Nursing Communication and Documentation Flashcards

Vocabulary flashcards covering nursing communication, relationship phases, documentation methods, and professional practices.

4 Phases of the Helping Relationship

Pre-interaction, orientation, working, termination

Pre-interaction Phase

The phase of the helping relationship where the nurse is getting rapport on the patient, setting up the room, checking their medical records, making sure to have all of the correct equipment for procedures, and setting up/preparing.

Orientation Phase

The phase of the helping relationship where the nurse is introducing yourself, stating what you will be doing today, completing said tasks, etc.

Working Phase

The phase of the working relationship when you are in the active parts of doing whatever task you are there to complete/ follow through with.

Termination Phase

The phase of the working relationship when you are completed with your tasks and/or the relationship is done because patient is being transferred or discharged, etc.

Lateral Violence

Workplace bullying between colleagues.

PIE Method of Documentation

Problem, intervention, evaluation; a method of documentation unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes.

Congruent Nonverbal Behavior

Nonverbal behavior that matches a verbal statement, such as when the nurse looks at client and stands with a relaxed body position while asking "How are you feeling this morning?"

Active Listening Indicator

A behavior indicating active listening while a client speaks, such as when the nurse nods the head periodically while the client is talking.

SBAR Format Beginning

A correct beginning statement when communicating with a provider, such as "Dr Thomas, this is Pat, the nurse caring for your client, Mr. Leo."

Client Education Rescheduling Indicators

Nonverbal client behaviors indicating education should be rescheduled: wringing the hands while the nurse is talking, looking down with shoulders slumped, arms crossed in front of the chest, and playing a game on a tablet.

Hearing Impaired Communication Techniques

Helpful communication techniques including: using sign language or gestures, making sure the client's hearing aides are in and working, facing the client while speaking, and using simple sentences.

Promoting a Trust Relationship

The way a nurse promotes a trust relationship with the client by following through when you say you will do something.

Borrowing Computer Passwords

If a nurse asks to borrow your computer password, the best action is to have the nurse contact IT to obtain a new password.

BEST Example of Nursing Documentation

An objective and detailed entry, such as "Ambulated 50 ft with assist of 1. VS after ambulation - 95, 22, 120/76."

Closed Question

A question asked by the nurse that allows for a yes or no answer.