Process recording example - Student Nurse Name: Mark Sklair...

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Student Nurse Name: Mark Sklair Client Init: R.A. Process Recording Date: 04 Apr 05 Time: 1145 www.mardair.com/adn Page 1 of 3 Introduction 84 year old male admitted for severe depression resulting from stress r/t compounded effect of multiple physical health problems beginning in the mid 1990’s (including elbow fx, pneumonia, vertebral plasty, UTI and pelvic fx. GAF = 30 Pt was sitting in Geriatric Day Room off in a corner, sunk deep into couch but seemingly alert to his surroundings. Overall appearance is neat and well groomed with slight smile on his face as I approached him. Pt has demonstrated moderate interest in MIG activities – participating in the exercises and word games – relatively enthusiastically. Pt seemed to be soliciting reactions to some of his responses to game questions. I selected a chair to his right an arm’s length away and attempted to hunker down as my seat placed my head almost 2 feet above his (patient is approx. 5’-0”) if I sat upright. Pt responded to my questions conservatively but not guarded. He maintained good eye contact and remained focused until the What Nurse Said or Did Analysis of Nurse Interaction What Client Said or Did Analysis of Client Interaction Open-ended: “What brought you here to Good Sam?” I introduced myself and asked a few questions about the book he was reading to “break the ice”. But there wasn’t much ice to break. Pt welcomed me to sit and he expressed a desire to converse. “Depression. I’ve had a lot of health problems lately. I fractured my pelvic bone.” Pt remains relaxed, somewhat slouched. He sounds tired but resolute in his state of affairs. No evidence of uncertainty at this point. Empathetic/Open-ended : “That’s probably slowed you down a bit. How did you get along with that fracture?” I was trying to create a level of privacy by redirecting the speaker of a nearby radio that others in the room were listening to. I didn’t want to seem distracted by my fiddling with the radio – but I was also having difficulty with some of the Pt’s quieter intonations. Pt didn’t seem to react adversely to my perception of a distraction. The Pt’s posture and position in the room seemed to belie his attitude. Pt was sitting under a window in a corner behind another Pt. “They took care of me at Beacon Hill. That’s where I live. I really want to get
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This note was uploaded on 12/11/2011 for the course NA 123 taught by Professor Na during the Spring '10 term at Abraham Baldwin Agricultural College.

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Process recording example - Student Nurse Name: Mark Sklair...

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