Glossary of Communication of the Nursing Process
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- What is he purpose of Written communication/ documentation.
- Serves as a permanent record of client information.
- What are the two categories for communication in the nursing process.
- Written and Verbally.
- When does reporting take place.
- When two or more people share information about client care.
- In what ways can verbal reporting take place.
- 1. Face to Face (team meeting or handoff or shift report.
2. Audio tape: Voice mail
3. Telephone (reports to case manager or physician)
- What must be accessible to member of the healthcare team who care for a client
- Accurate and complete data on the client.
- What information is essential when charting.
- -any new or change information
-signs & symptoms
-physician's orders carried out
-any change in the care plan
- What information should the client's record contain.
-communication (the plan of care and the client's progress to all members of the health care team)
-Reimbursement (documentation of client care to provide basis for decision making regarding compensation)
-Quality Assurance (Audit is a review of records and serve: quality assurance and reimbursement)
- What should you do if you make a mistake on a patient's chart.
- put a line through the error and initial it.
Some health care setting may require you to write explanation of what error was.
NEVER ERASE ANYTHING
- What are the principles of good documentation.
- -Conciseness (brief and to the point)
-Organization (Chronological flow of info. according to time procedures completed with client's reactions documented. Helps prevent out of sequence or fragmented data)
- What is the purpose of Universal Computer Based Patient Records.
- Allows clients to share health information with any practitioner regardless of institutional affiliation or time and place when care was originally provided.
- What is Point of Care Documentation.
- Documentation that takes place as care occurs.
- What is the goal of point of care documentation.
- To promote efficiency, accuracy and timeliness.
- Three Standardized Vocabulary Nursing & Medical Databases used are?
- NIC - Nursing Intervention Classification
NOC - Nursing Outcome Classification
NANDA - North American Nursing Diagnosis Association.
- What is nursing informatics?
- A combination of computer science, information science and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and the delivery of nursing care.
- When should a plan of care be generated and revised.
- Should be generated at admission and revised to reflect changes in the client's condition.
- What is a Kardex
- Information on the patient. It is usually kept in a portable file at the nurses station.
- Information Found on a Kardex
- Demographic - (name, age, occupation, religion, physician, dx)
Basic Needs - (diet, activity, hygiene, safety precautions)
Daily Nursing Procedures - (dressing changes, VS)
Therapies - (respiratory, etc.)
- The purpose of a Kardex
- A way to ensure continuity of care from one shift to another.
- Four types of Nursing Notes
- Narrative Notes
Focus DAR Notes
- Narrative Notes
- Information provided in written sentences or phrases; usually time sequenced.
- Advantages of Narrative Notes
- Easy to learn; easy to adjust length as needed; can be explained in detail
- Disadvantages of Narrative Notes
- Time consuming; difficult to retrieve information; irrelevant information ofter included; possibly unfocused and disorganized.
- SOAP Notes
- Progress note that relates to only one health problem
S- Subject data O- Objective data A - Assessment P- Plan
- Advantages of SOAP Notes
- All charting focuses on identified client problems; interdisciplinary - all team members chart on the same progress notes; easy to track progress for identified problems; steps in the nursing process are mirrored.
- Disadvantages of Soap Notes
- Difficult to master; specific focus makes it difficult to chart general information without identifying a problems; lengthy and time consuming
- PIE Notes
- Documentation is entered for each nursing diagnosis.
P - Problem I- Intervention E-Evaluations
- Advantages of PIE Notes
- Plan of care incorporated into progress notes; outcomes included; daily review to determine progress
- Disadvantages of PIE Notes
- Must read progress notes to determine plan of care; If problem has not been identified, difficult to chart; not multidisciplinary
- Focus DAR Notes
- D- Data
- Advantages of Focus DAR Notes
- Broad view permitting charting on any significant area, not just problems
- Disadvantages of Focus DAR Notes
- Not multidisciplinary; difficult to identify chronological order; progress notes may not relate to care plan
- Designed to free the nurse from writing out procedures done repeatedly.
- Charting by Exception (CBE)
- Documents only those findings that fall outside the standard of care.
- Clinical Pathways
- A way to guide the care of clients who have specific and generally predictable conditions.
- Information provided during Nurse to Nurse Oral Communication? Continuity between Shifts or Client Visits.
- -Name, age, room # of client
-Medical diagnoses, major procedures or surgery
-Physician name or group
-Significant assessment findings, including VS
-Diagnostic and laboratory test results
-Specific treatments (i.e. dressing changes, respiratory therapy)
- Nursing Rounds
- Walking rounds where nurses visit a group of clients, and the nurse assigned to each client summarizes the client's current status and plan or care.
- When is a report prompted to the Primary Care Provider.
- Prompted by a change in the client's condition.
