Week 1 - Fundamentals of Nursing

Communication

exchanging information or feelings between two or more people

influence others and obtain information

communication’s purpose

Sender

conveys a message, encoder

Message

what is being conveyed

Receiver

to whom the message is for, listener, observer, decoder

Response/feedback

message that the receiver returns to the sender

Verbal, Non-verbal, Electric

modes of communication

Intimate

physical contact to 1 ½ feet

Personal

physical contact to 1 ½ to 4 feet

Social

physical contact to 4 to 12 feet

Public

physical contact to 12 feet and beyond

Nursing Process

systematic, rational method of planning and providing individualized nursing care

Critical Thinking

a process of analyzing problems or phenomena based on gathered data

Creativity

results in development of new ideas and products and implementing new and better solutions

Assessment, Diagnosis, Planning, Intervention, Evaluation (ADPIE)

Steps in the nursing process

Assessment

to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs

Subjective and Objective

types of data

Subjective

symptoms, said by the patient or family

Objective

signs, observed by the nurse

Primary and Secondary

sources of data

Primary

data comes from client or patient

Secondary

data comes from all other sources except the client or patient

Diagnosis

to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions

Nursing Diagnosis

holistic, assesses the body, mind, and spirit. mainly considers how people’s lives are affected by the problems (human responses). focused on maximizing function and independence

Medical Diagnosis

narrow, focuses on the body. mainly considers problems with organs and system function. focused on treating the diseases and trauma

Planning

to develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions

Implementation

to assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

Evaluation

to determine whether to continue, modify, or terminate the plan of care

Pace and intonation

manner of speech

Simplicity

use of commonly understood words, brevity, and completeness

Clarity and brevity

direct and simple message is more effective, 5 W’s & 1 H

Timing and relevance

must be appropriate and must relate to the person or to the person’s interests and concerns. Sensitive to client’s needs

Adaptability

adjusting or altering spoken messages in accordance with behavioral cues from the client; individualized

Credibility

worthiness of belief, trustworthiness, and reliability

Humor

positive and powerful tool that must be used with care. helps clients adjust to difficult and painful situations

Ability of the communicator

ability to speak, hear, see, comprehend

Perceptions

each person is unique

Territoriality

personal space

Attitude

conveys beliefs, thoughts, and feelings about people and events

Therapeutic communication

Promotes understanding and can help establish a constructive relationship between the nurse and the client

SOLER

for physical attending

sit squarely

S in SOLER

open posture

O in SOLER

lean toward the person

L in SOLER

eye contact

E in SOLER

relaxed

R in SOLER

Actual, Risk, Wellness

types of diagnosis

Actual

client problem present at time of assessment

Risk

Clinical judgement that a problem does not exist but risk factors are present that may likely result in the development of a problem

Wellness

Health promotion diagnosis: client’s preparedness to implement behaviors to improve health condition.