Comprehensive Nursing Communication, Assessment, and Documentation Techniques

Communication

An interaction between 2 or more people involving an exchange of information.

5 Parts of Communication

Message, sender, method, receiver, feedback.

Message

The information being communicated.

Sender

The person who sends or initiates the message.

Receiver

The person receiving and interpreting the message.

Feedback

The receiver's response showing whether the message was understood.

Types of Communication

Verbal/written, nonverbal, aggressive/assertive, social, therapeutic.

Nonverbal Communication

Communication without spoken or written words.

Nonverbal Methods

Physical appearance/dress, body movement/posture, facial expressions, gestures, eye contact, touch, and silence.

Factors Affecting Communication

Biases, physical handicaps, hearing, vision, and illness.

Communication Blockers

False reassurance, minimizing/belittling, WHY questions, advising, agreeing/disagreeing, closed-ended questions, giving the answer, changing the subject, approving/disapproving.

Therapeutic Communication

Communication techniques that encourage the client to express thoughts and feelings.

Therapeutic Techniques

Reflecting, clarifying, open-ended questions, identifying thoughts/feelings, empathy, silence, giving information, offering self, general leads, and stating implied thoughts/feelings.

Reflecting

Repeating or reflecting the client's words to encourage communication and show attention.

Clarifying

Helping make the meaning of a statement clearer.

Open-Ended Questions

Questions that encourage the client to provide more information.

Empathy

Using understanding of the client's feelings as a therapeutic communication technique.

Nursing Process

A systematic method used by nurses to plan and provide care.

ADPIE

Assessment, Diagnosis, Planning, Implementation, Evaluation.

Purpose of Nursing Process

Provides the organizational framework for nursing practice and helps identify health problems.

Assessment

Collecting information about the client's health.

Primary Source of Assessment

The client.

Secondary Sources of Assessment

All sources other than the client.

Nursing Diagnosis

An actual or potential health problem that can be addressed through nursing measures.

Nursing Diagnosis vs Medical Diagnosis

A nursing diagnosis is NOT a medical diagnosis.

RN Role in Nursing Diagnosis

The RN analyzes data and identifies health problems.

LPN Role in Nursing Diagnosis

The LPN assists the RN by collecting data.

Planning

Creating goals and nursing interventions for identified problems.

Goal

A measurable, observable behavior the client should demonstrate after nursing interventions.

Goal Wording

Goals start with 'The patient/client will...'

Short-Term Goal

A goal achievable within hours, days, or weeks.

Long-Term Goal

A goal generally lasting 6 months or more or that may be open-ended.

SMART Goals

Specific, Measurable, Achievable, Realistic, Timely.