- Outcomes of Communication
- -Nurse and client solve healthcare problems together
-client cared for and understood
-family/significant other included in care
-health teaching concluded
-health promotion and prevention care are delivered
- What does verbal communication involve
- Involves the spoken or written word (i.e. TV, movies, books, computers)
- What does non verbal communication involve.
- gestures, facial expressions, posture, body movements, voice tone and volume, rate of speech and even dress.
- Congruent Relationships
- Nurses thoughts and feelings that match his or her expressions.
- Incongruent Relationships
- Nurses thoughts and feelings do not match his or her expressions.
- Sender factors that interfere with the encoding process.
- -unclear speech
-poor sentence structure
-inappropriate use of terminology or jargon
-lack of knowledge about the topic
- Receiver factors that interfere with the encoding process
- -lack of attention
-prejudice or bias
-preoccupation with another problem
-physical factors such as pain, drowsiness, or impairment of the senses
- What are the phases of the nurse-client relationship.
- Oriention Phase Of Nurse-Client Relationship
- Consist of introductions and an agreement between nurse and client about their mutual roles and responsibility.
The nurse and client get to know each other and develop trust and rapport.
- Working Phase of Nurse-Client Relationship
- Nurse and client participate together in nursing care activities.
- Termination Phase fo Nurse-Client Relationship
- Closure of the relationship and discharge planning.
- Elements of the Nurse Client Relationship.
- -Nurse and client knows each other names
-Roles and responsibilities clarified
-Parameters of the professional relationship are clear
-Mutual expectation agreed on
-Advocacy -being an advocate for the client's right to info. necessary to make decisions about treatment options and care
-Circle of confidentiality respected.
- Guidelines for facilitating communication
- -speak in normal tone of voice
--speak to client on adult level
-avoid engaging in multiple conversations at same time
-ask simple question that require simple answers
-keep atmosphere quiet and relaxed
-reduce or eliminate envir. noises
-get client's attention before speaking
-maintain eye contact
-assume client understand you
-don't rush client
-don't correct client when they make mistakes
-if you don't understand client, ask them to repeat themselves
- Ingredients of Therapeutic Communication.
Comfortable Sense of Self
- The ability to enter into another person's experience to perceive it accurately and to understand how the situation is viewed from the client's perspective.
This is done throught the process of reflective or "active" listening.
- Positive Regard
- Warmth, caring, interest, and respect for the person, seeing the person unconditionally or nonjudgemental.
- Comfortable Sense of Self
- Being aware of one's own personality, values, cultural bckground and style of communication.
- Non-Therapeutic Response
- Interfere with or block therapeutic communication.
- Name the Non-Therapeutic Responses
- Rescue Feelings
Changing the Subject
- Rescue Feelings
- Nurse believes that only he or she can meet the client's needs, alienating himself or herself from the healthcare team
- False Reassurance
- Giving reassurance that is not based on the real situation. Real reassurance must be based on fact.
- Giving Advice
- Based on on the nurse's experience and opinions. i.e., I think you should ...
- Changing the Subject
- usually indicates anxiety on the nurse's part. It is a way of resisting hearing about a client's distress, sadness and difficulties
- Being Moralistic
- Seeing a situation as good or bad, or right or wrong.
- What should you do when dealing with children and adolescent.
- -simplify speech
-provide information in a straightforward manner
-personal space and privacy
-limit setting, nurse must be seen as authoritative and being in charge but permitting freedom within reasonable, closely established behavioral limits that elicit participation in their reinforcement.
- In which cases are special situations used in communiction with clients
- children and adolescents
cross cultural communications
person in intensive care unit
- Is the acquisition of a skill or knowlege by practice, study or instruction.
- Two Learning Theories
- Behavioral Learning Theory
Cognitive Learning Theory
- Two Approaches to Learning
- The study of traditional classroom instruction.
The art and science of helping children learn.
- Based on an individual's need to know something.
The art and science of helping adults learn.
- Information Processing
- Sensory register, information is stored in short term memory and transferred to long term memory.
- Domains of Knowledge
- Cognitive -"thinking," learning facts, reaching conclusions, making decisions, or inferring.
Affective -emotions or feelings
Psychomotor - mastering a new taks or skill
- Qualities of Teaching-Learning Relationship
- Client focus - client education should focus on the client's specific needs.
Holism - consider the whole person (Martha Rogers theory)
Negotiation - nurse and client determine what is already know and what is important to learn
Interactive - dynamic, interactive process that involves participation from nurse and client.
- Purpose of Client Education
- Wellness Promotion
Restoration of Health or Function
Promotion of coping
- Wellness Promotion
- Education to promote optimum health and function.
- Disease Prevention
- Teaching clients the knowledge and skills for early detection or prevention of disease ad disabiltiy (i.e. breast self exam.)
