pub and then
when it came to it I just
couldn’t, I just sat on the
sofa and it started to
happen again. And then I
was worried if I went to the
Right pub I’d actually get ill in the
pub. And then it’d be really
embarrassing for everybody
Right so I just said I couldn’t go
and I think he’s getting a bit
Right to the end of his tether now,
because it just seems to
have come out of the blue,
and I’ve never suffered from
anything like this before.

So it sounds like he’s getting to Yeah, I am actually, yeah,

the end of his tether, but it also yeah.
sounds like you’re pretty fed up
with the whole thing as well
Julie, is that right?

Ok, so just so that I’ve got the No, not at all, I mean, I think
story straight, this all began we had a new manager at
about 6 months ago, before work, I work in a bank
that had you had anything like actually, and then we had a
this? new computer system put in
and so it became very much
more stressful for all the
staff, not just me, and I can
Right sort of see I was under a lot
Right more pressure and that
could be affecting me.

So just to make sure I’ve got - Yeah –

the right way around it, it
began 6 months ago, pressure
at work, you went to town, you - umm umm –
had the first of these attacks
and then since then you’ve had
some more of them, and now - Yeah, yeah –
it’s kind of got to the point
where you don’t want to go I don't no.
out, you don’t go to town by - No, I don’t want to risk it to
yourself… be honest.

Right, right. You’re not going to

the pub, you’re not socializing
like you used to, and you’re - No, no. –
avoiding things like exercise
and things like sex, and that’s Umm, umm
having a bit of a, taking its toll
on your relationship. - It is a bit, yeah yeah.

Ok, ok. And, looking at your...I - Well, Dr Jones said that it

know you’ve had an ECG that was ok and there were no
Dr. Jones organized for you a problems. And, you know, I
couple of months ago, what did feel relief you know
have you been told about the because obviously there has
results of that? been heart attacks in my
family, my dad died of one,
you know, at 72, so I’m
Oh right, OK. thinking it must be my heart,
there must be something
wrong with it and I did feel
pleased when Dr Jones said
that, but on the other hand
nothing’s changed, you
know, I’m still getting exactly
the same problems,
nothing, you know, I’m not
getting any help with it, I just
feel a bit like, well, so I
haven’t got a bad heart
according to the experts, but
I’m still getting all the same
symptoms and they’re
getting worse and worse.

So even though the GP’s told I do, I just can’t understand

you there’s nothing to worry it, what do you think it is,
about with your heart, do you doctor?
still worry that there might be
something wrong with your
heart?

Well Julie, I think I’d agree with

Dr Jones, I don’t think there is
anything wrong with your
heart. The reason I say that is
that you’ve had an ECG which
has come back perfectly
normal, and usually if there
was a problem with the heart
the ECG would pick something
up, also, you’ve got none of the
risk factors, really, for heart
disease because you don’t
smoke, your blood pressure
(from what I can gather from
your notes) has always been
fine, you’re fairly young, before
this you were pretty fit and
active, and also, I know you’re
worried about your dad having
had a heart attack, but actually,
he was a lot older than you are,
and so you’re not really in the
same risk bracket as he
would’ve been. So I don’t think - Right –
that there is a problem with I think I’ve been thinking
your heart, I guess what I’m more recently it could be,
wondering is whether actually because my friend has panic
what’s going on is a little more attacks, - Right - and I’ve
what Dr Jones thought, discussed it with her and she
whether actually this might be said, to be honest it just
the anxiety that’s giving you a sounds like that. I’ve always
lot of these symptoms. Have thought it was my heart, and
you ever thought it might be what I can’t understand is
that rather than a heart how my brain is making my
problem? heart start racing like it is.

Not really, no.

Right, right, ok. Has anyone

explained to you about anxiety
and panic attacks?

