Process Recording

Patient Initials: S F. Date: March 20, 2002 GOALS: 1. For patient a) To describe manifestations of anxiety and anger b) To identify the precipitating factors in the development of her anxiety c) To identify one or more ways to cope with the expressed feelings. a. Use therapeutic techniques appropriately b. Identify my own thoughts, feelings and behavior as Ms. S. F. talks about stressful situations c. Allows Ms. F as much time as she needs to think and response

Number of interaction: 6th hour

2. For nurse

NURSE

PATIENT

INFERENCES/COMME NTS

NURSES: Thoughts and Feelings

Good Morning Mrs. F. Good Morning. Im ready, where do we begin today?

Give recognition Mrs. F. was eager to begin todays session. Looked bright. Greeted me with a half smile. I did not respond to questions. Allowed Mrs. F. time to assume the initiative.

You sound pleased

Translating into feelings. Ive actually First time Mrs. F gained 5 pounds has spoken of Ill try at later since last week. her weight. point to validate I think Ive Signs of positive interpretation. eating better. feelings about May appetite is self. Grimacee, enormous. I shrugs even eat lunch shoulders, and now I am. But looks disgusted. oh well, it doesnt matter.

NURSE

PATIENT

INFERENCES/COMME NTS

NURSES: Thoughts and Feelings

What doesnt matter? If I continue to gain weight, I wont have any clothes to wear. I dont have a job. I cant afford. Youre really worried about this? Well, wouldnt you be? What do you do when you dont have any money. With it, how can I care for my son Ricky?

Exploring Express concern over welfare. Sound distressed Confirm level of significance of distress.

Verbalized the implied

Allow her to Mrs. F. Avoid a pursue these direct response factor and focus and focus on the on threat later. nurse. Give second reason for needing money.

NURSE

PATIENT

INFERENCES/COMME NTS

NURSES: Thoughts and Feelings

What do you think you could do? Go to work, I guess. How can I go to work or even look for a job? Im stuck in this place.

REFLECTING

Tone of voice is harsh and angry.

NURSING DIAGNOSIS

CUES

GOALS/ OBJECTIVES By the end of the first week of hospitalization, Mrs. F. will achieve successful adaptation to the hospital environment as evidenced by: a. Expressing a sense of safety and security b. Establishing rapport with staff

NURSING INTERVENTIO NS 1. Approach in a calm, selfassured manner. Take time to explain schedule procedure Answer call bell promptly

RATIONALE

EVALUATION

1.

Sit facing the floor

Look over her shoulder as she walks down the hall Distressed Because she Cannot lock Her room Door NURSING DIAGNOSIS Behavior disruption: Suspiciousness Related inadequate self concept and lowered self esteem

2.

3.

People displaying symptoms of suspicion, distrust and often threatened by interpersonal relationship therefore, a friendly but reserved approach is more likely to succeed

Patient responded with I hope they are on time I have to wait

CUES

GOALS/ OBJECTIVES By the end of the first week of hospitalization, Mrs. F. will be involved her total treatment plan through: a.) An increasing number of contracts with staff and patients b.) Exploring with the nurse relevant current and past experiences

NURSING INTERVENTIO NS 4) Make positive approach several times during evening. a) Invite Mrs. F. to: 1. Watch Tv 2. Meet other patients 3. Offer assistance at bedtime b)Attempt to find out: 1. What she usually does with her free time 2. Interests or hobbies past and

RATIONALE

EVALUATION

2. Wishes to stay in her room. Refuses to meet other patients

Opportunities for satisfying relationships and feelings of security are increased when the individual is able to see others as truthful, dependable and capable

Refused to come out of her room and said, Maybe tomorrow.

Trust and confidence are enhanced by a demonstration of concern and interest.

Responded to questions briefly and factually

CUES

GOALS/ OBJECTIVES Within the first 48 hours of hospitalization, Mrs. F will feel comfortable on the unit as evidenced by: a) Readiness to complete orientation to the unit Speaking at the moderate and tone

NURSING INTERVENTIO NS 5) Speak clearly. Slowly, briefly and in a quite tone 6) Asks for and answer questions in a friendly and unhurried manner 7) Introduce night nurse. Have her explain night sounds, cleaning details and possible unexpected sounds. Have Dalmane, 30 mg

RATIONALE

EVALUATION

3. Talks rapidly in a loud tone of voice Repeat herself Ask nurses to repeat, says I didnt hear. Possible refused of her medication because she is afraid to sleep with door unlocked.

Anxiety occurs when one is confronted with a situation that threatens ones self image A moderate degree of anxiety produces a decrease in perception. Therefore, clear, brief, repeated communication are needed to lessen level of anxiety and increase sense of trust

Accepted the sedatives after being reassured that rounds were really made

b)

NURSING DIAGNOSIS
Anxiety related to threat to self-concept

c)

Listen attentively to direction