Studied by 139 PeopleTags & Description
Therapeutic communication
professional communication with clients/patients; building a trusting patient-nurse relationship
Silence
moments of silence from the nurse to allow the patient to continue talking and explaining
Reflection
repeating what the patient said in order to get more specific information; “I feel alone” ... “you feel alone?” ... “yes, I feel alone since my wife died”
Facilitation
using phrases such as “please continue” and “go on” to encourage a patient to continue their explanation
Confirmation
ensures that the nurse and the patient are on the same track and that the collected information is accurate and complete
Non-therapeutic communication
words, phrases, actions, and tones that make a patient feel uncomfortable, increase their stress, and worsen their mental and physical wellbeing
“Ten traps” of interviewing
false assurance, unwanted advice, using authority, avoidance language, distancing, professional jargon, leading or biased questions, talking too much, interrupting, using “why” questions
Verbal communication
the words spoken and the tone used in a conversation, includes written words as well
Non-verbal communication
body language, facial expressions, gestures, eye contact, etc
Empathy
ability to understand the personal experience of the patient without bonding with them; keeps a professional relationship while also calming the patients anxiety about their situation
Sympathy
not good because it focuses on the nurses’ feelings rather than the patients’
Physical environment
sit equal to the patients’ level so that they do not feel intimidated when being interviewed, provide the patient with adequate privacy, minimize distractions
Note-taking
while interviewing, keep note-taking to a minimum in order to offer full, focused attention
Purpose of health assessment
gain an understanding of the patients’ beliefs, concerns, and perception of their health state
Can compile subjective and objective data
physical appearance, posture, ability to carry on a conversation, and demeanor
Phases of an interview
introduction, working phase, and conclusion
Introduction
keep it short and formal; introduce yourself, position, and the purpose of the interview
Working phase
used to collect data, verbal skills are assessed, physical health is noted
Culture
a set of beliefs, attitudes, and practices shared by a group of people or community that is followed, accepted, and passed down to other members of the group
Spirituality
a broad term to describe one’s existence and a belief in transcendence
religion
an organized system of beliefs as a shared experience
Sexual orientation
a person’s physical and emotional interest in others (LGBTQIA+)
Gender identity
a person’s inner sensibility that they are a man, a woman, neither, etc
Gender expression
outward demonstration of gender in relation to societal norms; dress, hairstyle, mannerisms, etc
Age
older adults need to be addressed respectfully, may take longer to interview because they have a “longer” story to tell, and may use therapeutic tough to provide empathy
Disabilities
can affect the interview because communication may not be fully received
Aphasia
a communication disorder due to brain damage; sudden on-set often from stroke or head injury; impairs expression and language understanding
Broca’s Aphasia
expressive and can become easily frustrated when forming simple words/sentences; damage to area responsible for speech production
Wernicke’s Aphasia
receptive; do not understand when you speak to them; damage to the part of the brain that controls language and ability and can be very frustrating
Cultural humility
recognizing there is diversity within every culture and within every person
Stereotyping
assuming a person has attributes, traits, beliefs, and values of a cultural group because they are apart of said group
Ethnocentrism
belief that one’s culture (race, ethnicity, or country) is better than others
Discrimination
unfair and different treatment of another person/group; denying another group opportunities and rights to participate fully in society
Prejudice
unfavorable prejudgement or preconceived idea about a person or group of people
Bias
attitude, opinion or inclination (can be positive or negative) towards a group of people; can be a conscious attitude (explicit) or an unconscious attitude (implicit)
Birth to 12 months
Infants
12 to 36 months
Toddlers
3 to 6 years
Preschoolers
7 to 12 years
School-age
Beginning to puberty
Adolescents
HIPAA
Health Insurance Portability and Accountability Act
SBAR
standardized communication
Situation
brief description of pertinent patient variables, demographics, clinical diagnosis, and location
Background
pertinent history as it directly relates to patient’s current health status
Assessment
pertinent assessment findings obtained with interpretation of data
Recommendation/Request
what you need or want for the patient in terms of medical treatment and/or assistance
ABCDE
how to prioritize care/interventions
Airway
is the airway open; is the patient choking
Breathing
respiratory rate; oxygen saturation
Circulation
pulse rate and rhythm, skin color, pain, paresthesia
Disability
level of consciousness; alert and oriented?
Environment
safety, hygiene, cause of injury
Recognize Cues
identify findings that may be abnormal; document them and report to the doctor/charge nurse
Analyze Cues
relate the abnormal findings to pathophysiology; make sense of the data
Prioritize Hypothesis
what is the problem; what is causing the problem; what is the most important problem to solve
Generate Solutions
what solutions/nursing interventions/tasks/medical/management/patient education can be established
Take Action
identify what needs to be done to help the patient
Evaluate Outcomes
did the patient’s condition improve? Worsen? Unchanged?
Effective/Indicated Care
actions that are adequate to produce the intended result and help the patient
Ineffective Care
actions that are not adequate to produce the intended result; do not help the patient
Unrelated/Non-Essential Interventions
actions that will not help the patient (not better nor worse)
Contraindicated Interventions
actions that can cause more harm to the patient
First-level of Priority Care
problems/issues that reflect critical findings, clinical deterioration and/or are life-threatening; require URGENT action
Second-level of Priority Care
problems/issues that may lead to clinical deterioration and may become life-threatening without intervention; require prompt (quick) action
Third-level of Priority Care
problems/issues that are focused on functional health, client education, and counseling; should be addressed but not urgent; is not acute in nature but required to support ADLs, knowledge level, and mental health; what may be a priority to the nurse is not always a priority to the patient
Listen to your patient
this is a collection of subjective data
“Symptoms”
are what the patient describes/explains is wrong
Look (inspection), Feel (palpation and percussion), Listen (auscultate)
identifies the objective data that can potentially explain the patient’s symptoms
“Signs”
are what can be measured (vital signs, physical exam, etc)
Confirm/Validate data
use laboratory data (blood results) or other diagnostic tools (x-ray, MRI, etc)
Documentation
use an Electronic Health Record (EHR)
Emergency
rapid, life-threatening (choking, drowning, cardiac arrest)
Complete/Comprehensive
new patient, past and present history, life-style, obtain baseline VS
Focused/Problem-based
existing information, specific health concern, does not cover non-related areas
Follow-up
annual exams, mini-assessment of previous finding, improvement of previous problem
Reason for Seeking Care
the chief complaint of the patient, why they are there (nausea/vomiting, loss of appetite, insomnia, gout, swollen ankle, etc); use the PQRSTU
Provocative/Palliative
what were you doing when the pain started? What makes it better/worse? What triggers it? What relieves it? What aggravates it?
Quality/Quantity
what does it feel like? Sharp? Dull? Stabbing? Burning? Crushing? Throbbing? Shooting? Stretching?
Region/Radiation
where is the pain located? Does the pain radiate/where to? Does the pain travel? Did it begin somewhere else?
Severity
on a scale of 0-10, what is the pain? Are certain activities limited due to the pain? How bad is it at its worst? Does the pain come in waves? Do you have to stop, sit down, lie down?
Timing
when did it start? How long does it last? How often does it occur? What were you doing when it first occurred? Does it wake you up at night? Seasonal? While eating/after eating? Specific time of the day?
Understanding
do you understand why the pain occurs? Do you understand what causes it? Do you understand how to help the pain go away?
Acknowledge
greet patient by documented name, eye contact, smile, acknowledge any guests
Introduce yourself
state name, role, and reason for visiting the patient's room