Clinical Interaction record
Date: 9/08/
Name:
Clinical Site:
Briefly describe the patient and the situations that led up to this interaction:
The patient in room 157L was alert and could communicate with ease when we entered the
room. The patient's skin was clear and had good color. Nurse Soon and I entered the patient's
room at around 8:30 am to administer his morning medication. I observed nurse Soon take vitals
and administer an injection into his abdominal region.
The patient says & does:
When nurse Soon and I entered the room, the patient greeted us warmly and made eye contact.
The patient asked about his physical therapy schedule. He also requested nurse Soon what the
injection what for and why it was necessary. He also asked us to show him how to use the TV
remote. After being asked how he was feeling, he responded, "I am feeling good, but I am
experiencing slight discomfort in my chest." The patient explained why he was at burke. He was
recently diagnosed with Chondrosarcoma, a rare type of cancer affecting the pelvic region's
cartilage. He recently underwent surgery to remove the cartilage from his right hip.
What does the nurse think & feel:
The patient in room 157L was pleasant. He is an adult male who had to have the cartilage in his
right hip extracted due a cancer diagnosis. When I entered his room, he was very friendly and
started communicating with me immediately. I felt bad for his situation and that he has cancer.
His position reminded me of my father's. I felt very empathetic about what he was going through
and his medical diagnosis.
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What does the nurse say and/or do:
When I entered the room, I introduced myself to the patient. I told him I was a student nurse at
Westchester community college. I checked the patient's band to confirm I was interacting with
the correct patient. I asked him to verify his name and DOB. I helped the patient turn on his TV
and to pull up his daily physical therapy schedule. I asked the patient what he was a patient at
burke and if he would tell me about his medical history. He then explains his diagnosis. He was
diagnosed with a rare form of cancer and had to have the cartilage in his hip removed and that
we would have undergo extensive therapy to get his mobility and range of motion back. He was
overall optimistic about recovering and getting back home. I told him my father recently went
through a cancer diagnosis and I understand what he's going through but he will get his therapy
and be on the road to recovery. Nurse soon then administer his injection and we left the room.
Nurse's interpretation of interaction:
This interaction went well. The patient was friendly and openly communicated with me. He was
in good spirits and was on the road to recovery.