NUR 111: Communication, Documentation, and Pain Management

Flashcards covering professional nurse relationships, communication techniques, documentation standards, and the physiology and classification of pain.

Pre-orientation phase

The initial phase where the nurse collects data on the patient before meeting them.

Orientation phase

The phase where the nurse meets the patient and defines goals and needs.

Working phase

The stage where data is gathered, problem solving occurs, and the nurse provides education to the patient.

Termination phase

The final phase where goals are met and incorporated into the patient's life.

Motivational Interviewing

A patient-centered, evidence-based counseling approach to help explore and resolve disputes about changing health behavior through empathy, collaboration, evocation, and change talk.

SACCIA

An acronym representing Sufficiency, Accuracy, Clarity, Contextualization, and Interpersonal Adaptation to ensure safe and effective relationships.

SBAR

A structured communication tool comprising Situation, Background, Assessment, and Recommendation to convey critical patient information.

AIDET technique

A communication framework consisting of Acknowledge, Introduce, Duration, Explain, and Thanks.

Empathy

The ability to understand someone's feelings because you know or can imagine how they feel.

Sympathy

Feeling concern, pity, or sadness for someone.

SURETY Model

An acronym for non-verbal communication: Sit at an angle, Uncross legs/arms, Relax, Eye-contact, Touch, and Your intuition.

Progressive communication

Communication that prioritizes own needs at the expense of others, using force, intimidation, and blame.

Assertive communication

A balanced approach that clearly expresses own needs while respecting the rights and feelings of others.

Passive communication

The act of putting others' needs before your own.

SOAPIE notes

A documentation format standing for Subjective, Objective, Assessment, Plan, Intervention, and Evaluation.

DAR

A documentation format standing for Data, Action, and Response.

PIE

A documentation format standing for Problem, Intervention, and Evaluation.

CIS (Clinical Information System)

A tool that gives access to EMAR, results, and medical history.

NCIS (Nursing / Clinical Information System)

A specialized clinical information system designed for nurses.

Transduction

The process where thermal, chemical, or mechanical injuries release stimuli that are converted into pain impulses at the periphery.

Transmission (of pain)

The release of excitatory neurotransmitters such as prostaglandins, histamine, bradykinin, and Substance P that send a pain message triggering an inflammatory response.

Perception

The process where the CNS extracts information like location, duration, and quality of a pain impulse as it moves up the spinal cord.

Modulation

The brain's release of inhibitory neurotransmitters like endogenous opioids, serotonin, norepinephrine, and GABA after recognizing a harmful impulse.

Gate Control Theory

The theory that the transmission of pain impulses to the CNS is controlled by a gate in the thalamus that opens or closes in response to sensory output.

Acute pain

Pain that comes on suddenly and has a short duration of $< 6\text{ months}$.

Chronic pain

Pain that lasts longer than $> 6\text{ months}$.

Intermittent pain

Pain that comes and goes in intervals.

Intractable pain

Pain that cannot be relieved, has no cure, or is resistant to treatment.

Referred pain

Pain felt in an area other than where it was produced, also known as radiating pain.

Nociceptive pain

Localized pain where receptors send impulses to the CNS via nerve pathways; includes cutaneous, visceral, and deep somatic types.

Cutaneous pain

Superficial pain pertaining to the skin's surface and underlying subcutaneous tissue.

Visceral pain

Soft tissue pain experienced from stimulation of deep internal pain receptors, often described as an ache or cramping.

Deep somatic pain

Also known as osteogenic pain, this involves pain in the bone, ligament, tendon, and blood vessels.

Neuropathic pain

Pain occurring as a result of destruction of peripheral nerves or the CNS, often described as burning, stabbing, or numbness.