NUR 160 Exam 1

Therapeutic communication

•Silence

•Open Ended Questions

•Restating, Clarifying

•Touch

•Collaboration

•Patient Education

Blocks to effective communication

•Changing the Subject

•Offering False Reassurance

•Giving Advise

•Defensive Comments

•Asking Prying/Probing Questions

•Using Cliches

Listening Inattentively

Purpose of patient records

The patient record (chart) needs to provide a concise accurate, and permanent record of past and current medical and nursing problems

Important info about patient records

•Only HCPs directly caring for the patient, or those involved in research or teaching, should have access to the chart.

•Patient information should not be discussed with anyone not directly involved in the patient’s care.

Brevity in Documentation

• Articles (a, an, the) may be omitted.

• The word “patient” omitted when subject of sentence.

• Choose which behaviors and observations are noteworthy.

Legibility & Completeness in Documentation

•If writing not legible, misperceptions can occur

•Be sure to include as much information as needed

Preventing falls

• Assess medications

• Remove clutter/ rugs

• Keep room well lit

• Change positions slowly

• Educate to keep active

• Limit bed confinement

Safety and interrelated concepts

Health care quality, communication, collaboration, care coordination, well being and resilience. 

The Joint Commission

An independent, nonprofit organization that accredits and certifies healthcare organizations to improve quality and address key patient safety concerns. ( National patient safety goals )

National patient safety goals

• Identify patients correctly

• Use medicines safely

• Use alarms safely

• Prevent infection

• Prevent mistakes in surgery

Near miss event

An incident that could have caused harm to a patient but did not, either because it was caught in time or by chance.

Incident report

A formal record of any unexpected event that affects or could affect patient or staff safety, used to improve care and prevent future errors.

Sentinel event

A serious, unexpected occurrence involving death, permanent harm, or severe temporary harm to a patient that signals the need for immediate investigation.

Adverse event

Any unintended injury or complication caused by healthcare management rather than the patient’s condition, which may or may not result in serious harm.

Guidelines to Reduce Legal Risk

• Maintain competence

• Document fully, accurately, factual, and timely

• Establish rapport 

• Communicating effectively

• Take care of yourself

TACIT mnemonic

•Therapeutic effect: Assess if the patient shows expected therapeutic effects

•Allergies: Check for signs of drug allergies or adverse reactions

•Contraindications: Verify there are no contraindications for giving the drugs

•Interactions: Consider possible interactions among medications

•Toxicity/overdose: Monitor for signs of drug toxicity or overdose

Nociception

pain perception

Pain threshold

Where pain is first perceived

Acute pain

Short term, as from injury

Chronic pain

Slower onset, lasts longer than 3 months beyond the healing process

Nociceptive pain 

Dull and aching

Somatic pain

Originates from skin, bones, or muscles

Visceral pain

Originates from abdominal or thoracic areas

Neuropathic pain

Results from nerve injury; stabbing and burning

Idiopathic pain

Nonspecific and of unknown origin