Process Recording			
																																	(5 pts.)
Student Name:   Colton Edwards

Patient Initials:  BW	  Age:  58        Gender: F

Demographic Data: (occupation, hometown, family information, etc.)
Patient had no prior occupation; she lived with her parents for several years, then alone in an apartment.  She lives in a small town several miles south of Mattoon.

Medical Diagnosis:
Patient was diagnosed with pyelonephritis.

Purpose for the interaction;
Establish rapport, monitor patient’s vitals.

Nurse’s goal for the interaction:
Increased level of trust and rapport between nurse and patient, take patient’s vitals while maintaining her comfort.

Patient’s goal for the interaction:
Humor nurse’s attempt for interaction, be as comfortable as possible.

Where interaction took place (including environmental factors such as noise, temperature, other people):
Patient’s hospital room-- room temperature normal, television on and relatively loud.  Patient had a private room-- no other patient in room.

Pertinent events immediately preceding the interaction:
Patient’s vitals were taken.

Nursing Diagnosis (5 pts.):
Imbalanced nutrition: less than body requirements related to inadequate nutritional intake as evidenced by less than 25% of meals eaten.
Risk for impaired skin integrity related to urinary incontinence as evidenced by elevated output due to diuretic & bed rest.

Nurse’s Conversation 
(25 pts.)	Client’s Conversation
(25 pts.)	Analysis 
(40 pts.)	Phase of 
Interaction
(10 pts.)	Alternative Responses
(20 pts.) 	
“Hello again. Okay, Ms. ______, we’re going to go ahead and take your vitals if that’s all right,” the nurse says cheerily, and he gave a small smile.
		Introductory, polite inflection. Meant to make patient feel comfortable and like she has a say in the process. Therapeutic; effective.	Orientation/ Initiation Phase	It could have been more appropriate to offer an alternative; possibly to come back soon if it wasn’t a good time.	

	“Sure, go ahead.” The patient seemed tired and not very given to talking.	Acknowledgement and agreement to assessment. Non-therapeutic (neutral), effective (her meaning came across clearly).	Orientation/ Initiation Phase	It would have been more helpful for the interaction as a whole if the patient was more warm and supportive, though she was fairly good-natured.	
“Okay, let me just get your blood ox. here, if I could get your finger… Then I’ll get your temperature, if you could just turn your head a little for me.” The nurse put the oximeter on her finger and took her temperature tympanically.
		Working, polite; trying to make vitals go as smoothly and quickly as possible. Therapeutic; effective. The nurse was involving the patient, making her a partner in care. This gives her a sense of control and speeds the interaction along.	Working Phase	The nurse could have started with a different set of vitals, or done it while having non-working conversation.	

	“All right.” The patient cooperated, willingly following the requests given by the nurse.	Patient was cooperating, aiming to facilitate process. Therapeutic (neutral); effective.	Working Phase	The patient could have been a bit warmer, though she was tired.	
“Okay, everything is looking good. Let’s go ahead and check your pulse…” The nurse took the patient’s pulse and respiration. “And then your blood pressure…” He took her blood pressure.
		The nurse continued to take vitals, explaining the process as he did it to make her a part of the process. Therapeutic; effective.	Working Phase	It would have been a good idea to tell the patient what her values were.	

	(No response) The patient continued to cooperate while watching television.	Patient continued to cooperate to facilitate assessment. Non-therapeutic, effective (Patient not speaking, but cooperative).	Working Phase	The patient could have made a verbal confirmation of the process or observed the process more closely.	
“All right, your blood pressure is __/__. Not too bad.” The nurse began actively watching what the patient was doing.
		Vitals reported; nurse’s response to relatively good blood pressure given. He began taking an interest in the patient’s activity, establishing more rapport. Non-therapeutic (except for observing the patient); not effective.	Working Phase	The nurse could have given a more in-depth elaboration of the patient’s blood pressure.	

	“Okay.” The patient continues to watch a television program, and laughs quietly at a funny part.	The patient acknowledged the reported vitals to show she wasn’t ignoring the nurse. She continued to watch her program, presumably to entertain herself. Non-therapeutic, effective (not very involved, but meeting her goals.)	Working Phase	The patient could have given more acknowledgement of the process or made conversation with the nurse.	
The nurse also laughed. “You like the Andy Griffith Show? I like watching it whenever it’s on at home.”		Showing interest in the patient, making conversation, and establishing rapport to encourage closeness between nurse and patient. Therapeutic, effective.	Working Phase	The nurse could have responded with a more involved question, or continued the conversation in a more in-depth way.	

	“Oh yeah, it‘s all right. There isn’t hardly anything on most of the time. Even at home, there’s never anything on though.” The patient chuckles.	Replying in a friendly manner, making small-talk. This is friendly and appeases the nurse. Therapeutic, effective.	Working Phase	The patient could have continued the conversation or made a response that directed conversation to the nurse.	
The nurse continued watching for a few moments. “Well, I’m going to go ahead and let you watch your program. I’ll be outside if you need anything, and I’m sure I’ll see you again soon enough.” He chuckled. “Goodbye!”		Excusing himself to let the patient rest and be entertained by her program. This aims to keep the patient comfortable, and he made a joke about the frequency of staff in and out of the patient’s room to be entertaining. Therapeutic, effective.	Terminat-
Ion Phase	The nurse could have decided to stay longer and continue conversation.	

	“Probably,“ she said as she laughed. “All right, ‘bye.”	Acknowledging care and humor; being polite and appeasing the nurse.	Terminat-
ion Phase	The patient could have been more verbal.	

Overall Summary (20 pts.):

     The interaction was fairly successful; the goals of vitals being taken and increased rapport were met.  The patient made it though the interaction with minimal discomfort, and the nurse and patient shared humor and a bit of bonding over a common interest.  The patient was tired and not extremely talkative, but she was polite and cooperated well.  Overall, goals were met, rapport was established, and the interaction was therapeutic.