Nurse (student): Shawn Milner

Client’s Initials: L.D.
-CVA with dysphagia
-HTN (unspecific essential)
-Diverticulosis of colon
-Dementia (uncomplicated)
(G-tube placed)
Date: 3/18/2005
Age: 83
Time: 1200
Gender: F
Location Setting: The client’s room was neat and clear and is the only resident of that room
although there is room for two. I had plenty of space to freely move and respond with
appropriate personal space. One icon of interaction I used for an introduction was the paintings
on her wall. Latter on in the evening beyond this conversation I talked to her about all of the
pictures of family on the wall and could asses part of her family social being. There are huge
windows to look out which are really bright, so on a different day than this conversation she had
me close the curtains before talking or doing anything else. I noticed that her door is usually shut
so by having a door she can have a sense of privacy in addition to being the only occupant of the
room. In her room she is able to fit a full dresser so she is able to have some selection in the
clothing she wears. She also has her own bathroom which may compliment her new toilet
training program. Her bed has side rail which can be removed, the top of the bed can be raised as
well as the bottom and it is a twin size mattress. She also has a television which she is captivated
by and interested in and is knowledgeable in adjusting the volume and channel. There is also a
chair in the room for visitors which is useful in maintaining eye contact level with the patient.
Nurse/Patient Dialogue

Communication Technique
Needed by Nurse

Nurse: “Hey, how are you doing”
Patient: Nods “o.k.”
Nurse: “How’s your pain”
Patient: “O.K.”
Nurse: “How would you say that is on a scale
of one to ten”
Patient: “A two”
Nurse: “How is your arm coming along”
Patient: “I don’t know”
Nurse: “Is it starting to get a little stronger and
more flexible”


(T) or NonTherapeutic



Focused assessment and


Focused assessment
Focused assessment and
verification and clarification


Acknowledgement and Assessment without aversion Silence T Assessment of why stopped painting and potentially exploring feelings of self coping w/ CVA.Patient: “I don’t know” (raises her right hand for a handshake and squeezes as tight as she can with a smile (as she does with other C. that’s how you can tell it’s art”. intermittently because the commercial is over). Nurse: “Wow. T Patient: “My right” Nurse: “I can tell. My son is a big shot at wal-mart. I would like to take that painting (on the wall) and touch it up a little with some white” Nurse: “That is one thing about art is that it is Acknowledgment.’s as kind of a theme of a joke)). All of my other daughters are teachers” (tells me more about her family history) (then just silence and sitting for a few minutes averting attention back to T. had time and materials” Patient: “I don’t know.k. Patient: (Nodding and grinning) (commercial T N T T N N . Nurse: “What hand do you paint with” Acknowledgement and Assessment T Offering Self. you have got quite a grip.N. “Would you paint again if you assessment and clarification. I like your paintings also Acknowledgment because they make people happier when they see them. it takes too much time. I paint pictures in my mind” Nurse: “That’s neat you must have quite an Acknowledgement and focused imagination”. Acknowledgement and Assessment T Offering Self. you have quite a grip with Acknowledgment that hand” Patient: “Every time I look at those paintings I feel happy. it gets better every time I look” Nurse: “When did you stop painting” Assessment to see if it was from moving to health facility or if from an emotional problem. that what you call a handshake” Patient: (Grinning Still) Nurse: “How’s your family” Patient: “Good” Nurse: “How are coping with your son-inlaws death” Patient: “I am doing o. that’s really amazing. always a work in progress” Patient: “I like it” Nurse: “Me too.V. Patient: “A while ago.A.

I asked when because I wonder if it is because of the healthcare facility that has discouraged her. but I didn’t really find out. I think this time I was more comfortable and able to accept silence even though the T. was on as kind of “something to do”. For instance I was able to narrow down a little bit about why she stopped painting. I did not push too far but at least I know that it may be more than her CVA that stopped her. This time I was ready and open for further exploration over and we watch together exchanging eye contact every once in a while when there is something funny). I think because I have had more experience with her I was able to guide and assess by asking better questions than before.V. . I think I might have closed her down from last time and she does not feel comfortable going further or just didn’t feel like it right now or because of some other reason. Evaluation: This time I learned that addressing problems rather than averting is easier and less uncomfortable for the patient and nurse. I don’t believe my client really initiated into every opening I gave her.