- Restoration of Health or Function
- When illness or dysfunction occurs, client education is important to help limit disability or restore function
- Promotion of Coping
- New and frightening procedures or adjust and continue to live with chronic illness or disability
- Cognitive learning theory
- Focuses on what is going on inside a person's head or the thinking process.
- Behavioral learning theory
- Holds that external environmental forces have a conditioning effect on people to either engage in or avoid certain behaviors.
- refers to rational thought, what one generally considers "thinking"
- What does Assessment For Learning involve
- Baseline Knowledge -finding out about previous client-education experiences may give some indication about where to begin.
-Cultural and language needs
-realistic approach - set priorities and try not to teach too much in any one teaching session
*consider energy level
*client's emotional state
- Assessing Learning Readiness
- *Motivation - starts with client's recognition of the need to know.
*Compliance - following or not following the recommended plan
*Sensory and Physical State - -i.e. clients with poor vision for comporomised fine motor skills may be unable to give SQ injections.
*Literacy - ability to read and write
- When Planning a teaching session
- *Focus on what client needs to know
*Avoid medical terminology
*Cient should be comfortable
*Family members/caregiver may be present
*Uninterrupted time must be available so that meals or necessary treatments do not interrupt the teaching session.
*Teaching should not occur just before an event (ie. discharge, surgery)
- Teaching Strategies
- *Lectures -formal presentation of informaiton by a teacher to a group of learner (cognitive learning)
*Discussion -exchange of ideas by sharing information, clarifying feelings, or asking questions through active participation
*Demonstration - explaining a skill while demonstrating it.
*Role Playing - acting out feelings or knowledge while another offers guidance and feedback
*Teaching Aids and Resources - pamplets, audiovisuals aids, equipment and models
- Evaluation of Learning
- Written test
Return Demonstration --skill performance
Simulation - evaluates whether the client can apply learning in different situations.
- Implemenation of Client Teaching
- *Meeting priority needs first i.e. physiological needs
*Comfortable environment - i.e, privacy is important thus close the curtains, sit near the client, speak quietly and face the client
*Individual Teaching Sessions -i.e, adults vs. children
*Teaching methods -cognitive, affective, psychomotor
- Lifespan Considerations
- Newborn & Infant -learn by interacting with their environment.
Toddler and Preschooler- parents are usually most effective teachers.
Child and Adolescent - understand cause and effect.
Adult and Older Adult - motivated by activities that enhance/maintain self esteem
- Helps client express their concerns and solve their own problems by investigating the situation and what some alternatives might be
- Communication and the Nursing Process
**Helping client get started
-Offering self (making self available to listen to client)
-Open-ended questions (asking neutral quest. that encourage client to ecpress concerns.)
-Opening remarks - (useing general statement based on observation and assessments about the client i.e, "you seem to be feeling better" provide the client w/ opportunity to respond. Avoid asking "Why" question b/c they are intrusive.
-Giving information -sharing relevant info. w/ client about his healthcare and well being.
-Looking at alternatives - helping client see option
-Using silence - allowing for pause in communication that permits nurse and client to think about what has taken place
-Summarizing - highlighting important points in conversation.
*Developing Communication skills - process recording to enhance comm. skills
- Active listining
- Involves the ability to focus on the client and what the client's message are about, conveying back to the client an accurate picture of what he or she is expressing.
- Repeating to the client the main content of his/her communciation
- identifying the main emotion themes contained in a communciation and directing these back to the client
- Word Root
- Core of the medical term and contains the fundamental meaning of the word. It is the foundation on which other elements are added to develop a complete term.
i.e. Dermatos - a term that describes a skin disease
- Word element place at the end of a word root that changes the meaning of the word
- Word element attached to the beginning of a word or word root
- The process of getting the purpose into code.
- A medium or carrier of a message.
- A way of being helpful by facilitiating interactions that focus on the client and the client's concern.
- Therapeutic communication
- Warm, caring interest and concern for the person
- Positive Regard
- The ability to see into the experience of another and understand how a situation is viewed from the other person's perspective.
- A message about a message that looks beyond just words.
- The nurse listening and restating content back to the client to verify the nurse's understanding with the client.
- Asking goal-directed questions to hel.p the lcient focus on key concerns.
- A pause in communication that allows the nurse and client time to think about what has taken place.
- Elicits more than a yes or no answer.
- Open-Ended questions.
- Four Major Types of Communication
- occurs when the client does not proceed along the pathway as planned
- May look like flowsheets or may use CBE documentation
- Nursing Discharge Summary
- Reecord started at initiation of care indicating possible discharge needs and client teaching.
- Medication Record
- Distinguished between routine and prn medication.
- Affective Learning
- changes beliefs, attitudes and values
- May point out deficits in learning that may not be evident in a single session
- A system of sending and receiving messages that forms a connection between the sender and the receiver
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