Ok, well perhaps it’ll be helpful Yeah, ok.

to sort of hear a little bit more
about that. What we have on
top of our kidneys is two little
glands, and they’re called our
adrenal glands, and they Yes, I have heard of that.
produce a hormone called
adrenaline, have you heard of
that?
- I do, I do, yeah, I do
Ok. And what adrenaline does remember that.
is it prepares us for situations
of fight or flight, is that a term
you perhaps remember from
biology at school? I think like if you’re in a
scary situation you either
- Do you remember what we fight or run away basically,
mean by fight or flight? your body sort of triggers
that to do it.

Yeah Yes. That’s exactly it, and

what’s released to allow you to
do the fight or flight response is
the adrenaline, so when your
body needs you to get ready to
do something, it surges out a
load of adrenaline, and the
adrenaline basically gets you
ready for action, so it does
things like it gets your heart
rate up, it gets your breathing
speed up, so that you’re ready
to run, it can sometimes make Yeah definitely, yeah
people feel as though their definitely, all of those
mouth is dry, it can sometimes actually.
make people feel a bit
lightheaded. Are those the kind
of symptoms that you can get?

Right, ok. What often happens

with people with panic is that
the first time that happens, the
first adrenaline release occurs
out of the blue, and perhaps at
times of stress, and you
mentioned that there was stuff
going on at work, you’re feeling
a bit stressed out, and in town
it was a bit hot – so that may
have been what was behind
that first panic attack. What Oh absolutely. I’ve started to
happens to people is that once really monitor my heart, and
they’ve had one panic attack when it starts to race I start
they go on to have more, and to get worried, and then it
the reason for that is that once starts getting faster and
you’ve had something like that faster, so it does feel…
happen to you, you’re kind of
there thinking, 'ooh will this
happen again.' Is that
something that you do?
- Yeah definitely –
Yes, yeah, You’re describing it
exactly Julie, that’s what we
call hypervigilance, so you’re
there kind of keeping a bit of
an eye on your heart, and for
most of us our heart rate will
go up and down all through the
day, but most of us don’t worry
about it because we don’t
notice it, but because you’ve
had a panic attack, you’re there
thinking ‘ooh what’s my heart
doing?’, then the minute it
starts to change you clock it,
you notice it, and then you Start worrying, I really do.
start to get anxious thoughts,
so you might... I keep thinking is it going to
be now, you know is my
Start worrying, yes so you. heart going to stop beating.

Yeah, yeah.

Right, so you get those kind of It does make sense, doctor.

anxious thoughts, and they’re –
very frightening, and because
you’re thinking ‘goodness me,
could my heart stop?’, that’s
making you more anxious, and
that causes even more
adrenaline to be released, and
that makes the symptoms even
more pronounced, and that
makes you believe even more
that there’s something wrong
with you. Does that make
sense, as to what might be
happening? I have, yeah, like not walking
to town or anything, I just
One of the things that you have won’t do it anymore.
been doing, which is something
a lot of people with anxiety do,
is that you’ve started to avoid
doing things that trigger it off. Right, yeah, right.

Exactly, exactly. And whilst in

the short term that alleviates
you’re symptoms because you
don’t have to get panicky,
what’s happening is that the
more you avoid doing things,
the less likely you are to ever
get around to ever finding out
whether or not anything awful
really happens. It does, it does make sense.

Does that make sense?

Well, if we are starting to tackle

this as if it were an anxiety
problem, there are a number of Ok
approaches. We can think
about tablets, we can think
about other kinda talking
approaches. There are pros and Oh right, OK.
cons to those, and side effects
that we need to discuss.

So I’m just slightly watchful of

the time, we seem to be Oh that’s fine, that’s fine.
coming to the end of today’s
session for the appointment,
but what I wonder is whether
we should meet again, perhaps
next week, and look again
more carefully at some of the
treatment options, and think
together about which might
suit you best. How would that
sound, Julie? No, I’ll make an
appointment to see you next
Any other questions before we week.
finish?
Ok, thank you Doctor.

That’s fine, and I’ll see you next

week. - Ok, thank you Doctor. -
It’s a pleasure, bye. - Bye.